Diagnostic Assessment — Anxiety Disorder
Example 1 of 1 · fictitious patient (Veteran DU)
Diagnostic Assessment
Anxiety Disorder
BOP Code: 101 of 2023 (Anxiety Disorder)
RH Code: 100 of 2023 (Anxiety Disorder)
ADF History
Veteran DU, date of birth 23 February 1980, Australian Army, Infantry Soldier (Rifleman, later Lance Corporal), enlisted 06 July 1998, medically discharged 04 October 2013. Operational service: East Timor, 20 September 1999 to 18 February 2000 (warlike); Afghanistan, 01 March 2010 to 29 July 2010 (warlike, aeromedically evacuated).
Occupational History
As an infantry soldier the veteran conducted combat patrols, vehicle checkpoints and cordon and search operations, under threat of ambush, improvised explosive devices and indirect fire. Infantry soldiers are exposed to killing and wounding, to the death and injury of comrades and civilians, to handling human remains and to morally difficult decisions under rules of engagement.
The trade also involves heavy load carriage, blast and weapons noise, sleep deprivation, prolonged separation from family, and a culture of heavy drinking, smoking and high caffeine and stimulant supplement use. Injured soldiers commonly face prolonged rehabilitation, loss of role and the stresses of medical discharge.
History
Veteran DU, an Army infantry soldier, developed generalised anxiety disorder on 10 December 2010, during rehabilitation after being held captive by insurgents and severely injured by an improvised explosive device on warlike service in Afghanistan in 2010, on a background of posttraumatic stress disorder, post-traumatic epilepsy, chronic pain, thyrotoxicosis, alcohol use disorder and a series of medications and substances. The disorder worsened on 15 June 2012 as he faced medical discharge without psychological care, requiring admission.
Timeline
- 17 May 2010 — During warlike service in Afghanistan the veteran was freed by a coalition raid after being held by insurgents for three days following an ambush. He had been bound, beaten and subjected to a mock execution. On 02 June 2010 he fired on a vehicle at a checkpoint, killing a man and a child, and he described intense guilt to the padre. "held captive three days, beaten"
- 28 Jul 2010 — An improvised explosive device detonated under the veteran's vehicle on warlike service. His section second-in-command was killed and his closest friend lost both legs. He had a moderate traumatic brain injury, an open right tibial fracture and bilateral ruptured eardrums, helped recover his friend's remains, and was evacuated. On 16 August 2010 he developed septic shock from the fracture and spent four days in intensive care. "IED, TBI, open tibial fracture"
- 20 Oct 2010 — A neurologist diagnosed post-traumatic epilepsy after two generalised seizures and commenced levetiracetam. A psychiatrist had diagnosed posttraumatic stress disorder on 05 October 2010 and alcohol use disorder followed on 24 November 2010. He was in a wheelchair with an external fixator, had daily tinnitus and continuous back and leg pain, and his partner had left him. "post-traumatic epilepsy, PTSD, AUD"
- 10 Dec 2010 — At the rehabilitation gym the veteran developed sudden, intense apprehension with tremor, palpitations, sweating and a fear that something terrible was about to happen, followed by constant worry about his health, his future and his family. He had taken mefloquine for vivax malaria the night before, extra oxycodone overnight, and that morning two energy drinks and a stimulant pre-workout. Graves thyrotoxicosis had been confirmed on 06 December. "apprehension, tremor, constant worry"
- 20 Jun 2011 — A consultant psychiatrist diagnosed generalised anxiety disorder after six months of excessive, uncontrollable worry with restlessness, fatigue, poor concentration, irritability, muscle tension and disturbed sleep, with a GAD-7 score of 12. Components due to thyrotoxicosis and to medication and substances were also recorded. Cognitive behavioural therapy commenced. "generalised anxiety disorder, GAD-7 12"
- 12 Mar 2012 — The veteran was notified of his proposed medical discharge. His brother had been critically wounded in Afghanistan in January, a close friend had died by suicide in February, and his new partner had miscarried in November 2011. His psychology sessions had stopped in September 2011 when the base psychologist position became vacant. He was non-weight-bearing after revision surgery for tibial non-union on 14 February 2012. "discharge notified, therapy interrupted"
- 18 Jun 2012 — The veteran was admitted to a mental health unit three days after a marked deterioration on 15 June 2012, with daily panic attacks, constant worry, inability to leave the house and a GAD-7 score of 20. In the preceding days he had taken mefloquine for relapsed malaria, smoked cannabis, taken a stimulant supplement and high-dose caffeine, and had his oxycodone halved. Graves disease had relapsed. "admitted, GAD-7 20, daily panic"
Symptoms
At onset the veteran had sudden intense apprehension with tremor, palpitations and sweating, followed by persistent, excessive and uncontrollable worry about his health, finances, relationships and future, with restlessness, irritability, muscle tension, poor concentration, fatigue and difficulty sleeping.
From June 2012 the worry became constant, with daily panic attacks, avoidance of leaving the house and inability to manage daily tasks, requiring admission. He now reports persistent worry most of the day, frequent panic symptoms in crowds and when driving, poor sleep and social withdrawal, despite medication and therapy.
Imaging
No imaging is required to establish this diagnosis.
Onset Date
The most likely date of onset of this condition is 10 Dec 2010.
