QBE Insurance (Australia) Limited v Mackay

DETERMINATION OF REVIEW PANEL
CITATION:	QBE Insurance (Australia) Limited v Mackay [2023] NSWPICMP 695
CLAIMANT:	Tegan Mackay
INSURER:	QBE Insurance (Australia) Limited
REVIEW PANEL
MEMBER:	Anthony Scarcella
MEDICAL ASSESSOR:	Thomas Newlyn
MEDICAL ASSESSOR:	Gerald Chew
DATE OF DECISION:	21 December 2023
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; medical assessment of whole person impairment (WPI) by Medical Assessor (MA) Roberts who determined that the claimant had a whole person impairment (WPI) of greater than 10%, that is, 18% WPI and also determined a treatment dispute; review sought by insurer under section 7.26; claimant suffered a psychological injury in a motor accident on 6 June 2019; consideration and application of clauses 6.201 to 6.228 of the Motor Accident Guidelines in respect of mental and behavioural disorders; Held – The Panel revoked the certificate issued by MA Roberts dated 13 June 2022; The Panel certified that claimant sustained a persistent depressive disorder with anxious distress and an excoriation (skin picking) disorder caused by the motor accident on 6 June 2019 that give rise to a WPI which is not greater than 10%, that is, 6%; the Panel certified that the 10 weekly psychological counselling sessions proposed in the allied health recovery request by the claimant’s psychologist dated 8 August 2020, relate to the injuries caused by the motor accident on 6 June 2019, are reasonable and necessary in the circumstances, and will improve the claimant’s recovery.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION The Review Panel: 1. Revokes the certificate issued by Medical Assessor Samson Roberts dated 13 June 2022. 2. Certifies that the claimant sustained a persistent depressive disorder with anxious distress and an excoriation (skin picking) disorder caused by the motor accident on 6 June 2019 that give rise to a whole person impairment which is not greater than 10%, that is, 6%. 3. Certifies that, the 10 weekly psychological counselling sessions proposed in the allied health recovery request by Ms Jackie Kingston of Just Psychology dated 8 August 2020, relate to the injuries caused by the motor accident on 6 June 2019; are reasonable and necessary in the circumstances; and will improve the claimant’s recovery.

STATEMENT OF REASONS

BACKGROUND

The claimant, Ms Tegan Mackay, is a 34-year-old woman who was involved in a motor accident on 6 June 2019 whilst a front seat passenger in a stationary motor vehicle that was rear-ended by another motor vehicle (the motor accident).
On 3 July 2019, Ms Mackay made a claim for personal injury benefits. The relevant compulsory third party insurer was QBE Insurance (Australia) Limited (the insurer).
Ms Mackay claims that she suffered injuries to her neck and back as well as psychological injuries as a result of the motor accident.
Ms Mackay’s claim is governed by the provisions of the Motor Accident Injuries Act2017 (MAI Act). This legislation provides a scheme for the compulsory third-party insurance of all motor vehicles registered in New South Wales and a scheme of statutory benefits (under Part 3) and compensation by way of lump sum damages (under Part 4) for persons injured in motor accidents in New South Wales.
A medical dispute about the degree of Ms Mackay’s whole person impairment (WPI) and a treatment dispute have arisen in connection with her claim. These constitute medical assessment matters under Schedule 2, cl 2(a) and (b) of the MAI Act respectively.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor: s 7.20 of the MAI Act.
The medical dispute was referred to the Personal Injury Commission (Commission) and the Commission assigned it to Medical Assessor Samson Roberts for assessment.
On 13 June 2022, Medical Assessor Roberts determined that Ms Mackay suffered an exacerbation of a major depressive disorder and an exacerbation of a generalised anxiety disorder caused by the motor accident and assessed her as having a WPI greater than 10%, that is, 18%. Medical Assessor Roberts also determined that the proposed psychology treatment related to the injuries caused by the motor accident; was reasonably necessary in the circumstances; and would improve Ms Mackay’s recovery (the Medical Assessment).

REVIEW PROCEDURE

The insurer sought a review of the Medical Assessment in accordance with s 7.26 of the MAI Act (the Review).
The President’s delegate determined that there was reasonable cause to suspect that the Medical Assessment was incorrect in a material respect and referred the matter to a Review Panel (the Panel).
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision-maker” is defined in cl 14A(1) of Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply.
The new review provisions provide that a review panel consists of two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission: s 7.26(5A) of the MAI Act. Accordingly, the President’s delegate has convened this Panel to conduct the review of the Medical Assessment.
Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor: s 41(2) of the PIC Act.
The Review of the Medical Assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect. The Review is by way of a new assessment of all matters with which the medical assessment is concerned: s 7.26(6) of the MAI Act. However, s 7.25 of the MAI Act provides that the review of a medical assessment can be made on the basis of any agreement by the parties as to the degree of permanent impairment from a particular injury and whether a particular injury was caused by the motor accident, without those matters having to be the subject of assessment.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application: Rule 128 of the PIC Rules.
On 22 May 2023, the Panel directed the parties to lodge with the Commission an indexed and paginated final bundle on which they relied in the Review (the insurer by 3 July 2023 and Ms Mackay by 7 August 2023).
On 28 August 2023, the Panel informed the parties that it considered a re-examination of Ms Mackay was required. Arrangements were made for Ms Mackay to be re-examined by Medical Assessor Thomas Newlyn and Medical Assessor Gerald Chew by video link (MS Teams) on 2 November 2023.

