1. The Review Panel revokes the certificate of Medical Assessor Abhishek Nagesh dated

26 July 2023 and issues a new certificate as follows:

(a) The Review Panel certifies the following injuries were caused by the motor accident:

(i) Post-traumatic stress disorder

(b) The Review Panel finds that the above injuries result in a whole person impairment of 6% which is not greater than 10%.

1. Samer Alkuheli (the claimant) was involved in a motor accident on 28 June 2020. He was the front seat passenger of a car when the driver had a sneezing fit, lost control of the car and drove into a telegraph pole. He sustained injuries to his neck, back, left shoulder, right hand and right knee. He later developed psychological symptoms of post-traumatic stress disorder, anxiety and depression.
2. The claimant made a claim for statutory benefits with Allianz Australia Insurance Limited (the insurer), the third-party insurer of the vehicle that he says caused the accident.
3. A medical dispute arose about whether the degree of the claimant's whole person impairment (WPI) is greater than 10% WPI. This is important because if there is a dispute about the degree of a claimant's WPI, damages for non-economic loss[1] cannot be awarded and disputes must be referred to a Medical Assessor/s for determination.
4. On 26 July 2023, Medical Assessor Abhishek Nagesh found the claimant's psychological injury post-traumatic stress disorder to be caused by the motor accident and assessed his WPI as 15%.
5. The insurer lodged an application with the Personal Injury Commission (Commission) seeking a review of Medical Assessor Nagesh's decision. This was allowed by the President's delegate and this Panel was convened to conduct the review.

1. Medical Assessor Nagesh was referred to assess a dispute about whether the psychological injury of post-traumatic stress disorder was caused by the motor accident and if so, what was the degree of permanent impairment.
2. The Medical Assessor found that the claimant's psychological symptoms met the DSM-5-TR criteria for a diagnosis of post-traumatic stress disorder. The Medical Assessor noted the claimant was in a car that struck a pole at a speed of 50 km/hr. The Medical Assessor accepted that the claimant was exposed to death and serious injury therefore satisfying Criterion A for post-traumatic stress disorder.

3. The Medical Assessor also referred to the other DSM-5-TR criteria for post-traumatic stress disorder which were satisfied:
   • Criteria B - Intrusion symptoms which include nightmares and flashbacks;
   • Criteria C - Avoidance of driving since the motor vehicle accident;
   • Criteria D - Negative alteration in cognition where he has developed a depressed mood, no pleasure or happiness in anything, and feels numb;
   • Criteria E - Arousal symptoms - Insomnia, irritability, diminished ability to concentrate;
   • Criteria F - Symptoms have been present for more than a month;
   • Criteria G - Symptoms are not due to substance misuse or medical condition, and
   • Criteria H - Symptoms have caused significant distress and socio-occupational impairment.
4. The Medical Assessor noted that there was no past history of post-traumatic stress disorder and therefore the post-traumatic stress disorder was caused by the motor accident. The Medical Assessor also questioned the claimant about his past history of anxiety and depression in 2014. The claimant stated that it was a while ago and he did not remember.
5. In terms of the degree of permanent impairment, this was assessed under the Psychiatric Impairment Rating Scale (PIRS). When the values for the areas of function were collated, there was a median Class of 3 and an aggregate score of 15. This resulted in a permanent impairment of 15% WPI.
6. The Medical Assessor also provided an assessment of the claimant's pre-existing impairment for which there was, in the Medical Assessor's view, a diagnosis of major depressive disorder. As the claimant was in Class 1 for all areas of function, the level of

pre-existing impairment was 0%. 7. The Medical Assessor did not consider the claimant's psychological symptoms to have improved with treatment and hence no allowance was made for any treatment effect. 8. The Medical Assessor concluded that the degree of permanent impairment caused by the motor accident was 15% WPI.