At that date the veteran was serving full time, in rehabilitation at his home unit after evacuation from warlike service in Afghanistan, confined to a wheelchair and frame with an external fixator on his right leg. That morning at the rehabilitation gym he developed sudden intense apprehension followed by persistent worry, which have continued since.
This date is appropriate because his psychiatric reviews of 05 October and 24 November 2010 recorded posttraumatic stress symptoms and drinking but no generalised worry, and he presented the same day, 10 December 2010, to the medical officer. The psychiatrist confirmed generalised anxiety disorder on 20 June 2011 after six months of symptoms dating from that day. It falls within uninterrupted full-time service.
For the onset factors, the 5 years before onset run from 10 Dec 2005 to 10 Dec 2010, the 2 years from 10 Dec 2008 to 10 Dec 2010, the 1 year from 10 Dec 2009 to 10 Dec 2010 and the 6 months from 10 Jun 2010 to 10 Dec 2010; his capture (14 to 17 May 2010), the checkpoint shooting (02 June 2010), the blast and death and injury of his friends (28 July 2010), septic shock (16 August 2010), the end of his relationship (October 2010) and his posttraumatic stress disorder (05 October 2010) all fall within each of them, and his 21 weeks in Afghanistan fall within the 5 years. The 2.5 years before onset run from 10 Jun 2008 to 10 Dec 2010 and contain his partner's miscarriage of 22 March 2009. The 3 months before onset run from 10 Sep 2010 to 10 Dec 2010, during which he could not exceed 2 METs and binge drank most weekends. The 30 days before onset run from 10 Nov 2010 to 10 Dec 2010 and contain the dichlorvos poisoning of 18 November; the 10 days run from 30 Nov 2010 and contain the cessation of diazepam on 03 December; the 2 days and 24 hours contain mefloquine, oxycodone intoxication, levetiracetam and the stimulant supplement; and the hour before onset contains 520 milligrams of caffeine. Epilepsy, tinnitus, persistent pain, obesity, thyrotoxicosis and alcohol use disorder were present on 10 December 2010.
For the worsening factors, the documented clinical worsening occurred on 15 Jun 2012, confirmed on admission on 18 June 2012 with the GAD-7 score risen from 12 to 20 and daily panic attacks. The 5 years before the worsening run from 15 Jun 2007 to 15 Jun 2012 and the 2 years from 15 Jun 2010 to 15 Jun 2012, containing the blast and his warlike service; the 1 year from 15 Jun 2011 contains his brother's wounding, his friend's suicide and his partner's miscarriage; the 6 months from 15 Dec 2011 contain the discharge notice and divorce; the 3 months from 15 Mar 2012 he was non-weight-bearing and binge drinking; the 30 days from 15 May 2012 contain the chlorpyrifos poisoning of 28 May; the 10 days contain the oxycodone reduction of 08 June; and the 24 hours and the hour before contain mefloquine, cannabis, levetiracetam, the stimulant supplement and 480 milligrams of caffeine.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Anxiety Disorder, namely generalised anxiety disorder (ICD-10 F41.1), with recorded components of anxiety disorder due to another medical condition (thyrotoxicosis) and substance/medication-induced anxiety disorder, under the Statements of Principles concerning anxiety disorder, Balance of Probabilities No. 101 of 2023 and Reasonable Hypothesis No. 100 of 2023.
Generalised anxiety disorder is excessive, persistent and difficult-to-control worry about many areas of life, present on most days for at least six months, with restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance, causing significant distress or impairment. Anxiety disorder due to another medical condition arises when a disorder such as thyrotoxicosis directly produces anxiety through its physiological effects, and substance/medication-induced anxiety disorder arises during or soon after intoxication with, withdrawal from or exposure to a substance or medicine. Severe traumatic and adverse life events, chronic illness and pain, other mental disorders and substance use are well-established causes and aggravators.
The disorder began on 10 December 2010 during rehabilitation from injuries sustained on warlike service, was diagnosed by a psychiatrist on 20 June 2011, and worsened on 15 June 2012, requiring admission.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
10 December 2010.
When did the veteran first present to a health / medical provider for this condition?
10 December 2010.
When was the condition confirmed / formally diagnosed?
20 June 2011.
When did the veteran first present to you (or your practice) for this condition?
21 August 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made by a consultant psychiatrist on 20 June 2011 under DSM criteria, after six months of excessive and uncontrollable worry about multiple areas of life with restlessness, fatigue, impaired concentration, irritability, muscle tension and sleep disturbance, causing marked impairment, with a GAD-7 score of 12. The psychiatrist recorded that the symptoms were not explained solely by his posttraumatic stress disorder, and recorded additional components due to thyrotoxicosis, confirmed biochemically, and to mefloquine, opioids, stimulants and caffeine. Thyroid function, cardiac assessment and EEG were reviewed to exclude other causes of the symptoms.
