Statement of Principles

concerning

PANIC DISORDER
(Reasonable Hypothesis)

(No. 55 of 2018)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 22 June 2018

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

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 panic disorder (Reasonable Hypothesis) (No. 55 of 2018).

2               Commencement

              This instrument commences on 23 July 2018.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning panic disorder No. 68 of 2009 (Federal Register of Legislation No. F2016C00975) made under subsections 196B(2) and (8) of the VEA is repealed.

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 panic disorder and death from panic disorder.

Meaning of panic disorder

(2)          For the purposes of this Statement of Principles, panic disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5):

1. Recurrent unexpected panic attacks.  A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

(i)            palpitations, pounding heart, or accelerated heart rate;

(ii)         sweating;

(iii)       trembling or shaking;

(iv)        sensations of shortness of breath or smothering;

(v)          feelings of choking;

(vi)        chest pain or discomfort;

(vii)     nausea or abdominal distress;

(viii)   feeling dizzy, unsteady, light-headed or faint;

(ix)        chills or heat sensations;

(x)          paraesthesias (numbness or tingling sensations);

(xi)        derealisation (feelings of unreality) or depersonalisation (being detached from oneself);

(xii)     fear of losing control or "going crazy"; or

(xiii)   fear of dying.

Note: Culture-specific symptoms (for example, tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen.  Such symptoms should not count as one of the four required symptoms.

B.            At least one of the attacks has been followed by one month (or more) of one or both of the following:

(i)            persistent concern or worry about additional panic attacks or their consequences (for example, losing control, having a heart attack, "going crazy"); or

(ii)         a significant maladaptive change in behaviour related to the attacks (for example, behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

C.            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, cardiopulmonary disorders).

D.           The disturbance is not better explained by another mental disorder (for example, the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Note: DSM-5 is defined in the Schedule 1 – Dictionary.

(3)          While panic disorder attracts ICD‑10‑AM code F40.01 or F41.0, in applying this Statement of Principles the meaning of panic 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), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from panic disorder

(5)          For the purposes of this Statement of Principles, panic disorder, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's panic 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 panic disorder and death from panic 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: MRCA, relevant service and VEA are 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 panic disorder or death from panic disorder with the circumstances of a person's relevant service:

(1)          experiencing a category 1A stressor within the five years before the clinical onset of panic disorder; 

Note:  category 1A stressor is defined in the Schedule 1 – Dictionary.

(2)          experiencing a category 1B stressor within the five years before the clinical onset of panic disorder;

Note:  category 1B stressor is defined in the Schedule 1 – Dictionary.

(3)          experiencing severe childhood abuse before the clinical onset of panic disorder;

Note:  severe childhood abuse is defined in the Schedule 1 – Dictionary.

(4)          experiencing the death of a significant other within the ten years before the clinical onset of panic disorder;

Note:  significant other is defined in the Schedule 1 – Dictionary.

(5)          having a clinically significant disorder of mental health from Specified List 1 within the ten years before the clinical onset of panic disorder; 

Note:  clinically significant disorder of mental health from Specified List 1 is defined in the Schedule 1 – Dictionary

(6)          having sleep apnoea within the ten years before the clinical onset of panic disorder;

(7)          having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical onset of panic disorder;

(8)          having a severe, chronic medical condition within the five years before the clinical onset of panic disorder;

Note:  severe, chronic medical condition is defined in the Schedule 1 – Dictionary.

(9)          having concussion or moderate to severe traumatic brain injury within the ten years before the clinical onset of panic disorder;

(10)      having epilepsy at the time of the clinical onset of panic disorder;

(11)      experiencing a category 2 stressor within the five years before the clinical onset of panic disorder;

Note:  category 2 stressor is defined in the Schedule 1 - Dictionary.

(12)      having migraine within the two years before the clinical onset of panic disorder;

(13)      experiencing a category 1A stressor within the five years before the clinical worsening of panic disorder; 

Note:  category 1A stressor is defined in the Schedule 1 – Dictionary.

(14)      experiencing a category 1B stressor within the five years before the clinical worsening of panic disorder;

Note:  category 1B stressor is defined in the Schedule 1 – Dictionary.

(15)      experiencing severe childhood abuse before the clinical worsening of panic disorder;

Note:  severe childhood abuse is defined in the Schedule 1 – Dictionary.

(16)      experiencing the death of a significant other within the ten years before the clinical worsening of panic disorder;

Note:  significant other is defined in the Schedule 1 – Dictionary.

