1. The Review Panel revokes the certificate of assessment of Medical Assessor Chew dated

5 October 2023 and certifies that post-traumatic stress disorder caused by the accident on

11 November 2021 is not a threshold injury for the purposes of the Motor Accident Injuries Act 2017.

1. Jose Carlos Tji (claimant) was injured in a motor accident at Lewisham on 11 November 2021 (accident). He subsequently made a claim for both statutory benefits under the Motor Accident Injuries Act 2017 (MAI Act) on Insurance Australia Limited t/as NRMA Insurance (insurer), the insurer of the other vehicle involved in the accident.
2. These proceedings involve a dispute between the claimant and the insurer as to whether for the purposes of the MAI Act a psychological injury caused by the accident is a threshold injury (dispute). The dispute is a medical dispute, as defined by s 7.17 of the MAI Act, and a medical assessment matter: Schedule 2 cl 2(e) of the MAI Act.
3. The dispute was referred to Medical Assessor Chew for assessment. On 5 October 2023 the Medical Assessor certified that the exacerbation of major depressive disorder caused by the accident is not a threshold injury for the purposes of the MAI Act (Assessment).
4. The insurer sought a review of the Assessment under s 7.26 of the MAI Act. The President's delegate subsequently determined that there was reasonable cause to suspect the Assessment was incorrect in a material respect. The review application was accepted and referred to this review panel (Panel) to conduct the review of the Assessment (Review).

1. The Panel is to conduct the Review in accordance with s 7.26 of the MAI Act. Section 7.26(5A) provides that the Panel is to be constituted by two Medical Assessors and a member assigned to the Motor Accidents Division of the Personal Injury Commission (Commission).
2. The Review 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: s 7.26(6) MAI Act.
3. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (Rules) are made pursuant to Part 5 of the Personal Injury Commission Act 2020 (PIC Act). The Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application: rule 128.
4. Version 9.3 of the Motor Accident Guidelines (Guidelines), effective from 6 December 2024, apply to the Review.

1. On 5 February 2025 the Panel made directions for the provision of a joint agreed indexed bundle that contained all material relied on by the parties for the purposes of the Review, together with written submissions relied on by the parties in the Review.
2. A joint bundle was subsequently lodged by the insurer on 18 February 2025. On

25 March 2025 the claimant lodged a separate bundle. 3. The Review was listed for case management of 31 March 2025 the clarify the position with respect to the documents relied on by the parties. The claimant's solicitor confirmed that the joint bundle lodged by the insurer contained the material the claimant relies on for the purposes of the Review, and that the claimant did not seek to rely on the documents he lodged in the separate bundle. That being the case, it was confirmed with the parties that the Panel would only consider the material contained in the joint bundle filed by the insurer.

1. The term "threshold injury" is defined in s 1.6 of the MAI Act and includes threshold psychological or psychiatric injury. A threshold psychological or psychiatric injury is a psychological or psychiatric injury that is not a recognised psychiatric illness: s 1.6(1)(a).
2. Section 1.6 provides that the regulations may exclude or include a specified injury from being a threshold psychological or psychiatric injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (Regulations) states that acute stress disorder and adjustment disorder are each included as a threshold injury for the purposes of the MAI Act. For the purposes of cl 4 "acute stress disorder" and "adjustment disorder" have the same meanings as in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association in May 2013: cl 4(3) of the Regulations.
3. Part 5 of the Guidelines contains the procedure for assessing whether an injury caused by a motor accident is a threshold injury for the purposes of the MAI Act. In respect of the medical assessment of whether an injury is a threshold injury, the Guidelines relevantly provide:

5.3 The assessment will determine whether the injury related to the claim is a soft tissue injury or a threshold psychological or psychiatric injury caused by the motor accident.

5.5 A diagnosis for the purpose of a threshold injury decision must be based on a clinical assessment by a medical practitioner or other suitably qualified person independent from the insurer.

5.6 The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:

(a) a comprehensive accurate history, including pre-accident history and pre-existing conditions

(b) a review of all relevant records available at the assessment

(c) a comprehensive description of the injured person's current symptoms

(d) a careful and thorough physical and/or psychological examination

(e) diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination."

1. Clauses 5.10, 5.11 and 5.12 of the Guidelines refer to the assessment of threshold psychological or psychiatric injury. These clauses provide:

"Threshold psychological or psychiatric injury assessment

5.10 In assessing whether an injury is a threshold psychological or psychiatric injury, an assessment of whether a psychiatric illness is present is essential.

