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No. 38 of 2019 Determinations/Veterans' Entitlements as made
This instrument is the Statement of Principles concerning chronic insomnia disorder (Balance of Probabilities).
Administered by: Veterans' Affairs
Registered 01 Mar 2019
Tabling HistoryDate
Tabled HR02-Apr-2019
Tabled Senate02-Apr-2019
Table of contents.

RMA-Red

 

Statement of Principles

concerning

CHRONIC INSOMNIA DISORDER
(Balance of Probabilities)

(No. 38 of 2019)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

 

Dated    1 March 2019

 

 

 

 

 

The Common Seal of the
Repatriation Medical Authority
was affixed to this instrument
at the direction of:

 

 

Professor Nicholas Saunders AO

Chairperson

 

 

  

Contents

1          Name........................................................................................................................................... 3

2          Commencement........................................................................................................................ 3

3          Authority..................................................................................................................................... 3

4          Application................................................................................................................................. 3

5          Definitions.................................................................................................................................. 3

6          Kind of injury, disease or death to which this Statement of Principles relates............... 3

7          Basis for determining the factors........................................................................................... 4

8          Factors that must exist............................................................................................................. 4

9          Relationship to service............................................................................................................. 7

10        Factors referring to an injury or disease covered by another Statement of Principles. 7

Schedule 1 - Dictionary............................................................................................. 8

1          Definitions.................................................................................................................................. 8

 

 


 

1               Name

This is the Statement of Principles concerning chronic insomnia disorder (Balance of Probabilities) (No. 38 of 2019).

2               Commencement

This instrument commences on 25 March 2019.

3               Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4               Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

5               Definitions

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

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

(1)          This Statement of Principles is about chronic insomnia disorder and death from chronic insomnia disorder.

Meaning of chronic insomnia disorder

(2)          For the purposes of this Statement of Principles, chronic insomnia disorder means a persistent disorder of sleep that meets the following diagnostic criteria (derived from DSM-5):

A.           A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:

(i)            difficulty initiating sleep;

(ii)          difficulty maintaining sleep, characterised by frequent awakenings or problems returning to sleep after awakenings; or

(iii)        early-morning awakening with inability to return to sleep.

B.           The sleep difficulty causes clinically significant distress or impairment in social, occupational, educational, academic, behavioural or other important areas of functioning.

C.           The sleep difficulty occurs at least three nights per week.

D.           The sleep difficulty is present for at least three months.

E.            The sleep difficulty occurs despite adequate opportunity for sleep and cannot be explained by inadequate circumstances for sleep.

F.            The sleep difficulty is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (for example, narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

Note 1:  This definition includes chronic insomnia disorder that is attributable to the effects of a substance (including a drug of abuse or a medication).

Note 2:  DSM-5 is defined in the Schedule 1 – Dictionary.

Death from chronic insomnia disorder

(3)          For the purposes of this Statement of Principles, chronic insomnia disorder, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's chronic insomnia disorder.

Note: terminal event is defined in the Schedule 1 – Dictionary.

7               Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that chronic insomnia disorder and death from chronic insomnia disorder can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

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

8               Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, chronic insomnia disorder or death from chronic insomnia disorder is connected with the circumstances of a person's relevant service:

(1)          having a clinically significant disorder of mental health as specified within the one year before the clinical onset of chronic insomnia disorder;

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

(2)          experiencing a category 1A stressor within the one year before the clinical onset of chronic insomnia disorder;

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

(3)          experiencing a category 1B stressor within the one year before the clinical onset of chronic insomnia disorder;

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

(4)          experiencing a category 2 stressor within the one year before the clinical onset of chronic insomnia disorder;

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

(5)          experiencing severe childhood abuse before the clinical onset of chronic insomnia disorder; 

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

(6)          having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the one year before the clinical onset of chronic insomnia disorder;

(7)          having a severe, chronic medical condition within the one year before the clinical onset of chronic insomnia disorder;

Note:  severe, chronic medical condition is defined in the Schedule 1 - Dictionary.

