Statement of Principles concerning anxiety disorder (Reasonable Hypothesis) (No. 100 of 2023)

This instrument is a Statement of Principles (No. 100 of 2023) made by the Repatriation Medical Authority under subsection 196B(2) of the Veterans' Entitlements Act 1986, and it comes into force on 28 November 2023 (s3; s2). It replaces the prior Statement of Principles concerning anxiety disorder No. 102 of 2014 (s4). The instrument is explicitly made for application in claims governed by section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 (s5).

Mechanically, the instrument does three things. First, it defines the injury/disease to which it relates: anxiety disorder, including death from anxiety disorder (s7(1), s7(8)). Second, it sets out the diagnostic criteria used to identify the relevant anxiety disorders by reference to the DSM-5-TR for categories such as generalised anxiety disorder, anxiety disorder due to another medical condition, substance/medication-induced anxiety disorder, and other specified or unspecified anxiety disorder (s7(2)-(6)). Third, it prescribes the factual factors that must exist, as a minimum, before a “reasonable hypothesis” can be said to connect anxiety disorder or death from anxiety disorder with a person’s relevant service; at least one listed factor in section 9 must exist (s9).

The instrument also states the Authority’s view that there is “sound medical‑scientific evidence” indicating a relationship can exist between anxiety disorder (and death from it) and relevant service rendered by veterans or service members (s8). It does not itself create statutory entitlements, nor does it set out administrative procedures or benefits; rather, it provides the evidentiary framework that decision makers apply when assessing whether the “reasonable hypothesis” threshold has been met under the VEA/MRCA claim processes (s5; s3). It also cross‑refers to other Statements of Principles when a factor in this instrument refers to an injury or disease covered by another Statement (s11).

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RMA Australian Government Coat of Arms

Statement of Principles

concerning

ANXIETY DISORDER (Reasonable Hypothesis)

(No. 100 of 2023)

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

Dated 25 October 2023.

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:<br>
<br> <br>Professor Terence Campbell AM<br>Chairperson<br>

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 (Reasonable Hypothesis) (No. 100 of 2023).

2 Commencement

This instrument commences on 28 November 2023.

3 Authority

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

4 Repeal

The Statement of Principles concerning anxiety disorder No. 102 of 2014 (Federal Register of Legislation No. F2014L01389) made under subsections 196B(2) and (8) of the VEA is repealed.

5 Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6 Definitions

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

7 Kind of injury, disease or death to which this Statement of Principles relates

(1) This Statement of Principles is about 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

(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;

(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

The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that anxiety disorder and death from anxiety disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

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

9 Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting anxiety disorder or death from anxiety disorder with the circumstances of a person's relevant service:

(1) being a prisoner of war before the clinical onset of generalised anxiety disorder;

(2) experiencing a category 1A stressor within the 5 years before the clinical onset of generalised anxiety disorder;

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

(3) experiencing a category 1B stressor within the 5 years before the clinical onset of generalised anxiety disorder;

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

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

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

(5) experiencing a potentially morally injurious event within the 5 years before the clinical onset of generalised anxiety disorder;

Note: potentially morally injurious event is defined in the Schedule 1 – Dictionary.

(6) having a family member or close friend who experiences 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.

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

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

(9) living or working in a hostile or life-threatening environment for a cumulative period of at least 4 weeks within the 5 years before the clinical onset of generalised anxiety disorder;

Note: hostile or life-threatening environment is defined in the Schedule 1 – Dictionary.

(10) experiencing a category 2 stressor within the 1 year 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.

(11) having a clinically significant disorder of mental health within the 10 years before the clinical onset of generalised anxiety disorder;

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

(12) having a medical illness which is life-threatening or which results in serious physical or cognitive disability within the 5 years before the clinical onset of generalised anxiety disorder;

(13) having an injury which is life-threatening or which results in serious physical or cognitive disability within the 5 years before the clinical onset of generalised anxiety disorder;

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

(15) having severe and permanent tinnitus at the time of the clinical onset of generalised anxiety disorder;

Note: severe and permanent tinnitus is defined in the Schedule 1 - Dictionary.

(16) having persistent pain of at least 3 months duration at the time of the clinical onset of generalised anxiety disorder;

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

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

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

(18) 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

(19) 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”;

(20) taking mefloquine within the 2 days 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;

(21) using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 2 days 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.