5.11 The assessment of whether a psychiatric illness is present must be made using the Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published by the American Psychiatric Association.

5.12 Where the symptoms associated with the injured person's psychological or psychiatric injury do not meet the assessment criteria for a recognised psychiatric illness, with the exception of acute stress disorder and adjustment disorder, the injury will be considered a threshold injury."

1. The Guidelines state as follows with respect to causation of injury:

6.5 An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or the Personal Injury Commission) in considering such issues.

6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:

'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:

1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'

This, therefore, involves a medical decision and a non-medical informed judgement.

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. In Briggs v IAG Limited t/a NRMA Insurance [2022] NSWSC 372 (Briggs), Wright J held at [35]:

"The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries."

1. It is necessary for the Panel to consider whether the accident caused or contributed to the diagnosed psychiatric condition: Briggs at [75]. Further, s 5D and s 5E of the Civil Liability Act 2002 apply to the MAI Act.

1. On 5 October 2023 Medical Assessor Chew certified that the exacerbation of major depressive disorder caused by the accident was not a threshold injury. He also determined that post-traumatic stress disorder was not caused by the accident.
2. In his reasons, the Medical Assessor recorded that the claimant had a history of psychotic depression. He was treated by his general practitioner and at Liverpool Hospital with medication and psychotherapy. While the psychosis resolved, his mood remained low.
3. The Medical Assessor recorded the following history of the accident:

"He reported that he was driving straight and accelerating as there was a green light when a car pulled out of a service station to the left of him and pulled in front. His car flipped on the roof. He was hanging by the seatbelt then unfastened himself..."

1. Following the accident the claimant reported pain, that his mood was low, and that he is more anxious when driving. The Medical Assessor found that the claimant had a history of a significant major depressive disorder with psychotic features, and that the accident exacerbated this condition. The Medical Assessor determined that the claimant did not present with post-traumatic stress disorder. The Medical Assessor did not refer to the DSM-5-TR diagnostic criteria. Nor did he provide reasons for his conclusion that the preexisting condition had been exacerbated by the accident.

1. The evidence relied on by the parties in the Review is contained in a joint bundle filed by the insurer in accordance with directions made by the Panel. The Panel has considered all the material in the joint bundle.
2. The application for personal injury benefits dated 14 December 2021 (claim form) contains the following description of the accident:

"I was driving straight along New Canterbury Road...on the right of two lanes. As I was driving past the intersection of Warden Road, motor vehicle...pulled out onto from 'Budget Petrol' onto New Canterbury Road on the left lane but swerved onto my lane and collided with my vehicle, causing my vehicle to flip and hit into a passing taxi...on the lane next to me (travelling in the opposite direction)."

1. It is recorded in the claim form that the claimant suffered injuries to his neck, lower back, left knee, and psychological injury.
2. A police report dated 23 December 2021 does not include a description of the accident. The claimant is referred to as the driver of "Accident Unit 1".
3. On 28 August 2023 Medical Assessor Home certified that accident caused injuries to the claimant's cervical spine, lumbar spine, right shoulder, and left knee were threshold injuries for the purposes of the MAI Act. In his reasons, the Medical Assessor recorded a history of the accident, the claimant's symptoms and his treatment. The claimant reported that he no longer experienced neck or right shoulder pain. He reported intermittent left knee pain, and lower back pain. The claimant was, in the opinion of the Medical Assessor, consistent in his clinical presentation.
4. In a report dated 14 February 2022 Dr Herald, orthopaedic surgeon, recorded that the claimant injured his right shoulder and left knee in the accident. The doctor diagnosed left knee medial meniscal tear, right shoulder impingement syndrome and a possible rotator cuff tear, and lumbar disc prolapse.
5. In a report dated 21 March 2022 Dr Herald noted complaints of right shoulder, left knee, and back pain. Treatment and investigation recommendations were made. On 2 May 2022

Dr Herald reported ongoing improvement in right shoulder symptoms following a cortisone injection. His main problem was his back pain that had increased "as he is limping with his left knee pain".