LEGISLATIVE FRAMEWORK

General provisions

Section 1.4 of the MAI Act defines ‘injury’ to mean a personal or bodily injury and includes a pre-natal injury; a psychological or psychiatric injury; and damage to artificial members, eyes or teeth, crutches or other aids or spectacle glasses.
Sections 5D (duty of care – general principles) and 5E (onus of proof) of the Civil Liability Act 2002 (the CLA) apply to the MAI Act: s 3B(2) of the CLA.
Ms Mackay’s claim and entitlements to compensation are governed by the provisions of the MAI Act. An injured person can make a claim for both economic losses and non-economic loss damages.
However, s 4.11 of the MAI Act provides that no damages for non-economic loss may be awarded in respect of injury unless the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident is greater than 10%.

Permanent impairment assessment

Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines version 9.2 effective from 10 November 2023 (the Guidelines).
The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association’s Guides to the Evaluation of Permanent Impairment Fourth Edition (AMA 4 Guides). The Guidelines are definitive in respect of the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed: cl 6.2 of the Guidelines.
Permanent impairment is assessed in accordance with Chapter 6 of the Guidelines.
Causation of injury is addressed in cls 6.5, 6.6 and 6.7 of the Guidelines.
Clause 6.6 of the Guidelines notes:
“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.”

Clause 6.7 of the Guidelines states:
“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.”
The assessment of permanent impairment in respect of mental and behavioural disorders is addressed in cls 6.201 to 6.228 of the Guidelines.
Clause 6.203 of the Guidelines states:
“The assessment of mental and behavioural disorders must be undertaken in accordance with the psychiatric impairment rating scale (PIRS) as set out in these Guidelines. Chapter 14 of the AMA 4 Guides (pages 291-302) is to be used for background or reference only.”
Clause 6.213 of the Guidelines states:
“The impairment must be attributable to a psychiatric diagnosis recognised by the current edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM-5-TR) or the current edition of the International Statistical Classification of Diseases & Related Health Problems (ICD). The impairment evaluation report must specify the diagnostic criteria on which the diagnosis is based.”
In respect of the PIRS, cl 6.219 of the Guidelines states that the behavioural consequences of psychiatric disorders are assessed on the following six areas of function, each of which evaluates an area of functional impairment:
(a)    self-care and personal hygiene (Table 6.11 of the Guidelines);
(b)    social and recreational activities (Table 6.12 of the Guidelines);
(c)    travel (Table 6.13 of the Guidelines);
(d)    social functioning (relationships) (Table 6.14 of the Guidelines);
(e)    concentration, persistence and pace (Table 6.15 of the Guidelines), and
(f)    adaptation (Table 6.16 of the Guidelines).
Tables 6.11 to 6.16 of the Guidelines identify the five classes of assessment within each of the six areas of function.
Clauses 6.225 to 6.228 and Table 6.17 of the Guidelines address the three step procedure involved in calculating psychiatric impairment.
Clauses 6.222 to 6.224 of the Guidelines address the adjustment for the effects of prescribed treatment to the assessment of WPI.
Clause 6.218 of the Guidelines states:
“In order to measure impairment caused by a specific event, the medical assessor must, in the case of an injured person with a pre-existing psychiatric diagnosis or diagnosable condition, estimate the overall pre-existing impairment using precisely the method set out in this part of the Guidelines, and subtract this value from the current impairment rating.”
Pre-existing impairment is addressed in cls 6.31, 6.32 and 6.33 of the Guidelines.
The evaluation of the permanent impairment may be complicated by the presence of an impairment in the same region that existed before the relevant motor accident. If there is objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the accident, then its value must be calculated and subtracted from the current WPI value. If there is no objective evidence of the pre-existing symptomatic permanent impairment, then its possible presence should be ignored: cl 6.31 of the Guidelines.
Pre-existing impairments should not be assessed if they are unrelated or not relevant to the impairment arising from the motor accident: cl 6.33 of the Guidelines.
Subsequent injury is addressed in cl 6.34 of the Guidelines which states:
“The evaluation of permanent impairment may be complicated by the presence of an impairment in the same region that has occurred subsequent to the relevant motor accident. If there is objective evidence of a subsequent and unrelated injury or condition resulting in permanent impairment in the same region, its value should be calculated. The permanent impairment resulting from the relevant motor accident must be calculated. If there is no objective evidence of a subsequent impairment, its possible presence should be ignored.”

Treatment and care assessment

Schedule 2, cl 2(b) of the MAI Act provides a treatment and care dispute as to whether any treatment and care provided or to be provided to the injured person is reasonable and necessary in the circumstances or relates to the injury caused by the motor accident, is a medical assessment matter for the purposes of Part 7.

