Diagnostic Assessment — Panic Disorder
Example 1 of 1 · fictitious patient (Veteran J)
Diagnostic Assessment
Panic Disorder
BOP Code: 56 of 2018 (Panic Disorder)
RH Code: 55 of 2018 (Panic Disorder)
ADF History
Veteran J, date of birth 11 August 1967, Royal Australian Navy, Boatswain's Mate (later Petty Officer Boatswain), enlisted as a junior recruit 17 January 1983, medically discharged 30 September 2016. Operational service: East Timor, 20 September 1999 to 18 February 2000 (warlike); Middle East Area of Operations (maritime security and boarding operations), 10 January 2009 to 20 July 2009 (warlike); Middle East Area of Operations (maritime security), 02 February 2013 to 25 August 2013 (warlike).
Occupational History
Boatswain's mates are the Navy's seamanship specialists. They operate and maintain sea boats, conduct boarding operations, handle lines, anchors and replenishment gear on open decks in all weather, crew small arms and perform damage control and firefighting duties. They work long watches with broken sleep, in confined steel compartments, and are routinely exposed to the risks of falls down ladders, crush injuries, drowning, fire and smoke.
Boarding party members on maritime security operations approach and search unknown vessels and are exposed to armed resistance, gunfire, the death and injury of shipmates and the handling of casualties. Long deployments separate sailors from family for six months or more, with limited communication, and the service culture of the period normalised heavy drinking ashore.
History
Veteran J, a boatswain's mate in the Royal Australian Navy, was abused as a 15-year-old junior recruit, developed obstructive sleep apnoea, alcohol use disorder and, after a shipboard fire in 2008 and an armed boarding in the Middle East in 2009, a moderate traumatic brain injury, post-traumatic epilepsy and posttraumatic stress disorder. He developed panic disorder on 18 March 2010, and it worsened markedly after his 2013 Middle East deployment, during which he could not obtain treatment.
Timeline
- 14 Jun 2006 — The veteran was referred by a Navy medical officer for loud snoring and daytime sleepiness affecting his watchkeeping. Diagnostic polysomnography showed moderate obstructive sleep apnoea with an apnoea-hypopnoea index of 24 events per hour. CPAP was commenced, but use at sea was inconsistent because of shared mess-deck accommodation. Earlier records noted that he had disclosed serious physical and sexual abuse by an adult instructor during junior recruit training in 1983, at age 15. "moderate OSA, AHI 24"
- 19 Mar 2007 — A Navy psychologist assessed him after an alcohol-related incident ashore. He reported drinking eight to ten standard drinks most nights in port, with failed attempts to cut down, tolerance and morning shakes. Alcohol use disorder of moderate severity was diagnosed and monthly counselling was commenced, continuing through 2010. "alcohol use disorder, monthly counselling"
- 12 Sep 2008 — During a peacetime exercise off Western Australia a fire broke out in the engine room of his frigate. He was trapped in a smoke-filled passageway and fell four metres down a ladder while escaping. He lost consciousness for about 40 minutes and had a Glasgow Coma Scale score of 10, with a small subdural haematoma on CT and an L5/S1 disc prolapse. He had a smoke inhalation injury and was ventilated for four days in intensive care. His closest friend, a petty officer, died in the fire, and the veteran helped recover his body before he collapsed. "moderate TBI, ventilated, smoke inhalation"
- 09 May 2009 — On warlike service in the northern Arabian Gulf the veteran was a member of a boarding party when the crew of a dhow opened fire. He was held at gunpoint for several minutes, sustained a gunshot wound to the left thigh with a laceration of the femoral artery and femoral nerve, and struck his head on the gunwale with a brief loss of consciousness. He saw his close friend, a leading seaman, shot and killed, and carried his body back to the sea boat. He underwent emergency vascular repair and received four units of blood. "GSW thigh, femoral artery repaired"
- 16 Nov 2009 — A consultant psychiatrist diagnosed posttraumatic stress disorder related to the fire and the boarding, with nightmares, hypervigilance and avoidance. Post-traumatic migraine had been diagnosed on 22 September 2009 and was treated with sumatriptan. His wife had told him by email on 20 June 2009, while he was deployed, that the marriage was over, and they separated on his return. On 03 December 2009 he had his first generalised tonic-clonic seizure and a neurologist diagnosed post-traumatic epilepsy, commencing levetiracetam. "PTSD, post-traumatic epilepsy, levetiracetam"
