Amendment Statement of Principles

concerning

ANXIETY DISORDER

No. 100 of 2016

for the purposes of the

Veterans’ Entitlements Act 1986

and

Military Rehabilitation and Compensation Act 2004

1. This Instrument may be cited as Amendment Statement of Principles concerning anxiety disorder No. 100 of 2016.
2. The Repatriation Medical Authority amends, under subsection 196B(8) of the Veterans’ Entitlements Act 1986, Statement of Principles concerning anxiety disorder Instrument No. 103 of 2014, by:

(A)             Replacing the definition of "anxiety disorder" in clause 3(b) as follows:

"(b) For the purposes of this Statement of Principles, "anxiety disorder" means generalised anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder or unspecified anxiety disorder and substance/medication-induced anxiety disorder, where:

"generalised anxiety disorder" means a mental disorder that meets the following diagnostic criteria (derived from DSM-5):

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance);
2. The individual finds it difficult to control the worry;
3. The anxiety and worry are associated with three (or more) in an adult, or one or more in a child, of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):

(i)                 restlessness or feeling keyed up or on edge;

(ii)              being easily fatigued;

(iii)            difficulty concentrating or mind going blank;

(iv)            irritability;

(v)               muscle tension; or

(vi)            sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep);

D.             The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning;

E.            The disturbance is not attributable to the physiological effects of a substance (for example, a drug of abuse, a medication) or another medical condition (for example, hyperthyroidism); and

F.             The disturbance is not better explained by another mental disorder (for example, anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

"anxiety disorder due to another medical condition" means a mental disorder that meets the following diagnostic criteria (derived from DSM-5):

1. Panic attacks or anxiety is predominant in the clinical picture;
2. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition;
3. The disturbance is not better explained by another mental disorder;
4. The disturbance does not occur exclusively during the course of a delirium; and
5. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

"other specified anxiety disorder" and "unspecified anxiety disorder" are mental disorders (derived from DSM-5) with prominent symptoms of anxiety that cause clinically significant distress or impairment in social, occupational or other important areas of functioning, however, these anxiety symptoms do not meet the full diagnostic criteria for any of the other anxiety disorders.

"substance/medication-induced anxiety disorder" means a mental disorder that meets the following diagnostic criteria (derived from DSM-5):

1. Panic attacks or anxiety is predominant in the clinical picture;
2. There is evidence from the history, physical examination or laboratory findings of both (i) and (ii):

(i)            the symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication; and

(ii)         the substance/medication involved is capable of producing the symptoms in Criterion A;

C.       The disturbance is not better explained by an anxiety disorder that is not substance/medication-induced.  Such evidence of an independent anxiety disorder includes the following:

(i)            the symptoms precede the onset of the substance/medication use; or

(ii)         the symptoms persist for more than one month after the cessation of acute withdrawal or severe intoxication; or

(iii)       there is other evidence suggesting the existence of an independent non-substance/medication-induced anxiety disorder (for example, a history of recurrent non-substance/medication-related episodes);

D.           The disturbance does not occur exclusively during the course of a delirium; and

E.            The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

This definition of anxiety disorder excludes the other anxiety disorders: agoraphobia, panic disorder, selective mutism, separation anxiety disorder, social anxiety disorder and specific phobia."; and

(B)             Deleting clauses 3(c) and 3(d); and

(C)             Inserting new factors (ba)(i) to (ba)(x) in clause 6 as follows:

"(ba) for substance/medication-induced anxiety disorder only:

(i)            taking a drug or a drug from a class of drugs from the specified list of drugs, within the 24 hours before the clinical onset of anxiety disorder; or

(ii)         using or inhaling a substance from the specified list of substances, where that substance has resulted in intoxication, within the 24 hours before the clinical onset of anxiety disorder; or

(iii)       taking a drug which results in the development of anxiety symptoms or panic attacks within the 24 hours before the clinical onset of anxiety disorder; or

(iv)        ingesting or inhaling a chemical or a substance, where that chemical or substance causes intoxication, and results in the development of anxiety symptoms or panic attacks within the 24 hours before the clinical onset of anxiety disorder; or

(v)          having ceased or reduced therapeutic or illicit drug use or other substance use within the seven days before the clinical onset of anxiety disorder; or

(vi)        having periodic, heavy alcohol consumption for the six months before the clinical onset of anxiety disorder; or

(vii)     having an alcohol use disorder or a substance use disorder at the time of the clinical onset of anxiety disorder; or

