Diagnostic Assessment — Tobacco Use Disorder
Example 1 of 1 · fictitious patient (Veteran AB)
Diagnostic Assessment
Tobacco Use Disorder
BOP Code: 51 of 2026 (Substance Use Disorder)
RH Code: 50 of 2026 (Substance Use Disorder)
ADF History
Veteran AB, date of birth 14 August 1987, Australian Army, Rifleman (Infantry Soldier), enlisted 03 September 2004, medically discharged 22 May 2014. Operational service: Iraq, 01 May 2006 to 30 November 2006 (warlike); Afghanistan, 15 February 2010 to 30 September 2010 (warlike).
Occupational History
Infantry soldiers patrol, man checkpoints and conduct security operations in high-threat environments, with exposure to rocket and mortar attack, improvised explosive devices, small arms fire, mass casualty events and the injury and death of colleagues and civilians. Long periods of boredom alternate with sudden danger, and sleep is short and disrupted.
In the period of this veteran's service, smoking was widespread and socially reinforced in infantry units: cigarettes were cheap or free on deployment, smoke breaks were the main break from duty, and smoking was an accepted way of coping with stress, fatigue and hunger. Heavy drinking was also normalised in barracks.
History
Veteran AB, an infantry soldier in the Australian Army, developed tobacco use disorder on 01 October 2006 during warlike service in Iraq, after a life-threatening rocket attack, a mass casualty bombing, bullying and a relationship break-up, on a background of childhood abuse, ADHD, conduct disorder and alcohol use disorder. The disorder worsened on warlike service in Afghanistan in 2010 after a blast injury and the death of a friend, and again in 2017 after medical discharge, with multiple comorbid mental health and substance use disorders.
Timeline
- 19 May 2006 — Before deployment, a Defence social worker recorded intimate partner violence by his fiancée, including threats, coercive control and two physical assaults, and a formal complaint of bullying by senior soldiers. A psychologist diagnosed generalised anxiety disorder. He was smoking about 8 cigarettes a day socially, without loss of control. His history recorded childhood abuse and neglect, ADHD diagnosed at age 8, oppositional defiant disorder at 10, conduct disorder at 14 and alcohol use disorder from 2005. "IPV, bullying, GAD, smokes socially"
- 12 Jun 2006 — During warlike service in Iraq a rocket struck his accommodation block at night. The room collapsed and he was trapped for about 20 minutes believing he would die. He had minor lacerations and was returned to duties the next day. "trapped after rocket strike"
- 20 Jul 2006 — First on scene after a vehicle-borne bomb at a checkpoint. He recovered human remains and treated critically injured casualties. In the same month he was ordered to turn away a family with an injured child at the checkpoint and later learned the child had died. He began smoking 20 to 25 cigarettes a day. "mass casualty, human remains"
- 14 Aug 2006 — Seen by the medical officer for insomnia, purging after binge eating and increasing smoking after his engagement ended. Bulimia nervosa was recorded. Nicotine patches 21 mg a day were prescribed to help him stop smoking. He continued to smoke while wearing the patches. "nicotine patches 21 mg prescribed"
- 04 Oct 2006 — Review recorded smoking 30 cigarettes a day, smoking within five minutes of waking and through the night, strong cravings, two failed attempts to stop since August, smoking on sentry against orders and continued smoking despite worsening asthma. Fagerstrom score 8. Insomnia disorder, posttraumatic stress symptoms and alcohol use disorder were recorded. Tobacco dependence was diagnosed, with onset dated to 01 October 2006 when he first met the criteria. "30 per day, Fagerstrom 8"
- 18 Apr 2010 — During warlike service in Afghanistan his vehicle struck an improvised explosive device. His closest friend in his section was killed beside him. He sustained an L1 compression fracture and continued on light duties in theatre with persistent back pain. Later that year a fire mission he had called caused civilian deaths. "IED, mate KIA, L1 fracture"
- 02 Oct 2010 — Post-deployment psychological screening recorded smoking 40 cigarettes a day with daily chewing tobacco since about 20 September 2010, up from 30 a day, with major depressive disorder, panic disorder, intermittent explosive disorder, binge-eating disorder and gambling disorder. No smoking cessation support had been available in Afghanistan. Varenicline was commenced but stopped after two weeks because of nightmares. "40 per day, chewing tobacco"
- 12 Apr 2017 — Admitted to a psychiatric unit after a suicide attempt, three years after medical discharge for posttraumatic stress disorder and chronic back pain. He was smoking 60 cigarettes a day and using cannabis, methamphetamine and hallucinogens. The admission recorded schizoaffective disorder, bipolar features, persistent depressive disorder, prolonged grief, agoraphobia, social anxiety, obsessive-compulsive disorder, borderline and antisocial personality disorders and anorexia nervosa, with unemployment, financial hardship and violence from his wife. "60 per day, multiple comorbidities"
Symptoms
At onset the veteran was smoking 30 cigarettes a day, lighting up within five minutes of waking and during the night, with strong cravings, irritability and poor concentration when he could not smoke, failed attempts to stop, smoking on sentry against orders, and continued smoking despite worsening asthma and wheeze. After onset his consumption rose further in periods of stress.