1. The records from "Injury Care" have been considered by the Panel. Referrals to Dr Verma, Dr Herald, and Ms Charmaine Moubarak, psychologist, dated 8 December 2021 refer to the accident, and record that the claimant's "current complaints" included:

"Poor sleep wtih distrubed [sic] sleep waking up from sleep

Difficulty driving to new locations due to nervousness"

1. The various certificates of capacity contained in the joint bundle include a diagnosis of "post-traumatic stress disorder with distubed [sic] sleep, hyperarousal, Insomnia and disturbed mood".
2. The contents of the referral dated 10 May 2022 have been considered, as have the reports from Navneet Mahajan to Dr Khan dated 3 June 2022, 5 September 2022,

28 November 2022, and 10 March 2023. 3. The Panel has considered the following radiological reports: MRI left knee dated

2 March 2022; MRI right shoulder dated 11 March 2022, and X-ray left knee, right shoulder, and lumbar spine dated 2 May 2022. 4. On 3 May 2022 Patrick Cormack, physiotherapist, reported to Dr Herald. Mr Cormack recorded a history that the claimant:

"...has largely worked uninterrupted in an administrative position where his duties are mostly sedentary but also involve retrieving stock (auto parts) and bringing it to customers. His employers have allowed him to avoid lifting and carrying stock since the accident, while continuing with his other duties."

1. The claimant's right shoulder "had not troubled him much lately". The left knee became painful with prolonged standing or walking (20-30 minutes), occasionally "giving-away". Squatting and using stairs were also painful in the left knee, at times. The lower back was stiff and painful with prolonged sitting, bending, stooping, and lifting. The claimant was described as being obese and there was generalised joint hypermobility.
2. In Mr Cormack's opinion, the claimant's knee pain was probably due to patello-femoral dysfunction, secondary to strain and subsequent chronic quadriceps weakness. The back pain was likely attributable to non-specific soft tissue strain. The right shoulder symptoms may have been due to rotator cuff dysfunction.
3. On 7 June 2022 Mr Cormack reported that the claimant's right shoulder pain had "virtually resolved. Apart from a little rotator cuff weakness, examination was essentially unremarkable". The left knee has improved, and the lower back pain "had settled".
4. The Allied Health Recovery Requests (AHRR) in the joint bundle have been considered.
5. On 7 February 2024 Jeffrey Tao reported to Dr Khan. The report relates to the claimant's attendance at exercise physiology sessions for ongoing rehabilitation following the accident. The claimant's left knee symptoms had improved. He reported lower back pain symptoms "of varying degrees".
6. The Panel has considered the insurer's internal review decision dated 9 February 2023. In relation to the claimant's psychological injury, the internal reviewer determined that a DSM-V diagnosis of post-traumatic stress disorder was "not verified", and the "reported clinical signs and behaviours do not satisfy this diagnosis as outlined in the DSM-V". The internal reviewer determined that the claimant's "psychological condition falls within the definition of a minor injury in accordance with Section 1.6(3) of the Act".
7. The Panel has considered the photographs in the joint bundle. The photograph on page 145 depicts a red KIA (Accident Unit 2 in the police report) on the tray of a flatbed truck. The photograph on page 146 is the claimant's vehicle on truck tray. Damage on the driver's side of the vehicle can be clearly seen. The photograph on page 147 is the claimant's vehicle on a ramp taken from behind. Damage to the driver's side of the KIA can be seen in the photograph on page 148 of the bundle. The photograph on page 149 depicts the KIA from the front. The photographs on pages 150-152 shown the claimant's vehicle upside down on the roadway.

1. The insurer's case is that there is insufficient evidence or clinical signs or symptoms to indicate that the claimant sustained a psychological condition that satisfies a diagnosis of a recognised psychiatric illness "as outlined in the DSM-V criteria".
2. In the alternative the insurer submits that any psychological injury suffered by the claimant as a result of the accident is a threshold injury.
3. The claimant's case is that following the accident he developed symptoms of anxiety, panic attacks, and flashbacks when he was driving, and that he suffers from post-traumatic stress disorder, a non-threshold injury for the purposes of the MAI Act.
4. The claimant also supports Medical Assessor Chew's finding that he aggravated a pre-existing major depressive disorder with psychotic features as a result of the accident.

1. The report prepared by the medical members of the Panel, Senior Medical Assessor Baker and Medical Assessor Singh, after their re-examination of the claimant follows.

