The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans’ Entitlements Act 1986.
Dated 4 March 2016
The Common Seal of the
Repatriation Medical Authority
was affixed to this instrument
at the direction of:
Professor Nicholas Saunders AO
Chairperson
1 Name
2 Commencement
3 Authority
4 Revocation
5 Application
6 Definitions
7 Kind of injury, disease or death to which this Statement of Principles relates
8 Basis for determining the factors
9 Factors that must exist
10 Relationship to service
11 Factors referring to an injury or disease covered by another Statement of Principles
Schedule 1 - Dictionary
1 Definitions
1 Name
This is the Statement of Principles concerning eating disorder (Reasonable Hypothesis) (No. 13 of 2016).
2 Commencement
This instrument commences on 4 April 2016.
3 Authority
This instrument is made under subsection 196B(2) of the Veterans’ Entitlements Act 1986.
4 Revocation
The Statement of Principles concerning eating disorder No. 47 of 2008, as amended, made under subsections 196B(2) and (8) of the VEA is revoked.
5 Application
This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.
6 Definitions
The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.
7 Kind of injury, disease or death to which this Statement of Principles relates
(1) This Statement of Principles is about eating disorder and death from eating disorder.
Meaning of eating disorder
(2) For the purposes of this Statement of Principles, eating disorder means:
(a) a group of mental disorders which are manifested by a dysfunctional eating pattern. This definition is limited to anorexia nervosa, binge-eating disorder, bulimia nervosa, and other specified feeding or eating disorder and unspecified feeding or eating disorder; and
(b) excludes pica, rumination disorder and avoidant/restrictive food intake disorder.
Note: anorexia nervosa, binge-eating disorder, bulimia nervosa and other specified feeding or eating disorder and unspecified feeding or eating disorder are defined in the Schedule 1 – Dictionary.
(3) While eating disorder attracts ICD‑10‑AM code F50.0, F50.1, F50.2, F50.3, F50.4 or F50.9, in applying this Statement of Principles the meaning of eating disorder is that given in subsection (2).
(4) For subsection (3), a reference to an ICD‑10‑AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‑10‑AM), Ninth Edition, effective date of 1 July 2015, copyrighted by the Independent Hospital Pricing Authority, ISBN 978‑1‑76007‑020‑5.
Death from eating disorder
(5) For the purposes of this Statement of Principles, eating disorder, in relation to a person, includes death from a terminal event or condition that was contributed to by the person’s eating disorder.
Note: terminal event is defined in the Schedule 1 – Dictionary.
8 Basis for determining the factors
The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that eating disorder and death from eating disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.
Note: relevant service is defined in the Schedule 1 – Dictionary.
9 Factors that must exist
At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting eating disorder or death from eating disorder with the circumstances of a person’s relevant service:
(1) experiencing a category 1A stressor within the two years before the clinical onset of eating disorder;
Note: category 1A stressor is defined in the Schedule 1 - Dictionary.
(2) experiencing a category 1B stressor within the one year before the clinical onset of eating disorder;
Note: category 1B stressor is defined in the Schedule 1 - Dictionary.
(3) experiencing a category 2 stressor within the one year before the clinical onset of eating disorder;
Note: category 2 stressor is defined in the Schedule 1 - Dictionary.
(4) experiencing the death of a significant other within the one year before the clinical onset of eating disorder;
Note: significant other is defined in the Schedule 1 - Dictionary.
(5) having a clinically significant disorder of mental health as specified within the two years before the clinical onset of eating disorder;
Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.
(6) having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the two years before the clinical onset of eating disorder;
(7) having experienced severe childhood abuse before the clinical onset of eating disorder;
Note: severe childhood abuse is defined in the Schedule 1 - Dictionary.
(8) being treated with the drug topiramate at the time of the clinical onset of eating disorder;
(9) experiencing a category 1A stressor within the two years before the clinical worsening of eating disorder;
Note: category 1A stressor is defined in the Schedule 1 - Dictionary.
(10) experiencing a category 1B stressor within the one year before the clinical worsening of eating disorder;
Note: category 1B stressor is defined in the Schedule 1 - Dictionary.
(11) experiencing a category 2 stressor within the one year before the clinical worsening of eating disorder;
Note: category 2 stressor is defined in the Schedule 1 - Dictionary.
(12) experiencing the death of a significant other within the one year before the clinical worsening of eating disorder;
Note: significant other is defined in the Schedule 1 - Dictionary.
(13) having a clinically significant disorder of mental health as specified within the two years before the clinical worsening of eating disorder;
Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 - Dictionary.