(22) 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 2 days before the clinical onset of substance/medication-induced anxiety disorder;

(23) 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 2 days before the clinical onset of substance/medication-induced anxiety disorder;

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

(24) 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;

(25) having periodic, heavy alcohol consumption for the 3 months before the clinical onset of substance/medication-induced anxiety disorder;

Note: periodic, heavy alcohol consumption is defined in the Schedule 1 – Dictionary.

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

(27) 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.

(28) having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 30 days before the clinical onset of substance/medication-induced anxiety disorder;

Note: acute cholinergic poisoning and organophosphorus ester are defined in the Schedule 1 – Dictionary.

(29) 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.

(30) 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.

(31) being a prisoner of war before the clinical worsening of anxiety disorder;

(32) experiencing a category 1A stressor within the 5 years before the clinical worsening of anxiety disorder;

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

(33) experiencing a category 1B stressor within the 5 years before the clinical worsening of anxiety disorder;

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

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

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

(35) experiencing a potentially morally injurious event within the 5 years before the clinical worsening of anxiety disorder;

Note: potentially morally injurious event is defined in the Schedule 1 – Dictionary.

(36) having a family member or close friend who experiences 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.

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

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

(39) living or working in a hostile or life-threatening environment for a cumulative period of at least 4 weeks within the 5 years before the clinical worsening of anxiety disorder;

Note: hostile or life-threatening environment is defined in the Schedule 1 – Dictionary.

(40) experiencing a category 2 stressor within the 1 year before the clinical worsening of anxiety disorder;

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

(41) having a clinically significant disorder of mental health within the 10 years before the clinical worsening of anxiety disorder;

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

(42) having a medical illness which is life-threatening or which results in serious physical or cognitive disability within the 5 years before the clinical worsening of anxiety disorder;

(43) having an injury which is life-threatening or which results in serious physical or cognitive disability within the 5 years before the clinical worsening of anxiety disorder;

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

(45) having severe and permanent tinnitus at the time of the clinical worsening of anxiety disorder;

Note: severe and permanent tinnitus is defined in the Schedule 1 - Dictionary.

(46) having persistent pain of at least 3 months duration at the time of the clinical worsening of anxiety disorder;

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

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

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

(48) 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.

(49) 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;

(50) taking mefloquine within the 2 days before the clinical worsening of anxiety disorder, where anxiety disorder persists after the discontinuation or tapering of mefloquine therapy;

(51) using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 2 days before the clinical worsening of anxiety disorder;

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

(52) 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 2 days before the clinical worsening of anxiety disorder;

(53) 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 2 days before the clinical worsening of anxiety disorder;

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

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

(55) having periodic, heavy alcohol consumption for the 3 months before the clinical worsening of anxiety disorder;

Note: periodic, heavy alcohol consumption is defined in the Schedule 1 – Dictionary.

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

(57) 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.

(58) having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 30 days before the clinical worsening of anxiety disorder;

Note: acute cholinergic poisoning and organophosphorus ester are defined in the Schedule 1 – Dictionary.

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

(60) 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(31) to 9(60) 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(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:

acute cholinergic poisoning means symptoms and signs due to the inhibition of acetylcholinesterase enzyme activity which occur within 24 hours following exposure. These symptoms and signs are acute paralysis, overwhelming bronchial secretions, bradycardia, gastrointestinal distress, miosis, lacrimation and diarrhoea.

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

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;

(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;

(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.

hostile or life-threatening environment means a situation or setting which is characterised by a pervasive threat to life or bodily integrity, such as would be experienced in the following circumstances:

(a) experiencing or being under threat of artillery, missile, rocket, mine or bomb attack;

(b) experiencing or being under threat of nuclear, biological or chemical agent attack; or

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.

organophosphorus ester means an agent used to inhibit acetylcholinesterase, and includes the organophosphate pesticides chlorpyrifos, dichlorvos, EPN, leptophos, methamidophos, mipafox (diisopropyl phosphorofluoridate), omethoate, parathion, TOCP (tri-ortho-cresyl phosphate), trichlorfon and trichlornat.

periodic, heavy alcohol consumption means sessions of heavy alcohol drinking to the point of intoxication at least once a month (binge drinking).

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.

potentially morally injurious event means an event that transgresses a person’s deeply held moral beliefs and expectations.