1. The re-examination was undertaken using MS Teams and attended by claimant and Medical Assessors Baker and Singh.

1. The claimant was born in Portugal. He does not remember much about his childhood. He was about 3 years old when his parents moved to Australia. He said he had a normal childhood. He does not remember many things from his childhood. He stated that when he tries to recall the past, he does not recall much. Both parents raised him. He has been to numerous schools because his parents would move home for employment. He was at Cabramatta Public Scholl until Year 3. Then his family moved to Busby, and he attended Busby West Pubic School and continued at Busby West High School until Grade 12.
2. The claimant remembers being bullied at school. He had snapped back at his peers whilst at school. He said there are not so many good memories from school time. He denied any history of abuse, neglect or trauma as a child. He said he may have been smacked by his parents, if he was naughty. At school, he stated that there was a lot of bullying and name-calling which was part of his school's normal environment. He never saw a school counsellor.
3. After high school, the claimant suffered his first episode of depressed mood. He began treatment in his late 20s with his general practitioner. He attended Liverpool TAFE, earned a Business Administration Certificate III. He then attended university. He had to drop out of university as so he could start work and help support his family financially. His father had become redundant, and the claimant had to work full-time to support his family.

1. The claimant stated that in his teens, he started to experience mental health symptoms. When he attempted to initiate sleep, he said he could hear voices calling names and it was difficult to fall asleep. He also suffered frequent nightmares. His nightmares had stopped. In his late 20s, the claimant saw a general practitioner at Waterloo, NSW. He attended this general practitioner as it was close to his work. This general practitioner was not his regular general practitioner. This general practitioner told him that had "psychotic depression". He had told this general practitioner that he had auditory hallucinations, which presented whilst he was initiating and waking from sleep. He heard "negative things" said to him. He also said he could hear arguments and would listen to his neighbour's fight. This experience was more prominent when he was trying to go to sleep. He discovered that should he play some background music or sound to distract himself he would fall asleep readily.
2. The claimant also saw his regular general practitioner and was referred to a psychologist and a psychiatrist. He attended each clinician for ongoing psychological treatment. His appointments ranged from weekly to monthly depending on his symptoms and their intensity. He was prescribed Lexapro (escitalopram) this is an evidence-based antidepressant treatment. He said he was also prescribed an "antipsychotic" medication however he could not recall the name of this medication.
3. The claimant said the medication did not help much. He felt that the medication just made him feel tired and helped him to sleep. He ceased this medication after about three to four years. He had to leave university because of his father's redundancy from employment. He commenced full-time work.
4. The claimant also attended his community mental health team for a few years. He said he had stopped his medications when he started to feel better, and he was symptom-free. He said his medications ceased when he was about 32 years of age. His medication had stopped many years before this accident. He said he did not have any residual symptoms of depression, auditory hallucinations or nightmares before the motor accident. Whilst depressed the claimant did not suffer from any self-harm or suicidal thoughts. He was not admitted to a mental health unit.
5. The claimant stated that he used to have anxiety in public and used to get paranoid, thinking that people might be talking about him. He stated he would never act on these thoughts and would never go or ask anyone about why they were looking at him or talking at him. He would generally move out of the situation and try to distract himself.

1. The claimant denied a history of use of alcohol and illicit substances, and he is a non-smoker. He denied a significant family history of mental illness and any significant medical history.
2. The claimant stated that he was working at the time of the accident. He had no psychological symptoms at the time of the accident. He worked as a service office administrator and worked full-time hours. He was not studying at that time and has not engaged in any education since the accident. He has been living with both his parents and two older sisters and an older brother.

1. The claimant stated that he was injured in a motor accident at Lewisham on

11 November 2021. On the day of the accident, he was driving home from work. He was driving straight, and accelerating as there was a green light, when suddenly a car pulled out of a service station to the left of him and pulled in front of him. His car flipped on its roof, and he was upside down. The bystanders and people at the fuel station pulled him out. Police and an ambulance attended the scene. His vehicle was towed from the accident scene. He was suspended by a seat belt when his vehicle flipped onto its roof. He managed to unlock the seat belt and fell. Bystanders assisted him in getting out of the car. He was not taken to the hospital. He was not experiencing any physical symptoms at that time. 2. The claimant's brother-in-law collected him from the scene of the crash and took him home. The following day the claimant attended his regular general practitioner. He stated that his general practitioner was not very helpful. He was later referred to attend an orthopaedic surgeon. He had developed back pain and left knee pain and was told that there was non-alignment in his left knee. He also attended a lawyer who helped him with his claim and facilitated access to treatment. He has not had any operations since the accident. He saw Dr Herald, orthopaedic surgeon, who diagnosed him with a left knee meniscal tear, right shoulder impingement syndrome, possible rotator cuff tear and lumbar disc prolapse with knee weakness. He was referred and attended physiotherapy to adjust the alignment of his knee as an alternative to knee surgery. He also consulted a chiropractor to assist with his physical injuries.