He now smokes 50 to 60 cigarettes a day despite chronic obstructive pulmonary disease, spends a large part of his disability income on tobacco, has made more than ten unsuccessful quit attempts and has severe withdrawal symptoms within an hour of his last cigarette.
Imaging
No imaging is required to establish this diagnosis.
Onset Date
The most likely date of onset of this condition is 01 Oct 2006.
At that date the veteran was on warlike service in Iraq as an infantry soldier manning checkpoints and conducting security patrols. In the preceding four months he had been trapped in a rocket strike on his accommodation, recovered human remains after a vehicle-borne bomb, turned away an injured child who later died, been bullied by senior soldiers, and ended an abusive engagement. He was taking prescribed nicotine patches and had untreated insomnia, posttraumatic stress disorder, bulimia nervosa and alcohol use disorder.
This date is appropriate because the social worker and psychology records of 19 May 2006 recorded social smoking of about 8 cigarettes a day without loss of control, and the review of 04 October 2006 recorded that he had met at least five of the diagnostic criteria for tobacco use disorder since 01 October 2006. It falls within continuous full-time warlike service.
For the category 1A and 1B stressor factors, the 2 years (Balance of Probabilities) and 5 years (Reasonable Hypothesis) before onset run from 01 Oct 2004 and 01 Oct 2001 respectively to 01 Oct 2006, and contain the rocket strike of 12 Jun 2006 and the bombing of 20 Jul 2006. For the category 2 stressor factors, the 6 months and 1 year before onset run from 01 Apr 2006 and 01 Oct 2005 to 01 Oct 2006, and contain the bullying from April 2006 and the end of his engagement in August 2006. For the bereavement factor, the 5 years before onset run from 01 Oct 2001 to 01 Oct 2006 and contain his brother's death on 14 Mar 2005. For the intimate partner violence factors, the 2 and 5 years before onset contain the violence from mid-2005 to August 2006. The moral injury of July 2006 falls within the 5 years before onset. The childhood abuse and neglect preceded onset, and the nicotine patches prescribed on 14 Aug 2006 were in use at onset.
For the worsening factors, there were two documented worsenings. The first was on 20 Sep 2010, on warlike service in Afghanistan, when consumption rose from 30 to 40 cigarettes a day with added chewing tobacco, recorded on 02 Oct 2010; the 5 years before it run from 20 Sep 2005 to 20 Sep 2010 and contain the blast and death of his friend on 18 Apr 2010, the civilian deaths later in 2010 and the Iraq events of 2006, and by then he had five months of persistent back pain. The second was on 12 Apr 2017, when consumption had risen to 60 a day; the 6 months and 1 year before it run from 12 Oct 2016 and 12 Apr 2016 and contain his unemployment, financial hardship and marital breakdown, and the 2 years before it contain his wife's violence from 2016.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Tobacco Use Disorder (ICD-10 F17.2), severe, under the Statements of Principles concerning substance use disorder, Balance of Probabilities No. 51 of 2026 and Reasonable Hypothesis No. 50 of 2026, in which tobacco is a listed substance.
