Generalised Anxiety Disorder

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 11 February 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 11 February 2025;
Recruit training records and later abuse response findings by the defence abuse response process, dated 18 February 2004;
An incident report by the iraq, dated 14 September 2006;
A mental health review by the medical officer, Garrison health centre, dated 21 March 2007;
A role 2 record and CT brain report by the medical officer and radiologist, Afghanistan, dated 22 June 2010;
A trauma admission and operation report by Role 3 hospital, dated 14 August 2010;
A neurology consultation and MRI brain report by the neurologist, dated 19 October 2010;
An intensive care discharge summary by the endocrinologist, dated 2 December 2010;
An emergency department record by the emergency physician, dated 20 December 2010;
An outpatient health record by the medical officer, Garrison health centre, dated 18 January 2011;
A psychiatric assessment by the consultant psychiatrist, dated 19 July 2011;
An incident report and deployed health record by the medical officer, Afghanistan, dated 20 August 2012;
An operation report by the spinal surgeon, dated 4 December 2012;
An admission summary by the consultant psychiatrist, dated 15 March 2013.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

20 January 2004 and 11 December 2014

Generalised Anxiety Disorder

You have stated that your condition was caused by:

experiencing a category 1A stressor within the 2 years before the clinical onset of generalised anxiety disorder
experiencing a category 1B stressor within the 2 years before the clinical onset of generalised anxiety disorder
experiencing severe childhood abuse before the clinical onset of generalised anxiety disorder
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
experiencing the death of a family member or close friend within the 2 years before the clinical onset of generalised anxiety disorder
experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical onset of generalised anxiety disorder
experiencing a category 2 stressor within the 6 months before the clinical onset of generalised anxiety disorder
having a clinically significant disorder of mental health within the 5 years before the clinical onset of generalised anxiety disorder
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
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
having epilepsy at the time of the clinical onset of generalised anxiety disorder
having persistent pain of at least 6 months duration at the time of the clinical onset of generalised anxiety disorder
being obese at the time of the clinical onset of generalised anxiety disorder
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
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”
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
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
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
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
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
having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced anxiety disorder
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
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
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

Diagnosis: Generalised Anxiety Disorder

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 11 February 2025, and is supported by a psychiatric assessment by the consultant psychiatrist, dated 19 July 2011.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Anxiety Disorder (Balance of Probabilities) (No. 101 of 2023)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

experiencing a category 1A stressor within the 2 years before the clinical onset of generalised anxiety disorder
experiencing a category 1B stressor within the 2 years before the clinical onset of generalised anxiety disorder
experiencing severe childhood abuse before the clinical onset of generalised anxiety disorder
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
experiencing the death of a family member or close friend within the 2 years before the clinical onset of generalised anxiety disorder
experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical onset of generalised anxiety disorder
experiencing a category 2 stressor within the 6 months before the clinical onset of generalised anxiety disorder
having a clinically significant disorder of mental health within the 5 years before the clinical onset of generalised anxiety disorder
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
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
having epilepsy at the time of the clinical onset of generalised anxiety disorder
having persistent pain of at least 6 months duration at the time of the clinical onset of generalised anxiety disorder
being obese at the time of the clinical onset of generalised anxiety disorder
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
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”
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
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
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
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
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
having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced anxiety disorder
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
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
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

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with constant, uncontrollable worry about your health, your future and your friends still deployed, with restlessness, muscle tension, tremor, palpitations, irritability, poor concentration and broken sleep on 18 January 2011.

The diagnosis was confirmed by a psychiatrist on 19 July 2011 on the DSM-5-TR criteria for generalised anxiety disorder: excessive, uncontrollable worry about multiple matters on more days than not for six months, with restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance causing significant impairment. GAD-7 was 16. The anxiety persisted after the thyrotoxicosis was controlled and mefloquine was stopped, so it was not wholly explained by a medical condition or substance, although both contributed at onset.

This has then led to further investigations and the diagnosis of your condition of Generalised Anxiety Disorder. I have accepted your condition of Generalised Anxiety Disorder.

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your peacetime service.

I have therefore accepted that this condition is related to your service with effect from 15 January 2011.