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) operational service under the VEA;

(b) peacekeeping service under the VEA;

(d) British nuclear test defence service under the VEA;

(e) warlike service under the MRCA; or

(f) non-warlike service under the MRCA.

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

severe and permanent tinnitus means tinnitus that is present every day and requires use of a tinnitus masking device or causes loss of concentration, extreme discomfort and interferes with sleep.

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;

(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;

(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.

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Statement of Principles

concerning

ANXIETY DISORDER (Reasonable Hypothesis)

(No. 100 of 2023)

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

Dated 25 October 2023.

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:<br>
<br> <br>Professor Terence Campbell AM<br>Chairperson<br>

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 (Reasonable Hypothesis) (No. 100 of 2023).

2 Commencement

This instrument commences on 28 November 2023.

3 Authority

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

4 Repeal

The Statement of Principles concerning anxiety disorder No. 102 of 2014 (Federal Register of Legislation No. F2014L01389) made under subsections 196B(2) and (8) of the VEA is repealed.

5 Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

The instrument rests on a small set of organising legal-medical concepts that drive its application: (1) the defined scope of “anxiety disorder”; (2) the “reasonable hypothesis” evidential threshold; (3) the list of factual factors sufficient to raise that hypothesis; (4) temporal, exposure and dosage thresholds; and (5) the requirement that factors be related to “relevant service” (s7; s9; s10).

Anxiety disorder is explicitly defined as one of a group of DSM-5-TR derived diagnoses: generalised anxiety disorder, anxiety disorder due to another medical condition, substance/medication-induced anxiety disorder, and other specified or unspecified anxiety disorders (s7(2)-(6)). The instrument records exclusions: it excludes agoraphobia, panic disorder, selective mutism, separation anxiety disorder, social anxiety disorder and specific phobia from its definition (s7(7)). The DSM-5-TR is formally incorporated by reference as the diagnostic standard (Schedule 1).

The legal evidential concept is the “reasonable hypothesis” standard. Section 9 begins by stating that at least one listed factor must exist before it can be said that a reasonable hypothesis has been raised connecting anxiety disorder or death from anxiety disorder with the circumstances of relevant service (s9 opening paragraph). The instrument therefore operationalises the threshold used by decision makers when applying the VEA or MRCA claims provisions referenced in s5.

Section 9 then lists many discrete factors that, singly, can suffice to meet that minimum requirement. These include events connected to service, such as being a prisoner of war, experiencing category 1A or 1B stressors within specific look‑back periods, or living or working in a hostile or life‑threatening environment for a cumulative period of 4 weeks within the 5 years before onset (s9(1)-(4), s9(9)). The instrument also treats non-service related medical and behavioural contributors as countable factors, such as having persistent pain of at least 3 months at time of onset (s9(16)), obesity (BMI 30+; s9(17); Schedule 1), regular heavy alcohol consumption (s9(25)), specific drug exposures and timing (e.g. mefloquine within 2 days where symptoms persist after discontinuation; s9(20)), and precise caffeine intake thresholds in the hour before onset (s9(29)-(30); Schedule 1).

Temporal and exposure thresholds are pervasive. Many factors are qualified by look‑back windows , 5 years, 2 years, 1 year, 2.5 years, 3 months, 2 days and 1 hour , and by the persistence or timing of symptoms relative to exposure (s9). Section 10 requires that the existence of any factor must be related to the person’s relevant service, and it contains a limiting rule that subsections 9(31) to 9(60) apply only in the context of material contribution or aggravation where the anxiety disorder pre‑existed before or during, but did not arise out of, relevant service (s10(1)-(2)). That creates a structural distinction between causal scenarios that arise out of service and those where service materially aggravated a pre‑existing condition.

Finally, the instrument consciously interacts with other Statements of Principles. Section 11 requires that if a factor in section 9 refers to an injury or disease covered by another Statement of Principles, then the factors in that other Statement apply according to its terms as in force from time to time. The Schedule defines a broad list of terms used throughout, for example category 1A and category 2 stressors, what constitutes a “corpse” for viewing exposures, and what is an “organophosphorus ester” (Schedule 1).

Taken together, the main conceptual approach is to anchor medico-legal assessment to a closed set of diagnostic criteria and a closed list of factors with precise temporal and exposure thresholds. Decision makers use these as the minimum factual basis for raising the reasonable hypothesis that a service connection exists.