History of symptoms and treatment following the motor accident

1. The claimant stated he took a week to recover from the accident and then returned back to work in his prior substantive role working fulltime hours. He stated that he continued to experience some pain. However, it got better after the treatment. His neck pain and pain in the right shoulder stopped after around 12 months. His knee pain continued for longer and improved with the treatment. The claimant attends a chiropractor once a month.
2. The claimant stated that his "mental health got a bit worse" after the accident. He started to pick and choose when going out and choosing with whom he would socialise. He said he had to keep in mind how long he had to go out and be away from his home as he would become more anxious and agitated the longer he was away from home. He had to think about saving money, as he feared he did not have enough to spend freely.
3. The claimant reported reliving the accident repeatedly. He began to avoid going out, especially to places that he had not driven to before the accident. He would avoid talking about the accident as he would be reminded of himself hanging upside down in the car, as well as him feeling very anxious, when thinking about the accident. He developed a fear of ending up in the same situation again. He feared being in a motor accident where his car had flipped, and he was hanging upside down without help to escape. He continued to feel angry and upset about the motor accident. He struggled to initiate and remain asleep. He would often feel angry and would have angry outbursts. He had an angry outburst during the re-examination, he said the repeated examinations made him feel angry. He said being told that nothing was wrong with him, also cause him to be angry. He had not acted on these angry feelings. He said that working in his role had repeatedly angered him as he often feels distressed by working in the same role of customer service for more than 10 years.
4. The claimant stated that ever since the accident, he has a fear of driving to areas of unknown location. However, he could drive to places that he knows, with some anxiety. He drives to work. Should he feel very anxious whilst driving to work he has to pull out of the stream of traffic into a street to stop driving. He said his heart starts to race and he starts to hyperventilate and struggles to breathe. He said he will also develop a negative and dysphoric mood. He said he struggled with poor motivation and low energy.
5. The claimant stated that he had to study the road map in detail to go to a place that he was not familiar with. He would make sure that the place had easy parking, or he would try to carpool or catch an Uber as an alternative to him driving. If none of these options were available, he would become too fearful of travelling to the unfamiliar location and he would then choose not to go there.
6. The claimant stated that he was referred to a psychologist for treatment. He said he did not find the psychological treatment provided helpful. He saw he attended this psychologist once in person and then about three times over the phone before stopping treatment. He had no sessions after that. He has not been prescribed any medication.
7. After the accident, he was often waking up in the middle of the night and was hearing the crash he experienced in the accident. He would wake up thinking that he was in the moment of the accident. He would at times be unable to go back to sleep as often he was hyperventilating and feeling anxious. He would frequently think of being in a crash again and being upside down caught in his car. He felt scared and had the fear that the accident might happen again. He was afraid of having this type of accident again, where he was driving on the street, and the other lanes of traffic would crash into his car. When starting to drive he would prepare for the type of accident. He worried about the unknown car crashing into him, as happened in the subject accident.
8. The claimant reported that he continued to isolate himself from his social connections and did not go out much or interact with friends because of the anxiety and fear of driving. He would mostly stay at home and spend time by himself. He did not enjoy the activities that he had enjoyed before the accident. These activities included, playing gaming, photography and astronomy. He continued to work in the same role fulltime after the motor accident. He said he had to work to support the family financially as his father cold not work. He found he no longer enjoyed work. He struggles to focus and concentrate if he is working in a busy environment or there was too much talk going around his desk.

Details of any relevant injuries or conditions sustained since the motor accident

1. The claimant stated that about one year ago he purchased a new car. When he got his new car someone rear-ended him in a subsequent motor accident. He reported that this subsequent motor accident was a minor incident and not like the major accident on

11 November 2021. He did not call the ambulance or the police. He did not make any physical or psychological injury claim. He went to his regular general practitioner as he had mild neck pain. He was prescribed Panadol (paracetamol). He did not report any impacts on his mental health because of this accident.

