Allianz Australia Insurance Limited v Sourenian

DETERMINATION OF REVIEW PANEL
CITATION:	Allianz Australia Insurance Limited v Sourenian [2025] NSWPICMP 618
CLAIMANT:	Mariam Sourenian
INSURER:	Allianz Insurance Australia Limited
REVIEW PANEL
MEMBER:	Alexander Bolton
MEDICAL ASSESSOR:	John Baker
MEDICAL ASSESSOR:	Steven Yeates
DATE OF DECISION:	18 August 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; whether the claimant’s psychiatric injuries arising out of a motor accident were threshold injuries; review of certificate and reasons of Medical Assessor (MA); claimant injured in a motor vehicle accident when driving a car and with her husband as a front seat passenger; T-bone accident; the MA diagnosed the claimant as having a non-threshold injury being post-traumatic stress disorder; Held – Review Panel considered several possible diagnoses but concluded that the claimant had suffered an adjustment disorder with mixed anxiety and depressed mood which is a threshold injury; certificate and reasons of MA revoked.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION 1. The Panel revokes the certificate of Medical Assessor Sidorov dated 10 April 2024. 2. The claimant has an adjustment disorder with mixed anxiety and depressed mood. 3. This is a threshold injury.

STATEMENT OF REASONS

INTRODUCTION

This is an application by the insurer for review of a certificate and reasons of Medical Assessor Sidorov (the Medical Assessor) dated 10 April 2024.
The Medical Assessor diagnosed the claimant as having a post-traumatic stress disorder which is not a threshold injury.
The following injuries were referred by the Personal Injury Commission (Commission) for assessment:
(a) psychiatric condition including, but not limited to, a post-traumatic stress disorder.

LEGISLATIVE BACKGROUND

Jurisdiction

Threshold injury

A threshold injury is defined in s 1.6 of the Motor Accident Injuries Act 2017 (the Act) which says;

“1.6 MEANING OF ‘THRESHOLD INJURY’

(1) For the purposes of this Act, a
‘threshold injury’ is, subject to this section, one or more of the following--
(a) a soft tissue injury,
(b) a psychological or psychiatric injury that is not a recognised psychiatric illness.”

In summary, if a person injured in a car accident does not have a recognised psychiatric injury, then the injured person’s statutory benefits cease in accordance with ss 3.11 and 3.28 of the Act. If a person injured in a car accident has a recognised psychiatric injury then that injury will be a non-threshold injury.
Section 1.6(4) provides that regulations may be made to exclude or include a specified injury from being a soft tissue injury or a threshold psychological or psychiatric injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (the MAI Regulation) further defines threshold injury to include “an injury to the spinal nerve root that manifests in neurological signs (other than radiculopathy)” and an acute stress disorder and an adjustment disorder (in terms of psychiatric or psychological injuries).
Section 1.6(5) says that the Motor Accident Guidelines (the Guidelines) may provide for the assessment of whether or not an injury is a threshold injury. Relevantly to the matters in issue in the claimant’s claim, cls 5.10 to 5.12 of the Guidelines are headed “threshold psychological or psychiatric injury assessment” and provides:
“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.”

Method of assessment

Part 5 of the Guidelines contain the procedure for assessing whether an injury resulting from the motor accident is a “threshold injury” for the purposes of the Act. In respect of the medical assessment of whether an injury is a threshold injury or not, 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   Diagnostic imaging is not considered necessary to assess threshold injury.
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.”

Bundles of documents

The parties have each presented their respective bundles of documents upon which they rely. The Panel have read all the documentation. If a particular document is not referred to by the Panel, this does not mean that the Panel or a Panel Member has not read it, in much the same manner as parties not referring to or not specifically relying on a document in their own bundle and submissions.
The fact that evidence is not referred to in these reasons does not mean it has been overlooked and nor is it required that each piece of evidence be mentioned – see WAEE v Minister for Immigration and Citizenship (2003) 75 ALO 630 at [46].The Panel is not required to “analyse every piece of information from every opinion contained in a document with which he [it] was provided” – see Farr v Insurance Australia Limited t/as NRMA Insurance Ltd [2014] NSWSC 1435 at [46]. The Panel has come to its own conclusion and has taken its own history.