1. The insurer's original reply submissions dated 15 September 2022 refer to its disagreement that the claimant has a permanent impairment of greater than 10% as a result of his psychological injuries caused by the motor accident. The insurer notes the claimant's reliance on the report of Dr Canaris dated 3 June 2022 but prefers the report of Dr Newlyn dated 25 January 2022. Specifically, the insurer refers to Dr Newlyn's finding that the claimant's psychological symptoms did not meet the diagnostic criteria for post-traumatic stress disorder or generalised anxiety disorder. Dr Newlyn diagnosed the claimant as suffering from a somatic symptoms disorder or pain which is not assessable for permanent impairment.

1. The insurer takes issue with the Medical Assessor's impairment evaluation of 0% due to the claimant's pre-accident history of major depressive disorder. The insurer notes the Medical Assessor's reference to a documented history of depression and anxiety in December 2014 but adds that there were similar reports in October 2018, less than two years before the motor accident, which the Medical Assessor is silent on.
2. The insurer says the various psychological symptoms reported in the 2018 evidence could materially change the areas of function scores in the assessment under the PIRS.
3. Specific clinical entries from Dr Saad Haloob include:
   • 16 October 2018 [R10] - "Reason for contact: Depression. Sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness and fearfulness, difficulty in concentrating and making decisions, headache and indigestion."
   • 16 December 2014 [R10] - "continual tiredness, sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness, anger or fearfulness, feelings of guilt or worthlessness or being unwanted, difficulty in concentrating and making decisions, headache, constipation or indigestion."

4. The insurer says the similarities in symptoms between 2014 and 2018 suggest chronic and continuing pre-accident symptoms that the Medical Assessor failed to address and take into account when assessing the claimant's pre-accident impairment.

1. The insurer says there are inconsistencies between the claimant's subjective reporting to the Medical Assessor when compared with the treating records and histories recorded by other medical practitioners. It is alleged the Medical Assessor failed to reconcile such inconsistencies and erred by relying solely upon the claimant's subjective reporting when evaluating impairment under the PIRS.
2. In this regard, the insurer takes issue with the categories (or areas of function) in "Travel", "Concentration, persistence and pace" and "Adaptation".

1. The claimant disputes that the claimant had any pre-existing condition. It is contended that the two clinical entries from the claimant's general practitioner (GP) Dr Saad Haloob are, "...sporadic complaints of psychological symptoms [with] no diagnosis ever made which pre-dated this claim". And further, "It is not unusual for a person to, from time to time, experience the (psychological) symptoms the claimant reported".
2. The claimant also disputes that there are any inconsistencies or error in the Medical Assessor's assessment made under the PIRS.

1. On 20 August 2024, the Panel issued a direction to the parties requesting indexed and paginated bundles of the information they relied upon. The Panel advised that unless documents are uploaded to the review file, the Panel would not be able to read and consider those documents. The parties responded with the insurer's bundle comprising of pages 1-326 and the claimant's 1-293.
2. The Panel has read the documentation relied upon by the parties. The Panel will only specifically refer to material that is relevant to the determination of the permanent impairment dispute and the issues in dispute.

1. These have been read and considered by the Panel. The Panel noted the pre-accident psychological symptoms recorded in the clinical notes in December 2014 and October 2018. The Panel also noted the claimant's psychological symptoms following the motor accident, including the clinical notes from GP Dr Saad Haloob and Zen Psychological Solutions. Noted also were the various GP referrals to psychologists in 2020 and the psychological symptoms associated with the referrals. The medical chronology from the insurer's solicitor was considered with the various alleged inconsistencies in the medical assessment certificate noted.
2. Liverpool Doctors clinical notes (complete record):

August 2020 entries - GP Dr Saad Haloob - Poor sleep, poor concentration, afraid of going into any car, forgetfulness, flashbacks and post-traumatic stress disorder.

• 16 October 2018 - Pre-accident sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness and fearfulness, difficulty in concentrating and making decisions, and
• 16 December 2014 -Continual tiredness, sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness, anger or fearfulness, feelings of guilt or worthlessness or being unwanted, difficulty in concentrating and making decisions.