The worsening was established on admission to a mental health unit on 18 June 2012, three days after a marked deterioration on 15 June 2012, with daily panic attacks, agoraphobic avoidance, a GAD-7 score of 20 and inability to manage daily activities, and the psychiatrist recorded a clinical worsening of the anxiety disorder.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 10 December 2010, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2010, where he was held captive, took part in a morally injurious shooting, was severely injured and acquired malaria, and in East Timor in 1999 to 2000, where he began smoking. The worsening factors apply to aggravation of the disorder.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Anxiety Disorder, No. 101 of 2023
Causative factors
Factor 9(1): experiencing a category 1A stressor within the 2 years before the clinical onset of generalised anxiety disorder; — MET
- The life-threatening blast of 28 July 2010 and his capture, beating and mock execution from 14 to 17 May 2010 were each category 1A stressors within the 2 years before onset, from 10 December 2008 to 10 December 2010, in the course of his service.
Factor 9(2): experiencing a category 1B stressor within the 2 years before the clinical onset of generalised anxiety disorder; — MET
- On 28 July 2010 he witnessed his friend killed, recovered his remains and carried the critically injured driver, and in April 2010 he killed an insurgent, all within the 2 years before onset.
Factor 9(3): experiencing severe childhood abuse before the clinical onset of generalised anxiety disorder; — MET
- Child protection records and every psychiatric history record serious physical and emotional abuse by his stepfather between ages 7 and 14, before onset.
Factor 9(4): having a family member or close friend who experiences a category 1A stressor within the 1 year before the clinical onset of generalised anxiety disorder; — MET
- His closest friend was critically injured, with bilateral amputations and life support, in the blast of 28 July 2010, within the 1 year before onset, from 10 December 2009 to 10 December 2010.
Factor 9(5): experiencing the death of a family member or close friend within the 2 years before the clinical onset of generalised anxiety disorder; — MET
- His close friend and section second-in-command was killed on 28 July 2010, within the 2 years before onset.
Factor 9(6): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical onset of generalised anxiety disorder; — MET
- His partner miscarried at 14 weeks on 22 March 2009, within the 2.5 years before onset, from 10 June 2008 to 10 December 2010.
Factor 9(7): experiencing a category 2 stressor within the 6 months before the clinical onset of generalised anxiety disorder; — MET
- His relationship broke down in October 2010 and he was socially isolated by his injuries, with continuing distress, within the 6 months before onset, from 10 June 2010 to 10 December 2010.
Factor 9(8): having a clinically significant disorder of mental health within the 5 years before the clinical onset of generalised anxiety disorder; — MET
- Posttraumatic stress disorder was diagnosed on 05 October 2010 and warranted ongoing treatment, within the 5 years before onset.
Factor 9(9): having a medical illness which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical onset of generalised anxiety disorder; — MET
- Septic shock from infection of his open fracture on 16 August 2010, requiring intensive care, was within the 3 years before onset.
Factor 9(10): having an injury which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical onset of generalised anxiety disorder; — MET
- His life-threatening traumatic brain injury and open tibial fracture of 28 July 2010 were within the 3 years before onset.
Factor 9(11): having epilepsy at the time of the clinical onset of generalised anxiety disorder; — MET
- Post-traumatic epilepsy, diagnosed on 20 October 2010, was present at onset.
Factor 9(12): having persistent pain of at least 6 months duration at the time of the clinical onset of generalised anxiety disorder; — MET
- Continuous lumbar pain since 2008 from load carriage in service, and continuous right leg pain since July 2010, interfering with work and daily activities, had lasted more than 6 months at onset.
Factor 9(13): being obese at the time of the clinical onset of generalised anxiety disorder; — MET
- His BMI was 31.7 on 06 December 2010; he was obese at onset after weight gain during immobilisation for his service injuries.
Factor 9(14): inability to undertake physical activity greater than 3 METs for a continuous period of at least the 3 months before the clinical onset of generalised anxiety disorder; — MET
- He was confined to a wheelchair and frame and unable to exceed 2 METs from 28 July 2010, including the whole of the 3 months before onset, from 10 September 2010 to 10 December 2010.
Factor 9(15): having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of anxiety are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical onset of “anxiety disorder due to another medical condition”; — MET
- Graves thyrotoxicosis confirmed on 06 December 2010 was directly producing his anxiety symptoms, recorded by his endocrinologist and psychiatrist, at onset.
Factor 9(16): taking mefloquine within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder, where substance/medication-induced anxiety disorder persists after the discontinuation or tapering of mefloquine therapy; — MET
- Mefloquine for vivax malaria acquired during his service was last taken on the evening of 09 December 2010, within the 24 hours before onset, and the anxiety persisted after the course.
Factor 9(17): using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder; — MET
- On the night of 09 December 2010 he took four extra doses of prescribed oxycodone and was drowsy and confused, an intoxicant dose of an opioid within the 24 hours before onset.
Factor 9(18): taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the development of anxiety symptoms during drug therapy and either: (a) the improvement of anxiety symptoms within days or weeks of discontinuing or tapering drug therapy; or (b) the redevelopment of anxiety symptoms on rechallenge with the same drug; where the drug was being taken within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder; — MET
- Levetiracetam, for epilepsy from his service brain injury, was taken within the 24 hours before onset; his anxiety improved on tapering in March 2011 and returned on rechallenge in April 2011, and it could not be substituted.
Factor 9(19): using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the development of anxiety symptoms, and where the psychoactive chemical or substance was being taken within the 24 hours before the clinical onset of substance/medication-induced anxiety disorder; — MET
- On the morning of onset he took a double serve of a DMAA stimulant pre-workout supplement and became tremulous and agitated, as on previous occasions, within the 24 hours before onset.