The accident

The accident occurred on 18 May 2023. The claimant was driving and her husband was a front seat passenger. As she was driving along, a truck reversed without notice and collided with her car. The truck was in the process of parking when the collision occurred suddenly and without warning. The claimant informed the Medical Assessor that her car was written off subsequently, for insurance purposes. Police and ambulance attended the scene.
The claimant explained to the Medical Assessor that she was very shocked by what had happened and, at the time of the impact, experienced significant fear of being seriously injured or even dying. She explained that her husband’s injuries were worse than hers as he was physically closer to the truck.

Insurer’s submissions

At paragraph 19 of the certificate of the Medical Assessor, the insurer submits that he purports to diagnose the claimant with post-traumatic stress disorder as a result of the subject accident. The insurer submits that the Medical Assessor fell into material error by not setting out how he reached his diagnosis and/or by failing to address the actual criteria set out by the DSM-5-TR.
The insurer referred to s 1.6(3) of the Act which defines a threshold psychological or psychiatric injury as an injury ‘that is not a recognised psychiatric illness’. The insurer notes that DSM-V-TR sets out a number of diagnostic criteria which must then be satisfied before a diagnosis is made. Clause 5.12 specifies that, if the claimant’s symptoms 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.
The insurer noted that the Medical Assessor did not address or mention the essential criterion F, G and H. In the absence of all the essential criteria being met, the insurer submits that the Medical Assessor erred in diagnosing the claimant with post-traumatic stress disorder.
The insurer submits that even on the claimant’s self-reporting, there has been no significant distress or impairment in important areas of functioning. The insurer contends that there is no evidence to suggest the claimant suffers significant distress or impairment in important areas of functioning.
The insurer says that throughout the certificate and reasons, the Medical Assessor noted the reports of Carl Neilsen, the claimant’s treating psychologist, dated 20 June 2023 and 17 November 2023. The insurer says that in the latter report dated 17 November 2023,
Mr Neilsen confirmed his diagnosis of post- traumatic stress disorder. When providing his diagnosis, and specifically with respect to criterion G, Mr Neilsen noted the claimant had difficulty showering and performing housework. The insurer says that notwithstanding this, there has been no indication that this difficulty is related to the claimant’s psychiatric injuries rather than her physical injuries.
Further, the insurer also says that the purported difficulty in showering and performing housework is entirely inconsistent with the claimant’s self- reporting to the Medical Assessor Sidorov, that is that she was independent with her activities of daily living and housework. The insurer says that had the Medical Assessor engaged with the material, he ought to have identified the inconsistency and put this to the claimant. In the circumstances, the insurer disputes Mr Neilsen’s diagnosis and highlights the inconsistency between the claimant’s self-report to Mr Neilsen and to the Medical Assessor.
The insurer says that despite the above, at paragraph 8 of his certificate, the Medical Assessor noted the claimant denied any mental health issues prior to the accident. The insurer says that when setting out his causation finding at paragraph 20, the Medical Assessor stated there were no identifiable causes for the diagnosis. The insurer says that from the certificate, it appears Medical Assessor accepted the claimant’s self-report that there was no history of mental health concerns.
The insurer submits that this is indicative of a failure to consider relevant material being clinical notes of Living Waters Medical Centre and further, a failure to engage with an argument, being that there was a history of a psychological diagnosis.
The insurer acknowledged that while the diagnostic criteria for post-traumatic stress disorder, attention deficit disorder and depression, or major depressive episode, differ, there is an overlap in the reported symptoms required for a diagnosis. On this basis the insurer says that, any pre-accident complaints are entirely relevant and warranted consideration by the Medical Assessor.
The claimant has been diagnosed with post-traumatic stress disorder, by Carl Neilsen, psychologist, and contends that diagnosis is as a result of the subject accident.
The insurer says that the application for personal injury benefits claim form completed on 21 June 2023 includes a diagnosis of acute stress disorder, a threshold injury for the purpose of s 1.6 of the Act.
The insurer referred to the claimant’s submission that the insurer has failed to obtain and serve medical evidence from a qualified expert regarding its position that her symptoms do not meet the DSM-5 diagnostic criteria for a diagnosis of post-traumatic stress disorder. The insurer says that it is not incumbent upon the insurer to serve qualified medical evidence in relation to the diagnosis of post-traumatic stress disorder. This submission is made on the basis that a diagnosis of post-traumatic stress disorder according to the DSM-5, is made on the basis of the claimant’s self-report of symptoms which satisfy the diagnostic criteria.
As set out in the internal review determination, the insurer disputes the claimant has satisfied the diagnostic criterion D which requires the following:
“D Negative alternations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidence by two (or more) of the following:
(a)   Inability to remember an important aspect of the traumatic event(s) (typically due to dis- sociative amnesia and not to other factors such as head injury, alcohol, or drugs).
(b)   Persistent and exaggerated negative believes or expectations about oneself, others, or the world (e.g. ‘I am bad,’ ‘No one can be trusted,’ ‘the world is completely dangerous,’ ‘My hold nervous system is permanently ruined’).
(c)   Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
(d)   Persistent negative emotional state (e.g. fear, horror, anger, guilt or shame).
(e)   Markedly diminished interest or participation in significant activities.
(f)    Feelings of detachment or estrangement from others.
(g)   Persistent inability to experience positive emotions (e.g. inability to experience happiness, satisfaction, or loving feelings).”
For criterion D to be satisfied, it must be accepted that there are two or more alterations in cognition and mood. In the initial allied health recovery request, the psychologist noted the following:
“she noted negative thinking characterised by anxious and depressive cognition regarding returning to pre MVA functioning.”
The insurer submits that the evidence does not suggest the claimant has demonstrated a persistent negative emotional state, persistent inability to experience positive emotions or persistent and exaggerated negative beliefs or expectations about oneself, others or the world.
The insurer referred to the allied health recovery request (AHRR) and submits that this did not indicate the claimant had an inability to remember an important aspect of the trauma or a markedly diminished interest or participation in significant events. As a consequence of this, the insurer submits that it does not consider the claimant has satisfied criterion D for a diagnosis of post-traumatic stress disorder.
Further, the claimant frequently attended Living Waters Family Medical Practice both prior to and following the accident. Those records indicate her past history to include a diagnosis of depression in November 2021 and attention deficit disorder in April 2022.
In view of the above, the insurer maintains that any psychiatric injury sustained in the subject accident is a threshold injury for the purpose of s 1.6 of the Act.