The instrument primarily affects claimants who are seeking to connect an anxiety disorder, or death from an anxiety disorder, to their “relevant service” as defined in the Schedule. Relevant service encompasses operational, peacekeeping, hazardous and British nuclear test defence service under the VEA, and warlike or non-warlike service under the MRCA (Schedule 1: relevant service). Section 5 states that the instrument applies to a claim to which section 120A of the VEA or section 338 of the MRCA applies, so the immediate practical audience is persons lodging or defending those statutory claims (s5).

Beyond claimants, the instrument affects clinicians and treating practitioners who provide diagnostic material, as the diagnostic criteria are set out in detail and refer to DSM-5-TR definitions for generalised anxiety disorder, anxiety disorder due to another medical condition, substance/medication-induced anxiety disorder, and other specified or unspecified anxiety disorder (s7(2)-(6); Schedule 1). Medical assessors, independent medical experts, and Decision Makers within the Department of Veterans' Affairs or tribunals will use the instrument’s factors and the Schedule definitions to determine whether a reasonable hypothesis has been established.

Veterans’ advocates, lawyers and accredited agents are affected because the instrument establishes the minimum factual triggers they must address in submissions; for example, if a claimant relies on an intoxication-related onset, evidence will be needed to meet the narrow timing thresholds such as drug or mefloquine intake within 2 days prior to clinical onset, or specified caffeine amounts within 1 hour (s9(20), s9(21), s9(29)-(30)). The Schedule defines such exposures in concrete terms, which shapes evidentiary strategies.

Decision‑makers and policy officials are affected in that the statement replaces the 2014 Statement of Principles and thereby changes the applicable evidentiary rubric from 28 November 2023 (s4; s2). Where section 11 brings another Statement of Principles into play, decision makers must consult and apply the other instrument’s terms, so administrative procedures must account for cross‑instrument dependencies (s11).

Finally, the Repatriation Medical Authority itself is named as the executing body; the instrument records the Authority’s view that there is sound medical‑scientific evidence linking anxiety disorder and relevant service (s8). The instrument therefore affects the institutional interface between RMA-supplied scientific guidance and the statutory claims framework of the VEA and MRCA.

This Statement of Principles does not create freestanding statutory duties or criminal sanctions; rather, it prescribes the evidential factors that must exist to raise a “reasonable hypothesis” connecting anxiety disorder or death from it to relevant service under the statutory claims processes it supports (s9; s5). The primary legal duty that arises from the instrument is imposed indirectly on decision makers and claim managers: they must apply these factors when assessing whether a reasonable hypothesis exists. The instrument therefore shapes administrative decision making by setting a mandatory list of possible founding factors for a reasonable hypothesis.

For claimants and their advisers, the practical duty is to establish at least one of the listed factors in section 9, and to show that the factor is related to relevant service as required by section 10(1). Section 10(2) further restricts how subsections 9(31) to 9(60) are applied; those subsections apply only in cases of material contribution to, or aggravation of, anxiety disorder where the disorder was suffered or contracted before or during relevant service but did not arise out of the service (s10(2)). This imposes a duty on applicants and advisers to attend to the timing and causal character of the disorder relative to service.

The instrument establishes rights indirectly through its evidentiary role. If a claimant can show the existence of a listed factor, and that it is related to relevant service, then the “reasonable hypothesis” threshold is met for that element of the statutory test; rights under the VEA/MRCA for entitlements that hinge on service connection may follow from that administrative finding. The instrument does not itself specify entitlement rules, but it establishes conditions that empower decision makers to find a service connection which is a precondition of entitlement under the statutes listed in s5.

Medical practitioners have the duty to apply the diagnostic criteria when diagnosing anxiety disorder for the purposes of these claims. The Statement sets the diagnostic benchmark by reference to DSM-5-TR criteria in s7, including the detailed symptom list for generalised anxiety disorder (s7(3)). Practitioners preparing medical reports should therefore document how the DSM-5-TR criteria are met or not met, and should record timelines and exposures that correspond to the temporal thresholds in section 9 and Schedule 1.

Section 11 imposes a duty on decision makers to apply other, relevant Statements of Principles where a factor in section 9 refers to an injury or disease covered by another Statement. That means rights and duties under other Statements can be invoked and applied in concert with this instrument (s11).