- 22 Mar 2010 — He presented to the base medical officer after three sudden episodes since 18 March 2010 of pounding heart, sweating, trembling, breathlessness, chest tightness, tingling in both hands and fear of dying, peaking within ten minutes and arising without warning. The first occurred while he was driving to the base. ECG, troponin, thyroid function, Holter monitoring and an echocardiogram were normal. Video EEG later captured two attacks with no epileptiform change. His psychiatric review of 02 March 2010 had recorded no panic attacks. "unexpected attacks, cardiac workup normal"
- 06 May 2010 — A consultant psychiatrist diagnosed panic disorder. He had had recurrent unexpected attacks, followed by more than a month of persistent worry about further attacks and of avoidance of driving and crowded shopping centres. The attacks occurred out of the blue, including during periods of sobriety, and were not confined to trauma reminders. Sertraline was commenced and titrated to 100 mg, and cognitive behavioural therapy was started. The Panic Disorder Severity Scale score was 17, improving to 12 by January 2013. "panic disorder, sertraline 100 mg"
- 22 Nov 2012 — During a peacetime man-overboard exercise off the New South Wales coast his sea boat capsized in heavy seas. He was trapped under the hull for about a minute and was recovered unconscious. He developed aspiration pneumonia and was admitted to intensive care for three days. He had seen a trainee crushed between the boat and the ship's side, and helped lift the critically injured trainee from the water. His divorce had been finalised on 14 February 2012. "near drowning, aspiration pneumonia"
- 02 Sep 2013 — One week after returning from seven months on warlike service in the Middle East, where his sertraline supply ran out in April and no psychologist or psychiatrist was available, he presented with daily panic attacks, refusal to leave his home except to attend the base, and an inability to drive. The Panic Disorder Severity Scale score was 21, up from 12 in January 2013. He was admitted to a mental health unit on 09 September 2013. On deployment he had been fired on by a suspected pirate skiff on 17 May 2013 and had a breakthrough seizure in July 2013. "daily attacks, PDSS 21, admitted"
Symptoms
At onset the veteran had recurrent, unexpected surges of intense fear with palpitations, sweating, trembling, breathlessness, a choking sensation, chest tightness, tingling in both hands, light-headedness, feelings of unreality and fear of dying, each peaking within ten minutes. Within a month he was constantly worried about the next attack and began avoiding driving, supermarkets and crowded places, and he started carrying a paper bag and a mobile phone everywhere.
After the worsening in 2013 the attacks became daily, and he developed agoraphobic avoidance, leaving home only for essential appointments. He now reports two to four attacks a week despite treatment, avoids public transport and shopping centres, does not drive on freeways, and relies on his adult son for shopping and transport.
Imaging
- 12 Sep 2008 — CT brain: "Small right frontal subdural haematoma, 4 mm, with no midline shift. Small right frontal contusion."
- 12 Sep 2008 — MRI lumbar spine: "Acute L5/S1 left posterolateral disc prolapse compressing the left S1 nerve root."
- 08 Dec 2009 — MRI brain: "Gliosis and haemosiderin staining in the right frontal lobe at the site of the 2008 contusion, consistent with a post-traumatic epileptogenic focus."
- 25 Mar 2010 — Transthoracic echocardiogram: "Structurally normal heart with normal biventricular function. No valvular abnormality."
Onset Date
The most likely date of onset of this condition is 18 Mar 2010.
At that date the veteran was serving full time as a petty officer boatswain at a naval base in Australia, on restricted duties after his return from warlike service in the Middle East. He was being treated for posttraumatic stress disorder, post-traumatic epilepsy, chronic lumbar radicular pain, chronic left leg neuropathic pain, post-traumatic migraine, alcohol use disorder and obstructive sleep apnoea. On the morning of 18 March 2010 he had his first unexpected panic attack while driving to the base.
This date is appropriate because his psychiatric review of 02 March 2010 specifically recorded that he had no panic attacks, and he presented to the base medical officer on 22 March 2010 describing three attacks, the first on 18 March 2010. The date falls within uninterrupted full-time service.
