Statement of Principles

concerning

ANXIETY DISORDER
(Balance of Probabilities)

(No. 101 of 2023)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 25 October 2023.

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 anxiety disorder (Balance of Probabilities) (No. 101 of 2023).

2               Commencement

              This instrument commences on 28 November 2023.

3               Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning anxiety disorder No. 103 of 2014 (Federal Register of Legislation No. F2014L01390) made under subsections 196B(3) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120B of the VEA or section 339 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 anxiety disorder and death from anxiety disorder.

Meaning of anxiety disorder

(2)          For the purposes of this Statement of Principles, anxiety disorder means:

(a)          generalised anxiety disorder; or

(b)          anxiety disorder due to another medical condition; or

(c)          substance/medication-induced anxiety disorder; or

(d)          other specified anxiety disorder or unspecified anxiety disorder;

where:

(3)          generalised anxiety disorder meets the following criteria (derived from DSM-5-TR):

(a)          Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance);

(b)          The individual finds it difficult to control the worry;

(c)          The anxiety and worry are associated with 3 (or more) in an adult, or one or more in a child, of the following 6 symptoms (with at least some symptoms having been present for more days than not for the past 6 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).

(4)          anxiety disorder due to another medical condition meets the following criteria (derived from DSM-5-TR):

(a)          Panic attacks or anxiety is predominant in the clinical picture;

(b)          There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition;

(c)          The disturbance is not better explained by another mental disorder;

(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.

(5)          substance/medication-induced anxiety disorder meets the following criteria (derived from DSM-5-TR):

(a)          Panic attacks or anxiety is predominant in the clinical picture;

(b)          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 or withdrawal from 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.

(6)          other specified anxiety disorder and unspecified anxiety disorder have 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 criteria for any of the other anxiety disorders (derived from DSM-5-TR).

(7)          This definition of anxiety disorder excludes: agoraphobia, panic disorder, selective mutism, separation anxiety disorder, social anxiety disorder and specific phobia.

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

Death from anxiety disorder

(8)          For the purposes of this Statement of Principles, anxiety disorder, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's anxiety disorder.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that anxiety disorder and death from anxiety disorder can be related to relevant service rendered by veterans 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 exist before it can be said that, on the balance of probabilities, anxiety disorder or death from anxiety disorder is connected with the circumstances of a person's relevant service:

(1)          experiencing a category 1A stressor within the 2 years before the clinical onset of generalised anxiety disorder;

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

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

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

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

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

(4)          having a family member or close friend who experiences a category 1A stressor within the 1 year before the clinical onset of generalised anxiety disorder;

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

(5)          experiencing the death of a family member or close friend within the 2 years before the clinical onset of generalised anxiety disorder;

(6)          experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical onset of generalised anxiety disorder;

(7)          experiencing a category 2 stressor within the 6 months before the clinical onset of generalised anxiety disorder;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service.  Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

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

(8)          having a clinically significant disorder of mental health within the 5 years before the clinical onset of generalised anxiety disorder;

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

(9)          having a medical illness which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical onset of generalised anxiety disorder;

(10)      having an injury which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical onset of generalised anxiety disorder;

(11)      having epilepsy at the time of the clinical onset of generalised anxiety disorder;

(12)      having persistent pain of at least 6 months duration at the time of the clinical onset of generalised anxiety disorder;

Note: persistent pain is defined in the Schedule 1 – Dictionary.

(13)      being obese at the time of the clinical onset of generalised anxiety disorder;

Note: being obese is defined in the Schedule 1 – Dictionary.

(14)      inability to undertake physical activity greater than 3 METs for a continuous period of at least the 3 months before the clinical onset of generalised anxiety disorder;

Note: MET is defined in the Schedule 1 – Dictionary

(15)      having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of anxiety are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical onset of “anxiety disorder due to another medical condition”;

(16)      taking mefloquine within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder, where substance/medication-induced anxiety disorder persists after the discontinuation or tapering of mefloquine therapy;

(17)      using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder;

Note: intoxicant dose and specified list of psychoactive substances are defined in the Schedule 1 – Dictionary.