Factor 9(20): having ceased or reduced therapeutic or illicit drug use or other substance use within the 10 days before the clinical onset of substance/medication-induced anxiety disorder; — MET
- Diazepam was ceased abruptly on 03 December 2010, 7 days before onset.
Factor 9(21): having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced anxiety disorder; — MET
- Alcohol use disorder, moderate, was diagnosed on 24 November 2010 and present at onset.
Factor 9(22): having smoked tobacco products in an amount of at least 0.5 pack-years before the clinical onset of substance/medication-induced anxiety disorder, and if smoking has ceased before the clinical onset of substance/medication-induced anxiety disorder, then that onset occurred within 3 months of cessation; — MET
- He had smoked 20 cigarettes a day since 1999, about 11 pack-years, and was still smoking at onset.
Factor 9(23): for persons without a regular caffeine habit, taking at least 200 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical onset of substance/medication-induced anxiety disorder; — MET
- He took 520 milligrams of caffeine in the hour before onset; his rehabilitation records show intake above 200 milligrams a day for only 11 days, so he had no regular caffeine habit as defined.
Factor 9(24): for persons with a regular caffeine habit, taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical onset of substance/medication-induced anxiety disorder; — MET
- The 520 milligrams of caffeine also exceeds 400 milligrams; his garrison records describe four to five cups of coffee a day, a regular habit, so the threshold was exceeded on either characterisation.
Worsening factors
Factor 9(25): experiencing a category 1A stressor within the 2 years before the clinical worsening of anxiety disorder; — MET
- The blast of 28 July 2010 was within the 2 years before the worsening, from 15 June 2010 to 15 June 2012, in the course of his service.
Factor 9(26): experiencing a category 1B stressor within the 2 years before the clinical worsening of anxiety disorder; — MET
- Witnessing his friend killed, recovering remains and carrying the critically injured driver on 28 July 2010 were within the 2 years before the worsening.
Factor 9(27): experiencing severe childhood abuse before the clinical worsening of anxiety disorder; — MET
- The severe childhood abuse by his stepfather occurred before the worsening.
Factor 9(28): having a family member or close friend who experiences a category 1A stressor within the 1 year before the clinical worsening of anxiety disorder; — MET
- His brother was critically wounded by an improvised explosive device on 21 January 2012, within the 1 year before the worsening.
Factor 9(29): experiencing the death of a family member or close friend within the 2 years before the clinical worsening of anxiety disorder; — MET
- His friend was killed on 28 July 2010 and another close friend from his section died by suicide on 11 February 2012, both within the 2 years before the worsening.
Factor 9(30): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical worsening of anxiety disorder; — MET
- His new partner miscarried on 19 November 2011, within the 2.5 years before the worsening.
Factor 9(31): experiencing a category 2 stressor within the 6 months before the clinical worsening of anxiety disorder; — MET
- Notice of medical discharge on 12 March 2012, loss of allowances, mortgage hardship and divorce proceedings caused continuing distress within the 6 months before the worsening.
Factor 9(32): having a clinically significant disorder of mental health within the 5 years before the clinical worsening of anxiety disorder; — MET
- Posttraumatic stress disorder under ongoing treatment was within the 5 years before the worsening.
Factor 9(33): having a medical illness which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical worsening of anxiety disorder; — MET
- The septic shock of 16 August 2010 was within the 3 years before the worsening.
Factor 9(34): having an injury which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical worsening of anxiety disorder; — MET
- The blast injuries of 28 July 2010 were within the 3 years before the worsening.
Factor 9(35): having epilepsy at the time of the clinical worsening of anxiety disorder; — MET
- Post-traumatic epilepsy, with a breakthrough seizure on 02 May 2012, was present at the worsening.
Factor 9(36): having persistent pain of at least 6 months duration at the time of the clinical worsening of anxiety disorder; — MET
- Continuous lumbar and right leg pain had lasted well over 6 months at the worsening.
Factor 9(37): being obese at the time of the clinical worsening of anxiety disorder; — MET
- His BMI was 33.5 at the worsening.
Factor 9(38): inability to undertake physical activity greater than 3 METs for a continuous period of at least the 3 months before the clinical worsening of anxiety disorder; — MET
- Non-weight-bearing after revision surgery on 14 February 2012, he could not exceed 2 METs throughout the 3 months before the worsening.
Factor 9(39): having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of anxiety are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical worsening of anxiety disorder; — MET
- Relapsed Graves thyrotoxicosis from May 2012 was directly driving his anxiety symptoms at the worsening.
Factor 9(40): taking mefloquine within the 24 hours before the clinical worsening of anxiety disorder, where anxiety disorder persists after the discontinuation or tapering of mefloquine therapy; — MET
- Mefloquine for relapsed vivax malaria was taken on 14 June 2012, within the 24 hours before the worsening, and the worsened anxiety persisted after it.
Factor 9(41): using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 24 hours before the clinical worsening of anxiety disorder; — MET
- He smoked cannabis to intoxication on the night of 14 June 2012, within the 24 hours before the worsening.