Psychiatric condition – post-traumatic stress disorder

The insurer noted the application for personal injury benefits claim form completed on
21 June 2023 included a diagnosis of acute stress disorder, which is a threshold injury for the purpose of s 1.6 of the Act.
The claimant submits that the insurer has failed to obtain and serve medical evidence from a qualified expert regarding its position that her symptoms do not meet the DSM-5 diagnostic criteria for a diagnosis of post-traumatic stress disorder. It is not incumbent upon the insurer to serve qualified medical evidence in relation to the diagnosis of post-traumatic stress disorder. This submission is made on the basis that a diagnosis of post-traumatic stress disorder according to the DSM-5, is made on the basis of the claimant’s self-report of symptoms which satisfy the diagnostic criteria.
The insurer disputes the claimant has satisfied the diagnostic criterion D.

The insurer noted that for criterion D to be satisfied, it must be accepted that there are two or more alterations in cognition and mood. The insurer noted that in the initial AHRR, the psychologist noted the following:
“she noted negative thinking characterised by anxious and depressive cognition regarding returning to pre MVA functioning.”
The insurer submits that the evidence does not suggest the claimant has demonstrated a persistent negative emotional state, persistent inability to experience positive emotions or persistent and exaggerated negative beliefs or expectations about oneself, others or the world.
The insurer submits that the AHRR does not indicate the claimant had an inability to remember an important aspect of the trauma or a markedly diminished interest or participation in significant events. Consequently, the insurer does not consider the claimant satisfies criterion D for a diagnosis of post-traumatic stress disorder.
The insurer also noted that the claimant frequently attended Living Waters Family Medical Practice both prior to and following the accident. The insurer submits that the records of that Medical Practice indicate her past history to include a diagnosis of depression in November 2021 and attention deficit disorder in April 2022.
The insurer maintains that any psychiatric injury sustained in the subject accident is a threshold injury for the purpose of s 1.6 of the Act.

Claimant’s submissions

The submissions lodged by the claimant do not address the review application. The submissions go to the correctness or otherwise of the insurer's application for review have and its lodgement.
The Panel proceeds on the basis that the claimant opposes the application for review.