Tobacco use disorder is a problematic pattern of tobacco use leading to clinically significant impairment or distress, shown by at least two of the DSM-5-TR criteria within a 12-month period, including using more than intended, persistent desire or failed efforts to cut down, craving, use in hazardous situations, continued use despite physical or psychological problems caused by it, tolerance and withdrawal. Nicotine dependence develops quickly under stress, and it is strongly associated with trauma exposure, posttraumatic stress disorder, depression, ADHD and other substance use disorders. It causes chronic lung disease, cardiovascular disease and cancers.
The diagnosis followed severe traumatic stressors, bullying, a relationship break-up and moral injury on warlike service in Iraq in 2006, in a young soldier with childhood adversity and several pre-existing mental health disorders. It began on 01 October 2006, worsened on warlike service in Afghanistan in 2010 and worsened again in 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
01 October 2006.
When did the veteran first present to a health / medical provider for this condition?
04 October 2006.
When was the condition confirmed / formally diagnosed?
04 October 2006.
When did the veteran first present to you (or your practice) for this condition?
03 September 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made on 04 October 2006 by a Defence medical officer, who documented at least five DSM criteria present since 01 October 2006: smoking larger amounts than intended (30 a day), persistent desire and two failed attempts to stop, strong cravings, smoking in physically hazardous situations on sentry, continued smoking despite worsening asthma, and withdrawal irritability and poor concentration when unable to smoke. His Fagerstrom Test for Nicotine Dependence score was 8, indicating high dependence. This meets the Statement of Principles definition of substance use disorder, derived from DSM-5-TR, with tobacco as the substance.
The worsenings were documented on 02 October 2010, with consumption rising to 40 cigarettes a day with chewing tobacco, and on 12 April 2017, with 60 cigarettes a day, six or more criteria (severe) and the failure of varenicline and nicotine replacement. A psychiatrist confirmed severe tobacco use disorder during the 2017 admission.
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 01 October 2006, after 1 July 2004, during continuous full-time warlike service in Iraq. 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 bullying, intimate partner violence and mental health disorders documented in barracks. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2006, where the disorder began, and in Afghanistan in 2010, where it first worsened. Factors that refer to another disorder bring in that disorder's own Statement of Principles.
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 Substance Use Disorder, No. 51 of 2026
Causative factors (clinical onset or clinical worsening)
Factor 9(1)(a): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: alcohol use disorder; — MET
- The veteran met the criteria for alcohol use disorder from 2005, drinking 10 to 12 standard drinks on most nights in barracks during peacetime service, with failed attempts to cut down and a disciplinary charge in March 2006. It was present at onset on 01 October 2006, and he smoked whenever he drank.
Factor 9(1)(b): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: anorexia nervosa; — MET
- Anorexia nervosa, binge-eating/purging type, was diagnosed during the admission of 12 April 2017, with a BMI of 16.8, restriction and fear of weight gain after discharge. He used cigarettes to suppress appetite. It was present at the second worsening.
Factor 9(1)(c): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: antisocial personality disorder; — MET
- A forensic psychiatrist diagnosed antisocial personality disorder on 12 April 2017, with a history of conduct disorder before age 15 and adult impulsivity, deceitfulness and disregard for safety documented through his service. It was present at the second worsening.
Factor 9(1)(d): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: attention-deficit/hyperactivity disorder; — MET
- ADHD, combined presentation, was diagnosed by a paediatrician at age 8 and persisted into adulthood, with inattention and impulsivity recorded by his platoon commander in 2006. It was present at onset on 01 October 2006. Nicotine is used by people with ADHD as self-medication.
Factor 9(1)(e): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: borderline personality disorder; — MET
- Borderline personality disorder was diagnosed by a psychiatrist on 12 April 2017, with unstable relationships, recurrent self-harm and chronic emptiness, and was present at the second worsening.