ASSESSMENT UNDER REVIEW

Medical Assessor Roberts examined Ms Mackay on 24 May 2022 and issued a certificate under s 7.23(1) of the MAI Act on 13 June 2022.
Medical Assessor Roberts was asked to assess the dispute between the parties about the degree of permanent impairment under Schedule 2, cl 2(a) of the MAI Act in respect of psychiatric conditions – psychological injuries.
Medical Assessor Roberts was also asked to assess the dispute between the parties about whether the 10 weekly psychological counselling sessions proposed in the allied health recovery request by Ms Jackie Kingston of Just Psychology dated 8 August 2020 (AHRR 4) relate to the injury caused by the motor accident; are reasonable and necessary in the circumstances; and will improve Ms Mackay’s recovery.
Medical Assessor Roberts took a detailed psychosocial history, pre-accident history, history of the motor accident and history of symptoms and treatment following the motor accident.
Ms Mackay informed Medical Assessor Roberts that she was involved in a near-miss motor accident in December 2019 that did not impact on her.
On mental state examination, Medical Assessor Roberts observed that Ms Mackay presented as a casually attired, neatly groomed woman whose hands were manicured. She appeared overweight, which was consistent with her account of weight gain. No psychomotor agitation was apparent during the assessment. She seemed overtly calm, even when discussing the extent of her symptoms and the extent of the limitations arising from them. He observed that Ms Mackay described a pervasively depressed mood and exhibited a restricted affect. She reported anxiety. She was able to present a detailed account of the motor accident and its effects without appearing at all upset or distressed. No features of a psychotic nature were apparent.
Medical Assessor Roberts recorded Ms Mackay’s current functioning in some detail.
Medical Assessor Roberts formed the view that there were no inconsistencies apparent in interview or on mental state examination.
Medical Assessor Roberts referred to and provided a summary of the relevant documentation provided to him.
Medical Assessor Roberts questioned Ms Mackay’s pre-accident diagnosis of attention deficit/hyperactivity disorder based on her presentation on examination to him that was in contrast to the history she presented to Dr Anthony Levine, psychiatrist. However, irrespective of the uncertainty regarding such diagnosis, Medical Assessor Roberts opined that the diagnosis would not be influenced in its course by an incident such as the motor accident. It represented a condition which impairs attention, concentration, organisation and the timely completion of tasks and which had been assertively treated with medication.
Medical Assessor Roberts opined that, the symptomatology presented by Ms Mackay and the material before him that post-dated the motor accident, supported the conclusion that she has suffered an exacerbation of a pre-existing major depressive disorder and an exacerbation of a generalised anxiety caused by the motor accident.
Medical Assessor Roberts assessed the degree of permanent impairment caused by the motor accident as 18% WPI after having deducted 4% WPI in respect of Ms Mackay’s

pre-existing major depressive disorder, generalised anxiety disorder and attention deficit/hyperactivity disorder.
In respect of the treatment dispute, Medical Assessor Roberts opined that the psychology treatment requested in AHRR 4 related to the injuries caused by the motor accident, is reasonable and necessary in the circumstances and will improve recovery.

EVIDENCE BEFORE THE PANEL

The evidence before the Panel consisted of the following:
(a)    the certificate issued by Medical Assessor Samson Roberts dated 13 June 2022;
(b)    the insurer’s indexed and paginated bundle of documents lodged on the Commission’s portal on 28 August 2023 (insurer’s documents);
(c)    Ms Mackay’s indexed and paginated bundle of documents lodged on the Commission’s portal on 7 August 2023 (Ms Mackay’s documents), and
(d)    Ms Mackay’s application to admit late documents dated 22 August 2023 (Ms Mackay’s AALD).

REVIEW OF EVIDENCE
Application for personal injury benefits

On 3 July 2019, Ms Mackay completed an application for personal injury benefits in respect of the motor accident (the application form).[1]
[1] Ms Mackay's documents at pages 13-18.
The application form set out the basic particulars of the motor accident and Ms Mackay described the accident as follows:
“My Subaru XV was stationary in traffic due to a red light ahead, in the far lane of the road. With no indication of brakes squealing or any other visual or audio we were struck heavily from behind by another motor vehicle … who did not break [sic: brake] before impact with my motor vehicle.”[2]
[2] Ms Mackay's documents at page 15.
In the application form, Ms Mackay described the injuries she suffered in the motor accident as follows:
“I have received a neck and back injury due to the accident. I am also experiencing acute stress and anxiety.”[3]
[3] Ms Mackay’s documents at page 15.
In the application form, Ms Mackay disclosed that she had suffered from anxiety prior to the motor accident.

Treating medical records and reports

Pre-accident

On 6 September 2016, Ms Mackay consulted Dr Angela Lam, general practitioner, of Alliance Medical Healthcare Centre reporting anxiety as a result of workplace bullying. She reported undergoing psychological counselling through the employee assistance program but felt that it was of little benefit. Dr Lam noted that Ms Mackay complained of being anhedonic and fatigued. Social interaction had been reduced. She had been recently married and was in a happy relationship. There was significant conflict between her parents. She had stopped exercising and had an elevated body mass index (BMI) of which she was self-conscious. Dr Lam prescribed her 50mg tablet of Pristiq daily and certified her unfit for work until 9 September 2016.[4]
[4] Insurer's documents at page 197.