(18)      taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the development of anxiety symptoms during drug therapy and either:

(a)          the improvement of anxiety symptoms within days or weeks of discontinuing or tapering drug therapy; or

(b)          the redevelopment of anxiety symptoms on rechallenge with the same drug;

where the drug was being taken within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder;

(19)      using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the development of anxiety symptoms, and where the psychoactive chemical or substance was being taken within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder;

Note: intoxicant dose is defined in the Schedule 1 – Dictionary.

(20)      having ceased or reduced therapeutic or illicit drug use or other substance use within the 10 days before the clinical onset of substance/medication-induced anxiety disorder;

(21)      having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced anxiety disorder;

(22)      having smoked tobacco products in an amount of at least 0.5 pack-years before the clinical onset of substance/medication-induced anxiety disorder, and if smoking has ceased before the clinical onset of substance/medication-induced anxiety disorder, then that onset occurred within 3 months of cessation;

Note: one pack-year is defined in the Schedule 1 - Dictionary.

(23)      for persons without a regular caffeine habit, taking at least 200 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical onset of substance/medication-induced anxiety disorder;

Note: regular caffeine habit is defined in the Schedule 1 – Dictionary.

(24)      for persons with a regular caffeine habit, taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical onset of substance/medication-induced anxiety disorder;

Note: regular caffeine habit is defined in the Schedule 1 – Dictionary.

(25)      experiencing a category 1A stressor within the 2 years before the clinical worsening of anxiety disorder;

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

(26)      experiencing a category 1B stressor within the 2 years before the clinical worsening of anxiety disorder;

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

(27)      experiencing severe childhood abuse before the clinical worsening of anxiety disorder;

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

(28)      having a family member or close friend who experiences a category 1A stressor within the 1 year before the clinical worsening of anxiety disorder;

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

(29)      experiencing the death of a family member or close friend within the 2 years before the clinical worsening of anxiety disorder;

(30)      experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical worsening of anxiety disorder;

(31)      experiencing a category 2 stressor within the 6 months before the clinical worsening of anxiety disorder;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service.  Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

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

(32)      having a clinically significant disorder of mental health within the 5 years before the clinical worsening of anxiety disorder;

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

(33)      having a medical illness which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical worsening of anxiety disorder;

(34)      having an injury which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical worsening of anxiety disorder;

(35)      having epilepsy at the time of the clinical worsening of anxiety disorder;

(36)      having persistent pain of at least 6 months duration at the time of the clinical worsening of anxiety disorder;

Note: persistent pain is defined in the Schedule 1 – Dictionary.

(37)      being obese at the time of the clinical worsening of anxiety disorder;

Note: being obese is defined in the Schedule 1 – Dictionary.

(38)      inability to undertake physical activity greater than 3 METs for a continuous period of at least the 3 months before the clinical worsening of anxiety disorder;

Note: MET is defined in the Schedule 1 – Dictionary.

(39)      having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of anxiety are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical worsening of anxiety disorder;

(40)      taking mefloquine within the 24 hours before the clinical worsening of anxiety disorder, where anxiety disorder persists after the discontinuation or tapering of mefloquine therapy;

(41)      using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 24 hours before the clinical worsening of anxiety disorder;

Note: intoxicant dose and specified list of psychoactive substances are defined in the Schedule 1 – Dictionary.

(42)      taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the worsening of anxiety symptoms during drug therapy and either:

(a)          the improvement of anxiety symptoms within days or weeks of discontinuing or tapering drug therapy; or

(b)          the worsening of anxiety symptoms on rechallenge with the same drug;

where the drug was being taken within the 24 hours before the clinical worsening of anxiety disorder;

(43)      using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the worsening of anxiety symptoms, and where the psychoactive chemical or substance was being taken within the 24 hours before the clinical worsening of anxiety disorder;

Note: intoxicant dose is defined in the Schedule 1 – Dictionary.