Medical evidence

The clinical notes of Living Waters Medical Centre include attendances from October 2019.
The claimant frequently attended Living Waters Medical Centre in the lead up to the subject accident. The first post-accident attendance was on 24 May 2023, which was six days post- accident, however, no reference is made to the subject accident, nor any injuries sustained in the accident. Thereafter, the claimant consistently attended from June 2023 until records were provided in October 2023, with the clinical entries making no mention of the subject accident or the injuries allegedly sustained.
The claimant attended Seven Hills Physiotherapy & Sport Injuries Centre on
29 August 2023 at which time it was noted she had been involved in the subject accident. She stated the pain in the neck started the same day. She also reported sharp right sided thoracic spine pain. The impression was whiplash and lower back pain post-accident.
The certificates of capacity dated 20 June 2023 include a diagnosis of cervical spine aggravation, thoracic spine strain and acute stress disorder. The remaining certificates of capacity reflect a diagnosis of cervical spine aggravation, thoracic spine strain and post-traumatic stress disorder.
The insurer referred to the diagnosis of the claimant with post-traumatic stress disorder, by Mr Neilsen, psychologist, and his contention that this diagnosis is as a result of the subject accident. This report was referred to within the certificate and reasons of the Medical Assessor but does not form any specific part of the bundles of documents of either party.
Mr Neilsen would appear to be part of the organisation of Insightul Minds for which there is reference within the AHRR band also as an entry in the clinical notes of Workers Doctors dated 20 June 2023. The Medical Assessor also said that he considered in his certificate a report of Mr Nielsen dated 17 November 2023.
Clinical records of Workers Doctors in 2023 recorded symptoms of anxiety, sleep disturbance, low mood, depressive symptoms, anxiety, stress and a diagnosis of post-traumatic stress disorder.
In the clinical notes of Workers Doctors and an entry of 20 June 2023, Mr Neilsen is reported as writing;
“Due to her MVA Ms Soureninan [sic] noted a deterioration in her mental state characterized by repeated disturbing and unwanted memories pertaining to her MVA and specifically regarding the impact of the collision itself. She noted avoidance of driving and social interactions as well as of speaking about the MVA generally. She noted negative thinking characterized by anxious and depressive cognitions regarding returning to pre MVA functioning. Ms Sourenian noted fluctuations in arousal ranging from hypervigilance to irritability and low mood. Due to her MVA Ms Sourenian is unable to do grocery shopping. She has become socially withdrawn and has difficulties showering. Ms Sourenin [sic] has difficulties doing housework.”