On 20 September 2016, Ms Mackay consulted Dr Lam reporting that she still had up and down days with fluctuating moods. Her return to work on 12 September 2016 may have exacerbated her symptoms. Dr Lam counselled her in respect of relaxation techniques and strategies and certified her unfit for work until 2 October 2016.[5]
[5] Insurer's documents at page 198.
On 30 September 2016, Ms Mackay consulted Dr Lam reporting that she remained anxious. Dr Lam noted that her depressive symptoms appeared to be improving but that she still experienced panic-type symptoms when thinking about work. Dr Lam opined that self-esteem appeared to be the main barrier. Dr Lam counselled her and prepared a mental health treatment plan.[6]
[6] Insurer's documents at page 198.
On 12 October 2016, Ms Mackay consulted Dr Lam reporting that she remained intermittently anxious and that Pristiq was providing some symptomatic relief.[7]
[7] Insurer's documents at pages 198-199.
On 28 March 2017, Ms Mackay consulted Dr Lam reporting that she had recently commenced a foundation university course and eventually, wanted to commence a degree in business/economics/finance. Dr Lam noted that she was quite stressed and provided counselling and prescribed one 50mg Pristiq tablet daily.[8]
[8] Insurer's documents at page 199.
On 4 November 2017, Ms Mackay consulted Dr Lam reporting that over the course of 2016/2017 her mental health had improved but that, in recent months, she had become anhedonic and was unsure of the trigger. Dr Lam observed that she was flat and unmotivated. Ms Mackay reported anxiety symptoms with some triggers and that the initial psychotherapy sessions were unhelpful. Dr Lam provided counselling and referred her back for psychotherapy. Another prescription for one 50mg Pristiq tablet daily was issued. Dr Lam issued another mental health treatment plan.[9]
[9] Insurer's documents at page 200.
On 5 August 2018, Ms Mackay consulted Dr Lam advising that she was coping well since restarting her university studies. She also reported that her dysmenorrhoea had improved with Pristiq. Dr Lam issued another prescription for Pristiq.[10]
[10] Insurer's documents at pages 200-201.
In January 2019, Ms Mackay was referred to Ms Jackie Kingston, psychologist, of Just Psychology by Dr Lam in respect of difficulties related to stress and anxiety symptoms. The first consultation took place on 15 January 2019.[11]
[11] Insurer's documents at page 301.
On 23 February 2019, Ms Mackay consulted Dr Lam advising that Ms Kingston queried a possible diagnosis of attention deficit/hyperactivity disorder. Dr Lam noted that her brother was so diagnosed as an adult and that her sister may have similar symptoms. Ms McKay recalled being bored at school and achieving good marks without studying very hard. Dr Lam issued another prescription for Pristiq and referred Ms Mackay to Dr Anthony Levine, consultant psychiatrist.[12]
[12] Insurer's documents at page 201.
On 6 March 2019, Dr Levine reported to Dr Lam.[13] Dr Levine noted that Dr Lam had referred Ms Mackay for management of attention deficit/hyperactivity disorder, major depressive disorder and anxiety.
[13] Insurer's documents at pages 28-29.
Dr Levine’s diagnosis was one of attention deficit/hyperactivity disorder. He took a history from Ms Mackay of lifelong difficulties with poor concentration, being overly distracted and easily bored. She described losing items, often being late for appointments and zoning out during conversations. She struggled to relax doing nothing, frequently tapping her feet. Whilst she felt the desire to interrupt others, she was able to refrain. She moved between jobs and roles when she was bored and boredom was also associated with a drop in productivity. Dr Levine noted that her brother had been recently diagnosed with attention deficit/hyperactivity disorder.
Dr Levine also diagnosed a major depressive disorder which had been partially treated. He took a history from Ms Mackay that, for the past 2.5 years, her mood had been mostly low, hyper-reactive to environmental and interpersonal triggers and more prone to extremes. She described crying frequently and having suicidal ideation once a week. She described anhedonia. This episode commenced after she was married and she had been treated with 100mg of desvenlafaxine, which had ameliorated symptoms.
Dr Levine also diagnosed Ms Mackay with anxiety – panic disorder. He took a history from Ms Mackay that she struggled with anxiety. There were many things which would produce anxiety, including anything that was new, starting university, driving, attending the gym, speaking to her manager and her husband’s family. She disliked confrontation and this caused her anxiety. At times, anxiety impaired her function, such as when she was housebound for 12 months (at 27 years of age) and ceased driving. Somatic symptoms were experienced in her chest, stomach, shoulders and her hands and her feet felt hot and sweaty. There was no reduction in energy levels when she was very anxious.
Dr Levine noted that Ms Mackay had been consulting Ms Jackie Kingston and had experienced benefits therefrom.
Dr Levine opined that, given the predominance and chronicity of her depressive and anxiety symptoms, the first treatment objective was to treat her depression and anxiety and then address her attention deficit/hyperactivity disorder. He recommended an increase in the dosage of desvenlafaxine.
On 1 April 2019, Ms Mackay consulted Dr Lam reporting that she had consulted Dr Levine, who had confirmed a diagnosis of mild attention deficit/hyperactivity disorder. Dr Lam noted that her anxiety was still quite severe and switched her medication from Pristiq to Lexapro (one 10mg tablet daily).[14]
[14] Insurer's documents at page 201.
On 23 April 2019, Dr Lam addressed a letter “to whom it may concern”, presumably to Ms Mackay’s employer at the time, in support of her application for flexible/shortened working hours due to her recent diagnosis of adult attention deficit/hyperactivity disorder.[15] The letter suggested that Ms Mackay be rostered on for mornings, allowing for an early start and an early finish. Dr Lam stated that it was anticipated that Ms Mackay may be able to return to her full hours of employment over the next four months.
[15] Insurer's documents at page 30.
On 23 April 2019, Dr Lam also addressed a letter “to whom it may concern”, presumably to an educational institution attended by Ms Mackay, in support of her application to withdraw from the study unit in the current semester without academic or financial penalty due to long-standing symptoms that had deteriorated followed by a formal diagnosis of adult attention deficit/hyperactivity disorder on 22 March 2019.[16] Dr Lam stated that, as a result, Ms Mackay had been unable to continue with her studies.
[16] Insurer's documents at page 31.
On 21 May 2019, Ms Mackay consulted Dr Lam advising that she was gradually improving, being able to focus more on conversations. However, she was still quite symptomatic with anxiety and low self-esteem.[17]
[17] Insurer's documents at page 202.
On 21 May 2019, Dr Lam addressed a letter “to whom it may concern”, again presumably to Ms Mackay’s employer at the time, advising of a gradual improvement in her condition as a result of her flexible return to work schedule and that she was now ready to return to full-time hours, with rest breaks and some flexibility in the course of her working day.[18]
[18] Insurer's documents at page 32.