For the Balance of Probabilities factors with a two-year window, the 2 years before onset run from 18 Mar 2008 to 18 Mar 2010; this period contains the fire of 12 September 2008, the smoke inhalation injury, the chronic lumbar condition and the marital separation. For the five-year factors, the 5 years before onset run from 18 Mar 2005 to 18 Mar 2010; this contains the obstructive sleep apnoea diagnosed in June 2006, the alcohol use disorder diagnosed in March 2007, the moderate traumatic brain injury and the death of his closest friend in September 2008, and the posttraumatic stress disorder. For the Reasonable Hypothesis factors, the 5 years before onset run from 18 Mar 2005 to 18 Mar 2010 and contain the boarding of 09 May 2009 on warlike service; the 10 years before onset run from 18 Mar 2000 to 18 Mar 2010; and the 2 years before onset run from 18 Mar 2008 to 18 Mar 2010, during which post-traumatic migraine was diagnosed. The epilepsy was established on 03 December 2009 and present at onset. The abuse occurred in 1983, long before onset.
For the worsening factors, the documented worsening is 02 Sep 2013. The 2 years before the worsening run from 02 Sep 2011 to 02 Sep 2013 and contain the capsize and near drowning of 22 November 2012, the finalised divorce and his 2013 warlike deployment. The 5 years before the worsening run from 02 Sep 2008 to 02 Sep 2013 and contain the fire of 12 September 2008, the boarding of 09 May 2009 and the death of both friends. The 10 years before the worsening run from 02 Sep 2003 to 02 Sep 2013, and migraine was active throughout the 2 years before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Panic Disorder (ICD-10-AM F41.0), under the Statements of Principles concerning panic disorder, Balance of Probabilities No. 56 of 2018 and Reasonable Hypothesis No. 55 of 2018.
Panic disorder is an anxiety disorder characterised by recurrent, unexpected panic attacks: abrupt surges of intense fear or discomfort that peak within minutes and are accompanied by physical symptoms such as palpitations, sweating, trembling, breathlessness, chest pain, dizziness and paraesthesia, and by cognitive symptoms such as fear of dying or of losing control. The attacks are followed by persistent worry about further attacks or by maladaptive behaviour to avoid them, and many people go on to develop agoraphobic avoidance. The condition is associated with prior trauma, other mental health disorders, brain injury, chronic medical illness and major life stress.
The diagnosis followed the veteran's childhood abuse in junior recruit training, a shipboard fire with a traumatic brain injury in 2008, and an armed boarding on warlike service in 2009 in which he was wounded and a close friend was killed. It began on 18 March 2010, was diagnosed by a psychiatrist on 06 May 2010 and worsened in 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 March 2010.
When did the veteran first present to a health / medical provider for this condition?
22 March 2010.
When was the condition confirmed / formally diagnosed?
06 May 2010.
When did the veteran first present to you (or your practice) for this condition?
17 June 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 06 May 2010 using the DSM-5 based criteria adopted in the Statement of Principles. The veteran had recurrent unexpected panic attacks, each with more than four of the specified symptoms (palpitations, sweating, trembling, shortness of breath, a choking sensation, chest discomfort, paraesthesia, derealisation and fear of dying), followed by more than a month of persistent worry about further attacks and avoidance of driving and crowded places.
Physiological and medical causes were excluded: ECG, troponin, thyroid function, Holter monitoring and echocardiography were normal, video EEG recorded two typical attacks without epileptiform change, and attacks occurred during periods of documented sobriety. The attacks were unexpected and not confined to trauma reminders, so they were not better explained by his posttraumatic stress disorder. The Panic Disorder Severity Scale score was 17 at diagnosis, 12 in January 2013 and 21 at the documented worsening on 02 September 2013.
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 18 March 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, including the shipboard fire of 2008 and the capsize of 2012. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Middle East in 2009, where he was wounded and his friend was killed, and in 2013, when the condition worsened.
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 Panic Disorder, No. 56 of 2018
Causative factors
Factor 9(1): experiencing a category 1A stressor within the two years before the clinical onset of panic disorder; — MET
- On 12 September 2008, during a peacetime exercise, the veteran was trapped in a smoke-filled passageway during an engine-room fire and fell four metres down a ladder while escaping, sustaining a moderate brain injury and a smoke inhalation injury that required ventilation. This was a life-threatening event 18 months before onset, within the 2 years from 18 March 2008 to 18 March 2010.