Factor 9(1)(f): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: binge-eating disorder; — MET
- Binge-eating disorder, with weekly binges and weight gain of 18 kilograms in 2010, was diagnosed by a psychologist on 02 October 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(g): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: bipolar disorder; — MET
- Bipolar I disorder was diagnosed after a manic episode in 2015 and was present at the second worsening on 12 April 2017. He smoked up to 60 cigarettes a day when elevated.
Factor 9(1)(h): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: bulimia nervosa; — MET
- Bulimia nervosa, with weekly binge eating and self-induced vomiting to meet body composition standards, was diagnosed by a medical officer in August 2006 and was present at onset on 01 October 2006.
Factor 9(1)(i): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: cannabis use disorder; — MET
- Cannabis use disorder developed after discharge, with daily use from 2015 to manage pain and sleep, and was present at the second worsening on 12 April 2017.
Factor 9(1)(j): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: conduct disorder; — MET
- Conduct disorder, adolescent-onset, was diagnosed at age 14 and its criteria were still met at age 19, with fighting, theft and property damage recorded in his first two years of service. It was present at onset on 01 October 2006.
Factor 9(1)(k): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: gambling disorder; — MET
- Gambling disorder, with online sports betting losses of more than 30,000 dollars in 2009 and 2010 and failed attempts to stop, was diagnosed on 02 October 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(l): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: generalised anxiety disorder; — MET
- Generalised anxiety disorder was diagnosed by a psychologist in May 2006, with six months of uncontrollable worry, tension and poor sleep in barracks, and was present at onset on 01 October 2006.
Factor 9(1)(m): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: hallucinogen use disorder; — MET
- Hallucinogen use disorder, with repeated LSD and psilocybin use from 2015, was diagnosed on 12 April 2017 and was present at the second worsening.
Factor 9(1)(n): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: intermittent explosive disorder; — MET
- Intermittent explosive disorder, with recurrent verbal and physical outbursts, was diagnosed on 02 October 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(o): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: major depressive disorder; — MET
- Major depressive disorder was diagnosed on 02 October 2010 after two months of low mood, anhedonia and suicidal thoughts, and was present at the first worsening on 20 September 2010.
Factor 9(1)(p): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: oppositional defiant disorder; — MET
- Oppositional defiant disorder was diagnosed at age 10 and its criteria were still met at age 19, with repeated defiance of supervisors leading to two charges in 2006. It was present at onset on 01 October 2006.
Factor 9(1)(q): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: panic disorder; — MET
- Panic disorder, with recurrent unexpected panic attacks from mid-2010, was diagnosed on 02 October 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(r): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: persistent depressive disorder; — MET
- Persistent depressive disorder, with chronic depressed mood for more than two years after discharge, was diagnosed on 12 April 2017 and was present at the second worsening.
Factor 9(1)(s): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: posttraumatic stress disorder; — MET
- A psychiatrist diagnosed posttraumatic stress disorder in December 2006, with intrusive memories, nightmares and hypervigilance dating from September 2006 after the traumatic events in Iraq. It was present at onset on 01 October 2006.
Factor 9(1)(t): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: prolonged grief disorder; — MET
- Prolonged grief disorder, over the death of his closest friend in his section in April 2010, was diagnosed on 12 April 2017 and was present at the second worsening.
Factor 9(1)(u): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: social anxiety disorder; — MET
- Social anxiety disorder was diagnosed on 12 April 2017, with avoidance of social situations since discharge, and was present at the second worsening.
Factor 9(1)(v): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: stimulant use disorder; — MET
- Stimulant use disorder, with methamphetamine use from 2016, was diagnosed on 12 April 2017 and was present at the second worsening.
Factor 9(1)(w): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: tobacco use disorder. — MET
- Tobacco use disorder, established on 01 October 2006, was itself present at the first worsening on 20 September 2010 and at the second worsening on 12 April 2017, and the established dependence drove the escalation in use at each worsening.