Post-accident

On 1 July 2019, Ms Mackay consulted Dr Lam and reported that, on 6 June 2019, she was a front seat passenger of a car driven by her husband that was stopped at traffic lights in a 60 kmph zone when impacted very hard by another vehicle from behind. Dr Lam recorded Ms Mackay’s initial symptoms as neck pain, neck stiffness, low back pain, bilateral shoulder pain and intense trauma with symptoms that included frequent flashbacks, avoidance, hypervigilance and hyperarousal. Dr Lam also recorded a severe mental health disruption, noting flashbacks and intrusive thoughts, particularly towards the end of the day. Ms Mackay did attempt to return to work after the motor accident but had a severe sense of dread prior to driving home. She suffered from severely disturbed sleep. Dr Lam booked her in for an emergency appointment with a psychiatrist. Dr Lam provided psychoeducation and noted that her symptoms were highly suspicious of early-onset post-traumatic stress disorder.[19]
[19] Insurer's documents at pages 202-203
On 10 July 2019, Ms Mackay consulted Dr Levine, who noted that escitalopram was found to be of limited value; a trial of sertraline 100mg produced one week of improved symptoms but rapidly waned; and there were ongoing benefits from dexamphetamine. Dr Levine proposed an increase in sertraline to 150mg for one week and an increase to 200mg, if symptoms did not markedly improve. If dexamphetamine was not contributing to anxiety, Ms Mackay should trial ceasing it for a day to see if anxiety is relieved. If not, she should continue with dexamphetamine. She should consult a psychologist for anxiety and panic and Dr Lam should prepare a mental health care plan. On his return from travel, Dr Levine was to explore the possibility of eye movement desensitisation and reprocessing (EMDR).[20]
[20] Insurer's documents at page 33.
On 16 July 2019, Ms Mackay consulted Dr Lam advising that her physical symptoms were settling down but that, mentally, she was “in a pretty bad place”.[21] Dr Lam noted that her symptoms included very low moods, low motivation and unusual negative thoughts (dying/violence). Ms Mackay attempted returning to work for three days a week but ended up needing to take a week off work. Dr Levine diagnosed post-traumatic stress disorder and suggested that she undergo EMDR. Positivity and mindfulness strategies were not really working. Dr Lam ceased her Lexapro 20mg tablets and switched her to sertraline 100mg tablets twice daily on the advice of Dr Levine.
[21] Insurer's documents at page 204.
On 17 July 2019, Ms Mackay consulted Dr Levine, who noted that she had tried one day off dexamphetamine and that there was no significant change to her anxiety symptoms. Whilst sertraline 200mg seemed to have helped with her panic attacks, she still presented as depressed with low mood, anhedonia, low levels of energy, less social interaction, broken sleep and a reduction in appetite. Escitalopram 20mg had previously worked for mood but following the motor accident, it was ineffective at managing panic. Desvenlafaxine was ineffective. Dr Levine suggested a trial of duloxetine. Dr Levine noted that Ms Mackay expressed a concern that the overall benefits of attending work (maintaining resilience and a sense of productivity) were outweighed by the negative effects of finding it overwhelming and at times, traumatising. She described a tendency towards very harsh self-judgment, as well as being vigilant for this in others towards her. It was unclear to Dr Levine whether this was part of a depressive disorder or whether it was an aspect of her personality that the depressive disorder had activated.[22]
[22] Insurer's documents at page 34.
On 31 July 2019, Ms Mackay consulted Dr Lam advising that Dr Levine had commenced her on fluoxetine and stopped sertraline. Anxiety symptoms, including intrusive thoughts, had lessened but she suffered from physical symptoms including, dizziness and her legs feeling like jelly. She found afternoons at work very difficult. Driving was an issue due to anxiety. Her symptoms escalated towards the afternoon with thoughts of needing to drive home. She managed to drive but experienced severe anxiety, palpitations and hyperarousal during the drive.[23]
[23] Insurer's documents at pages 204-205.
On 28 August 2019, Ms Mackay consulted Dr Levine who reported to Dr Lam that 60mg of dexamphetamine daily had resulted in a marked improvement in her symptoms of attention deficit/hyperactivity disorder. There had been a shift in self-image as Ms Mackay realised that many of her previous difficulties were attributed to attention deficit/hyperactivity disorder rather than being lazy or silly. Once Ms Mackay’s mood and anxiety symptoms stabilised, Dr Levine suggested investigating the possibility of using EMDR to treat her traumatic memories.[24]
[24] Insurer's documents at page 35.
On 28 August 2019, Ms Mackay also consulted Dr Lam advising that she was conscious that her anxiety was worse and that she was experiencing psychosomatic symptoms, such as, a sensation of weakness. She had been driving during daylight hours only to the gym which is 20 minutes away but felt anxious and managed to make it there. They discussed her consultation with Dr Levine.[25]
[25] Insurer's documents at page 206.
On 1 October 2019, Ms Mackay consulted Dr Lam reporting that her mood had been a bit flat and that she was anxious about not working and not earning an income. A few days earlier she had felt very anxious with no apparent trigger. She was very wary and nervous when driving. Dr Lam recommended that she bring forward her next consultation with Dr Levine.[26]
[26] Insurer's documents at pages 206-207.
On 15 October 2019, Ms Mackay consulted Dr Lam reporting severe anxiety symptoms to the extent that she was picking at her skin, deep enough to cause an ulcerated lesion on her left forearm. She was unable to cope with her studies. She experienced a nightmare after driving home in the dark following a talk with a trainer who mentioned sitting exams. On examination, Dr Lam observed that Ms Mackay was very anxious and picking at the same ulcerated spot on her arm continuously. Dr Lam provided psychoeducation and prescribed duloxetine 60mg capsules and diazepam 2mg tablets.[27]
[27] Insurer's documents at page 207.
On 19 October 2019, Ms Kingston addressed a report in respect of Ms Mackay “to whom this may concern”.[28] Ms Kingston reported that Ms Mackay had completed the depression, anxiety and stress scale (DASS-21) and that her current scores indicated extremely severe levels across all measures. Ms Mackay’s score on the Kessler psychological distress scale (K10) indicated that she may be experiencing severe levels of distress consistent with a diagnosis of severe depression and anxiety. Ms Kingston opined that Ms Mackay was experiencing symptoms suggestive of anxiety and depression, including, apprehension about her future; feelings of worthlessness and helplessness; difficulty controlling her worries; heart rate increase; and difficulty with concentration and focus. Ms Kingston reported that, in the 22 consultations since 15 January 2019, she had applied cognitive behavioural strategies to address Ms Mackay symptoms. Progress with psychiatric medication and psychological intervention had been limited. Although, there had been some signs of improvement prior to the motor accident. Ms Kingston opined that Ms Mackay currently presented with severe symptoms that significantly impacted her personal and social functioning, as well as her ability to function and/or effectively find work.
[28] Ms Mackay's documents at page 69.
On 23 October 2019, Ms Mackay consulted Dr Levine who reported to Dr Lam that Ms Mackay continued to struggle with symptoms of anxiety and depression. Ms Mackay described symptoms of low moods, anxiety, reduced levels of functioning, sleep difficulties, low levels of energy and motivation, anhedonia and lack of libido. Dr Levine noted that she continued to engage in psychological treatments and medication trials and that there had been a growing frustration at the ongoing functional impacts from her psychiatric conditions. Dr Levine opined that Ms Mackay was not yet ready to return to work.[29]
[29] Insurer's documents at page 300.
On 12 November 2019, Ms Mackay consulted Dr Lam reporting her concern that her multiple medications had been of little benefit. She reported that she was struggling, feeling very tired, unmotivated and having difficulties sleeping. She felt frustrated and severely anxious about her inability to return to work but did not yet feel ready to do so. Dr Lam queried the possibility of inpatient therapy.[30]
[30] Insurer's documents at page 208.
On 10 December 2019, Ms Mackay consulted Dr Lam reporting that she felt her anxiety had only improved minimally. She had experienced a panic attack whilst at the gym. Dr Lam provided further psychoeducation to avoid overanalysing panic attacks as there were often no triggers but rather, a symptom of cumulative severe anxiety.[31]
[31] Insurer's documents at page 209.
On 18 December 2019, Ms Mackay consulted Dr Levine who reported to Dr Lam that Ms Mackay had ongoing symptoms of anxiety and depression and was currently trialling mirtazapine 30mg, was on pregabalin 75mg and dexamphetamine 60mg daily. He recommended that she continue to consult her psychologist for anxiety and panic.[32]
[32] Insurer's documents at page 39.
On 13 January 2020, Ms Mackay consulted Dr Lam reporting that she could no longer enjoy anything. She never attended any outings, events or social gatherings without her husband or a friend. She found going home difficult and was plagued by severe anxiety at the thought of having to go home. She described her sleep as excellent since being on mirtazapine. Dr Lam noted that she needed to be monitored closely in respect of her anhedonia and flatness symptoms.[33]
[33] Insurer's documents at page 210.
On 8 August 2020, Ms Kingston completed an allied health recovery request in respect of Ms Mackay.[34] Ms Kingston requested services in the form of 10 weekly psychological counselling sessions on the basis of Ms Mackay’s severe symptoms of anxiety and depression. Ms Kingston opined that current symptoms significantly impacted Ms Mackay’s personal and social functioning, as well as her ability to function and/or effectively find work. Ms Mackay and her psychiatrist were seeking to find the best medication to manage her symptoms but that process had had its challenges and at times, exacerbated her symptoms. Her anxiety symptoms related specifically to driving and were exacerbated by a second accident on 13 December 2019 (this is presumably a reference to the near-miss motor accident referred to by Medical Assessor Roberts).
[34] Insurer's documents at pages 247-251.
On 20 October 2020, Ms Mackay consulted Dr Levine who reported to Dr Lam that he had seen Ms Mackay on a weekly basis for much of the duration of treatment. He reported that there had been psychologist treatment running in tandem with medical treatment. When medications were not helping, EMDR was trialled for trauma. COVID-19 forced tele-psychiatry and the tack was changed to pharmacotherapy and psychodynamic supportive psychotherapy with cognitive behaviour therapy through computer modules via St Vincent’s Anxiety Clinic and her psychologist. There had been slow improvement in symptoms and functioning. Some medications were helping. Ms Mackay had returned to university and was able to function in a technically difficult course (neurophysiology). She continued to have loving support from her husband and despite anxiety, engaged in exercise and some social interactions. Dr Levine opined that Ms Mackay needed to continue with psychologist and psychiatric appointments.[35]
[35] Insurer's documents at page 239.
On 28 May 2021, Ms Mackay consulted Dr Levine who reported to Dr Lam that he had seen Ms Mackay on a weekly basis for much of the duration of treatment. He noted that Ms Mackay still awaited EMDR for trauma from a psychiatrist who was seeing patients face-to-face at the time. He reported that there were ongoing functional deficits, when comparing current levels of function with function prior to the motor accident, evidenced by depressive and anxiety symptoms causing limitations. He provided a detailed list of such limitations and noted that, despite the same, Ms Mackay was attending university and was able to engage with two subjects but that it fell below her previous level of functioning in which she was able to maintain full-time employment whilst studying full-time. Dr Levine described Ms Mackay’s ongoing issues to include trauma, concerns about having children, demoralisation and the impact of her continued sick role on relationships. He provided a list of current medications.[36]
[36] Insurer's documents at pages 68-69.