1. The claimant stated that his mental health had not improved and his symptoms had not fully remitted since the motor accident. He said he continues to "struggle" most days. He gets anxious while he is driving and has to stop at times as the anxiety affects his capacity to drive safely. He continues to think that something bad may happen. He said he feared having a further motor accident where he is injured. He said when anxious whilst driving his right hand "gets weak" and he loses power in this hand gripping the steering wheel. When anxious gets the a "shaking feeling in his hands" but he cannot see his hands shaking visibly. He said his "anxiety kicks in when he has to go out." He continues to have anxiety in social situations, and he avoids social events. He remains suspicious of others and often "thinks that people are talking" about him. He does not have a clear rationale for why he might be getting these thoughts other than due to his anxiety.
2. The claimant also stated that he may have a sudden surge of negative and dysphoric mood. His mood has gone down in the last two to three weeks. To the extent that he has started to feel quite depressed, and he has started to think that he is not moving forward in his life, and he feels stuck. He has been worried and has random moments of tears. He stated that his mood was fine before the recent decline in the last few months. He was supposed to see a psychologist on Saturday, but the appointment was cancelled which again makes him feel upset, angry and frustrated. He stated that he has shut down and that is his way of coping when he starts to feel depressed and teary.
3. The claimant stated that with the fear of having the accident he avoids anything that reminds him and brings back the memory of the motor accident. Has repeated instances of reliving the motor accident, where he feels that he is again in the accident. This has often caused him to suffer nightmares and has resulted in disturbed and broken sleep. He avoids driving to new places. He meticulously plans his travel to reduce his fear of driving. He remains quite anxious and hypervigilant when driving especially when there is an intersection on the road. He avoids talking about the accident because he does not want to remember or think about been upside down in the car. He does not enjoy activities or other things in his life. He has become emotionally detached from others and spends his leisure time alone.
4. The claimant continues to sleep less. He may sleep between four to six hours. He said his reduced period of sleep has become his routine and that he would wake refreshed in the morning as if he had slept for eight hours. His appetite is normal. He often has one meal a day, which is dinner. He has never been regular with his meals before the motor accident. Recently, he has lost weight, and he stated that he thinks he may have lost 10kg in the last two months without him trying to reduce weight.

1. The claimant continues to see his regular general practitioner. He does not see a psychiatrist. He is currently not on any psychotropic medications. The proposed treatment was, for him to reattend a psychologist, however he had not yet seen a psychologist.

1. The claimant was seen using video conference over MS Teams. He was sitting comfortably during the assessment. He maintained good eye-to-eye contact and a rapport was established. He appeared clean and was dressed appropriately. He was calm during the assessment. There were no signs of agitation or retardation. He described his mood as low and anxious and his affect was restricted and mood congruent. He described his sleep and appetite as disturbed. He described low levels of energy and motivation and lack of pleasure. He described repeated memories of the accident. He reported avoidance towards events and towards driving which brings back the memories of the accident. There was avoidance of talking about the accident and experience of reliving the accident. He fears having the accident again. He has a sensation in his body, "that something bad may happen" and then his hands shake. He denied having any active or passive suicidal thoughts, intents or plans. He had no thoughts of harming others. He did not describe any grandiosity, racing thoughts or increased energy levels. There was no evidence of formal thought disorder, no delusional pattern of thinking and no perceptual abnormalities. He was insightful into his condition and his judgment was intact.

1. The claimant stated that his self-care is normal. He showers and brushes his teeth twice a day. He may cook sometimes. He does not do laundry. He may do some cleaning at home when his mother is not around to clean. His efforts are "not as perfect as his mother's".
2. The claimant may walk the dog. He described his hobby of astronomy which he was not as engaged in since the motor accident. He rarely goes to the field to photograph the night sky as he would have before the accident. In 2023 he was able to take first photography of the Milky Way. He travelled to Jervis Bay to avoid scattered city light. He said he planned for three months to get the courage to drive to this preferred location. He undertook this activity alone.
3. The claimant booked an Airbnb so that he could overnight there. He had to study and plan the whole trip in very detail. He studied the road map. Because he paid for his accommodation ahead of time, he felt compelled to complete this trip. In total since the accident, he has travelled on two occasions since 2021. The first time was to Jervis Bay in 2023 and then to Palm Beach in the middle of 2024.

