Statement of Principles
concerning
PANIC DISORDER
No. 69 of 2009
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 panic disorder No. 69 of 2009.
Determination
2. The Repatriation Medical Authority under subsection 196B(3)
and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a) revokes
Instrument No. 10 of 1999, as amended by Instrument No. 59 of 1999, concerning
panic disorder; and
(b) determines
in their place this Statement of Principles.
Kind of injury, disease
or death
3. (a) This Statement of Principles is about panic
disorder and death from panic disorder.
(b)
For the purposes of this Statement of
Principles, "panic disorder" means a psychiatric condition
meeting the following diagnostic criteria (derived from DSM-IV-TR):
A. The person has experienced
both:
(1) recurrent unexpected panic
attacks; and
(2) at least
one of the attacks has been followed by one month (or more) of one (or more) of
the following:
(i) persistent
concern about having additional attacks;
(ii) worry
about the implications of the attack or its consequences (e.g., losing control,
having a heart attack, "going crazy"); or
(iii) a
significant change in behaviour related to the attacks.
B. The panic
attacks can occur in the presence or absence of agoraphobia.
C. The panic
attacks are not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g.,
hyperthyroidism).
D. The panic
attacks are not better accounted for by another mental disorder, such as social
phobia (e.g., occurring on exposure to feared social situations), specific
phobia (e.g., on exposure to a specific phobic situation), obsessive-compulsive
disorder (e.g., on exposure to dirt in someone with an obsession about
contamination), posttraumatic stress disorder (e.g., in response to stimuli
associated with a severe stressor), or separation anxiety disorder (e.g., in
response to being away from home or close relatives).
(c)
Panic disorder attracts ICD-10-AM code F40.01 or
F41.0.
(d)
In the application of this Statement of
Principles, the definition of "panic disorder" is that given
at paragraph 3(b) above.
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 panic disorder and death from panic 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, panic disorder or death from panic
disorder is connected with the circumstances of a person’s relevant service
is:
(a)
experiencing a category 1A stressor within the
two years before the clinical onset of panic disorder; or
(b)
experiencing a category 1B stressor within the
two years before the clinical onset of panic disorder; or
(c)
being the victim of severe childhood abuse
within the 15 years before the clinical onset of panic disorder; or
(d)
experiencing the death of a significant other
within the one year before the clinical onset of panic disorder; or
(e)
having a clinically significant psychiatric
condition from specified list 1, at the time of the clinical onset of panic
disorder; or
(f)
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 panic disorder; or
(g)
having epilepsy at the time of the clinical
onset of panic disorder; or
(h)
experiencing a category 1A stressor within the
two years before the clinical worsening of panic disorder; or
(i)
experiencing a
category 1B stressor within the two years before the clinical worsening of
panic disorder; or
(j)
experiencing the death of a significant other
within the one year before the clinical worsening of panic disorder; or
(k)
having a clinically significant psychiatric
condition from specified list 2, at the time of the clinical worsening of panic
disorder; or
(l)
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 panic disorder; or
(m)
having epilepsy at the time of the clinical
worsening of panic disorder; or
(n)
inability to obtain appropriate clinical
management for panic disorder.
Factors
that apply only to material contribution or aggravation
7. Paragraphs 6(h) to 6(n) 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 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 or more 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)
being an eyewitness to a person being killed or
critically injured;
(b)
viewing corpses or critically injured casualties
as an eyewitness;
(c)
being an eyewitness to atrocities inflicted on
another person or persons;
(d)
killing or maiming a person; or
(e)
being an eyewitness to or participating in, the
clearance of critically injured casualties;
"a
clinically significant psychiatric condition from specified list 1" means one of the Axis I or Axis II disorders of mental health listed
below:
(a)
a mood disorder;
(b)
a substance dependence or substance abuse
disorder;
(c)
acute stress disorder;
(d)
anxiety disorder;
(e)
obsessive-compulsive disorder;
(f)
phobic anxiety;
(g)
posttraumatic stress disorder;
(h)
substance-induced anxiety disorder;
(i)
eating disorder;
(j)
schizophrenia;
(k)
avoidant personality disorder;
(l)
borderline personality disorder;
(m)
dependent personality disorder;
(n)
histrionic personality disorder; or
(o)
obsessive-compulsive personality disorder,
that attract a
diagnosis under DSM-IV-TR and are severe enough to warrant ongoing management.
The ongoing management may involve regular visits (for example, at least
monthly), to a psychiatrist, clinical psychologist or general practitioner;
"a
clinically significant psychiatric condition from specified list 2" means one of the Axis I disorders of mental health listed below:
(a)
a mood disorder;
(b)
a substance dependence or substance abuse
disorder;
(c)
acute stress disorder;
(d)
anxiety disorder;
(e)
obsessive-compulsive disorder;
(f)
phobic anxiety;
(g)
posttraumatic stress disorder;
(h)
substance-induced anxiety disorder;
(i)
eating disorder; or
(j)
schizophrenia,
that attract a
diagnosis under DSM-IV-TR and are severe enough to warrant ongoing management.