Factor 9(42): taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the worsening of anxiety symptoms during drug therapy and either: (a) the improvement of anxiety symptoms within days or weeks of discontinuing or tapering drug therapy; or (b) the worsening of anxiety symptoms on rechallenge with the same drug; where the drug was being taken within the 24 hours before the clinical worsening of anxiety disorder; — MET
- Levetiracetam, shown on rechallenge to worsen his anxiety and unable to be substituted, was taken within the 24 hours before the worsening.
Factor 9(43): using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the worsening of anxiety symptoms, and where the psychoactive chemical or substance was being taken within the 24 hours before the clinical worsening of anxiety disorder; — MET
- He took a double serve of the DMAA pre-workout supplement on the morning of 15 June 2012 and became agitated, within the 24 hours before the worsening.
Factor 9(44): having ceased or reduced therapeutic or illicit drug use or other substance use within the 10 days before the clinical worsening of anxiety disorder; — MET
- His oxycodone dose was halved on 08 June 2012, 7 days before the worsening.
Factor 9(45): having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of anxiety disorder; — MET
- Alcohol use disorder and opioid use disorder were present at the worsening.
Factor 9(46): having smoked tobacco products in an amount of at least 0.5 pack-years before the clinical worsening of anxiety disorder, and if smoking has ceased before the clinical worsening of anxiety disorder, then that worsening occurred within 3 months of cessation; — MET
- He was still smoking 20 cigarettes a day at the worsening, more than 12 pack-years.
Factor 9(47): taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical worsening of anxiety disorder; — MET
- He took about 480 milligrams of caffeine in the hour before the worsening.
Factor 9(48): inability to obtain appropriate clinical management for anxiety disorder before the clinical worsening of anxiety disorder. — MET
- The base psychologist position was vacant from September 2011, interrupting therapy for five months, and his trauma program referral was waitlisted for seven months before the worsening. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Anxiety Disorder, No. 100 of 2023
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of generalised anxiety disorder; — MET
- From 14 to 17 May 2010, during warlike service in Afghanistan, the veteran was captured by insurgents after his vehicle was disabled in an ambush, held bound in a compound for three days, beaten and threatened with execution at gunpoint, until freed by a coalition raid. He was held by an enemy force in a warlike operation and was therefore a prisoner of war before onset on 10 December 2010.
Factor 9(2): experiencing a category 1A stressor within the 5 years before the clinical onset of generalised anxiety disorder; — MET
- On 28 July 2010, during warlike service in Afghanistan, an improvised explosive device detonated under his vehicle. He sustained a traumatic brain injury, an open fracture of the right tibia and fibula and burst eardrums, and was aeromedically evacuated. The blast and his capture in May 2010 were each life-threatening events within the 5 years before onset, from 10 December 2005 to 10 December 2010.
Factor 9(3): experiencing a category 1B stressor within the 5 years before the clinical onset of generalised anxiety disorder; — MET
- In the 28 July 2010 blast on warlike service in Afghanistan the veteran saw his section second-in-command killed, and before evacuation he helped carry the critically injured driver and recover his friend's remains. In April 2010 he had shot and killed an insurgent at close range. Each was within the 5 years before onset.
Factor 9(4): experiencing severe childhood abuse before the clinical onset of generalised anxiety disorder; — MET
- Child protection records from 1989 and the veteran's psychiatric history record repeated serious physical assaults and emotional abuse by his stepfather between the ages of 7 and 14, including beatings causing a fractured forearm at age 10. This severe childhood abuse occurred before onset and has been recorded consistently by every treating psychiatrist.
Factor 9(5): experiencing a potentially morally injurious event within the 5 years before the clinical onset of generalised anxiety disorder; — MET
- On 02 June 2010, during warlike service in Afghanistan, the veteran fired on a vehicle that failed to stop at a checkpoint under the rules of engagement; a man and a child in the vehicle were killed and it carried no weapons. He has described the event to his psychiatrist as a betrayal of everything he believed about being a soldier. It was within the 5 years before onset.
Factor 9(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; — MET
- The veteran's closest friend, the vehicle driver, was critically injured in the same blast on 28 July 2010 on warlike service, with bilateral leg amputations and a period on life support. The friend's life-threatening event was within the 2 years before onset, from 10 December 2008 to 10 December 2010.
Factor 9(7): experiencing the death of a family member or close friend within the 5 years before the clinical onset of generalised anxiety disorder; — MET
- The veteran's close friend and section second-in-command was killed in the blast of 28 July 2010 on warlike service in Afghanistan, within the 5 years before onset.
Factor 9(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; — MET
- The veteran's partner miscarried at 14 weeks on 22 March 2009, recorded in his garrison health record when he was granted compassionate leave. He experienced the miscarriage as a parent within the 2.5 years before onset, from 10 June 2008 to 10 December 2010.
Factor 9(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; — MET
- From 01 March 2010 to 29 July 2010 the veteran served on warlike service in Afghanistan, conducting combat patrols under frequent small-arms fire and improvised explosive device threat, a cumulative period of 21 weeks within the 5 years before onset.
Factor 9(10): experiencing a category 2 stressor within the 1 year before the clinical onset of generalised anxiety disorder; — MET
- In October 2010, during his rehabilitation, his partner of six years ended their relationship and moved out, and he was socially isolated at home by his injuries, unable to drive or see his section. He described continuing distress and worry about both. These category 2 stressors began within the 1 year before onset and arose from the consequences of his warlike service.