In brief, the instrument confers no positive statutory entitlements itself; it configures the evidential duties of claimants, clinicians and decision makers by listing the minimum factors necessary to raise the reasonable hypothesis that links anxiety disorder to relevant service, and by prescribing their temporal and definitional parameters.

The instrument contains no penal provisions, criminal sanctions, civil penalties or administrative fines. It is a normative evidentiary instrument used in the adjudication of statutory claims under the VEA and the MRCA; it does not, in itself, create enforcement mechanisms or compliance penalties. The statutory authority for making the instrument is subsection 196B(2) of the Veterans' Entitlements Act 1986 (s3), and the instrument’s functions are limited to defining medical concepts and setting factual factors relevant to the “reasonable hypothesis” threshold (s7; s9).

Enforcement in practice occurs through the VEA and MRCA claims processes rather than through this document. The Statement is a tool for decision makers in those statutory frameworks; adverse findings (for example, that a claimant has not demonstrated any of the section 9 factors or that a factor is not related to relevant service under section 10) will affect entitlement outcomes under the relevant statutes. The instrument itself does not state the consequences of an adverse finding, nor does it detail appeal routes. Those procedural and enforcement features sit within the VEA and MRCA statutory schemes, which are referenced in this Statement (s5).

The instrument does include provisions that limit its scope and interaction with other Statements of Principles. Section 11 requires the application of the factors in other Statements when section 9 refers to an injury or disease covered by another Statement; that is a procedural requirement for decision makers applying multiple Statements in a single claim (s11). However, this is not framed as an enforcement provision; it is a rule for correct application of Statements of Principles.

In practical terms, the only enforcement consequence the instrument produces is evidentiary: decision makers will accept or reject a service connection based on whether the instrument’s criteria are met. The instrument’s specific temporal, dosage and exposure thresholds create de facto gates that can lead to acceptance or denial of a claim, but the instrument does not itself prescribe penalties for non-compliance nor does it set out mechanisms for penalising false statements or fraud. Those matters are handled under the broader statutory or administrative frameworks beyond this instrument.

The Statement of Principles is made under subsection 196B(2) of the Veterans' Entitlements Act 1986 and is intended to be used in the statutory schemes referenced in section 5; specifically, claims to which section 120A of the VEA or section 338 of the MRCA apply (s3; s5). The instrument therefore operates as a medical-evidentiary adjunct to those statutes. It does not itself amend, repeal, or vary the VEA or MRCA; it provides the factual framework decision makers use when applying the statutory tests for service connection.

Section 11 contains an express rule for interaction with other Statements of Principles. If a factor in section 9 refers to an injury or disease that is the subject of another Statement of Principles made under subsection 196B(2) of the VEA, then the factors in that other Statement apply according to its terms as in force from time to time (s11). This creates a cross-referential regime: where conditions overlap, decision makers must consult the relevant Statements and apply the terms of the other instruments as current. That imposes a procedural interaction requiring administrative coordination between Statements of Principles.

The instrument anchors its diagnostic standards to DSM-5-TR (Schedule 1). That means clinical assessment for the purposes of VEA/MRCA decision making will be measured against an internationally recognised psychiatric taxonomy. The instrument does not incorporate other diagnostic manuals. Use of the DSM-5-TR therefore affects how medical reports are framed and which clinical criteria are determinative.

Schedule 1 contains defined medical and exposure terms that have potential interaction with other areas of law and medical practice. For example, the definition of organophosphorus ester lists specific chemical agents; exposures to these agents may also be relevant to occupational health, environmental regulation, or civil tort claims. The Statement does not state how it interplays with those other regimes, but the inclusion of specific chemicals and exposures makes cross‑disciplinary evidence likely to be used in multiple legal contexts.

The instrument repeals the previous Statement of Principles concerning anxiety disorder No. 102 of 2014 (s4). That repeal changes which Statement applies to claims arising after its commencement date. Decision makers will therefore need to apply the 2023 Statement from 28 November 2023 onward, and to be alert to transitional or retrospective application questions that may arise under the VEA or MRCA. The instrument itself does not set transitional rules; those are governed by the relevant statutes and administrative practice.