(44)      having ceased or reduced therapeutic or illicit drug use or other substance use within the 10 days before the clinical worsening of anxiety disorder;

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

(46)      having smoked tobacco products in an amount of at least 0.5 pack-years before the clinical worsening of anxiety disorder, and if smoking has ceased before the clinical worsening of anxiety disorder, then that worsening occurred within 3 months of cessation;

Note: one pack-year is defined in the Schedule 1 - Dictionary.

(47)      taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical worsening of anxiety disorder;

(48)      inability to obtain appropriate clinical management for anxiety disorder before the clinical worsening of anxiety 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(25) to 9(48) apply only to material contribution to, or aggravation of, anxiety disorder where the person's anxiety 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(3) 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:

                                             anxiety disorder—see subsections 7(2) to 7(7).

                               being obese means having a Body Mass Index (BMI) of 30 or greater.

Note: BMI is defined in the Schedule 1 - Dictionary.

                               BMI means W/H2 where:

(a)          W is the person's weight in kilograms; and

(b)          H is the person's height in metres.

                               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 a witness to a person being killed or critically injured;

(c)          being a witness 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 a witness.

Note: corpse and witness are 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, ethnicity, sexuality, 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; or

(f)           having a family member or close friend experience a major deterioration in their health.

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

(a)          another anxiety disorder (including panic disorder);

(b)          bipolar disorder or related disorder;

(c)          depressive disorder;

(d)          disruptive, impulse-control or conduct disorder;

(e)          dissociative disorder;

(f)           elimination disorder;

(g)          feeding or eating disorder;

(h)          gambling disorder;

(i)            gender dysphoria;

(j)            neurocognitive disorder;

(k)          neurodevelopmental disorder;

(l)            obsessive-compulsive or related disorder;

(m)        paraphilic disorder;

(n)          personality disorder;

(o)          schizophrenia spectrum or other psychotic disorder (including schizophrenia);

(p)          sexual dysfunction;

(q)          sleep-wake disorder (including chronic insomnia disorder, narcolepsy, sleep apnoea and restless legs syndrome);

(r)           somatic symptom disorder or related disorder; or

(s)           trauma- and stressor-related disorder (including acute stress disorder, adjustment disorder and posttraumatic stress 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-TR means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022.

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

                               intoxicant dose means a dose sufficient to cause disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses.

                               MET means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute, 1.0 kcal/kg of body weight per hour, or resting metabolic rate.

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               one pack-year means the amount of tobacco consumed in smoking 20 cigarettes per day for a period of 1 year, or an equivalent amount of tobacco products.

Note 1: An equivalent amount of tobacco products is 7,300 grams of smoking tobacco by weight, either in cigarettes, pipe tobacco or cigars, or a combination of same. For pipe tobacco, cigars or combinations of multiple tobacco types, 1 gram of tobacco is considered to be equal to one cigarette.

Note 2: Pack-years are calculated by dividing the number of cigarettes smoked per day by 20 and multiplying this number by the number of years the person has smoked. For example, smoking 10 cigarettes per day for 10 years is equal to 5 pack-years, and smoking 40 cigarettes per day for 10 years is equal to 20 pack-years.

                               persistent pain means:

(a)          continuous; or

(b)          severe, frequent and intermittent pain,

                               which may or may not be ameliorated by analgesic medication and is of a level to cause interference with usual work or activities of daily living.

                               regular caffeine habit means consuming the equivalent of more than 200 milligrams of caffeine from beverages, drugs or foods daily for at least 2 weeks.

                               relevant service means:

(a)          eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)          peacetime 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 18 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 18 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.

                               specified list of psychoactive substances means:

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

(b)          cannabis;

(c)          cocaine;

(d)          inhalants;

(e)          opioids; or

(f)           phencyclidine (PCP, angel dust).

Note: inhalants is defined in the Schedule 1 – Dictionary.

                               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.

                               witness means a person who experiences an incident at the time it occurs and can give direct evidence of it. This excludes persons exposed only to public broadcasting or mass media coverage of the incident.