On 5 November 2021, Ms Mackay consulted Dr Levine who reported to Dr Lam.[37] Dr Levine provided a summary of medication changes and dietary modifications. He confirmed that Ms Mackay continued to be treated by a psychologist with supportive and psychodynamic psychotherapy. EMDR with Dr Lidbury continued. Dr Levine reported that there were ongoing functional deficits, when comparing current levels of function with function prior to the motor accident, evidenced by depressive and anxiety symptoms causing limitations. He provided a detailed list of such limitations and noted that, despite the same, Ms Mackay was attending university and was able to engage with two subjects but that it fell below her previous level of functioning in which she was able to maintain full-time employment whilst studying full-time. Dr Levine described Ms Mackay’s ongoing issues to include trauma, protracted duration of unresolved legal issues, excoriation disorder resulting in localised numbness in the legs, concerns about having children, demoralisation and the impact of her continued sick role on relationships. He provided a list of current medications.
[37] Ms Mackay’s documents at pages 101-102.
On 6 May 2022, Ms Mackay consulted Dr Levine who reported to Dr Lam. Dr Levine provided a current list of Ms Mackay’s medications. Dr Levine reviewed and summarised Ms Mackay’s functioning in respect of social, self-care, home care, travel, studies, concentration and employment. He noted that there were ongoing EMDR sessions with Dr Lidbury.[38]
[38] Insurer's documents at pages 359-360.
On 18 August 2023, Ms Mackay consulted Dr Levine who updated Dr Lam on Ms Mackay’s progress.[39] Dr Levine reported that, socially, Ms Mackay was still isolated. She found it difficult to go out and attend family celebrations, reporting increased anxiety, hypervigilance and agitation. She relied on her husband as a support person to allow her to leave home. She finds herself exhausted and when she has visited restaurants on three occasions in 2023, the experience was stressful, difficult and challenging. Prior to the motor accident, she would see friends weekly and would communicate with them by phone daily.
[39] Ms Mackay's AALD at pages 1-2.
In respect of self-care, Ms Mackay reported to Dr Levine that she was showering and brushing her teeth daily and washing her hair once per week rather than every two days as she was doing prior to the motor accident. She had neglected exercise. Prior to the motor accident she had a personal trainer and exercised about five times per week. She had gained weight. There were days where she stayed in her pyjamas. She reported skin irritation making it difficult to apply make-up. Prior to the motor accident she wore make-up daily. Prior to the motor accident she attended the hairdresser every six to eight weeks and now attends the hairdresser three times per year.
In respect of home care, Ms Mackay reported to Dr Levine that prior to the motor accident she was house proud, maintaining high levels of hygiene. She now relied on her husband to clean the home. She no longer cooked, relying on her husband to do the cooking.
In respect of travel, Ms Mackay reported to Dr Levine that she could not travel independently and needed to travel with her husband. She found it extremely uncomfortable to leave home, even with her husband. Prior to the motor accident, she travelled independently. The last time she drove was on 2 January 2023, accompanied by her husband. She was still uncomfortable in a car travelling as a passenger and had screamed out on one occasion, when driving through an intersection.
In respect of her studies and concentration, Ms Mackay reported to Dr Levine that she was unable to sustain a normal study load, withdrawing from studies in the first semester of 2023. Prior to the motor accident, she was employed full-time and enrolled as a full-time student. She read for pleasure and was able to read large novels within a day. She now struggles to read. Prior to the motor accident, she was able to follow complex instructions (assembling a Lego kit). Now, she is unable to follow instructions for adult Lego kits.
In respect of employment, Ms Mackay reported to Dr Levine that she had been unable to maintain any employment due to mood and anxiety symptoms. She was last employed in July 2019. Prior to the motor accident, she maintained full-time employment as well as university studies.
Dr Levine noted new symptoms of stress reported to him by Ms Mackay. She described eczema like skin changes on her neck, cheeks and eyelids that were precipitated by stress and felt itchy. She had developed an excoriation disorder, which is a recognised stress response, characterised by skin picking causing ulcerations that scar. Those were present on her arms, legs, hands, face and torso.