Mr Neilsen diagnosed post-traumatic stress disorder.
Mr Neilsen said;
“The following details how Mrs Mariam Sourenian meets the criteria for PTSD as per DSM V.
Criterion A:
Exposure to psychological trauma threatening serious injury /death:
Criterion B:
Intrusive Symptoms:
Repeated disturbing and unwanted memories pertaining to her MVA and specifically regarding the impact of the collision itself.
Criterion C:
Avoidant behaviour:
She noted avoidance of driving and social interactions as well as of speaking about the MVA generally.
Criterion D:
Negative changes in thoughts and mood:
She noted negative thinking characterized by anxious and depressive cognitions regarding returning to pre MVA functioning.
Criterion E:
Changes in arousal:
Ms Sourenian noted fluctuations in arousal ranging from hypervigilance to irritability and low mood.
Criterion F:
Symptoms more than a month:
Her symptoms have,lasted for longer than one (1) month in duration
Criterion G:
Considerable distress:
Due to her MVA Ms Sourenian is unable to do grocery shopping. She has become socially withdrawn and has difficulties showering. Ms Sourenin (sic)has difficulties doing housework
Criterion H:
Symptoms are not due to a medical condition or some form of substance use:
She denied any illicit substance or alcohol abuse”.
To the Medical Assessor, the claimant reported;
“After about one week, she attended her general practitioner at the Living Waters Family Medical Centre. She stated that, by that time, she was experiencing significant anxiety about driving and was advised by her general practitioner not to drive and to try not to think about the subject accident. She stated that she found this not possible and continued to have intrusive thoughts and nightmares about the accident, which disturbed her sleep. She tried to avoid any reminders of the accident, including by driving, and her mood became more unstable, and at times, she experienced a low mood, with a diminished interest in her usual activities, feeling generally detached from others and finding it hard to experience positive emotions and enjoy herself. She also became more hypervigilant, on edge, easily startled and irritable. In this context, she started seeing a psychologist and has been having sessions since then every two to three weeks. She stated that she has found it somewhat helpful, but her symptoms have persisted. She has also been referred to a physiotherapist and has been seeing them once a week to once a fortnight. There was no evidence of the development of mania or psychosis.”
The Medical Assessor referred to a clinical record of Mr Nielsen, with an initial entry on
20 June 2023 outlining the claimant’s psychological symptoms, specifically noting that she met the diagnostic criteria for a post-traumatic stress disorder, as per the DSM-5. He observed record of subsequent consultations noting ongoing trauma related symptoms, with associated anxiety and depressive symptoms.
The Medical Assessor concluded that the claimant met the diagnostic criteria for a post-traumatic stress disorder, as per DSM-5. He said that this was based on a history the claimant being involved in a serious motor vehicle accident where she had a fear of serious injury or death, with the subsequent development of intrusion symptoms, including;
(a)    recurrent, involuntary and intrusive;
(b)   distressing memories, as well as nightmares regarding the accident;
(c)    persistent avoidance of stimuli associated with the subject accident;
(d)   negative alterations in cognitions and mood associated with the subject accident;
(e)   marked alterations in arousal and reactivity associated with the subject accident characterised by increased irritability;
(f)     hypervigilance;
(g)   an exaggerated startle response;
(h)   difficulties with concentration, and
(i)    sleep disturbance.
An AHRR report of 21 June 2023 provided a diagnosis of post-traumatic stress disorder and noted;
(a)   exposure to psychological trauma threatening serious injury/death;
(b)   the claimant was involved in a motor vehicle accident and sustained serious injuries;
(c)   intrusive symptoms;
(d)   repeated disturbing and unwanted memories pertaining to her accident and specifically regarding the impact of the collision itself;
(e)   avoidant behaviour;
(f)    avoidance of driving and social interactions as well as of speaking about the accident generally;
(g)   negative changes in thoughts and mood;
(h)   negative thinking characterized by anxious and depressive cognitions regarding returning to pre accident functioning;
(i)    changes in arousal;
(j)    fluctuations in arousal ranging from hypervigilance to irritability and low mood;
(k)   symptoms for more than a month;
(l)    her symptoms have lasted for longer than one month in duration;
(m)     considerable distress;
(n)   due to her accident the claimant is unable to do grocery shopping;
(o)   she has become socially withdrawn and has difficulties showering;
(p)   the claimant has difficulties doing housework;
(q)   symptoms are not due to a medical condition or some form of substance use, and
(r)    she denied any illicit substance or alcohol abuse.