Finally, the instrument’s repeated references to “relevant service” tie it to statutory definitions in the Schedule (relevant service includes various VEA and MRCA service categories). That alignment ensures the Statement operates within the defined statutory concepts of service. The Statement does not otherwise modify other statutes, but it is integral to the evidence‑based application of statutory entitlement provisions.

The instrument records a single explicit amendment action: the repeal of the prior Statement of Principles concerning anxiety disorder No. 102 of 2014 (Federal Register No. F2014L01389) (s4). The new Statement is dated 25 October 2023 and commences on 28 November 2023 (instrument date and s2). No other amendments, revocations, or transitional provisions are included in the text.

Mechanically, the repeal clause (s4) means that from commencement the 2014 Statement no longer applies. The instrument does not include transitional rules or grandfathering language; it states only that the prior Statement is repealed. Where claims overlap the repeal/commencement boundary, the applicable statutory rules for transitional application under the VEA or MRCA will control how a decision maker treats historical facts and prior decisions. The Statement itself does not provide guidance on whether claims lodged before the commencement are to be assessed under the old or new Statement; that is a procedural matter outside the instrument’s text.

The Schedule is part of the instrument and contains definitions that operationalise the terms used throughout. Any future amendments to the Schedule definitions, for example to the list of specified psychoactive substances or the definition of category stressors, would materially change the instrument’s application; however, the instrument as published contains the current definitions and does not document previous versions of the Schedule.

There is no recorded history of earlier amendments to this 2023 instrument in the text provided. Similarly, the instrument does not record any saving provisions, ministerial instruments, or delegated instrument changes. It is a self-contained Statement that supersedes the 2014 Statement as of the stated commencement date (s4; s2).

For administrative users, the important amendment history note is practical: the 2014 Statement is repealed and replaced, so medical assessors, claims officers and legal advisers must apply the 2023 criteria and factors from 28 November 2023 onwards. No other amendment entries are recorded in the instrument itself.

The instrument contains no litigation history, and it names no judicial decisions. It is a Statement of Principles made under subsection 196B(2) of the Veterans' Entitlements Act 1986 and sets out medical and evidentiary criteria for decision makers (s3; s9). The text does not cite or summarise any cases, nor does it include references to tribunal or court determinations.

Because the Statement is an administrative instrument used as an evidentiary foundation in statutory claims, any litigation that may relate to its application would arise within the context of appeals and judicial review under the VEA or MRCA processes. The instrument itself does not record prior litigation, nor does it provide commentary on potential legal disputes or case law. Where issues of interpretation, such as the meaning of “reasonable hypothesis”, the temporal windows in section 9, or the scope of definitions in Schedule 1, are contested in future cases, those disputes will be resolved in courts or tribunals applying the instrument as part of the statutory scheme; there is nothing in the instrument’s text that reports existing judicial treatment.

Accordingly, users should treat the instrument as a current administrative medical framework, free of embedded litigation references. Legal practitioners preparing appeals or judicial review applications will need to rely on primary statutory materials, administrative records, and any case law that post‑dates this Statement. The instrument itself offers no litigation guidance nor does it flag particular points of legal uncertainty drawn from adjudicative history.

This instrument contains a number of technical thresholds, exclusions and cross‑references that create practical traps for claimants, clinicians and decision makers if they are not carefully observed.