(8)          having persistent pain for at least the three months before the clinical onset of chronic insomnia disorder;

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

(9)          having tinnitus for at least the three months before the clinical onset of chronic insomnia disorder;

(10)      being pregnant at the time of the clinical onset of chronic insomnia disorder;

(11)      being treated with a drug or a drug from a class of drugs from the specified list of drugs, for a continuous period of at least seven days before the clinical onset of chronic insomnia disorder, where the last dose of the drug was received within the 30 days before the clinical onset of chronic insomnia disorder;

Note:  specified list of drugs is defined in the Schedule 1 - Dictionary.

(12)      being treated with a drug for a continuous period of at least seven days before the clinical onset of chronic insomnia disorder, where:

(a)           the involved drug is capable of producing a prominent and severe disturbance in sleep; and

(b)          the drug is associated in the individual with the development of insomnia symptoms during drug therapy; and

(c)           the last dose was received within the 30 days before the clinical onset of chronic insomnia disorder;

(13)      being treated with mefloquine within the two months before the clinical onset of chronic insomnia disorder;

(14)      having a clinically significant disorder of mental health as specified within the one year before the clinical worsening of chronic insomnia disorder;

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

(15)      experiencing a category 1A stressor within the one year before the clinical worsening of chronic insomnia disorder;

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

(16)      experiencing a category 1B stressor within the one year before the clinical worsening of chronic insomnia disorder;

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

(17)      experiencing a category 2 stressor within the one year before the clinical worsening of chronic insomnia disorder;

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

(18)      having a medical illness or injury, which is life-threatening or which results in serious physical or cognitive disability, within the one year before the clinical worsening of chronic insomnia disorder;

(19)      having a severe, chronic medical condition within the one year before the clinical worsening of chronic insomnia disorder;

Note:  severe, chronic medical condition is defined in the Schedule 1 - Dictionary.

(20)      having persistent pain for at least the three months before the clinical worsening of chronic insomnia disorder;

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

(21)      having tinnitus for at least the three months before the clinical worsening of chronic insomnia disorder;

(22)      being pregnant at the time of the clinical worsening of chronic insomnia disorder;

(23)      being treated with a drug or a drug from a class of drugs from the specified list of drugs, for a continuous period of at least seven days before the clinical worsening of chronic insomnia disorder, where the last dose of the drug was received within the 30 days before the clinical worsening of chronic insomnia disorder; 

Note:  specified list of drugs is defined in the Schedule 1 - Dictionary.

(24)      being treated with a drug for a continuous period of at least seven days before the clinical worsening of chronic insomnia disorder, where:

(a)           the involved drug is capable of producing a prominent and severe disturbance in sleep; and

(b)          the drug is associated in the individual with the worsening of insomnia symptoms during drug therapy; and

(c)           the last dose was received within the 30 days before the clinical worsening of chronic insomnia disorder;

(25)      being treated with mefloquine within the two months before the clinical worsening of chronic insomnia disorder;

(26)      inability to obtain appropriate clinical management for chronic insomnia disorder.

9               Relationship to service

(1)          The existence in a person of any factor referred to in section 8, must be related to the relevant service rendered by the person.

(2)          The factors set out in subsections 8(14) to 8(26) apply only to material contribution to, or aggravation of, chronic insomnia disorder where the person's chronic insomnia disorder was suffered or contracted before or during (but did not arise out of) the person's relevant service.

10           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 8 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

 


 

Schedule 1 - Dictionary  

Note: See Section 5

1               Definitions

 In this instrument:

                 category 1A stressor means one of the following severe traumatic events:

(a)           experiencing a life-threatening event;

(b)          being subject to a serious physical attack or assault including rape and sexual molestation; or

(c)           being threatened with a weapon, being held captive, being kidnapped or being tortured.

category 1B stressor means one of the following severe traumatic events:

(a)           killing or maiming a person;

(b)          being an eyewitness to a person being killed or critically injured;

(c)           being an eyewitness to atrocities inflicted on another person;

(d)          participating in the clearance of a corpse or a critically injured casualty; or

(e)           viewing a corpse or a critically injured casualty as an eyewitness.