Generalised Anxiety Disorder (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 11 February 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 11 February 2025;
Recruit training records and later abuse response findings by the defence abuse response process, dated 18 February 2004;
An incident report by the iraq, dated 14 September 2006;
A mental health review by the medical officer, Garrison health centre, dated 21 March 2007;
A role 2 record and CT brain report by the medical officer and radiologist, Afghanistan, dated 22 June 2010;
A trauma admission and operation report by Role 3 hospital, dated 14 August 2010;
A neurology consultation and MRI brain report by the neurologist, dated 19 October 2010;
An intensive care discharge summary by the endocrinologist, dated 2 December 2010;
An emergency department record by the emergency physician, dated 20 December 2010;
An outpatient health record by the medical officer, Garrison health centre, dated 18 January 2011;
A psychiatric assessment by the consultant psychiatrist, dated 19 July 2011;
An incident report and deployed health record by the medical officer, Afghanistan, dated 20 August 2012;
An operation report by the spinal surgeon, dated 4 December 2012;
An admission summary by the consultant psychiatrist, dated 15 March 2013.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

20 January 2004 and 11 December 2014

Generalised Anxiety Disorder (Worsening)

You have stated that the worsening of your condition was caused by:

being a prisoner of war before the clinical worsening of anxiety disorder
experiencing a category 1A stressor within the 5 years before the clinical worsening of anxiety disorder
experiencing a category 1B stressor within the 5 years before the clinical worsening of anxiety disorder
experiencing severe childhood abuse before the clinical worsening of anxiety disorder
experiencing a potentially morally injurious event within the 5 years before the clinical worsening of anxiety disorder
having a family member or close friend who experiences a category 1A stressor within the 2 years before the clinical worsening of anxiety disorder
experiencing the death of a family member or close friend within the 5 years before the clinical worsening of anxiety disorder
experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical worsening of anxiety disorder
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
experiencing a category 2 stressor within the 1 year before the clinical worsening of anxiety disorder
having a clinically significant disorder of mental health within the 10 years before the clinical worsening of anxiety disorder
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
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
having epilepsy at the time of the clinical worsening of anxiety disorder
having severe and permanent tinnitus at the time of the clinical worsening of anxiety disorder
having persistent pain of at least 3 months duration at the time of the clinical worsening of anxiety disorder
being obese at the time of the clinical worsening of anxiety disorder
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
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
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
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
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
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
having ceased or reduced therapeutic or illicit drug use or other substance use within the 10 days before the clinical worsening of anxiety disorder
having periodic, heavy alcohol consumption for the 3 months before the clinical worsening of anxiety disorder
having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of anxiety disorder
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
having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 30 days before the clinical worsening of anxiety disorder
taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical worsening of anxiety disorder
inability to obtain appropriate clinical management for anxiety disorder before the clinical worsening of anxiety disorder

Diagnosis: Generalised Anxiety Disorder (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Anxiety Disorder (Reasonable Hypothesis) (No. 100 of 2023)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

being a prisoner of war before the clinical worsening of anxiety disorder
experiencing a category 1A stressor within the 5 years before the clinical worsening of anxiety disorder
experiencing a category 1B stressor within the 5 years before the clinical worsening of anxiety disorder
experiencing severe childhood abuse before the clinical worsening of anxiety disorder
experiencing a potentially morally injurious event within the 5 years before the clinical worsening of anxiety disorder
having a family member or close friend who experiences a category 1A stressor within the 2 years before the clinical worsening of anxiety disorder
experiencing the death of a family member or close friend within the 5 years before the clinical worsening of anxiety disorder
experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 2.5 years before the clinical worsening of anxiety disorder
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
experiencing a category 2 stressor within the 1 year before the clinical worsening of anxiety disorder
having a clinically significant disorder of mental health within the 10 years before the clinical worsening of anxiety disorder
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
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
having epilepsy at the time of the clinical worsening of anxiety disorder
having severe and permanent tinnitus at the time of the clinical worsening of anxiety disorder
having persistent pain of at least 3 months duration at the time of the clinical worsening of anxiety disorder
being obese at the time of the clinical worsening of anxiety disorder
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
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
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
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
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
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
having ceased or reduced therapeutic or illicit drug use or other substance use within the 10 days before the clinical worsening of anxiety disorder
having periodic, heavy alcohol consumption for the 3 months before the clinical worsening of anxiety disorder
having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of anxiety disorder
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
having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 30 days before the clinical worsening of anxiety disorder
taking at least 400 milligrams of caffeine from beverages, drugs or foods within the 1 hour before the clinical worsening of anxiety disorder
inability to obtain appropriate clinical management for anxiety disorder before the clinical worsening of anxiety disorder