Factor 9(2): experiencing a category 1A stressor within the 2 years before clinical onset or clinical worsening; — MET
- On 12 June 2006 a rocket struck the accommodation block where the veteran was sleeping, killing no one but collapsing the room around him; he was trapped for 20 minutes believing he would die. This life-threatening event was within the 2 years before onset on 01 October 2006. On 18 April 2010 his vehicle was struck by an improvised explosive device, within the 2 years before the first worsening.
Factor 9(3): experiencing a category 1B stressor within the 2 years before clinical onset or clinical worsening; — MET
- On 20 July 2006 the veteran was first on scene after a vehicle-borne bomb at a checkpoint and recovered human remains and treated critically injured casualties. This was within the 2 years before onset. On 18 April 2010 he witnessed a member of his section being killed, within the 2 years before the first worsening.
Factor 9(4): experiencing a category 2 stressor within the 6 months before clinical onset or clinical worsening; — MET
- From April 2006, within the 6 months before onset, the veteran was persistently bullied by two senior soldiers in his platoon in barracks and on deployment, recorded in a complaint of 19 May 2006, and his engagement ended in August 2006. Before the second worsening, from October 2016 to April 2017, he was unemployed, in severe financial hardship and his marriage had broken down.
Factor 9(5): experiencing the death of a person with whom one has a close family bond or a close personal relationship, within the 5 years before clinical onset or clinical worsening; — MET
- The veteran's older brother was killed in a car crash on 14 March 2005, within the 5 years before onset on 01 October 2006. His closest friend in his section was killed on 18 April 2010, within the 5 years before the first worsening.
Factor 9(6)(a): having experienced as a child (under the age of 18) one of the following: serious physical, emotional, or sexual harm; before clinical onset or clinical worsening; — MET
- Child protection and school counsellor records document serious physical and emotional abuse by his stepfather from age 6 to 15, including a fractured forearm at age 11, all before onset in 2006.
Factor 9(6)(b): having experienced as a child (under the age of 18) one of the following: neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing by adults with obligations to provide such necessities; before clinical onset or clinical worsening; — MET
- Child protection records document neglect from age 6 to 14, with inadequate food, missed medical care and long periods unsupervised while his mother was unwell, before onset in 2006. He began smoking at 13.
Factor 9(7): taking a medically prescribed substance from the same pharmacological class as the diagnosed substance use disorder, at the time of clinical onset; — MET
- On 14 August 2006 a medical officer prescribed nicotine patches 21 mg a day in an attempt to stop the veteran's increasing smoking. He was using the prescribed patches while continuing to smoke at the onset of tobacco use disorder on 01 October 2006. Nicotine replacement and tobacco are the same pharmacological class.
Factor 9(8): experiencing intimate partner violence within the 2 years before clinical onset or clinical worsening; — MET
- From mid-2005 to August 2006, within the 2 years before onset, his then fiancée subjected him to threats, coercive control, humiliation and two physical assaults, recorded by a Defence social worker in May 2006. His wife's violence and threats from 2016 were recorded before the second worsening.
Worsening factors
Factor 9(9): inability to obtain appropriate clinical management for substance use disorder before clinical worsening. — MET
- During warlike service in Afghanistan in 2010 no smoking cessation counselling or pharmacotherapy was available in theatre and cigarettes were freely supplied. After discharge in 2014 he waited more than ten months for a mental health and addiction service appointment. The tobacco use disorder worsened each time. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before clinical worsening.
Reasonable Hypothesis — Statement of Principles concerning Substance Use Disorder, No. 50 of 2026
Causative factors (clinical onset or clinical worsening)
Factor 9(1)(a): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: agoraphobia; — MET
- A psychiatrist diagnosed agoraphobia during the admission of 12 April 2017, when the veteran had not left his house alone for eight months for fear of panic in crowds and open places, a fear that began after crowd-borne threats on warlike service in Iraq and Afghanistan. It was present at the second worsening.
Factor 9(1)(b): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: alcohol use disorder; — MET
- Alcohol use disorder, established in 2005, persisted through warlike service in Iraq, where he drank heavily on rest and recreation and at the base, and was present at onset on 01 October 2006.