1. Application for personal injury benefits dated 24 July 2020 -

indicates musculoskeletal injuries with psychological symptoms/injuries of anxiety, lethargy, poor concentration, depression and post-traumatic stress disorder. 2. Certificate of capacity / fitness (dated various) - first certificate dated 14 July 2020. Multiple joints pain and lower back pain. Forgetfulness and anxiety secondary to possible concussion. Hand tremor. 3. GP Mental health treatment plan dated 14 July 2020 - Referral for generalised anxiety following motor vehicle accident. 4. GP Referral to Mr Kasm Abaie dated 14 July 2020 - Referral written by Dr Haloob. Presenting problem of tiredness, lethargic, anxious and poor concentration. 5. GP Referral to Ms Zeina Boutros dated 11 August 2020 - Referral written by Dr Haloob. Presenting problem of flashback and post-traumatic stress disorder from recent car accident. Feels low and afraid from going into any car. Poor sleep. Poor concentration.

1. Dr Thomas Newlyn, psychiatrist, report dated 25 January 2022 - Claimant denied any previous mental health symptoms. Described psychological symptoms following the motor accident but is resistant to treatment. Claimant did not meet the criteria for post-traumatic stress disorder. Diagnosed illness anxiety disorder care (avoidant type) which is somatic symptom disorder. This has resulted in long-term impairment in functioning but is not assessable for impairment under the relevant guidelines.
2. Dr Christopher Canaris, psychiatrist, report dated 3 June 2022 - Noted mood problems going back as far as 2014. Claimant's compliance with treatment appears to be poor while associated with a perception that no one is providing him with treatment. Diagnosed

post-traumatic stress disorder related to the motor accident. The major depressive disorder was pre-existing. However, the combination of physical problems and post-traumatic stress disorder may well have aggravated the major depressive disorder.

Impairment evaluation was 24%. Pre-existing impairment was difficult to ascertain. In 2014 and 2018 there were sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness and fearfulness and difficulty in concentrating and making decisions. Class 2 ratings for social and recreational activities, social functioning and concentration, persistence and pace (3 categories). Under the PIRS, pre-existing impairment estimated at 4%. This translated to a final WPI of 20% related to the motor accident.

1. The surveillance report of Allied Universal dated 15 December 2023 and further report dated 28 April 2024 together with footage (three mp4 DVDs) were viewed by the Panel. The footage showed the claimant walking around the streets of Sydney and the CBD, often stopping for long periods looking at and texting or browsing on his phone.

1. At the preliminary conference on 28 October 2024, the Panel determined that the claimant be re-examined. The re-examination report of Medical Assessors Chew and Rikard-bell is as follows:

Before the accident, Mr Alkuheli indicated that he was well. He was able to care for himself and he was the carer of a friend who was epileptic whom he would see regularly and may stay overnight. He related well to his wife, child and sister. He could concentrate well and socialise with friends regularly. Mr Alkuheli was working as a carer and he could travel without restrictions. At the time of the accident, Mr Alkuheli was residing with his sister. Overall, there was likely a degree of depression before the motor vehicle accident, however, he reported this did not impact negatively on daily functioning.

The details regarding the personal history were a little difficult to obtain. Mr Alkuheli stated he completed Year 5 at school and then worked as a mechanic for three years. He moved to Syria he believes in about 2008 and stayed in Syria for eight years arriving back in Australia in 2016.

In Australia Mr Alkuheli has worked as a carer for four years and has occasionally carried out mechanical work, however, he was not employed as a mechanic. Mr Alkuheli did not want to talk about his relationship with his girlfriend, however, they have been together for several years. Although he stated they did reside together it was unclear as to how long this had been.

There is no history of serious illnesses, injuries or conditions. There is no current medication. Previously he was taking painkillers and medication for stress. In addition, he smokes a substance provided by a friend, however, he was unsure if the substance was heroin or amphetamines, however, he did not think the substance was marijuana. There is no family history of psychiatric illnesses and no drug or alcohol issues.