(viii)   smoking an average of at least 20 cigarettes per day, or the equivalent thereof in other tobacco products, for at least the six months before the clinical onset of anxiety disorder, and where smoking has ceased, the clinical onset of anxiety disorder has occurred within three months of smoking cessation; or

(ix)        for persons without a regular caffeine habit, taking at least 200 milligrams of caffeine from beverages, drugs or foods within the one hour before the clinical onset of anxiety disorder; or

(x)          for persons with a regular caffeine habit, taking at least 800 milligrams of caffeine from beverages, drugs or foods within the one hour before the clinical onset of anxiety disorder; or"; and

(D)        Inserting new factors (na) to (ni) in clause 6 as follows:

"(na) taking a drug or a drug from a class of drugs from the specified list of drugs, within the 24 hours before the clinical worsening of anxiety disorder; or

(nb) using or inhaling a substance from the specified list of substances, where that substance has resulted in intoxication, within the 24 hours before the clinical worsening of anxiety disorder; or

(nc) taking a drug which results in the re-development or worsening of anxiety symptoms or panic attacks within the 24 hours before the clinical worsening of anxiety disorder; or

(nd) ingesting or inhaling a chemical or a substance, where that chemical or substance causes intoxication, and results in the development of anxiety symptoms or panic attacks within the 24 hours before the clinical worsening of anxiety disorder; or

(ne) having ceased or reduced therapeutic or illicit drug use or other substance use within the seven days before the clinical worsening of anxiety disorder; or

(nf) having periodic, heavy alcohol consumption for the six months before the clinical worsening of anxiety disorder; or

(ng) having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of anxiety disorder; or

(nh) smoking an average of at least 20 cigarettes per day, or the equivalent thereof in other tobacco products, for at least the six months before the clinical worsening of anxiety disorder, and where smoking has ceased, the clinical worsening of anxiety disorder has occurred within three months of smoking cessation; or

(ni) taking at least 400 milligrams of caffeine from beverages, drugs or foods within the one hour before the clinical worsening of anxiety disorder; or"; and

(E)         Inserting the following definitions in clause 9 in alphabetical order:

'"alcohol" is measured by the alcohol consumption calculations utilising the Australian Standard of ten grams of alcohol per standard alcoholic drink;';

'"cigarettes per day, or the equivalent thereof in other tobacco products" means either cigarettes, pipe tobacco or cigars, alone or in any combination, where one tailor-made cigarette approximates one gram of tobacco; or one gram of cigar, pipe or other smoking tobacco;';

'"inhalants" means breathable chemicals that produce psychoactive vapours or fumes and include organic solvents, aerosols and anaesthetics;';

'"intoxication" means a transient state following the administration of alcohol or other psychoactive substance, resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses;';

'"organic solvents" means:

(a)          aliphatic hydrocarbon solvents; or

(b)          aromatic hydrocarbon solvents; or

(c)          chlorinated organic solvents; or

(d)          oxygenated organic solvents;';

'"periodic, heavy alcohol consumption" means sessions of heavy alcohol drinking to the point of intoxication at least once a month;';

'"regular caffeine habit" means consuming the equivalent of more than 400 milligrams of caffeine from beverages, drugs or foods daily for at least two weeks;';

'"specified list of drugs" means:

(a)          corticosteroids, excluding topical corticosteroids;

(b)         doxycycline;

(c)          efavirenz;

(d)         hydralazine;

(e)          ketamine;

(f)           lidocaine;

(g)         mefloquine;

(h)         pramipexole;

(i)           ropinirole;

(j)           statins;

(k)         sympathomimetics; or

(l)           topiramate;';

'"specified list of substances" means:

(a)          amphetamine and amphetamine-type substances, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy);

(b)          cannabis;

(c)          cocaine;

(d)          inhalants; or

(e)          opioids;'; and

(F)          Deleting the definition of "ICD-10-AM code" in clause 9.

3.                     The amendments made by this instrument apply to all matters to which Instrument No. 103 of 2014, section 120B of the Veterans’ Entitlements Act 1986 and section 339 of the Military Rehabilitation and Compensation Act 2004 apply.

4.                     The amendments made by this instrument take effect from 28 November 2016.

Dated this   twenty-eighth   day of   October   2016

The Common Seal of the  )

Repatriation Medical Authority )

was affixed to this instrument   )

at the direction of:   )

PROFESSOR NICHOLAS SAUNDERS AO

CHAIRPERSON