Diagnostic scope and exclusions. The instrument adopts DSM-5-TR derived criteria and explicitly excludes several anxiety-related disorders: agoraphobia, panic disorder, selective mutism, separation anxiety disorder, social anxiety disorder and specific phobia (s7(3); s7(7); Schedule 1). A clinician’s diagnosis must therefore map to one of the enumerated categories to fall within this Statement. A report diagnosing panic disorder or social anxiety disorder will not, on its face, engage this Statement.
Minimal factor requirement and single-factor sufficiency. Section 9 sets out that at least one of the listed factors must exist to raise a reasonable hypothesis (s9). Many claimants and advisers may assume multiple factors are required; the instrument requires only one qualifying factor, but that single factor must be shown to be related to relevant service under s10(1). Failure to link the factor to relevant service is a common failing.
Temporal windows are tight and varied. Look‑back periods and exposure windows include, among others, 5 years (category 1A/1B stressors for onset/worsening; s9(2)-(3), s9(32)-(33)), 2 years (family member categories; s9(6), s9(36)), 1 year (category 2 stressor; s9(10), s9(40)), 2.5 years (miscarriage, fetal death, stillbirth; s9(8), s9(38)), 2 days (mefloquine and other drug intoxications; s9(20), s9(50)-(52)), 1 hour (caffeine thresholds; s9(29)-(30)), 3 months (pack-years smoking cessation link; s9(27), s9(57)), and 30 days (acute cholinergic poisoning; s9(28), s9(58)). Meeting or disproving these windows often turns on precise contemporaneous notes, pharmacy records, service logs and medical records.
Substance/medication‑induced criteria require timing and persistence detail. For mefloquine, the factor is mefloquine intake within 2 days before onset where symptoms persist after discontinuation or tapering (s9(20)). For other substances, the instrument requires both that the symptoms developed during or soon after intoxication/withdrawal and that the substance is capable of producing those symptoms (s7(5)). Rechallenge or improvement on cessation are listed evidentiary clues (s9(22), s9(52)). Practically, missing medication timing records or insufficient follow‑up documentation can prevent meeting these factors.
Caffeine and regular habit thresholds. For persons without a regular caffeine habit, 200 mg of caffeine within 1 hour before clinical onset is a qualifying factor; for regular consumers the threshold is 400 mg within 1 hour (s9(29)-(30); Schedule 1). The instrument defines “regular caffeine habit” as more than 200 mg daily for at least 2 weeks. Failure to document consumption or to account for habitual use will be decisive.
Pre‑existing disorder vs material contribution rules. Section 10(2) states that subsections 9(31) to 9(60) apply only to material contribution to, or aggravation of, anxiety disorder where the anxiety disorder was suffered or contracted before or during, but did not arise out of, relevant service. That distinction can be very consequential. If a claimant alleges onset arising out of service, the 31-60 factors are inapplicable; if the disorder pre‑existed and service is said to have aggravated it, those factors are the ones to consider (s10(2)). Misclassifying the causal posture of the claim will lead to incorrect application of the factors.
Narrow definition of “corpse”. The definition of corpse includes “human remains or body parts of one or more persons who have met a violent or horrific death” but expressly excludes seeing a closed body bag or viewing a body in an open‑casket coffin (Schedule 1). That specification may surprise parties who expect incidental or mediated exposure to be treated as equivalent.
Hostile or life‑threatening environment is narrowly described. The Schedule’s definition limits the concept to pervasive threats of artillery, missile, rocket, mine or bomb attack, nuclear/biological/chemical agent attack, or involvement in combat or combat patrols (Schedule 1). Exposure to other dangerous but non-specified settings may not meet the definition.
Interaction with other Statements of Principles. Section 11 requires application of other Statements when a section 9 factor refers to injuries or diseases covered by those Statements. Practitioners must check cross‑references; failure to do so risks missing governing factors in the other instrument (s11).
Objective thresholds for physiological capacity and obesity. Several factors are thresholded in measurable terms, including BMI≥30 (s9(17); Schedule 1), inability to undertake physical activity greater than 3 METs for at least 3 months (s9(18); Schedule 1), and pack‑year smoking thresholds (s9(27); Schedule 1). Documentary evidence such as weight/height records, exercise testing or historical medical notes will be required to prove these thresholds.

These “gotchas” are all rooted in the text. Practitioners should therefore be precise when collecting and presenting evidence, and should carefully map factual narratives to the exact definitions and time windows in section 9 and the Schedule.

Compliance, in this context, means preparing and presenting the evidence that will permit a decision maker to find that a reasonable hypothesis exists linking anxiety disorder or death from anxiety disorder to a person’s relevant service. The instrument prescribes discrete, concrete evidentiary elements and definitions that must be matched.