Factor 9(2): experiencing a category 1B stressor within the two years before the clinical onset of panic disorder; — MET
- In the same fire on 12 September 2008 the veteran helped recover the body of a petty officer who had died from burns and smoke, participating in the clearance of a corpse and viewing it as an eyewitness. This occurred within the 2 years before onset.
Factor 9(3): experiencing severe childhood abuse before the clinical onset of panic disorder; — MET
- From February to July 1983, while he was a 15-year-old junior recruit at a naval training establishment, the veteran was repeatedly beaten and sexually assaulted by an adult instructor, abuse he disclosed to Navy medical staff and which is recorded in his health file. The abuse was perpetrated by an adult working with him while he was under 16, in the course of his service, and occurred before onset.
Factor 9(4): experiencing the death of a significant other within the five years before the clinical onset of panic disorder; — MET
- The petty officer who died in the fire of 12 September 2008 was the veteran's closest friend of 15 years and the godfather of his son. His death occurred 18 months before onset, within the 5 years from 18 March 2005 to 18 March 2010.
Factor 9(5): having a clinically significant disorder of mental health from Specified List 1 within the five years before the clinical onset of panic disorder; — MET
- Alcohol use disorder was diagnosed on 19 March 2007 and managed with monthly counselling, and posttraumatic stress disorder was diagnosed by a psychiatrist on 16 November 2009 and treated with regular psychiatric review. Both are on Specified List 1, warranted ongoing management, and were present within the 5 years before onset. Both arose from his service: the drinking culture ashore and the 2008 fire.
Factor 9(6): having sleep apnoea within the five years before the clinical onset of panic disorder; — MET
- Moderate obstructive sleep apnoea, with an apnoea-hypopnoea index of 24, was diagnosed on polysomnography on 14 June 2006 and was present continuously to onset, within the 5 years before 18 March 2010. CPAP use at sea was inconsistent because of mess-deck accommodation.
Factor 9(7): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the two years before the clinical onset of panic disorder; — MET
- The smoke inhalation injury of 12 September 2008 required four days of mechanical ventilation in intensive care and was life-threatening, and the moderate traumatic brain injury in the same incident left him with post-traumatic epilepsy and cognitive slowing. Both occurred within the 2 years before onset, during peacetime service.
Factor 9(8): having a severe, chronic medical condition within the two years before the clinical onset of panic disorder; — MET
- The L5/S1 disc prolapse sustained in the ladder fall of 12 September 2008 caused chronic left S1 radicular pain that confined him to restricted duties and required daily oxycodone and pregabalin and weekly physiotherapy, supervised by a pain specialist and his medical officer, throughout the 2 years before onset.
Factor 9(9): having concussion or moderate to severe traumatic brain injury within the five years before the clinical onset of panic disorder; — MET
- In the ladder fall of 12 September 2008 the veteran lost consciousness for about 40 minutes, had a Glasgow Coma Scale score of 10 and a subdural haematoma and frontal contusion on CT, which is a moderate traumatic brain injury. It occurred 18 months before onset, within the 5-year window.
Factor 9(10): having epilepsy at the time of the clinical onset of panic disorder; — MET
- Post-traumatic epilepsy was diagnosed by a neurologist after a generalised tonic-clonic seizure on 03 December 2009, with a right frontal gliotic focus on MRI, and was being treated with levetiracetam on 18 March 2010. The epilepsy followed the brain injury sustained in the shipboard fire.
Factor 9(11): experiencing a category 2 stressor within the two years before the clinical onset of panic disorder; — MET
- After his return from deployment in July 2009 he separated from his wife, who had ended the marriage while he was away, and attended relationship counselling. He was also isolated from his former shipmates on restricted shore duties because of his injuries, which caused him ongoing distress. Both occurred within the 2 years before onset.
Worsening factors
Factor 9(12): experiencing a category 1A stressor within the two years before the clinical worsening of panic disorder; — MET
- On 22 November 2012, during a peacetime man-overboard exercise, the veteran's sea boat capsized and he was trapped under the hull and recovered unconscious. This life-threatening event occurred within the 2 years before the worsening documented on 02 September 2013, a window running from 02 September 2011.