Mr Alkuheli was very vague about previous psychiatric illnesses or problems. I asked him about any previous mental health issues and he stated he could not remember. The documentation indicated there was a consultation with a psychologist in 2018 and 2019 and he did not disagree with this statement.

There are no previous significant motor vehicle accidents, although there may have been a minor accident that did not result in any ongoing difficulties and he stated he could not remember when this accident occurred. There are no Workers' Compensation claims, insurance claims or legal issues.

I asked Mr Alkuheli about the motor vehicle accident on 23 June 2020 and he became a little more animated. He explained his friend was the driver and he was in the front passenger seat when there was a collision with a pole and they were travelling at 50 km/hour, although he did not want to volunteer too much information about the accident. I note that previously Mr Alkuheli has reported that the airbags deployed, however, he stated he could not remember. There was a brief loss of consciousness and the vehicle was unable to be repaired. I asked Mr Alkuheli whether the driver was injured and he stated he did not want to talk about it as it was too distressing. Mr Alkuheli received treatment in hospital but was sent home and advised there were no major injuries. He said he feels very frustrated as "nobody" is trying to help him and that he wants to be treated in a hospital setting.

History of symptoms and treatment following the accident

Mr Alkuheli stated there were several sessions with a psychologist "years ago." He saw Xena Boutros in 2018 and 2019 and there were three further sessions of treatment in September and October 2020.

Mr Alkuheli has difficulty sleeping and will usually wake up late. There are nightmares and memories of the motor vehicle accident and there is quite severe pain in his neck and back, as well as his head and he feels numb throughout his body. The pain fluctuates and can reach a level of 10/10. He feels his life has been destroyed. His appetite fluctuates and his weight is low at 50 kg. Mr Alkuheli's mood is very low and feels angry and frustrated at the lack of assistance he has received. Although he did not declare suicidal thoughts, he stated he finds it hard to live. There is a lot of anxiety but no panic attacks. Mr Alkuheli avoids socialising and feels rather hopeless and helpless. Mr Alkuheli struggles with pain and poor sleep with interruptions and difficulty breathing at night and nightmares. He said treatment with physiotherapy has been helpful for the pain but the benefits have been limited and he has a shake that distresses him. Mr Alkuheli does not have contact with his son regularly and will only see him every two months.

Mr Samer Alkuheli attended the interview unaccompanied and was assessed via video conference. An Arabic interpreter was provided to facilitate the assessment.

Mr Alkuheli presented as a neatly dressed man of stated age of small medium build with a thick beard and wearing a cap. His eye contact was good. He cooperated with the interview process and was able to remain focused for over 100 minutes. At times he appeared irritable and uncomfortable throughout the interview. His speech was normal in tone and volume and he used the interpreter. There was no abnormality of perception. Mr Alkuheli's affect was depressed and irritable with some reactivity and he seemed very stressed. His cognitive function appeared normal, and his thoughts were logical. Mr Alkuheli complained there have been problems since the motor vehicle accident with pain and depression and he has not received adequate treatment or help. Mr Alkuheli's main wish is to feel better, receive some help for the tremor and pain, as well as reunite with his wife and child and return to a normal life. Mr Alkuheli acknowledged after the accident that he could not continue as the carer of a friend with epilepsy and he transferred the benefit to caring for his sister who had suffered obstetric complications; however, he stated, "To be honest, I don't help her much." Mr Alkuheli confirmed he uses substances that have been helpful over the last 6 months as when he uses drugs, he has more energy and he feels a little better. Mr Alkuheli is of Mandian religion and previously he would attend church, however after the accident he has not been attending church regularly.

Mr Alkuheli stated he does not shower regularly and he will eat meals erratically. Although he is officially the carer of his sister, she will do most of the cooking and cleaning. Nevertheless, he is able to dress and feed himself adequately and he presented well at the assessment. Therefore, there is mild impairment of self-care and personal hygiene.

In terms of social functioning, Mr Alkuheli has a stable relationship with his sister and brother-in-law. He occasionally has contact with his son. At the time of the accident, he was residing with his sister and he said it has become more difficult to see his wife and son as he avoids socialising. Therefore, there is mild impairment of social functioning.