Factor 9(11): having a clinically significant disorder of mental health within the 10 years before the clinical onset of generalised anxiety disorder; — MET
- A consultant psychiatrist diagnosed posttraumatic stress disorder on 05 October 2010, after the capture and blast on warlike service, and commenced sertraline and trauma-focused therapy. This clinically significant disorder of mental health was within the 10 years before onset and warranted ongoing management.
Factor 9(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; — MET
- On 16 August 2010 the veteran developed septic shock from infection of his open tibial fracture, requiring intensive care, vasopressors and ventilation for four days. This life-threatening medical illness was within the 5 years before onset and followed the blast on warlike service.
Factor 9(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; — MET
- The injuries of 28 July 2010 on warlike service, a moderate traumatic brain injury and an open tibial fracture with major blood loss, were life-threatening and left him with serious physical disability. They were within the 5 years before onset.
Factor 9(14): having epilepsy at the time of the clinical onset of generalised anxiety disorder; — MET
- The veteran had post-traumatic generalised seizures on 14 September and 18 October 2010, and a neurologist diagnosed post-traumatic epilepsy on 20 October 2010 and commenced levetiracetam. The epilepsy, a result of the brain injury on warlike service, was present at onset on 10 December 2010.
Factor 9(15): having severe and permanent tinnitus at the time of the clinical onset of generalised anxiety disorder; — MET
- Since the blast of 28 July 2010 the veteran has had loud bilateral tinnitus every day. An audiologist fitted tinnitus masking devices on 24 November 2010 because it prevented sleep and concentration. This severe and permanent tinnitus, caused by blast on warlike service, was present at onset.
Factor 9(16): having persistent pain of at least 3 months duration at the time of the clinical onset of generalised anxiety disorder; — MET
- The veteran has had continuous lumbar pain since 2008 from carrying heavy loads, worse after his 2010 deployment, and continuous right leg pain since the tibial fracture, both requiring daily analgesia and stopping him working and driving. The pain was present for far longer than 3 months at onset.
Factor 9(17): being obese at the time of the clinical onset of generalised anxiety disorder; — MET
- On 06 December 2010 the veteran weighed 112 kilograms at a height of 1.88 metres, a BMI of 31.7, after gaining 18 kilograms during immobilisation for his blast injuries on warlike service. He was obese at onset.
Factor 9(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; — MET
- From the blast on 28 July 2010 the veteran was confined to a wheelchair and then a frame with an external fixator, unable to walk more than a few metres, and his physiotherapist recorded that he could not exceed 2 METs. This continued for more than 4 months, including the whole of the 3 months before onset, from 10 September 2010 to 10 December 2010.
Factor 9(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”; — MET
- On 06 December 2010 the veteran was found to be thyrotoxic from Graves disease (free T4 48 picomoles per litre, TSH below 0.01, TSH receptor antibodies positive), with tremor, palpitations and heat intolerance. An endocrinologist recorded that the thyrotoxicosis was directly producing anxiety symptoms through its effect on the nervous system, and the psychiatrist recorded an anxiety disorder due to another medical condition alongside generalised anxiety disorder. It was present at onset.
Factor 9(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; — MET
- On 08 December 2010 an infectious diseases physician diagnosed Plasmodium vivax malaria acquired on warlike service in Afghanistan and treated it with mefloquine, the last dose taken on the evening of 09 December 2010, within the 2 days before onset. The anxiety persisted after mefloquine was completed.
Factor 9(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; — MET
- On the night of 09 December 2010 the veteran took four extra doses of immediate-release oxycodone, prescribed for his blast injuries, and his housemate found him drowsy and confused. Opioids are on the specified list, and this intoxicant dose was within the 2 days before onset. A substance use disorder was later diagnosed.
Factor 9(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; — MET
- Levetiracetam, commenced on 20 October 2010 for post-traumatic epilepsy from the blast, was being taken within the 2 days before onset. The veteran's anxiety eased within two weeks when it was tapered in March 2011 and returned when it was restarted in April 2011 after lamotrigine caused a rash and valproate was unsuitable, so it could not be ceased or substituted in the long term.
Factor 9(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; — MET
- At the rehabilitation gym on the morning of 10 December 2010 the veteran took a double serve of a pre-workout supplement containing 1,3-dimethylamylamine (DMAA), a stimulant, and became tremulous, agitated and flushed. He had noted jittery anxiety on previous occasions with it. This intoxicant dose was within the 2 days before onset.
Factor 9(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; — MET
- Diazepam 5 milligrams three times a day, prescribed for muscle spasm after his blast injuries, was ceased abruptly by the rehabilitation team on 03 December 2010, 7 days before onset.
Factor 9(25): having periodic, heavy alcohol consumption for the 3 months before the clinical onset of substance/medication-induced anxiety disorder; — MET
- From September to December 2010, during rehabilitation after the blast, the veteran drank to intoxication with 12 to 16 standard drinks on most weekends, recorded by his medical officer and the alcohol and other drugs counsellor. This binge drinking occurred at least once a month throughout the 3 months before onset.
Factor 9(26): having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced anxiety disorder; — MET
- A psychiatrist diagnosed alcohol use disorder, moderate, on 24 November 2010, after his drinking increased following his capture and the blast on warlike service. It was present at onset on 10 December 2010.