Factor 9(13): experiencing a category 1B stressor within the two years before the clinical worsening of panic disorder; — MET
- In the capsize of 22 November 2012 he saw a trainee crushed between the sea boat and the ship's side and helped lift the critically injured trainee from the water, participating in the clearance of a critically injured casualty. This was within the 2 years before the worsening.
Factor 9(14): experiencing severe childhood abuse before the clinical worsening of panic disorder; — MET
- The severe physical and sexual abuse by an adult instructor in 1983, while the veteran was a 15-year-old junior recruit, occurred before the worsening in 2013.
Factor 9(15): experiencing the death of a significant other within the five years before the clinical worsening of panic disorder; — MET
- The death of his closest friend in the fire of 12 September 2008 falls within the 5 years before the worsening, from 02 September 2008 to 02 September 2013, as does the death of his close friend, a leading seaman, on 09 May 2009.
Factor 9(16): having a clinically significant disorder of mental health from Specified List 2 within the five years before the clinical worsening of panic disorder; — MET
- Posttraumatic stress disorder and alcohol use disorder, both on Specified List 2, were under ongoing psychiatric and psychological management throughout the 5 years before the worsening.
Factor 9(17): having sleep apnoea within the five years before the clinical worsening of panic disorder; — MET
- Obstructive sleep apnoea persisted throughout the 5 years before the worsening, and he was unable to use CPAP reliably on board during his 2013 deployment.
Factor 9(18): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the two years before the clinical worsening of panic disorder; — MET
- The near drowning of 22 November 2012 caused aspiration pneumonia requiring three days in intensive care, a life-threatening illness within the 2 years before the worsening.
Factor 9(19): having a severe, chronic medical condition within the two years before the clinical worsening of panic disorder; — MET
- The chronic lumbar radicular pain continued throughout the 2 years before the worsening, requiring daily opioid and neuropathic medication and regular physiotherapy supervised by his pain specialist, and it limited him to restricted duties.
Factor 9(20): having concussion or moderate to severe traumatic brain injury within the five years before the clinical worsening of panic disorder; — MET
- The moderate traumatic brain injury of 12 September 2008 falls within the 5 years before the worsening, which run from 02 September 2008 to 02 September 2013.
Factor 9(21): having epilepsy at the time of the clinical worsening of panic disorder; — MET
- Post-traumatic epilepsy was present at the worsening, with a breakthrough seizure in July 2013, and levetiracetam was increased in September 2013.
Factor 9(22): experiencing a category 2 stressor within the two years before the clinical worsening of panic disorder; — MET
- The divorce was finalised on 14 February 2012, and through 2012 and 2013 he had ongoing conflict with a new divisional officer over his restricted duties and a stressful workload he felt unable to control. These caused him ongoing distress within the 2 years before the worsening.
Factor 9(23): inability to obtain appropriate clinical management for panic disorder. — MET
- During his deployment from February to August 2013 the ship's medical stores could not resupply sertraline after April and there was no access to a psychologist or psychiatrist for four months. His cognitive behavioural therapy stopped, and the panic disorder worsened from a Panic Disorder Severity Scale score of 12 to 21. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Panic Disorder, No. 55 of 2018
Causative factors
Factor 9(1): experiencing a category 1A stressor within the five years before the clinical onset of panic disorder; — MET
- On 09 May 2009, on warlike service in the northern Arabian Gulf, the crew of a dhow opened fire on his boarding party. He was held at gunpoint and shot in the left thigh, with a femoral artery laceration. This was a life-threatening event and being threatened with a weapon, 10 months before onset and within the 5 years from 18 March 2005 to 18 March 2010.
Factor 9(2): experiencing a category 1B stressor within the five years before the clinical onset of panic disorder; — MET
- During the same boarding on 09 May 2009 he was an eyewitness to a leading seaman being shot and killed, and he carried the body back to the sea boat. This occurred on warlike service within the 5 years before onset.
Factor 9(3): experiencing severe childhood abuse before the clinical onset of panic disorder; — MET
- The veteran was repeatedly beaten and sexually assaulted by an adult instructor from February to July 1983 while a 15-year-old junior recruit. The abuse occurred before onset, and its effect on his vulnerability to anxiety was compounded by the trauma of his warlike service in 2009.
Factor 9(4): experiencing the death of a significant other within the ten years before the clinical onset of panic disorder; — MET
- The leading seaman killed on 09 May 2009 on warlike service had been the veteran's close friend and boarding partner for six years. His death was within the 10 years before onset, from 18 March 2000 to 18 March 2010.