Medical examination

The claimant was examined by Medical Assessor Yeates and Medical Assessor Baker on
30 July 2025. Their examination report follows;
1.            Psychosocial history and pre-accident history
Mrs Sourenian was born in Aleppo, Syria, and raised with her mother, father, and three older brothers. Her father owned a tow truck company, and her mother managed home duties. The family lived in Aleppo, where Mrs Sourenian said she experienced favourable developmental conditions within a supportive family environment. She denied any domestic violence and was closest emotionally to her eldest brother. She was a healthy child and young person who reached her developmental milestones at the usual times. She denied any physical, sexual, or emotional trauma outside of herself and was not persecuted for her Armenian Christian religion in Syria. She was not exposed to war or conflict during her upbringing and left Syria before serious conflicts began. Mrs Sourenian mentioned that her family was financially comfortable.
Mrs Sourenian attended local private schools in Aleppo. She had a circle of friends and was never suspended or expelled. She completed Year 12 with very good results. Her school marks were high enough for university admission, but she was prevented from attending by her father. After high school, she stayed at home and enjoyed her life, as she did not need to work, which she said was common for women in Syria. Mrs Sourenian married at 24 and moved to Australia in 1991 with her husband, who was a panel beater and listed among preferred skilled migrants. She had her first and only child in 1995 — a much-wanted pregnancy after three previous miscarriages. She started working as a cake decorator in the late 1990s at a cake shop in Blacktown and Padstow for about 10 years. Later, she worked as a driver for disabled children, taking them to and from school. She was involved in an accident around 2010, falling downstairs and fracturing her sternum, which prevented her from returning to driving work.
Mrs Sourenian was robbed at knifepoint around 2010 for jewellery, which she handed over, and did not sustain physical injury. However, she experienced pervasive anxiety that warranted referral to a psychiatrist due to persistent fears. She gradually improved over 1 to 1 ½ years and had no further symptoms once she moved house 13 years ago. She has never had a psychiatric admission. There is no history of suicidal ideation, intent, or attempt. She is under the care of her GP, Dr Philip Castleman, and other GPs in the associated practice. She currently takes medication for type 2 diabetes, a statin, and fluoxetine 20mg. She has had a left-sided nephrectomy for a congenital non-functioning pelvic kidney.
There is no history suggestive of a primary psychotic illness or bipolar disorder. There is no family history of major mental illness, addictions, or suicide. Mrs Sourenian occasionally drinks alcohol, about one to two drinks per month. She has never used illicit drugs and does not gamble. There is no forensic history.
2.   History of the motor accident
On 18 May 2023, Mrs. Sourenian was at a friend's house with her husband and left to buy some seeds from a shop. She was driving and entered a street, and while travelling at around 40 km/h, a truck reversed into her vehicle. She was wearing a seatbelt, and the airbags did not deploy; however, the left side airbags of her vehicle were damaged by the truck. Police and ambulance attended the scene, and Mrs. Sourenian was able to exit the car without issue. She did not lose consciousness but was distressed. She was taken to the hospital but did not sustain any immediate physical injuries.
3.   History of symptoms and treatment following the motor accident
In terms of physical symptoms, Mrs. Sourenian said she developed pain in her left shoulder, which she consulted her GP about, leading to a CT scan. Later, she was offered but declined the injection of corticosteroid in her neck to address the shoulder pain due to the perceived risks.
In terms of psychological symptoms, Mrs. Sourenian mentioned that after several weeks, she became more concerned about her kidney, which had concurrent medical conditions, including the need for stenting of the ureter every two weeks. She also felt anxious about driving and was affected by her husband’s anxiety and nightmares. She reported disturbed sleep and frequent awakenings due to the need for toileting. Mrs. Sourenian recalled the accident and had fears about the impact on her husband if she had not braked when she did. She exhibited diffuse anxiety and depressive symptoms but showed no features consistent with major depressive disorder, such as pervasive guilt, hopelessness, worthlessness, or suicidal thoughts.
Mrs. Sourenian reported being referred to a psychiatrist after consulting her legal counsel; the psychiatrist prescribed fluoxetine 20 mg, which had some effect. She saw this psychiatrist twice in person and then followed up via WhatsApp.
4.   Details of any relevant injuries or conditions sustained since the motor accident
There are no other relevant injuries or conditions sustained since the motor accident.

CLINICAL EXAMINATION

5. Mental state examination
The mental state examination revealed a woman of Middle Eastern descent dressed in casual clothes, appearing congruent with her stated age. Her social manner was polite and suitable. The mood was euthymic and her affect was somewhat restricted, with occasional reactivity. Thought content was reality-oriented, with no signs of psychosis, severe disturbance, suicidality, or internalised thoughts. The thought form was normal. Her speech was grammatically correct, well-structured, syntactically sound, and spontaneously elaborated. Judgment was not acutely impaired, and there were no perceptual disturbances. Cognitive function appeared broadly normal, with no need for formal testing. Insight was modest.
6. Current functioning
Mrs Sourenian currently lives with her husband of 40 years. She showers daily and eats two regular meals each day. She undertakes the regular domestic duties such as cleaning, laundry, and cooking but is somewhat limited by pain in her left shoulder. Her recreational activities include watching television and going out for dinner with her friends. She will leave the house with her husband for social events but has declined some of these invitations due to pain. She can leave the house without a support person. She drives up to 30 minutes, including on her own, and will catch public transport as required. She described her relationship with her husband and son as “very good.” She did not report a loss of friendships. She can concentrate on television and reading but has difficulty holding the book due to ongoing left shoulder pain. She has not worked in a paid or unpaid capacity since 2010 and has been a recipient of a disability support pension since 2003.