In terms of concentration, Mr Alkuheli is able to focus on his mobile phone for most of the day and he was able to concentrate for over 100 minutes at the assessment, although he stated he is not able to concentrate very well. Therefore, there is mild impairment of concentration, persistence and pace.

In terms of social and recreational activities, Mr Alkuheli rarely goes out. Friends will occasionally visit him, and he can visit them, but he requires encouragement and pushing and is very reluctant to interact. Therefore, there is moderate impairment of social and recreational activities.

In terms of adaptation, prior to the accident, Mr Alkuheli was in a carer role, however after the accident, the care arrangement changed from caring for a client to caring for his sister, although he is not fulfilling the caring role as well as he should and is less effective. Overall, there is mild impairment of adaptation.

In terms of travel, Mr Alkuheli has a motor vehicle and can drive short distances, however, he will only drive on certain occasions or if there is an urgent appointment. Therefore, there is mild impairment of travel.

1. Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (Guidelines).
2. Version 9.3 of the Guidelines, effective from 6 December 2024, applies to the review.
3. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.
4. Permanent impairment is assessed in accordance with Chapter 6 of the Guidelines. Specifically, the assessment of psychiatric impairment draws from the chapter "Mental and behavioural disorders" which commence at cl 6.201 of the Guidelines.

1. It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychological or psychiatric condition.
2. Causation is dealt with at clauses 6.5-6.7 of the Guidelines. An abridged form of the requirements is contained in clause 6.7 which states:

6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.

1. Further, the provisions of the Civil Liability Act 2002 apply, in particular s 5D and 5E.

1. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[2]
2. The evaluation should only consider the impairment as it is at the time of the assessment.[3]
3. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[4]
4. The Panel refers to the above re-examination report of Medical Assessors Chew and Rikard-Bell and adopts the findings in their entirety. The Panel reconvened on 17 March 2025 and discussed the re-examination report findings before collectively making the below determinations.

1. The Panel accepted the claimant developed posttraumatic stress disorder following the subject motor vehicle accident. The relevant criteria satisfied under the DSM-5-TR are outlined below:

1. A traumatic event (the motor vehicle accident) 2. Re-experiencing phenomena with nightmares and flashbacks

1. Avoidant behaviours with avoidance of driving

1. Negative cognitions with low mood, lack of pleasure and feelings of numbness 2. Marked alterations in arousal with insomnia, irritability and hypervigilance 3. Duration of more than one month 4. Significant impairment of functioning 5. Not due to substance use or other medical condition

1. The claimant sustained multiple musculoskeletal injuries as a result of the motor accident on 28 June 2020. Psychological symptoms were noted as early as in the Certificate of Capacity / Fitness dated 4 August 2020. These included forgetfulness and anxiety with a recommendation for referral to a psychologist, Mr Kasm Abaie. The psychological symptoms persisted and a GP mental health plan was made and he was referred to Ms Zeina Boutros, forensic psychologist. The claimant's psychological symptoms have persisted since, and were present at the time of original medical assessment and now in the Panel proceedings.
2. The Panel was therefore satisfied that the subject motor vehicle accident is a more than negligible contributing factor to the development of posttraumatic stress disorder (309.81, F43.1).

1. The claimant's impairment is considered permanent. Although the claimant says nobody is trying to help him, there has been extensive referrals made by his GP to various psychologists with Ms Xena Boutros seeing him in 2018 and 2019 and with three further sessions of treatment in September and October 2020. It has now been almost 5 years since the motor accident and the medical members of the Panel were satisfied that it has become well stabilised and unlikely to change substantially and by not more than 3% in the next year with or without medical treatment.[5]

Degree Of Permanent Impairment Psychiatric Impairment Rating Scale

1. The determination as to permanent impairment is made in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment (Fourth Edition) and Part 6 of the Motor Accident Guidelines.