Factor 9(1)(c): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: anorexia nervosa; — MET
- Anorexia nervosa, binge-eating/purging type, with a BMI of 16.8, was diagnosed on 12 April 2017 and was present at the second worsening. He smoked heavily to suppress appetite.
Factor 9(1)(d): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: antisocial personality disorder; — MET
- Antisocial personality disorder was diagnosed on 12 April 2017, after conduct disorder in adolescence and escalating risk-taking after warlike service. It was present at the second worsening.
Factor 9(1)(e): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: attention-deficit/hyperactivity disorder; — MET
- ADHD, diagnosed in childhood, persisted and was recorded as impairing his work during warlike service in Iraq. It was present at onset on 01 October 2006.
Factor 9(1)(f): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: borderline personality disorder; — MET
- Borderline personality disorder was diagnosed on 12 April 2017, with unstable relationships, self-harm and chronic emptiness that began after his warlike service. It was present at the second worsening.
Factor 9(1)(g): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: binge-eating disorder; — MET
- Binge-eating disorder developed during warlike service in Afghanistan in 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(h): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: bipolar disorder; — MET
- Bipolar I disorder was diagnosed after a manic episode in 2015, a year after medical discharge for posttraumatic stress disorder from warlike service, and was present at the second worsening on 12 April 2017.
Factor 9(1)(i): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: bulimia nervosa; — MET
- Bulimia nervosa was present during warlike service in Iraq, diagnosed in August 2006, and was present at onset on 01 October 2006. He smoked to suppress appetite after purging.
Factor 9(1)(j): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: cannabis use disorder; — MET
- Cannabis use disorder, with daily use from 2015 to manage pain from the 2010 blast injury and nightmares from warlike service, was present at the second worsening on 12 April 2017.
Factor 9(1)(k): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: conduct disorder; — MET
- Conduct disorder, diagnosed at age 14, continued to meet the criteria at onset on 01 October 2006, with fighting and property damage recorded during warlike service in Iraq.
Factor 9(1)(l): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: gambling disorder; — MET
- Gambling disorder, with daily online betting from the base during warlike service in Afghanistan, was present at the first worsening on 20 September 2010.
Factor 9(1)(m): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: generalised anxiety disorder; — MET
- Generalised anxiety disorder, diagnosed in May 2006, was present during warlike service in Iraq and at onset on 01 October 2006.
Factor 9(1)(n): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: hallucinogen use disorder; — MET
- Hallucinogen use disorder, with use of LSD and psilocybin from 2015 in an attempt to treat posttraumatic stress disorder from warlike service, was present at the second worsening on 12 April 2017.
Factor 9(1)(o): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: insomnia disorder; — MET
- Insomnia disorder, with sleep onset over two hours and three hours' sleep a night for more than three months, was diagnosed during warlike service in Iraq in September 2006 and was present at onset on 01 October 2006. He smoked through the night.
Factor 9(1)(p): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: intermittent explosive disorder; — MET
- Intermittent explosive disorder developed after warlike service in Iraq and was present during warlike service in Afghanistan, at the first worsening on 20 September 2010.
Factor 9(1)(q): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: major depressive disorder; — MET
- Major depressive disorder developed during warlike service in Afghanistan after the death of a section member in April 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(r): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: obsessive-compulsive disorder; — MET
- Obsessive-compulsive disorder, with checking rituals focused on weapons, locks and contamination that began after warlike service, was diagnosed on 12 April 2017 and was present at the second worsening.
Factor 9(1)(s): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: oppositional defiant disorder; — MET
- Oppositional defiant disorder, diagnosed in childhood, still met the criteria during warlike service in Iraq and was present at onset on 01 October 2006.
Factor 9(1)(t): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: panic disorder; — MET
- Panic disorder began during warlike service in Afghanistan after the blast of 18 April 2010 and was present at the first worsening on 20 September 2010.