Note: corpse and eyewitness are also defined in the Schedule 1 - Dictionary.

                 category 2 stressor means one of the following negative life events, the effects of which are chronic in nature and cause the person to feel ongoing distress, concern or worry:

(a)           being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;

(b)          experiencing a problem with a long-term relationship including the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation and divorce;

(c)           having concerns in the work or school environment including ongoing disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, and experiencing bullying in the workplace or school environment;

(d)          experiencing serious legal issues including being detained or held in custody, ongoing involvement with the police concerning violations of the law, and court appearances associated with personal legal problems;

(e)           having severe financial hardship including loss of employment, long periods of unemployment, foreclosure on a property and bankruptcy;

(f)           having a family member or significant other experience a major deterioration in their health; or

(g)          being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability.

Note: significant other is also defined in the Schedule 1 - Dictionary.

                             chronic insomnia disorder—see subsection 6(2).

                             clinically significant disorder of mental health as specified means one of the following conditions, which is of sufficient severity to warrant ongoing management:

(a)           acute stress disorder;

(b)          alcohol use disorder;

(c)           anxiety disorder;

(d)          attention-deficit/hyperactivity disorder (including other specified attention-deficit/hyperactivity disorder and unspecified attention-deficit/hyperactivity disorder);

(e)           bipolar disorder;

(f)           depressive disorder;

(g)          eating disorder;

(h)          obsessive-compulsive disorder;

(i)            panic disorder;

(j)            posttraumatic stress disorder;

(k)          schizophrenia;

(l)            somatic symptom disorder;

(m)        specific phobia; or

(n)          substance use disorder.

Note 1:  Management of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.

Note 2:  To warrant ongoing management does not require that any actual management was received or given for the condition.

corpse means the human remains or body parts of one or more persons who have met a violent or horrific death.

Note:  Examples of a violent or horrific death may include, but are not limited to, death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks and motor vehicle accidents.  Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition.

                 DSM-5 means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  Arlington, VA, American Psychiatric Association, 2013.

                 eyewitness means a person who experiences an incident first hand and can give direct evidence of it.  This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

                             MRCA means the Military Rehabilitation and Compensation Act 2004.

                 persistent pain means:

(a)           continuous pain; or

(b)          almost continuous pain; or

(c)           frequent, severe, intermittent pain;

             which is severe enough to interfere with usual work or leisure activities or activities of daily living.

                             relevant service means:

(a)           eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)           peacetime service under the MRCA.

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

                 severe childhood abuse means:

(a)           serious physical, emotional, psychological or sexual harm whilst a child aged under 16 years; or

(b)          neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 16 years;

where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child.

                 severe, chronic medical condition means an illness that:

(a)           substantially impacts on social, occupational or other important areas of functioning; and

(b)          requires on-going daily or almost daily management of symptoms under the supervision of a registered health practitioner, including assistance with activities of daily living, bed rest, dietary modification, drug therapy, nursing care, oxygen therapy and physiotherapy; and

(c)           is of a type that:

(i)            does not usually resolve spontaneously; or

(ii)          is rarely cured completely; or

(iii)        may progress to a life-threatening illness. 

Note:  Examples of severe, chronic medical conditions include, but are not limited to, poorly controlled asthma, diabetes, epilepsy or chronic obstructive pulmonary disease; severe psoriasis; and chronic kidney disease requiring dialysis.

                 significant other means a person who has a close family bond or a close personal relationship and is important or influential in one's life.

                 specified list of drugs means:

(a)           amphetamines;

(b)          antihistamines;

(c)           barbiturates;

(d)          benzodiazepines;

(e)           beta-blockers;

(f)           corticosteroids, excluding topical or inhaled corticosteroids;

(g)          methylphenidate;

(h)          modafinil;

(i)            monoamine oxidase inhibitors;

(j)            naltrexone;

(k)          non-benzodiazepine hypnotics (Z-drugs);

(l)            norepinephrine and dopamine reuptake inhibitors;

(m)        opiate or opioid analgesics;

(n)          phentermine;

(o)          selective serotonin uptake inhibitors;

(p)          serotonin and norepinephrine reuptake inhibitors; or

(q)          theophylline.

                             terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)          respiratory failure;

(c)           cardiac arrest;

(d)          circulatory failure; or

(e)           cessation of brain function.

                             VEA means the Veterans' Entitlements Act 1986.