Factor 9(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; — MET
- The veteran began smoking on warlike service in East Timor in 1999 and smoked 20 cigarettes a day continuously to onset, about 11 pack-years, far exceeding 0.5 pack-years, and was still smoking at onset.
Factor 9(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; — MET
- On 18 November 2010, while on light duties at the base pest control store during his rehabilitation, the veteran was splashed with dichlorvos from a leaking drum and developed miosis, profuse bronchial secretions, bradycardia, vomiting and diarrhoea within hours. He was treated with atropine. This acute cholinergic poisoning was 22 days before onset, within the 30 days the factor sets.
Factor 9(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; — MET
- In the hour before onset on 10 December 2010 the veteran took 520 milligrams of caffeine (two 250 millilitre energy drinks and the pre-workout supplement). The rehabilitation records show that his intake had been above 200 milligrams a day for only 11 days, so he did not have a regular caffeine habit as defined, and his intake exceeded 200 milligrams.
Factor 9(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; — MET
- The 520 milligrams of caffeine taken in the hour before onset also exceeds 400 milligrams. His garrison records before the blast describe him drinking four to five cups of coffee a day, which would make him a person with a regular caffeine habit; on either characterisation of his habit the relevant threshold was exceeded.
Worsening factors
Factor 9(31): being a prisoner of war before the clinical worsening of anxiety disorder; — MET
- The veteran was held by insurgents as a prisoner of war from 14 to 17 May 2010 on warlike service in Afghanistan, before the worsening on 15 June 2012.
Factor 9(32): experiencing a category 1A stressor within the 5 years before the clinical worsening of anxiety disorder; — MET
- The life-threatening blast of 28 July 2010 and his captivity in May 2010, both on warlike service, were within the 5 years before the worsening, from 15 June 2007 to 15 June 2012.
Factor 9(33): experiencing a category 1B stressor within the 5 years before the clinical worsening of anxiety disorder; — MET
- Witnessing his friend killed, recovering his remains and carrying the critically injured driver on 28 July 2010, and killing an insurgent in April 2010, all on warlike service, were within the 5 years before the worsening.
Factor 9(34): experiencing severe childhood abuse before the clinical worsening of anxiety disorder; — MET
- The severe childhood physical and emotional abuse by his stepfather between ages 7 and 14 occurred before the worsening.
Factor 9(35): experiencing a potentially morally injurious event within the 5 years before the clinical worsening of anxiety disorder; — MET
- The checkpoint shooting of 02 June 2010 on warlike service, in which a man and child were killed, was within the 5 years before the worsening, and it featured in his nightmares and guilt in 2012.
Factor 9(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; — MET
- On 21 January 2012 the veteran's younger brother, serving in Afghanistan, was wounded by an improvised explosive device and evacuated with life-threatening injuries, within the 2 years before the worsening. The veteran's own experience of warlike service intensified his fear for his brother.
Factor 9(37): experiencing the death of a family member or close friend within the 5 years before the clinical worsening of anxiety disorder; — MET
- His friend killed on warlike service on 28 July 2010, and another close friend from his section who died by suicide on 11 February 2012 after returning from Afghanistan, died within the 5 years before the worsening.
Factor 9(38): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical worsening of anxiety disorder; — MET
- His new partner miscarried at 11 weeks on 19 November 2011, within the 2.5 years before the worsening, from 15 December 2009 to 15 June 2012.
Factor 9(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; — MET
- His 21 weeks of warlike service in Afghanistan from 01 March 2010 to 29 July 2010 were within the 5 years before the worsening.
Factor 9(40): experiencing a category 2 stressor within the 1 year before the clinical worsening of anxiety disorder; — MET
- On 12 March 2012 the veteran was notified of his proposed medical discharge, his allowances ceased, he could not meet his mortgage repayments and he began divorce proceedings, causing continuing distress and worry. These category 2 stressors, arising from his injuries on warlike service, were within the 1 year before the worsening.
Factor 9(41): having a clinically significant disorder of mental health within the 10 years before the clinical worsening of anxiety disorder; — MET
- Posttraumatic stress disorder, diagnosed on 05 October 2010 after warlike service and under ongoing treatment, was within the 10 years before the worsening.
Factor 9(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; — MET
- The septic shock of 16 August 2010, following the blast injury on warlike service, was within the 5 years before the worsening.
Factor 9(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; — MET
- The life-threatening blast injuries of 28 July 2010 on warlike service, and their serious physical disability, were within the 5 years before the worsening.
Factor 9(44): having epilepsy at the time of the clinical worsening of anxiety disorder; — MET
- Post-traumatic epilepsy from the brain injury on warlike service persisted, with a breakthrough seizure on 02 May 2012, and was present at the worsening.
Factor 9(45): having severe and permanent tinnitus at the time of the clinical worsening of anxiety disorder; — MET
- Blast-related tinnitus requiring masking devices and disturbing sleep every night was present at the worsening.
Factor 9(46): having persistent pain of at least 3 months duration at the time of the clinical worsening of anxiety disorder; — MET
- Continuous lumbar and right leg pain, worse after revision surgery for non-union in February 2012, was present for well over 3 months at the worsening.
Factor 9(47): being obese at the time of the clinical worsening of anxiety disorder; — MET
- The veteran's BMI was 33.5 on 15 June 2012, after further weight gain during non-weight-bearing after revision surgery; he was obese at the worsening.