1. The claimant needs inspiration to enjoy his hobbies since the motor accident. He is not engaging in gaming much since the accident. He is too tired at times from work, poor sleep and from needing to complete other tasks at home to spend time gaming. In his recreational time, he may watch TikTok. He will avoid videos of accidents as "they still trigger" him.
2. The claimant may look at the telescope he stores at home. He will think about whether to plan another trip but usually will not pursue it further. He said he was not able to plan much ahead. He stated that he has become more isolated and "cynical" after the accident. He said he had "a lot of anger" because of the accident.
3. The claimant mostly stays at home and does not socialise. He does not go out much on weekends as driving and anxiety cause him to have barriers with his past friendship circle. He may go out if a friend picks him up from his home, but this is rare. He said he had no friends and had stopped socialising with his past friendship circle as frequently as he would have before the accident. He has not been into a relationship before or after the accident.
4. The claimant has a good relationship with his siblings and parents, and he would take his mother for grocery shopping mostly on weekends. He reliably attends his fulltime work. He carries a high workload. He works in customer service, and he finds the role very demanding. He sometimes lags behind his peers with his rate of task completion. He said he can catch up within day or two. He is able to meet his list of things to do at work without significant concerns from his employer. The list of complex tasks can get long and sometimes his motivation is variable, resulting in a slowing of his pace of task completion at work. He feels like his employment is a thankless job though he still "works really hard and to help his customers". He is often angry, annoyed, and dysphoric for no reason.

1. The claimant's presentation was consistent with the history provided by other medical examiners during the clinical interview and mental state examination.
2. The claimant's report of no recurrence of his major depressive disorder with psychotic features since it entered full remission many years before the motor accident is consistent with the clinical record.
3. The diagnosis of major depressive disorder with psychotic features was made by a general practitioner. The diagnosis was not made by a psychiatrist. The nature of his psychotic features are, in the opinion of the medical members of the Panel, more consistent with hypnopompic and hypnogogic hallucinations. These types of perceptual experience are within normal human experience. These symptoms are often self-limiting and associated with altered sleep patterns as reported by the claimant. Removal of antipsychotic medication is expected not to result in any relapse of these symptoms as reported by the claimant.
4. The claimant's presentation was reliable and consistent with his prior assessments and reports.

1. The claimant has sustained a psychological injury as a result of the motor accident on

11 November 2021. He developed symptoms of anger, avoidance, and anxiety with repeated episodes of reliving the accident by hearing the "crash" and being in the moment "hanging upside down distress in his car" because of the accident. He relied on others to assist him exit his car after he had fallen inside his car. He had nightmares and distressing memories of the motor accident. He developed sleep disturbance with frequent nightmares and waking from sleep in a panic attack with the content of his nightmares and panics been the motor accident. 2. The claimant frequently re-lived the accident and re-experienced parts of the accident reoccurring. The claimant was exposed to serious motor accident, that did cause a serious psychological injury. His serious psychological injury is characterised by:

(a) Intrusion symptoms: The claimant's intrusion symptoms include re-living part of the accident including frequent re-hearing of the crash in the accident and re-living the moment of hanging upside down trapped in the vehicle.

(b) Avoidance symptoms: Avoidance symptoms include the claimant's avoidance of thinking about the motor accident, avoidance talking about the accident, and avoidance of past friendship circles and social groups.

(c) Negative alterations in cognition and mood: Negative alterations in cognition and mood include fearing the accident will happen again and he will be trapped hanging upside down in a car crash. Slow completion of complex work and tasks such as planning his trip to photograph the night sky. Frequent severe panic attacks that result in him having to stop driving due to increased heart rate, hyperventilation, and tremor. Recurrent negative thoughts that he has been abandoned to solve his own problems without effective medical help.

(d) Alterations in arousal and reactivity: Poor sleep with him having difficulty initiating and remaining a sleep Frequent anger and angry outbursts about the motor accident.