Medico-legal reports

Dr Naresh Verma: 28 April 2020

On 28 April 2020, Dr Naresh Verma, consultant psychiatrist and occupational physician, provided an early specialist opinion report at the request of the insurer.[40]
[40] Insurer’s documents at pages 40-44.
Dr Verma conducted a file review and provided a summary of the history and relevant facts therefrom. The history was, in the main, consistent with the evidence.
Dr Lam agreed to participate in a teleconference with Dr Verma after he had provided her with a list of topics and questions she may expect during the discussion. Dr Verma explained that their conversation would be documented in a report, namely, his early specialist opinion report. Ms Mackay did not participate in the teleconference.
Dr Verma reported that there was general agreement that Ms Mackay had symptoms of post-traumatic stress disorder and major depression due to the motor accident. However, she did have a pre-existing anxiety which had been heightened as part of her post-traumatic stress disorder. In addition, there was pre-existing attention deficit/hyperactivity disorder.
In respect of prognosis, Dr Verma stated that there was agreement that Ms Mackay’s psychiatric symptoms were stagnant. Different and targeted treatment strategies were required to assist her to move forward, especially because the triggering motor accident had occurred 10 months ago and her return to work had failed. Dr Verma opined that Ms Mackay’s prognosis was guarded unless improvement occurred soon.
Dr Verma opined that the main factors influencing Ms Mackay’s response to the motor accident were her ongoing symptoms of major depression and post-traumatic stress disorder together with her pre-existing attention deficit/hyperactivity disorder, generalised anxiety disorder and panic disorder.
Dr Verma diagnosed a major depressive disorder and post-traumatic stress disorder caused by the motor accident. The wider context was one of a pre-existing generalised anxiety disorder with panic disorder and attention deficit/hyperactivity disorder. He opined that Ms Mackay’s ongoing symptoms were the main barrier to recovery.
Dr Verma referred to treatment considerations and encouraging involvement in managing her issues. He and Dr Lam agreed that given her symptoms, targeted treatment such as EMDR would assist Ms Mackay.
Dr Verma and Dr Lam agreed on the following steps for Ms Mackay’s management:
(a)    consulting Dr Levine on a regular basis for ongoing EMDR treatment and for post-traumatic stress disorder and depression management;
(b)    the psychologist should consider a deeper level of therapy such as, schema therapy to help address underlying maladaptive schema/personality vulnerabilities, and
(c)    ongoing review by Dr Lam.