The ongoing management may involve regular visits (for example, at least
monthly), to a psychiatrist, clinical psychologist or general practitioner;
"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;
"an eyewitness" means a person
who observes an incident first hand and can give direct evidence of it. This
excludes a person exposed only to media coverage of the incident;
"death from 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;
"DSM-IV-TR" means the American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC, American Psychiatric Association, 2000;
"ICD-10-AM code" means a number assigned to a particular kind of injury or disease
in The International Statistical Classification of Diseases and Related Health
Problems, 10th Revision, Australian Modification (ICD-10-AM), Sixth Edition,
effective date of 1 July 2008, copyrighted by the National Centre for
Classification in Health, Sydney, NSW, and having ISBN 978 1 74210 016 6;
"obsessive-compulsive
disorder" means a psychiatric condition that
meets the following diagnostic criteria (derived from DSM-IV-TR):
A.
Either obsessions or compulsions:
Obsessions as
defined by (1), (2), (3), and (4):
(1)
recurrent and persistent thoughts,
impulses, or images that are experienced, at some time during the disturbance,
as intrusive and inappropriate and that cause marked anxiety or distress;
(2)
the thoughts, impulses, or images
are not simply excessive worries about real-life problems;
(3)
the person attempts to ignore or
suppress such thoughts, impulses, or images, or to neutralise them with some
other thought or action; and
(4)
the person recognises that the
obsessional thoughts, impulses, or images are a product of his or her own mind
(not imposed from without as in thought insertion).
Compulsions as
defined by (1) and (2):
(1)
repetitive behaviours (e.g., hand
washing, ordering, checking) or mental acts (e.g., praying, counting, repeating
words silently) that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly; and
(2)
the behaviours or mental acts are
aimed at preventing or reducing distress or preventing some dreaded event or
situation; however, these behaviours or mental acts either are not connected in
a realistic way with what they are designed to neutralise or prevent or are
clearly excessive.
B.
At some point during the course of the disorder, the person has
recognised that the obsessions or compulsions are excessive or unreasonable.
This criteria does not apply to children.
C.
The obsessions or compulsions cause marked distress, are time consuming
(take more than 1 hour a day), or significantly interfere with the person's
normal routine, occupational (or academic) functioning, or usual social
activities or relationships.
D.
If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it (e.g., preoccupation with food in the
presence of an eating disorder; hair pulling in the presence of
trichotillomania; concern with appearance in the presence of body dysmorphic
disorder; preoccupation with drugs in the presence of a substance use disorder;
preoccupation with having a serious illness in the presence of hypochondriasis;
preoccupation with sexual urges or fantasies in the presence of a paraphilia;
or guilty ruminations in the presence of major depressive disorder).
E.
The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition;
"panic attack" means a
discrete period of intense fear or discomfort, in which four (or more) of the
following symptoms developed abruptly and reached a peak within 10 minutes:
(a)
palpitations, pounding heart, or accelerated
heart rate;
(b)
sweating;
(c)
trembling or shaking;
(d)
sensations of shortness of breath or smothering;
(e)
feeling of choking;
(f)
chest pain or discomfort;
(g)
nausea or abdominal distress;
(h)
feeling dizzy, unsteady, light headed or faint;
(i)
derealisation (feelings of unreality) or
depersonalisation (being detached from oneself);
(j)
fear of losing control or going crazy;
(k)
fear of dying;
(l)
paraesthesias (numbness or tingling sensations);
or
(m)
chills or hot flushes.
This definition
is derived from DSM-IV-TR;
"phobic anxiety" means a psychiatric condition which significantly limits an
individual’s normal routine, occupational and social activities by excessive or
unreasonable persistent fears brought on by the presence or anticipation of
certain situations or objects. The exposure to the stimulus invariably provokes
an immediate anxiety response such as a panic attack and the response is
recognised as being excessive or unreasonable by the affected individual. This
definition includes the diagnoses agoraphobia, social phobia or a specific
phobia as derived from DSM-IV-TR;
"relevant
service" means:
(a) eligible war service (other than operational service)
under the VEA; or
(b) defence service (other than
hazardous 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;
"substance-induced anxiety
disorder" means a psychiatric condition that
meets the following diagnostic criteria (derived from DSM-IV-TR):
A.
Prominent anxiety, panic attacks, or obsessions or compulsions
predominate in the clinical picture.
B.
There is evidence from the history, physical examination, or laboratory
findings of either (1) or (2):
(1)
the symptoms in Criterion A
developed during, or within 1 month of, substance intoxication or withdrawal;
(2)
medication use is aetiologically
related to the disturbance.
C.
The disturbance is not better accounted for by an anxiety disorder that
is not substance induced. Evidence that the symptoms are better accounted for
by an anxiety disorder that is not substance induced might include the
following: the symptoms precede the onset of the substance use (or medication
use); the symptoms persist for a substantial period of time (e.g., about a
month) after the cessation of acute withdrawal or severe intoxication or are
substantially in excess of what would be expected given the type or amount of
the substance used or the duration of use; or there is other evidence
suggesting the existence of an independent non-substance-induced anxiety
disorder (e.g., a history of recurrent non-substance-related episodes).
D.
The disturbance does not occur exclusively during the course of a
delirium.
E.
The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
This diagnosis
should be made instead of a diagnosis of substance intoxication or substance
withdrawal only when the anxiety symptoms are in excess of those usually
associated with the intoxication or withdrawal syndrome and when the anxiety
symptoms are sufficiently severe to warrant independent clinical attention;
"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.
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
11. This Instrument takes effect from 11 November 2009.
Dated this twenty-eighth day of October 2009
The Common Seal of
the )
Repatriation
Medical Authority )
was affixed to this
instrument )
in the presence of: )
KEN DONALD
CHAIRPERSON