Determinations

7. Diagnosis
Mrs. Sourenian presents with symptoms and signs consistent with an adjustment disorder with mixed anxiety and depressed mood. An adjustment disorder describes a psychological syndrome resulting from a specific stressor that causes functional impairment. The panel considered that Mrs. Sourenian had several contributing factors to her adjustment disorder. The first was her serious kidney condition, which disrupts sleep. The second was ongoing left shoulder pain. The third was a motor vehicle accident and a diffuse set of depressive and anxious symptoms described above, resulting from the psychological distress of the accident. Each of these factors acts in concert and leads to an adjustment disorder that has persisted due to ongoing pain and an unrelated health condition (kidney).
In the panel’s view, Mrs. Sourenian’s symptoms are out of proportion to the severity or intensity of the stressors and have caused only modest functional impairment. The symptoms do not resemble normal bereavement and have persisted because of ongoing pain and stress. Both anxiety and mood symptoms are present, hence the qualifier “with mixed anxiety and depressed mood,”
Adjustment Disorder – DSM-5-TR
This diagnosis of DSM-5-TR F 43.23 adjustment disorder with mixed anxiety and depressed mood is defined by the following criteria:
A. The development of emotional or behavioural symptoms in response to an identifiable
stressor(s) occurring within 3 months of the onset of the stressor(s).
This criterion is met because, within several weeks after the motor accident, Mrs Sourenian developed mixed symptoms, mixed anxiety and depressed mood.
B. These symptoms or behaviours are clinically significant, as evidenced by one or both of
the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor,
taking into account the external context and the cultural factors that might influence
symptom severity and presentation.
There is marked distress related to the accident.
2. Significant impairment in social, occupational, or other important areas of functioning.
Mrs Sourenian has functional impairment in the form of an ongoing depressed mood, causing her to decline social invitations and experience anxiety while driving.
C. The stress-related disturbance does not meet the criteria for another mental disorder
and is not merely an exacerbation of a pre-existing mental disorder.
Mrs Sourenian’s symptoms do not meet criteria for another mental disorder, and the history and examination are not consistent with an exacerbation of a pre-existing mental disorder.
D. The symptoms do not represent normal bereavement.
Mrs Sourenian’s symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do not persist
for more than an additional 6 months.
Mrs Sourenian has continued to suffer from the consequences of the motor accident because of pain and this unresolved stressor has caused her adjustment disorder with mixed anxiety and depressed mood to become chronic.
Comments on consistency
The evaluation was consistent with the documents provided, and there were no inconsistencies identified at the interview.
Review Panel Deliberations
The panel considered several other diagnoses. The first was major depressive disorder. This diagnosis was not considered appropriate in the view of the panel because several clinical features were absent. Firstly, the pervasiveness of the low mood was not accompanied by the other criteria for major depressive disorder, such as hopelessness, suicidal ideation, weight change, or mood-driven sleep disturbance. Moreover, the global clinical impression was not consistent with major depressive disorder.
The panel also considered the diagnosis of post-traumatic stress disorder. However, the panel was not persuaded that the accident met criterion A of the criteria for post-traumatic stress disorder. Furthermore, there were insufficient clinical features to satisfy the subsequent criteria of post-traumatic stress disorder (criteria B-G).
Considering the symptoms reported, no other DSM-5 diagnoses were considered appropriate by the panel. Thus, an adjustment disorder diagnosis was made considering the mixed anxiety and depressive symptoms with an accompanying minor functional impairment.
Conclusion
The panel concluded that Mrs Sourenian has sustained an adjustment disorder with mixed anxiety and depressed mood diagnosis because of the subject accident. According to the Act, adjustment disorder is defined as a threshold injury. Therefore, Mrs Sourenian has sustained a threshold injury.

The Panel met on 13 August 2025 to discuss the Medical Assessors’ findings on examination. The legal Member of this Panel did not participate in the medical examination but prior to the Panel meeting on 13 August 2025, the legal Member has had the benefit of reading and considering the Medical Assessors examination report. On 13 August 2025 the Panel met and all discussed the examination findings and the issues going to causation and assessment of WPI. It is from this teleconference of the Panel that the Panel has agreed and reached its final conclusion and determination.
The Panel adopts the report of Medical Assessor Yeates and Senior Medical Assessor Baker.

Causation/reasons

Paragraphs 1.6 to 1.7 of the Permanent Impairment Guidelines are found under the heading “Causation of injury” and provide;
“1.6 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 judgment.
1.7 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.”
In the context of determining questions of causation in relation to motor accidents in accordance with “the … principles that would be applied by a court (or assessor) in considering such issues”, the reference in par 1.5 to “common law principles” is to be understood as referring to the legal principles that courts or claims assessors are required to apply in determining causation. This includes not only common law principles, in the strict sense, but also such principles as modified or explained by statutory provisions, such as s 5D of the Civil Liability Act 2002 (NSW) (CL Act), where applicable. This approach is consistent with Windeyer J’s observation in Gammage v The Queen (1969) 122 CLR 444 at 462; [1969] HCA 68 that:
“for the present purposes [of that case concerning the law of homicide], it is misleading to speak glibly of the common law in order to compare and contrast it with a statute. In any consideration of common-law rules it is necessary to take one's stand at some point of time. It is necessary too to be clear whether what is being spoken of as the common law at that point of time comprehends all statutory modifications of it then in force or only its pristine form.”