After the condition arose, it was worsened during your service. Your captivity by militia on warlike service in Iraq in 2006 preceded the worsening. On 20 August 2012, on warlike service in Afghanistan in 2012, an Afghan soldier opened fire inside the patrol base and rounds struck the vehicle beside you, a life-threatening event, within the 5 years before the worsening. In the insider attack of 20 August 2012, on warlike service in Afghanistan in 2012, you saw the unit's interpreter shot dead, within the 5 years before the worsening. The abuse by an adult instructor in February 2004, when you were 17, preceded the worsening. On 2 May 2012, on warlike service in Afghanistan in 2012, you were ordered to hold your position while a wounded insurgent you could have treated died in front of you, an event that transgressed your moral beliefs, within the 5 years before the worsening. Your younger brother was seriously wounded by an IED on warlike service in Afghanistan in June 2012, a life-threatening event, within the 2 years before the worsening. A close friend from your 2010 platoon died by suicide in January 2013, within the 5 years before the worsening. Your new partner miscarried at 10 weeks in October 2012, within the 2.5 years before the worsening. On warlike service in Afghanistan in 2012 (February to September 2012) you lived and patrolled under IED, rocket and insider threat for about seven months, within the 5 years before the worsening. From October 2012 you were bullied by a supervisor in a rehabilitation platoon and fell into debt after loss of allowances, causing you ongoing distress, within the 1 year before the worsening. Posttraumatic stress disorder, diagnosed in March 2011 from your service in Iraq and Afghanistan, and depressive disorder, diagnosed in October 2012, warranted ongoing management within the 10 years before the worsening. The life-threatening thyroid storm of 2 December 2010 was within the 5 years before the worsening, and Graves disease relapsed in February 2013. The life-threatening gunshot wound of 14 August 2010, with lasting foot drop, was within the 5 years before the worsening. Post-traumatic epilepsy was present on levetiracetam at the worsening. Severe daily tinnitus from the 2010 blast persisted at the worsening. Chronic low back pain, operated on in December 2012 and continuing afterwards, had lasted far more than 3 months and was present at the worsening. Your BMI was 32.2 at the worsening. After lumbar fusion on 4 December 2012 you were restricted to walking short distances and could not undertake activity greater than 3 METs continuously for the 3 months before the worsening, from 15 December 2012 to 15 March 2013. Graves disease relapsed in February 2013 with a free T4 of 31 pmol/L, and the tremor, palpitations and agitation at the worsening were directly related to the hyperthyroidism. You were again given mefloquine on 13 and 14 March 2013 for a further vivax malaria relapse, despite your epilepsy and previous reaction, within the 2 days before the worsening. After your lumbar fusion you were taking oxycodone at doses causing documented drowsiness, within the 2 days before the worsening. Levetiracetam, which could not be ceased, remained associated in you with worsening anxiety, as shown by the improvement on tapering and recurrence on rechallenge in 2011, and was taken within the 2 days before the worsening. You drank to intoxication on 14 March 2013, and alcohol is associated in you with worsening anxiety, within the 2 days before the worsening. Your post-operative oxycodone was reduced on 8 March 2013, within the 10 days before the worsening. You drank to intoxication at least monthly throughout the 3 months before the worsening, from December 2012 to March 2013. Alcohol use disorder was present at the worsening. By the worsening you had smoked about 10 pack-years and had not ceased. On 20 February 2013, on light duties in a quartermaster store, you were again exposed to chlorpyrifos and treated for acute cholinergic poisoning, within the 30 days before the worsening. On 15 March 2013 you took about 450 milligrams of caffeine from energy drinks and tablets within the 1 hour before the worsening. You waited five months for trauma-focused therapy after your return in September 2012, your psychiatric review was interrupted by your surgery, and mefloquine was prescribed again despite your epilepsy and previous reaction.

This has then led to further investigations and the diagnosis of your condition of Generalised Anxiety Disorder (Worsening). I have accepted your condition of Generalised Anxiety Disorder (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your wartime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 20 August 2012.

Generalised Anxiety Disorder — example determination letter

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Reference Determination Content

Generalised Anxiety Disorder

Evidence

Your service

Generalised Anxiety Disorder

Generalised Anxiety Disorder (Worsening)

Evidence

Your service

Generalised Anxiety Disorder (Worsening)