Factor 9(5): having a clinically significant disorder of mental health from Specified List 1 within the ten years before the clinical onset of panic disorder; — MET
- Posttraumatic stress disorder, diagnosed on 16 November 2009 and arising in part from the boarding on warlike service, and alcohol use disorder, diagnosed on 19 March 2007 and escalating after his return from the Middle East, were both under ongoing management within the 10 years before onset.
Factor 9(6): having sleep apnoea within the ten years before the clinical onset of panic disorder; — MET
- Obstructive sleep apnoea was diagnosed on 14 June 2006 and persisted through his 2009 warlike deployment, when CPAP could not be used in shared mess-deck accommodation, and up to onset.
Factor 9(7): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical onset of panic disorder; — MET
- The gunshot wound of 09 May 2009, with femoral artery laceration requiring emergency vascular repair and transfusion of four units of blood, was a life-threatening injury on warlike service within the 5 years before onset. It left him with a femoral nerve injury and weakness of the left leg.
Factor 9(8): having a severe, chronic medical condition within the five years before the clinical onset of panic disorder; — MET
- The femoral nerve injury from the 2009 gunshot wound caused chronic neuropathic pain in the left leg, requiring daily pregabalin and oxycodone supervised by a pain specialist and limiting him to restricted duties, within the 5 years before onset.
Factor 9(9): having concussion or moderate to severe traumatic brain injury within the ten years before the clinical onset of panic disorder; — MET
- During the boarding on 09 May 2009 he struck his head on the gunwale, lost consciousness for about two minutes and had post-traumatic amnesia, which is a concussion sustained on warlike service within the 10 years before onset.
Factor 9(10): having epilepsy at the time of the clinical onset of panic disorder; — MET
- Post-traumatic epilepsy, diagnosed on 03 December 2009 and treated with levetiracetam, was present at onset on 18 March 2010. The first seizure occurred within months of the concussion sustained on warlike service, which lowered his seizure threshold.
Factor 9(11): experiencing a category 2 stressor within the five years before the clinical onset of panic disorder; — MET
- On 20 June 2009, while he was on warlike service in the Middle East, his wife told him by email that she was ending the marriage, and he was unable to return home or speak to his children for a month. The separation, social isolation and relationship counselling caused him ongoing distress within the 5 years before onset.
Factor 9(12): having migraine within the two years before the clinical onset of panic disorder; — MET
- Post-traumatic migraine was diagnosed on 22 September 2009, after the head injury on warlike service, and was treated with sumatriptan. It was active within the 2 years before onset, from 18 March 2008 to 18 March 2010.
Worsening factors
Factor 9(13): experiencing a category 1A stressor within the five years before the clinical worsening of panic disorder; — MET
- The armed boarding of 09 May 2009 and the firing on his ship by a suspected pirate skiff on 17 May 2013, both on warlike service in the Middle East, were life-threatening events within the 5 years before the worsening, from 02 September 2008 to 02 September 2013.
Factor 9(14): experiencing a category 1B stressor within the five years before the clinical worsening of panic disorder; — MET
- His witnessing of his friend's death and carrying of the body on 09 May 2009, on warlike service, falls within the 5 years before the worsening.
Factor 9(15): experiencing severe childhood abuse before the clinical worsening of panic disorder; — MET
- The severe abuse in junior recruit training in 1983 occurred before the worsening, which followed his 2013 warlike deployment.
Factor 9(16): experiencing the death of a significant other within the ten years before the clinical worsening of panic disorder; — MET
- His close friend was killed on warlike service on 09 May 2009, within the 10 years before the worsening, from 02 September 2003 to 02 September 2013.
Factor 9(17): having a clinically significant disorder of mental health from Specified List 2 within the ten years before the clinical worsening of panic disorder; — MET
- Posttraumatic stress disorder and alcohol use disorder were present and under management within the 10 years before the worsening, and both worsened during his 2013 warlike deployment.
Factor 9(18): having sleep apnoea within the ten years before the clinical worsening of panic disorder; — MET
- Obstructive sleep apnoea was present throughout the 10 years before the worsening and went largely untreated during his 2013 warlike deployment.
