Statement of Principles concerning anxiety disorder No. 103 of 2014

Statement of Principles concerning anxiety disorder No. 103 of 2014

made under subsection 196B(3) of the

Veterans' Entitlements Act 1986

Compilation No. 2  

Compilation date:   24 September 2018

Includes amendments up to: Veterans' Entitlements (Statements of Principles—Category 1B Stressor) Amendment Determination 2018 (No. 87 of 2018) (F2018L01188)

The day of commencement of this Amendment Determination is 24 September 2018.

About this compilation

This compilation

This is a compilation of the Statement of Principles concerning anxiety disorder No. 103 of 2014 that shows the text of the law as amended and in force on 24 September 2018.

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.

Application, saving and transitional provisions for provisions and amendments

If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.

Modifications

If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.

Self‑repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.

Statement of Principles

concerning

ANXIETY DISORDER

No. 103 of 2014

for the purposes of the

Veterans' Entitlements Act 1986

and

Military Rehabilitation and Compensation Act 2004

Title

1. This Instrument may be cited as Statement of Principles concerning anxiety disorder No. 103 of 2014.

Determination

2. The Repatriation Medical Authority under subsection 196B(3) and (8) of the Veterans' Entitlements Act 1986 (the VEA):

(a) revokes Instrument No. 102 of 2007 concerning anxiety disorder; and

(b) determines in its place this Statement of Principles.

Kind of injury, disease or death

3. (a) This Statement of Principles is about anxiety disorder and death from anxiety disorder.

(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.

Basis for determining the factors

4. 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 Military Rehabilitation and Compensation Act 2004 (the MRCA).

Factors that must be related to service

5. Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.

Factors

6. The factor that 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 is:

(a)                for generalised anxiety disorder, other specified anxiety disorder or unspecified anxiety disorder only:

(i)                experiencing a category 1A stressor within the two years before the clinical onset of anxiety disorder; or

(ii)              experiencing a category 1B stressor within the two years before the clinical onset of anxiety disorder; or

(iii)           having a significant other who experiences a category 1A stressor within the one year before the clinical onset of anxiety disorder; or

(iv)            experiencing a category 2 stressor within the six months before the clinical onset of anxiety disorder; or

(v)              having a clinically significant disorder of mental health as specified within the five years before the clinical onset of anxiety disorder; or

(vi)            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 anxiety disorder; or

(vii)         having epilepsy at the time of the clinical onset of anxiety disorder; or

(viii)       having persistent pain of at least six months duration at the time of the clinical onset of anxiety disorder; or

(ix)            experiencing the death of a significant other within the one year before the clinical onset of anxiety disorder; or

(x)              being the victim of severe childhood abuse before the clinical onset of anxiety disorder; or

(xi)            being obese at the time of the clinical onset of anxiety disorder; or

(b)               for anxiety disorder due to another medical condition only, having an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological disorder, where the medical condition is a direct physiological cause of the anxiety at the time of the clinical onset of anxiety disorder; or

(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

(c)               experiencing a category 1A stressor within the two years before the clinical worsening of anxiety disorder; or

(d)              experiencing a category 1B stressor within the two years before the clinical worsening of anxiety disorder; or

(e)               having a significant other who experiences a category 1A stressor within the one year before the clinical worsening of anxiety disorder; or

(f)                experiencing a category 2 stressor within the six months before the clinical worsening of anxiety disorder; or

(g)              having a clinically significant disorder of mental health as specified within the five years before the clinical worsening of anxiety disorder; or

(h)              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 anxiety disorder; or

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

(j)                having persistent pain of at least six months duration at the time of the clinical worsening of anxiety disorder; or

(k)              experiencing the death of a significant other within the one year before the clinical worsening of anxiety disorder; or

(l)                being the victim of severe childhood abuse before the clinical worsening of anxiety disorder; or

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

(n)              having a medical condition as specified at the time of the clinical worsening of anxiety disorder; or

(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

(o)               inability to obtain appropriate clinical management for anxiety disorder.

Factors that apply only to material contribution or aggravation

7. Paragraphs 6(c) to 6(o) 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 not arising out of) the person's relevant service.

Inclusion of Statements of Principles

8.                   In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Other definitions

9.                   For the purposes of this Statement of Principles:

"a 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;

"a 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;

"a 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 work loads, 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;

"a 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)                a bipolar disorder or related disorder;

(b)               a depressive disorder;

(c)                a disruptive, impulse-control or conduct disorder;

(d)               a dissociative disorder;

(e)                a feeding disorder or eating disorder;

(f)                a neurocognitive disorder;

(g)               a neurodevelopmental disorder;

(h)               a paraphilic disorder;

(i)                 a personality disorder;

(j)                 a schizophrenia spectrum disorder or other psychotic disorder;

(k)               a sexual dysfunction;

(l)                 a sleep-wake disorder;

(m)             a somatic symptom disorder or related disorder;

(n)               a trauma and stressor-related disorder;

(o)               an obsessive compulsive disorder or related disorder;

(p)               another anxiety disorder; or

(q)               gender dysphoria;

"a 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.

"a medical condition as specified" means an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological condition, that causes symptoms consistent with anxiety and panic attacks as a direct physiological consequence of the condition;

"a 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;

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

"an eyewitness" means a person who experiences 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;

"being obese" means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of 30 or greater.

The BMI = W/H2 and where:

W is the person's weight in kilograms; and

H is the person's height in metres;

"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;

"death from 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;

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

"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;

"persistent pain" means:

(a)           continuous;

(b)          almost continuous; or

(c)           frequent, severe, intermittent pain,

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

"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;

"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;

"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;

"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;

"terminal event" means the proximate or ultimate cause of death and includes:

(a)                pneumonia;

(b)               respiratory failure;

(c)                cardiac arrest;

(d)               circulatory failure; or

(e)                cessation of brain function;

"the medical condition is a direct physiological cause of the anxiety" means one or more of the medical condition's signs or symptoms present as signs or symptoms of anxiety or panic attacks and are directly related to the pathological process of the medical condition, and:

(a)                the anxiety disorder has a close temporal relationship with the onset or exacerbation of the medical condition, and the anxiety disorder developed at the same time or after the onset of the medical condition;

(b)               treatment which causes remission of the medical condition also results in remission of the anxiety symptoms; or

(c)                features of the anxiety disorder, such as an unusual age of onset, a qualitative difference in symptoms, or disproportionately severe or unusual symptoms, are inconsistent with a primary diagnosis of any of the anxiety spectrum disorders.

Application

10. This Instrument applies to all matters to which section 120B of the VEA or section 339 of the MRCA applies.

Date of effect

10.              This Instrument takes effect from 17 November 2014.

Endnotes

Endnote 1—About the endnotes

The endnotes provide information about this compilation and the compiled law.

The following endnotes are included in every compilation:

Endnote 1—About the endnotes

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history

Abbreviation key—Endnote 2

The abbreviation key sets out abbreviations that may be used in the endnotes.

Legislation history and amendment history—Endnotes 3 and 4

Amending laws are annotated in the legislation history and amendment history.

The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.

The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.

Misdescribed amendments

A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.

If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history. 

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history