1. The accident was severe as the car that hit the claimant's vehicle was travelling with sufficient force to roll his car unexpectantly. He fell from having hanging upside down by his seatbelt. He fears that the motor accident will happen again. He tries to actively avoid traumatic event including the motor accident happening again by meticulous planning to reduce his fear and anxiety of driving. He continues to avoid driving to areas that are unknown to him. He is also avoidant of talking about the accident and avoids content on TV or TikTok related to motor accidents.
2. The claimant has withdrawn himself from his social interactions, lost interest in significant activities, including his hobbies and other social activities. He has also reported anger and irritability towards customers and the public and is often hypervigilant when he is out in public. He has struggled to focus and concentrate at work on his complex role in customer service.
3. The claimant reported panic symptoms when driving such as hyperventilation, weakness in his hands, heart palpitations and inner restlessness. The claimant has a pre-existing history of major depressive disorder with psychotic symptoms for which he had received treatment many years ago. He was not on medication for few years before the accident. He was able to manage his symptoms by himself without any relapse of this mood disorder. He was maintaining well. His mood disorder was in full remission prior to this motor accident in 2021. He was able to look after himself. There were no issues in his ability to hold his job. There were ongoing difficulties with social and recreational activities with him rarely socialising and rarely participating in his friendship circles or hobby of astronomy. He was not able to drive freely without suffering repeated episodes of panic requiring him to leave the stream of traffic and settle his panic attack prior to continuing work. He had a good relationship with his family. He has difficulty with his concertation persistence and pace and was slow in completing allocated tasks compared to his peers.
4. The claimant meets the DSM-5-TR diagnostic criteria of F 43.1 post-traumatic stress disorder.

1. Prior to the accident the claimant had been diagnosed with a major depressive disorder. He was in full remission from this condition prior to the accident. He was maintaining well without any psychological or psychiatric treatment for many years before the motor accident. He had worked since about 20 years of age for his employer in a fulltime role.

1. The claimant did not have any residual impairments from his pre-existing depression. The claimant did have anxiety symptoms. His anxiety symptoms before the accident were not diagnosed as a DSM-5-TR diagnosed condition. Anxiety symptoms are common between many psychiatric and psychological conditions as they related to the normal core emotion of fear. The claimant was not impaired in his activities of daily living prior to this motor accident. His daily functioning prior to the accident was normal.
2. The medical members of the Panel are satisfied that the nature and severity of the accident could cause the development of symptoms of post-traumatic stress disorder. The claimant's symptoms of post-traumatic stress disorder have persisted for many years after treatment had been commenced. The symptoms of post-traumatic stress disorder may have fluctuated at different assessments however the claimant's post-traumatic stress disorder symptoms of anger, panic attacks causing increased heart rate, hyperventilation and tremor, as well as his avoidance and marked social isolation since the accident, have persisted resulting in the claimant remaining markedly isolated from his peers outside of the work setting.
3. For these reasons, the motor accident on 11 November 2021 did cause the psychological injury defined as DSM-5-TR F 43.1 post-traumatic stress disorder.

1. The evidence with respect to the claimant's pre-accident psychological history has been considered by the Panel. The Panel gives weight to and agrees with the finding by its medical members that the claimant was in full remission from his pre-existing depression at the time of the accident.
2. The medical members of the Panel have provided detailed reasons for their finding that the claimant satisfies the diagnostic criteria in the DSM-5-TR for post-traumatic stress disorder. The Panel agrees with and adopts those reasons. The Panel finds that the claimant suffers from post-traumatic stress disorder.
3. The Panel has considered the evidence describing the circumstances in which the accident occurred, including the history given by the claimant when he was re-examined by the medical members of the Panel. In particular, the Panel notes that following the collision, the claimant's car flipped on its roof, and that he was suspended upside down by a seat belt. The Panel finds that the accident could have caused post-traumatic stress disorder.
4. The Panel is satisfied that the accident was a necessary condition of the occurrence of the post-traumatic stress disorder, and but for the accident the claimant would not have developed post-traumatic stress disorder. He was not suffering from post-traumatic stress disorder when the accident occurred and has developed symptoms that satisfy the diagnostic criteria for post-traumatic stress disorder following the accident.
5. The Panel finds that as a result of the accident the claimant suffered a psychological injury diagnosed as post-traumatic stress disorder.
6. Post-traumatic stress disorder is not a threshold injury. Accordingly, the Panel finds that post-traumatic stress disorder caused by the accident is not a threshold injury for the purposes of the MAI Act.
7. Because the Panel's diagnosis of the psychological injury caused by the accident differs from Medical Assessor Chew's diagnosis the Panel revokes the Medical Assessor's certificate and certifies that post-traumatic stress disorder caused by the accident on 11 November 2021 is not a threshold injury for the purposes of the MAI Act.