(17)      having a clinically significant disorder of mental health from Specified List 2 within the ten years before the clinical worsening of panic disorder; 

Note:  clinically significant disorder of mental health from Specified List 2 is defined in the Schedule 1 – Dictionary

(18)      having sleep apnoea within the ten years before the clinical worsening of panic disorder;

(19)      having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical worsening of panic disorder;

(20)      having a severe, chronic medical condition within the five years before the clinical worsening of panic disorder;

Note:  severe, chronic medical condition is defined in the Schedule 1 – Dictionary.

(21)      having concussion or moderate to severe traumatic brain injury within the ten years before the clinical worsening of panic disorder;

(22)      having epilepsy at the time of the clinical worsening of panic disorder;

(23)      experiencing a category 2 stressor within the five years before the clinical worsening of panic disorder;

Note:  category 2 stressor is defined in the Schedule 1 - Dictionary.

(24)      having migraine within the two years before the clinical worsening of panic disorder;

(25)      inability to obtain appropriate clinical management for panic 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(13) to 9(25) apply only to material contribution to, or aggravation of, panic disorder where the person's panic 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.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                             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)          killing or maiming a person;

(b)          being an eyewitness to a person being killed or critically injured;

(c)          being an eyewitness to atrocities inflicted on another person;

(d)          participating in the clearance of a corpse or a critically injured casualty; or

(e)          viewing a corpse or a critically injured casualty as an eyewitness.

Note: corpse and eyewitness are 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 ongoing 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 ongoing 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, ongoing 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.

Note: significant other is also defined in the Schedule 1 - Dictionary.

                             clinically significant disorder of mental health from Specified List 1 means one of the following conditions, which is of sufficient severity to warrant ongoing management:

(a)          acute stress disorder;

(b)          agoraphobia;

(c)          alcohol use disorder;

(d)          anxiety disorder;

(e)          attention-deficit/hyperactivity disorder;

(f)           bipolar disorder;

(g)          conduct disorder;

(h)          conversion disorder;

(i)            depressive disorder;

(j)            dissociative disorder;

(k)          eating disorder;

(l)            illness anxiety disorder;

(m)        insomnia disorder;

(n)          obsessive-compulsive disorder;

(o)          oppositional defiant disorder;

(p)          personality disorder;

(q)          posttraumatic stress disorder;

(r)           schizophrenia;

(s)           separation anxiety disorder;

(t)            social anxiety disorder;

(u)          somatic symptom disorder;

(v)          specific phobia; or

(w)        substance use disorder.

Note 1: "Management" of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.

Note 2: To "warrant ongoing management" does not require that any actual management was received or given for the condition.

                              clinically significant disorder of mental health from Specified List 2 means one of the following conditions, which is of sufficient severity to warrant ongoing management:

(a)          acute stress disorder;

(b)          agoraphobia;

(c)          alcohol use disorder;

(d)          anxiety disorder;

(e)          attention-deficit/hyperactivity disorder;

(f)           bipolar disorder;

(g)          conduct disorder;

(h)          conversion disorder;

(i)            depressive disorder;

(j)            dissociative disorder;

(k)          eating disorder;

(l)            illness anxiety disorder;

(m)        insomnia disorder;

(n)          obsessive-compulsive disorder;

(o)          oppositional defiant disorder;

(p)          posttraumatic stress disorder;

(q)          schizophrenia;

(r)           separation anxiety disorder;

(s)           social anxiety disorder;

(t)            somatic symptom disorder;

(u)          specific phobia; or

(v)          substance use disorder.

Note 1: "Management" of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.

Note 2: To "warrant ongoing management" does not require that any actual management was received or given for the condition.

                               corpse means the human remains or body parts of one or more persons who have met a violent or horrific death. 

Note: Examples of a violent or horrific death may include death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks or motor vehicle accidents.  Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition.

                               DSM-5 means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  Arlington, VA, American Psychiatric Association, 2013.

                             eyewitness means a person who observes an incident first hand and can give direct evidence of it.  This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

                              MRCA means the Military Rehabilitation and Compensation Act 2004.

panic disorder—see subsection 7(2).

                             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.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                             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.

                             severe, chronic medical condition means an illness which substantially impacts on social, occupational or other important areas of functioning; and requires on-going daily or almost daily management of symptoms.  This management may include, but is not limited to, assistance with activities of daily living, bed rest, dietary modification, drug therapy, nursing care, oxygen therapy or physiotherapy.  This management must be supervised by a registered health practitioner.  Severe, chronic medical conditions do not usually resolve spontaneously, are rarely cured completely and may progress to life-threatening illnesses.  

Note: Examples of these conditions include poorly controlled asthma, chronic obstructive pulmonary disease, poorly controlled diabetes mellitus, inflammatory bowel disease, pemphigus, psoriasis and rheumatoid arthritis.

                             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.