Factor 9(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; — MET
- After revision surgery for non-union of the tibial fracture from warlike service on 14 February 2012 he was non-weight-bearing on crutches and unable to exceed 2 METs throughout the 3 months before the worsening, from 15 March 2012 to 15 June 2012.
Factor 9(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; — MET
- Graves thyrotoxicosis relapsed in May 2012 after carbimazole was stopped (free T4 41 picomoles per litre), and the endocrinologist recorded that it was directly driving his tremor, palpitations and anxiety at the worsening.
Factor 9(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; — MET
- A relapse of the Plasmodium vivax malaria acquired on warlike service in Afghanistan was treated with mefloquine on 14 June 2012, within the 2 days before the worsening, and the worsened anxiety persisted after it was completed.
Factor 9(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; — MET
- On the night of 14 June 2012 the veteran smoked cannabis to intoxication with friends, recorded on admission. Cannabis is on the specified list, and this was within the 2 days before the worsening.
Factor 9(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; — MET
- Levetiracetam, which cannot be ceased or substituted for his epilepsy from warlike service and which has been shown to worsen his anxiety on rechallenge, was taken daily up to the worsening.
Factor 9(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; — MET
- On the morning of 15 June 2012 he took a double serve of the DMAA pre-workout supplement before upper-body gym rehabilitation and became tremulous and agitated, as on previous occasions; this was within the 2 days before the worsening.
Factor 9(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; — MET
- His oxycodone dose was reduced by half by the pain team on 08 June 2012, 7 days before the worsening.
Factor 9(55): having periodic, heavy alcohol consumption for the 3 months before the clinical worsening of anxiety disorder; — MET
- Throughout the 3 months before the worsening the veteran binge drank to intoxication most weekends, recorded by his medical officer.
Factor 9(56): having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of anxiety disorder; — MET
- Alcohol use disorder, moderate, and opioid use disorder were present at the worsening, recorded on admission on 18 June 2012.
Factor 9(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; — MET
- He was still smoking 20 cigarettes a day at the worsening, more than 12 pack-years in total, all since he began on warlike service in East Timor.
Factor 9(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; — MET
- On 28 May 2012, on light duties with the base grounds section, he was drenched by chlorpyrifos when a spray hose ruptured, with miosis, bronchial secretions, bradycardia and diarrhoea treated with atropine, 18 days before the worsening.
Factor 9(59): taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical worsening of anxiety disorder; — MET
- In the hour before the worsening he took about 480 milligrams of caffeine from energy drinks and the pre-workout supplement.
Factor 9(60): inability to obtain appropriate clinical management for anxiety disorder before the clinical worsening of anxiety disorder. — MET
- From September 2011 the base psychologist position was vacant, interrupting his cognitive behavioural therapy for five months, his referral to a trauma recovery program was waitlisted for seven months, and his only treatment in that period was medication reviews. The anxiety disorder worsened before treatment resumed. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The anxiety disorder is a sequela of the veteran's accepted posttraumatic stress disorder, traumatic brain injury and post-traumatic epilepsy, tinnitus, chronic lumbar and right leg pain and alcohol use disorder, and of the medicines prescribed for them. It has in turn contributed to his depressive symptoms, social withdrawal and inability to work since discharge.
Unintended Consequence
Met. Mefloquine, levetiracetam, oxycodone and the abrupt cessation of diazepam, all prescribed or directed by ADF health providers and paid for by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA), each contributed to the onset and to the worsening of the anxiety disorder.
Inability to Attain Appropriate Medical Management
MET. From September 2011 the base psychologist position was vacant and the veteran's cognitive behavioural therapy for generalised anxiety disorder stopped for five months, while his referral to a trauma recovery program was waitlisted for seven months, leaving medication reviews as his only treatment while he faced discharge, bereavement and family trauma. The disorder worsened to daily panic and admission on 18 June 2012. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of evidence-based psychological treatment amounted to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 1989, Child protection records (as recorded in psychiatric history)
- 22 Mar 2009, Garrison health record, Medical Officer
- 17 May 2010, Deployed health record and padre's report, Afghanistan
- 28 Jul 2010, Role 3 trauma record and aeromedical evacuation record, Afghanistan
- 16 Aug 2010, Intensive care discharge summary, Intensivist
- 05 Oct 2010, Psychiatric assessment, Consultant psychiatrist
- 20 Oct 2010, Neurology consultation and EEG, Neurologist
- 18 Nov 2010, Emergency treatment record, Medical Officer
- 24 Nov 2010, Audiology report, Audiologist
- 06 Dec 2010, Endocrinology consultation and thyroid function tests, Endocrinologist
- 08 Dec 2010, Infectious diseases consultation, Infectious diseases physician
- 10 Dec 2010, Garrison health record, Medical Officer
- 20 Jun 2011, Psychiatric review, Consultant psychiatrist
- 12 Mar 2012, Garrison health record, Medical Officer
- 28 May 2012, Emergency treatment record, Medical Officer
- 18 Jun 2012, Mental health unit admission record, Consultant psychiatrist
- Statement of Principles concerning Anxiety Disorder (Balance of Probabilities) No. 101 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Anxiety Disorder (Reasonable Hypothesis) No. 100 of 2023, Repatriation Medical Authority
