Statement of Principles

concerning

EATING DISORDER
(Reasonable Hypothesis)

(No. 15 of 2025)

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

Dated    17 December 2024.

Professor Terence Campbell AM

Chairperson

by and on behalf of

The Repatriation Medical Authority

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 eating disorder (Reasonable Hypothesis) (No. 15 of 2025).

1.                Commencement

              This instrument commences on 28 January 2025.

1.                Authority

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

1.                Repeal

The Statement of Principles concerning eating disorder (Reasonable Hypothesis) (No. 13 of 2016) (Federal Register of Legislation No. F2016L00261) made under subsections 196B(2) and (8) of the VEA is repealed.

1.                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.

1.                Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

1.                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

1.           For the purposes of this Statement of Principles, eating disorder:
   1.           means a persistent disturbance of eating or eating-related behaviour resulting in the altered consumption or absorption of food, which significantly impairs physical health or psychosocial functioning; and
   2.           includes:
      1.                anorexia nervosa;
      2.             bulimia nervosa;
      3.           binge-eating disorder;
      4.            pica;
      5.              rumination disorder;
      6.           avoidant/restrictive food intake disorder
      7.        other specified feeding or eating disorder; and
      8.      unspecified feeding or eating disorder; and
   3.           excludes:
      1.                anorexia;
      2.             orthorexia nervosa; and
      3.           polyphagia.

anorexia nervosa means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.            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;

1.            Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight;
2.            Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise; and
3.            Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

bulimia nervosa means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           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 (e.g., within any 2-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 (e.g., a feeling that one cannot stop eating or control what or how much one is eating); and

1.            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;
2.           The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months;
3.            Self-evaluation is unduly influenced by body shape and weight; and
4.           The disturbance does not occur exclusively during episodes of anorexia nervosa.

binge-eating disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
   1.             Eating, in a discrete period of time (e.g., within any 2-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 (e.g., a feeling that one cannot stop eating or control what or how much one is eating); and

1.            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;
   5.            Feeling disgusted with oneself, depressed, or very guilty afterward;
2.           Marked distress regarding binge eating is present;
3.            The binge eating occurs, on average, at least once a week for 3 months; and
4.            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.

pica means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           Persistent eating of non-nutritive, nonfood substances over a period of at least 1 month;

1.           The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual;
2.            The eating behaviour is not part of a culturally supported or socially normative practice; and
3.            If the eating behaviour occurs in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

rumination disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.            Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out;

1.            The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis);
2.           The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder; and
3.            If the symptoms occur in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention.

avoidant/restrictive food intake disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.            An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) associated with one (or more) of the following:
   1.             Significant weight loss (or failure to achieve expected weight gain or faltering growth in children);
   2.          Significant nutritional deficiency;
   3.        Dependence on enteral feeding or oral nutritional supplements; and
   4.         Marked interference with psychosocial functioning; and

1.            The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice;
2.            The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced; and
3.           The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

other specified feeding or eating disorder means a category of disorder of mental health applying to (derived from DSM-5-TR):

1.            Presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate, but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class; and

1.            includes:
   1.              atypical anorexia nervosa;
   2.           bulimia nervosa (of low frequency and/or limited duration);
   3.         binge-eating disorder (of low frequency and/or limited duration);
   4.          purging disorder; and
   5.            night eating syndrome.

atypical anorexia nervosa means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           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; and

1.            Individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa.

bulimia nervosa (of low frequency and/or limited duration) means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           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 and/or for less than 3 months.

binge-eating disorder (of low frequency and/or limited duration) means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months.

purging disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           Recurrent purging behaviour to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.

night eating syndrome means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal;

1.            There is awareness and recall of the eating;
2.           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;
3.            The night eating causes significant distress and/or impairment in functioning; and
4.           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 condition or to an effect of medication.

unspecified feeding or eating disorder means a disorder of mental health meeting the following diagnostic criteria (derived from DSM-5-TR):

1.           This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class; and

1.            Is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific feeding and eating disorder and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).

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

1.           While eating disorder attracts ICD‑10‑AM codes: F50.0, F50.1, F50.2, F50.3, F50.4, F50.8, F50.9, in applying this Statement of Principles the meaning of eating disorder is that given in subsection (2).
2.           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 eating disorder

1.           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.

1.                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: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

1.                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 during the 2 years before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, binge-eating disorder or avoidant/restrictive food intake disorder;

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

1.           experiencing a category 1B stressor during the 2 years before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, binge-eating disorder or avoidant/restrictive food intake disorder;

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

1.           experiencing a category 2 stressor during the 2 years before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, binge-eating disorder or avoidant/restrictive food intake disorder;

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

1.           being the subject of bullying during the 2 years before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, binge-eating disorder or avoidant/restrictive food intake disorder;

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

1.           experiencing the death of an important or influential person who has a close family bond or personal relationship, during the 2 years before the clinical onset or clinical worsening of binge-eating disorder;
2.           having one of the following clinically significant disorders of mental health during the 2 years before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, binge-eating disorder or avoidant/restrictive food intake disorder:
   1.           alcohol use disorder;
   2.           anxiety disorder;
   3.           attention-deficit/hyperactivity disorder;
   4.           depressive disorder;
   5.           gender dysphoria;
   6.            obsessive compulsive disorder;
   7.           panic disorder;
   8.           personality disorder;
   9.             posttraumatic stress disorder;
   10.             social anxiety disorder; or
   11.           substance use disorder.

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

1.           having experienced as a child (under the age of 18) one of the following;
   1.           serious physical, emotional, or sexual harm;
   2.           neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing by an adult;

before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder;

1.           having experienced as a child (under the age of 18) sexual abuse before clinical onset or clinical worsening of other specified feeding or eating disorder;
2.           experiencing regular food insecurity for a continuous period of 3 months at the time of clinical onset or clinical worsening of binge-eating disorder;

Note: food insecurity is defined in the Schedule 1 – Dictionary.

1.       having type 1 diabetes mellitus for at least the 3 months before clinical onset or clinical worsening of anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake disorder;
2.       inability to obtain appropriate clinical management for eating disorder before clinical worsening.

1.            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 clinical worsening aspects of factors set out in section 9 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.
2.            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:

                               bullying means repeated unwanted, aggressive behaviour that involves an observed or perceived imbalance of power.

Note: Bullying may inflict physical, psychological, or social harm. Examples of bullying include physical (e.g. hitting, kicking, spitting, damaging property), verbal (e.g. teasing, insults, slurs), social (e.g. gossiping, spreading rumours, social exclusion), and cyberbullying.

                                category 1A stressor means one of the following severe traumatic events:

(a)          experiencing a life-threatening event including an illness or injury;

(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;

(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, 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 environment including on-going disharmony with fellow work colleagues, perceived lack of social support within the work environment, perceived lack of control over tasks performed and stressful workloads;

(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)           experiencing prejudice or discrimination based on gender, or behaviour or attitudes that foster stereotyped social roles based on gender (sexism);

(g)          experiencing adverse prejudicial differential treatment or unequal access to opportunities based on membership to a particular racial group.

                               clinically significant disorder of mental health means a disorder of mental health which is of sufficient severity to warrant ongoing management.

Note: 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.

                               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.

                               eating disorder—see subsection 7(2).

                               food insecurity means a lack of regular access to enough safe and nutritious food for normal growth and development and an active and healthy life, and can result from an unavailability of food and/or a lack of resources to obtain food.

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               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 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.