(14) having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the two years before the clinical worsening of eating disorder;
(15) being treated with the drug topiramate at the time of the clinical worsening of eating disorder;
(16) inability to obtain appropriate clinical management for eating disorder.
10 Relationship to service
(1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.
(2) The factors set out in subsections 9(9) to 9(16) apply only to material contribution to, or aggravation of, eating disorder where the person’s eating disorder was suffered or contracted before or during (but did not arise out of) the person’s relevant service.
11 Factors referring to an injury or disease covered by another Statement of Principles
In this Statement of Principles:
(1) if a factor referred to in section 9 applies in relation to a person; and
(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;
then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
Note: See Section 6
1 Definitions
In this instrument:
anorexia nervosa means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5):
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Note: DSM-5 is also defined in the Schedule 1 - Dictionary.
binge-eating disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5):
A. Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
1. Eating, in a discrete period of time (for example, within any two-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances; and
2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal;
2. Eating until feeling uncomfortably full;
3. Eating large amounts of food when not feeling physically hungry;
4. Eating alone because of feeling embarrassed by how much one is eating; or
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for three months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviour as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
Note: DSM-5 is also defined in the Schedule 1 - Dictionary.
bulimia nervosa means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5):
A. Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:
1. Eating, in a discrete period of time (for example, within any two-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances; and
2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Note: DSM-5 is also defined in the Schedule 1 - Dictionary.
category 1A stressor means one of the following severe traumatic events:
(a) experiencing a life-threatening event;
(b) being subject to a serious physical attack or assault including rape and sexual molestation; or
(c) being threatened with a weapon, being held captive, being kidnapped, or being tortured.
category 1B stressor means one of the following severe traumatic events:
(a) being an eyewitness to a person being killed or critically injured;
(b) viewing corpses or critically injured casualties as an eyewitness;
(c) being an eyewitness to atrocities inflicted on another person or persons;
(d) killing or maiming a person; or
(e) being an eyewitness to or participating in, the clearance of critically injured casualties.
Note: eyewitness is also defined in the Schedule 1 - Dictionary.
category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel on-going distress, concern or worry:
(a) being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;
(b) experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce;
(c) having concerns in the work or school environment including on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment;
(d) experiencing serious legal issues including being detained or held in custody, on-going involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;
(e) having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property or bankruptcy;
(f) having a family member or significant other experience a major deterioration in their health; or
(g) being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability.
clinically significant disorder of mental health as specified means one of the following conditions, which is of sufficient severity to warrant ongoing management, which may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner:
(a) agoraphobia;
(b) alcohol use disorder;
(c) anxiety disorder;
(d) attention-deficit/hyperactivity disorder;
(e) bipolar disorder;
(f) depressive disorder;
(g) obsessive compulsive disorder;
(h) panic disorder;
(i) personality disorder;
(j) posttraumatic stress disorder;
(k) schizophrenia;
(l) social anxiety disorder; or
(m) substance use disorder.
DSM-5 means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
eating disorder—see subsection 7(2).
eyewitness means a person who observes an incident first hand and can give direct evidence of it. This excludes a person exposed only to media coverage of the incident.
MRCA means the Military Rehabilitation and Compensation Act 2004.
other specified feeding or eating disorder and unspecified feeding or eating disorder are mental disorders (derived from DSM-5) with prominent symptoms of feeding and eating disorders that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. However, these symptoms do not meet the full diagnostic criteria for any of the other feeding and eating disorders. Examples of presentations that can be specified using the "other specified" designation include the following:
- Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual's weight is within or above the normal range.
- Bulimia nervosa (of low frequency or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviours occur, on average, less than once a week or for less than three months.
- Binge-eating disorder (of low frequency or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week or for less than three months.
- Purging disorder: Recurrent purging behaviour to influence weight or shape (for example, self-induced vomiting; misuse of laxatives, diuretics or other medications) in the absence of binge eating.
- Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual's sleep-wake cycle or by local social norms. The night eating causes significant distress or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.
Note: DSM-5 is also defined in the Schedule 1 - Dictionary.
relevant service means:
(a) operational service under the VEA;
(b) peacekeeping service under the VEA;
(c) hazardous service under the VEA;
(d) British nuclear test defence service under the VEA;
(e) warlike service under the MRCA; or
(f) non-warlike service under the MRCA.
severe childhood abuse means:
(a) serious physical, emotional, psychological or sexual harm whilst a child aged under 16 years; or
(b) neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 16 years;
where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child.
significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.
terminal event means the proximate or ultimate cause of death and includes the following:
(a) pneumonia;
(b) respiratory failure;
(c) cardiac arrest;
(d) circulatory failure; or
(e) cessation of brain function.
VEA means the Veterans' Entitlements Act 1986.