Factor 9(1)(u): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: persistent depressive disorder; — MET
- Persistent depressive disorder, a chronic continuation of the depression that began on warlike service in Afghanistan, was present at the second worsening on 12 April 2017.
Factor 9(1)(v): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: posttraumatic stress disorder; — MET
- Posttraumatic stress disorder arising from the rocket attack and the vehicle-borne bomb on warlike service in Iraq in mid-2006 was present from September 2006, at onset on 01 October 2006.
Factor 9(1)(w): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: prolonged grief disorder; — MET
- Prolonged grief disorder over a section member killed beside him on warlike service in Afghanistan on 18 April 2010 was diagnosed on 12 April 2017 and was present at the second worsening.
Factor 9(1)(x): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: schizophrenia or schizoaffective disorder; — MET
- Psychotic symptoms persisting outside mood episodes from 2016 led to a diagnosis of schizoaffective disorder, bipolar type, on 12 April 2017, which was present at the second worsening. The treating psychiatrist linked the illness to trauma and substance use after warlike service.
Factor 9(1)(y): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: social anxiety disorder; — MET
- Social anxiety disorder developed after medical discharge and was present at the second worsening on 12 April 2017.
Factor 9(1)(z): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: stimulant use disorder; — MET
- Stimulant use disorder, with methamphetamine use from 2016 to counter fatigue and depression after warlike service, was present at the second worsening on 12 April 2017.
Factor 9(1)(aa): having one of the following clinically significant disorders of mental health at the time of clinical onset or clinical worsening: tobacco use disorder. — MET
- Tobacco use disorder, which began on warlike service in Iraq on 01 October 2006, was present at the first worsening on warlike service in Afghanistan on 20 September 2010 and at the second worsening on 12 April 2017.
Factor 9(2): experiencing a category 1A stressor within the 5 years before clinical onset or clinical worsening; — MET
- On warlike service in Iraq on 12 June 2006 a rocket struck the veteran's accommodation and he was trapped in the collapsed room believing he would die, within the 5 years before onset. On warlike service in Afghanistan on 18 April 2010 his vehicle was struck by an improvised explosive device, within the 5 years before the first worsening.
Factor 9(3): experiencing a category 1B stressor within the 5 years before clinical onset or clinical worsening; — MET
- On warlike service in Iraq on 20 July 2006 he recovered human remains and treated critically injured casualties after a vehicle-borne bomb, and on warlike service in Afghanistan on 18 April 2010 he witnessed his section member being killed. These were within the 5 years before onset and before the first worsening.
Factor 9(4): experiencing a category 2 stressor within the 1 year before clinical onset or clinical worsening; — MET
- Throughout warlike service in Iraq from May 2006 he was bullied by senior soldiers in his platoon and his engagement ended in August 2006, within the 1 year before onset. In the year before the second worsening he was socially isolated, unemployed and separated after medical discharge for posttraumatic stress disorder from warlike service.
Factor 9(5): experiencing the death of a person with whom one has a close family bond or a close personal relationship, within the 5 years before clinical onset or clinical worsening; — MET
- His closest friend in his section was killed beside him on warlike service in Afghanistan on 18 April 2010, within the 5 years before the first worsening on 20 September 2010 and the 7 years before the second. His brother died on 14 March 2005, within the 5 years before onset.
Factor 9(6)(a): having experienced as a child (under the age of 18) one of the following: serious physical, emotional, or sexual harm; before clinical onset or clinical worsening; — MET
- The veteran suffered serious physical and emotional abuse by his stepfather from age 6 to 15, documented in child protection records, before onset on warlike service in Iraq in 2006.
Factor 9(6)(b): having experienced as a child (under the age of 18) one of the following: neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing by adults with obligations to provide such necessities; before clinical onset or clinical worsening; — MET
- Child protection records document serious neglect from age 6 to 14, before onset in 2006.
Factor 9(7): taking a medically prescribed substance from the same pharmacological class as the diagnosed substance use disorder, at the time of clinical onset; — MET
- On warlike service in Iraq on 14 August 2006 a medical officer prescribed nicotine patches 21 mg a day, which the veteran was using, while continuing to smoke, at onset on 01 October 2006.