Factor 9(19): having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical worsening of panic disorder; — MET
- The life-threatening gunshot wound of 09 May 2009, sustained on warlike service, falls within the 5 years before the worsening.
Factor 9(20): having a severe, chronic medical condition within the five years before the clinical worsening of panic disorder; — MET
- Chronic neuropathic pain from the femoral nerve injury sustained on warlike service required daily medication under specialist supervision throughout the 5 years before the worsening, including during his 2013 deployment.
Factor 9(21): having concussion or moderate to severe traumatic brain injury within the ten years before the clinical worsening of panic disorder; — MET
- The concussion of 09 May 2009 on warlike service falls within the 10 years before the worsening.
Factor 9(22): having epilepsy at the time of the clinical worsening of panic disorder; — MET
- Post-traumatic epilepsy was present at the worsening, with a breakthrough seizure in July 2013 on warlike service when his levetiracetam supply ran low.
Factor 9(23): experiencing a category 2 stressor within the five years before the clinical worsening of panic disorder; — MET
- During his seven-month warlike deployment in 2013 he was socially isolated from his children, with communications restricted for long periods, and he was in ongoing dispute over custody arrangements after the divorce. These caused him ongoing distress within the 5 years before the worsening.
Factor 9(24): having migraine within the two years before the clinical worsening of panic disorder; — MET
- Post-traumatic migraine persisted through the 2 years before the worsening, with weekly attacks during his 2013 warlike deployment recorded by the ship's medical officer.
Factor 9(25): inability to obtain appropriate clinical management for panic disorder. — MET
- On warlike service in the Middle East from February to August 2013 the veteran's sertraline supply ran out in April and there was no psychologist or psychiatrist available for four months. His treatment stopped and the panic disorder worsened to daily attacks with a Panic Disorder Severity Scale score of 21.
The % contribution of the causes is 100% and significant.
Sequelae
The panic disorder is a sequela of the veteran's accepted conditions, particularly the posttraumatic stress disorder, the moderate traumatic brain injury with post-traumatic epilepsy, and the chronic pain conditions arising from the 2008 fire and the 2009 boarding. In turn, the panic disorder has contributed to agoraphobic avoidance, increased alcohol use for symptom relief and social withdrawal.
Unintended Consequence
Not met. No treatment provided or funded by the Commonwealth caused the panic disorder. The interruption of treatment during the 2013 deployment is addressed under inability to obtain appropriate clinical management.
Inability to Attain Appropriate Medical Management
MET. From April to August 2013, on warlike service in the Middle East, the veteran's prescribed sertraline ran out and could not be resupplied, and no psychologist or psychiatrist was available, so his established cognitive behavioural therapy and medication both stopped. The panic disorder worsened from a Panic Disorder Severity Scale score of 12 in January 2013 to 21 on 02 September 2013, with daily attacks and an admission to a mental health unit. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational circumstances that prevent a member from continuing prescribed treatment amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 Jun 2006, Diagnostic polysomnography report, Sleep physician
- 19 Mar 2007, Psychology assessment, Navy psychologist
- 12 Sep 2008, Trauma admission, CT brain and intensive care discharge summary, Tertiary hospital
- 12 Sep 2008, MRI lumbar spine, Radiologist
- 09 May 2009, Casualty report and operation note, Role 3 hospital, Middle East
- 22 Sep 2009, Neurology consultation, Neurologist
- 16 Nov 2009, Psychiatric assessment, Consultant psychiatrist
- 08 Dec 2009, MRI brain and epilepsy clinic letter, Neurologist
- 02 Mar 2010, Psychiatric review, Consultant psychiatrist
- 22 Mar 2010, Outpatient health record, Medical Officer, Naval base health centre
- 25 Mar 2010, Echocardiogram and Holter monitor reports, Cardiologist
- 06 May 2010, Psychiatric assessment, Consultant psychiatrist
- 22 Nov 2012, Intensive care discharge summary, Regional hospital
- 02 Sep 2013, Outpatient health record, Medical Officer, Naval base health centre
- 09 Sep 2013, Mental health unit admission, Consultant psychiatrist
- Statement of Principles concerning Panic Disorder (Balance of Probabilities) No. 56 of 2018, Repatriation Medical Authority
- Statement of Principles concerning Panic Disorder (Reasonable Hypothesis) No. 55 of 2018, Repatriation Medical Authority