2. Pre-existing Major Depressive Disorder (not assessed here - see below)

Mr Alkuheli stated he does not shower regularly and he will eat meals erratically. Although he is officially the carer of his sister, she will do most of the cooking and cleaning. Nevertheless, he is able to dress and feed himself adequately and he presented well at the assessment. Therefore, there is mild impairment of self-care and personal hygiene.

In terms of social and recreational activities, Mr Alkuheli rarely goes out. Friends will occasionally visit him and he can visit them, but he requires encouragement and pushing and is very reluctant to interact. Therefore, there is moderate impairment of social and recreational activities.

In terms of travel, Mr Alkuheli has a motor vehicle and can drive short distances, however, he will only drive on certain occasions or if there is an urgent appointment. Therefore, there is mild impairment of travel.

In terms of social functioning, Mr Alkuheli has a stable relationship with his sister and brother-in-law. He occasionally has contact with his son. At the time of the accident, he was residing with his sister and he said it has become more difficult to see his wife and son as he avoids socialising. Therefore, there is mild impairment of social functioning.

In terms of concentration, Mr Alkuheli is able to focus on his mobile phone for most of the day, which appeared consistent with long periods spent looking at his mobile phone in the surveillance reports and footage. He was also able to concentrate for over 100 minutes at the assessment, although he stated he is not able to concentrate very well. Therefore, there is mild impairment of concentration, persistence and pace.

In terms of adaptation, prior to the accident, Mr Alkuheli was in a carer role, however after the accident, the care arrangement changed from caring for a client to caring for his sister, although he is not fulfilling the caring role as well as he should and is less effective. Overall, there is mild impairment of adaptation.

Psychiatric Impairment Rating Scale - Pre-existing impairment

Mr Alkuheli was independent before the accident and described managing himself well as well as caring for a friend with epilepsy. Therefore, there was no impairment of self-care and personal hygiene.

Mr Alkuheli socialised and interacted with friends well and he would go out regularly. Therefore, there is no impairment of social and recreational activities.

Mr Alkuheli was able to drive without restrictions before the motor vehicle accident. Therefore, there was no impairment of travel.

Mr Alkuheli was able to relate well to his wife, friends and family without any issues. Therefore, there was no impairment of social functioning.

Mr Alkuheli was able to concentrate and focus without any restrictions. Therefore, there was no impairment of concentration, persistence and pace.

Mr Alkuheli was able to provide adequate care and cared for a friend without any issues. Therefore, there was no impairment of adaptation.

Apportionment - pre-existing/subsequent impairment:

There is 0% apportionment for pre-existing injuries (see also reasons below)

There is no adjustment for treatment effect as there is currently no psychological treatment received.

1. The degree of permanent impairment caused by the motor accident is 6%.
2. Permanent impairment ratings take symptoms into account, however the percentage permanent impairment is not a direct measure of disability.

1. The claimant's GP, Dr Saad Haloob, noted in December 2014 that the claimant had symptoms of continual tiredness, sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness, anger or fearfulness, feelings of guilt or worthlessness or being unwanted, difficulty in concentrating and making decisions.
2. These symptoms were almost identical some four years later in October 2018 (and less than two years before the motor accident) where there were sleeping problems, eating problems, inability to enjoy normally enjoyable things, tension and anxiety, irritableness and fearfulness, difficulty in concentrating and making decisions.
3. The Panel considered these psychological symptoms were likely to satisfy the DSM-5-TR criteria for major depressive disorder. However, the psychiatric diagnosis, as assessed above under the PIRS table above, results in a permanent impairment of 0% WPI.
4. Accordingly, while the Panel considered the claimant to have a psychiatric diagnosis before the motor accident, there was nil % impairment and no deduction for pre-existing impairment is necessary.

1. The Panel concludes that the claimant's injury caused by the motor accident results in a whole person impairment of 6% which is not greater than 10%. The certificate issued by Medical Assessor Abhishek Nagesh dated 26 July 2023 is therefore revoked. A new certificate is issued at the front of this determination.

[5] Permanency of impairment, AMA 4 Guides, page 315.