The approach is also consistent with the remarks of Campbell J in Owen v Motor Accidents Authority of NSW [2012] NSWSC 650 at [27] where it was held that:
“the question to be assessed [under the previous Motor Accidents Medical Guidelines which were relevantly in substantially the same terms as the 2018 Guidelines] is one of legal causation involving mixed questions of fact and law arising principally from the law of negligence as modified by Civil Liability Act 2002, s.5 D. (See s.3B(2)).”
Section 5D of the CL Act relevantly provides:
“(1) A determination that negligence caused particular harm comprises the following elements—
(a) that the negligence was a necessary condition of the occurrence of the harm (factual causation), and
(b) that it is appropriate for the scope of the negligent person’s liability to extend to the harm so caused (scope of liability).
…
(4) For the purpose of determining the scope of liability, the court is to consider (amongst other relevant things) whether or not and why responsibility for the harm should be imposed on the negligent party.”
This review is a new assessment of all matters with which the medical assessment is concerned. The original medical assessment related to whether the injuries sustained in the motor accident were threshold or non-threshold as defined under the Act.
The Panel must ask itself in considering whether the accident contributed to the claimant’s injuries as referred to it by the Commission, whether the claimant’s condition arises because of contribution by the accident, and whether the accident materially contributed to that condition.
On the balance of probabilities, can it be said that the claimant suffered a recognisable psychiatric injury? For the reasons discussed above in the report of the Medical Assessors, the Panel does find that the accident gave rise to a psychiatric injury.
Following the accident, the claimant did seek psychological assistance and treatment. However, the nature of the injury was not, in the finding of the Panel, a recognised psychiatric injury.
Would the impairment have occurred, if not for the accident? The Panel is satisfied that the accident and impact has had a more than negligible effect on the psychiatric condition suffered by the claimant. This is because up to and at the time of the accident she was not seeking psychiatric treatment. Prior to the accident the claimant was driving without restriction and without anxiety.
The claimant exhibited mixed anxiety and depressive symptoms but showed no features consistent with major depressive disorder, such as pervasive guilt, hopelessness, worthlessness, or suicidal thoughts. She also felt anxious about driving and was affected by her husband’s anxiety and nightmares.
The Panel must also ask itself in considering whether the accident contributed to the claimant’s injuries as referred to it by the Commission, whether the claimant’s condition arises because of contribution by the accident, and whether the accident materially contributed to that condition. The Panel is satisfied that this is the position but the Panel is not satisfied that the claimant has suffered a psychiatric illness such that she has suffered a non-threshold psychiatric injury.
On the balance of probabilities, can it be said that the claimant suffered a recognisable psychiatric injury? For the reasons discussed above in the report of the Medical Assessors, the Panel does not find that this can be answered in the affirmative.
Would the impairment have occurred, if not for the accident? The Panel is satisfied that the accident and impact has had a more than negligible effect on the claimant’s psychiatric condition suffered by the claimant. However, the claimant has not demonstrated a recognisable psychiatric injury in terms of s 1.6 of the Act.
The claimant has demonstrated on examination symptoms and signs consistent with an adjustment disorder with mixed anxiety and depressed mood. An adjustment disorder describes a psychological syndrome resulting from a specific stressor that causes functional impairment. The Panel considered that the claimant had several contributing factors to her adjustment disorder. As described in the medical examination report, the first was her serious kidney condition, which disrupts sleep. The second was ongoing left shoulder pain. The third was the subject motor vehicle accident and a diffuse set of depressive and anxious symptoms described above, resulting from the psychological distress of the accident. Each of these factors acts in concert and leads to an adjustment disorder that has persisted due to ongoing pain and an unrelated health condition of her kidney.

Conclusion

The claimant is diagnosed by the Panel as having an adjustment disorder with mixed anxiety and depressed mood.
This is a threshold injury.

Determination

The Panel revokes the certificate of Medical Assessor Sidorov dated 10 April 2024.
The claimant has an adjustment disorder with mixed anxiety and depressed mood.
This is a threshold injury.

[2025] NSWPICMP 618

18 August 2025