Establish the diagnosis against DSM-5-TR criteria. The first compliance task is to ensure the diagnosis of anxiety disorder is one of the categories captured by the Statement: generalised anxiety disorder, anxiety disorder due to another medical condition, substance/medication-induced anxiety disorder, or other specified/unspecified anxiety disorder (s7(2)-(6); Schedule 1). Clinical reports should explicitly reference DSM-5-TR criteria and document how the individual meets each required criterion, for example the 6‑month duration and symptom list for generalised anxiety disorder (s7(3)).
Identify at least one qualifying factor in section 9 and document it precisely. Section 9 requires at least one factor to exist before the reasonable hypothesis is raised. For each pleaded factor, gather contemporaneous service records, medical records, pharmacy records, unit logs, court or police documents, death certificates, and corroborating witness statements to prove the occurrence, timing and relationship to relevant service. Map each documentary piece to the specific subsection used. For example, if relying on a category 1A or 1B stressor within 5 years of onset, identify the stressor, date(s) and the link to service (s9(2)-(3); Schedule 1).
Be attentive to timing windows and dosage thresholds. Where a factor depends on a precise window or dose, such as mefloquine within 2 days (s9(20)) or caffeine thresholds within 1 hour (s9(29)-(30)), collect pharmacy dispensing records, prescriptions, menus, beverage receipts, witness statements, or laboratory tests confirming metabolites where available. For smoking history, calculate pack‑years with the Schedule 1 method and document cessation dates if relevant (s9(27); Schedule 1).
Where the factor is a medical condition or symptom threshold, document objective measures. For obesity, record height and weight contemporaneous to onset to calculate BMI (Schedule 1; s9(17)). For inability to undertake >3 METs, obtain physical capacity testing or medical notes that record exertional capacity and functional limitations (s9(18); Schedule 1). For persistent pain, provide clinical notes documenting duration and interference with activities (s9(16); Schedule 1).
Link the factor to relevant service as required by section 10. Every factor must be related to the person’s relevant service (s10(1)). When the claimant alleges material contribution or aggravation of a pre‑existing condition, ensure the correct subset of factors is relied upon (subsections 9(31)-9(60) apply only where disorder was suffered or contracted before or during, but did not arise out of, service; s10(2)). The narrative must therefore specify whether the disorder is alleged to have arisen out of service or whether service materiality/aggravation is the claim.
Check for cross‑References to other Statements of Principles. If any factor references an injury or disease covered by another Statement, gather evidence and apply the other Statement’s factors as required by section 11 (s11). For example, if a factor refers to traumatic brain injury or another discrete condition that has its own Statement, incorporate that Statement’s factors into your evidence bundle.
Prepare medical reports to address alternative explanations and exclusion criteria. The DSM-derived criteria include exclusions, such as ruling out that disturbance is attributable to the physiological effects of a substance or another medical condition, and ruling out better explanations by other mental disorders (s7(3)(e)-(f)). Medical reports should address these exclusions head on and provide reasoned opinions why anxiety disorder is the appropriate diagnosis for the claim.
Use corroborative service evidence for stressors. For stressor-based factors, obtain service logs, operations reports, disciplinary records, or witness statements that link the stressor to the claimant’s service period and that establish the timing relative to clinical onset or worsening (s9(2)-(5), s9(31)-(35)).
For substance/medication-induced claims, document cessation, rechallenge, or persistence. The Statement places evidentiary weight on improvement after cessation, redevelopment on rechallenge, and persistence after discontinuation for specific drugs (s7(5); s9(22), s9(52)). If relying on such mechanisms, obtain and present drug cessation records, symptom timelines, and any rechallenge documentation.
Record attempts to obtain clinical management where relevant. One of the listed factors for clinical worsening is inability to obtain appropriate clinical management before worsening (s9(60)). Evidence may include appointment records, referral letters, waitlist documentation, or correspondence showing failure to access treatment.
Prepare legal submissions to map facts to subsections. For decision makers, prepare a matrix that ties each factual assertion to the exact subsection in s9 and the definition in Schedule 1. Where multiple factors are present, set out why each is met or not met, and explain how they relate to relevant service per s10.
Anticipate the need for precision in contested cases. Because the Statement sets narrow thresholds and definitions, expect decision makers to treat near‑misses (for example, 72 hours instead of 48 hours, or 180 days instead of 6 months) as potentially disqualifying. Where possible, obtain corroborative objective records rather than relying solely on retrospective accounts.

In sum, compliance means very deliberate, evidence-focused preparation that maps diagnosis and factual history to the Statement’s enumerated factors, timing windows and definitions. Medical reports must be explicit in mapping DSM-5-TR criteria, exposure timing and objective thresholds. Legal and claims submissions must explain how the chosen factor is related to relevant service as required by section 10, and must apply any cross-referenced Statements of Principles under section 11.

Statement of Principles concerning anxiety disorder (Reasonable Hypothesis) (No. 100 of 2023)

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