Factor 9(8): having persistent pain of at least 3 months, which is severe enough to interfere with daily living, at the time of clinical onset or clinical worsening; — MET
- The veteran sustained an L1 compression fracture in the blast on warlike service in Afghanistan on 18 April 2010. By the first worsening on 20 September 2010 he had five months of back pain that stopped him patrolling and sleeping, and by the second worsening he had seven years of chronic pain limiting walking, sitting and work. He smoked to cope with pain.
Factor 9(9): experiencing a morally injurious event within the 5 years before clinical onset or clinical worsening; — MET
- On warlike service in Iraq in July 2006 he was ordered to turn away a family with an injured child at a checkpoint, and learned the child later died, within the 5 years before onset. On warlike service in Afghanistan in 2010 a fire mission he called caused civilian deaths, within the 5 years before the first worsening.
Factor 9(10): experiencing intimate partner violence within the 5 years before clinical onset or clinical worsening; — MET
- From mid-2005 to August 2006, during his pre-deployment training and warlike service in Iraq, his fiancée subjected him to threats, coercive control and physical assaults, recorded by a Defence social worker in May 2006. This was within the 5 years before onset. From 2016 his wife's violence was recorded before the second worsening.
Worsening factors
Factor 9(11): inability to obtain appropriate clinical management for substance use disorder before clinical worsening. — MET
- On warlike service in Afghanistan in 2010 no smoking cessation support or pharmacotherapy was available, cigarettes were freely supplied in ration packs and canteens, and smoking was the accepted means of coping with stress. The tobacco use disorder worsened to 40 cigarettes a day with daily chewing tobacco.
The % contribution of the causes is 100% and significant.
Sequelae
The tobacco use disorder is a sequela of the veteran's accepted posttraumatic stress disorder, depressive, anxiety and other substance use disorders and chronic back pain, each arising from his warlike service. It has in turn caused chronic obstructive pulmonary disease and worsened his asthma, and it contributes to his financial hardship and cardiovascular risk.
Unintended Consequence
Met. Nicotine patches were prescribed by a Defence medical officer on 14 August 2006 and used alongside continued smoking at onset, and varenicline prescribed in October 2010 was stopped because of nightmares, after which his smoking rose further. The supply of cheap and free cigarettes on deployment by the Commonwealth also reinforced the disorder. These are unintended consequences of treatment and arrangements provided by the Commonwealth while he was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On warlike service in Afghanistan in 2010 no smoking cessation counselling or pharmacotherapy was available, cigarettes were freely supplied and smoking was the accepted way to cope with stress, and his consumption rose from 30 to 40 cigarettes a day. After discharge he waited more than ten months for a mental health and addiction service appointment, during which it rose to 60 a day. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of treatment through service channels and operational constraints amount to an inability to obtain appropriate clinical management before clinical worsening.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 19 May 2006, Social work assessment, Defence social worker
- 19 May 2006, Psychological assessment, Psychologist
- 12 Jun 2006, Outpatient health record, Medical Officer, Role 1 health facility, Iraq
- 14 Aug 2006, Outpatient health record, Medical Officer, Role 1 health facility, Iraq
- 04 Oct 2006, Outpatient health record, Medical Officer, Role 1 health facility, Iraq
- 11 Dec 2006, Psychiatric assessment, Consultant psychiatrist
- 18 Apr 2010, Trauma admission and CT report, Role 3 hospital, Afghanistan
- 02 Oct 2010, Post-operational psychological screening, Psychologist
- 22 May 2014, Medical Employment Classification Review Board report, Senior Medical Officer
- 12 Apr 2017, Psychiatric inpatient discharge summary, Consultant psychiatrist
- Statement of Principles concerning Substance Use Disorder (Balance of Probabilities) No. 51 of 2026, Repatriation Medical Authority
- Statement of Principles concerning Substance Use Disorder (Reasonable Hypothesis) No. 50 of 2026, Repatriation Medical Authority