Dr Graham George: 18 December 2020

On 30 November 2020, Ms Mackay consulted Dr Graham George, psychiatrist, at the request of the insurer. Dr George prepared a report dated 18 December 2020.[41]
[41] Insurer's documents at pages 53-67.
The educational, employment, psychiatric, medical, family and personal/social histories taken by Dr George were, in the main, consistent with the evidence.
Dr George took a detailed history of presenting complaints consistent with the evidence.
On mental state examination, Dr George observed that Ms Mackay’s affect was tense and that there was little to no eye contact during the entire interview. Her mood appeared somewhat agitated. She appeared somewhat guarded in her general manner. Thought form was normal and she did not exhibit any psychotic phenomena. She did not have any pressure of speech or flight of ideas, nor did she have any looseness of association, derailment or tangential thinking. She did not appear to be responding to any perceptual stimuli during the interview. Generally, her cognitions appeared intact and she appeared to be of, at least, average intelligence. She appeared to have reasonable insight and judgment at the interview.
Dr George’s diagnosis was one of attention deficit/hyperactivity disorder and an exacerbation of a major depressive disorder with anxiety, which, essentially appeared to be in remission to a large degree. Ms Mackay did not have sufficient symptoms to diagnose chronic post-traumatic stress disorder at that time.
Dr George did not believe that Ms Mackay’s mild exacerbation of her chronic depressive disorder would have any significant impact on her ability to obtain, engage and maintain employment in the future. Her premorbid anxiety and depression have affected her ability to work. There has only been a minor impact on fitness for work due to the motor accident.
Dr George opined that less than 10% of Ms Mackay’s current psychological or psychiatric disability was attributable to the motor accident.
Dr George opined that Ms Mackay’s injuries had stabilised so as to enable him to assess permanent impairment.
Dr George assessed Ms Mackay’s pre-accident degree of permanent impairment as 6% WPI.
Dr George assessed the degree of permanent impairment caused by the motor accident as 6% WPI.
Dr George concluded, therefore, that Ms Mackay’s permanent impairment caused by the motor accident was 0% WPI.

Dr Ben Teoh: 6 May 2021

On 6 May 2021, Ms Mackay consulted Dr Ben Teoh, psychiatrist, at the request of her lawyers. Dr Teoh prepared a report dated 6 May 2021.[42]
[42] Ms Mackay's documents at pages 94-99.
Dr Teoh took a history that did not include the pre-accident treatment provided by Dr Levine and Ms Kingston relating to Ms Mackay’s mental health. Significantly, Dr Teoh stated that there was no history of other medical conditions apart from optical atrophy and the injuries Ms Mackay sustained in the motor accident. He stated that there had been no past psychiatric illness.
On mental state examination, Dr Teoh observed that Ms Mackay’s speech was coherent. She was not thought disordered. She was cooperative and spontaneous during the interview. She reported chronic pain and physical disability. She had been experiencing acute anxiety attacks with breathlessness, palpitations and dizziness. She experienced insomnia and nightmares. She reported social isolation and lack of motivation. She had been preoccupied with negative thoughts and admitted that she had been irritable. There was no evidence of psychotic symptoms or suicidal ideation. Cognitive functions were intact. There was no evidence of short or long-term memory impairment.
Dr Teoh opined that Ms Mackay’s condition was consistent with a diagnosis of major depression under the DSM-5 diagnostic criteria caused by the motor accident. He also opined that she had achieved maximum medical recovery.
Dr Teoh opined that Ms Mackay’s prognosis was guarded because her condition had persisted despite intensive treatment.
Dr Teoh assessed the degree of permanent impairment caused by the motor accident as 15% WPI.

SUBMISSIONS

Insurer’s submissions

In its submissions dated 5 July 2023, the insurer appeared to accept that Ms Mackay had suffered a psychiatric or psychological injury caused by the motor accident because the submissions focused on a criticism of Medical Assessor Roberts’ pre-existing and current PIRS assessments.
The insurer submitted that, on the basis of the available evidence, the following impairment ratings would apply:
(a) pre-existing PIRS median impairment rating: class 2 = 6% WPI, and
(b) current PIRS median impairment rating: class 3 = 11% WPI.
Accordingly, the degree of permanent impairment caused by the motor accident is 5% WPI after subtracting 6% WPI (pre-existing condition) from 11% (current condition).

Ms Mackay’s submissions

Ms Mackay relied on the findings and opinions expressed by Dr Teoh in his report dated 6 May 2021.
Ms Mackay suffers from major depression which was caused by the motor accident.
The material lodged in these proceedings evidences a comprehensive clinical justification supporting Dr Teoh’s opinion and his assessment of permanent impairment as being greater than 10% WPI.

THE RE-EXAMINATION

Preamble

The Panel re-examination and assessment of Ms Mackay was undertaken via audio-visual link (MS Teams). Medical Assessor Newlyn and Medical Assessor Chew undertook the

re-examination and assessment jointly.
Ms Mackay was 34 years of age at the time of the re-examination. At the time of the interview, she was in her home unit. Her husband, Scott, worked in another room during the assessment. Her cat was absent at the start of the assessment and returned later to lie at her feet.

Medical history

Ms Mackay was 154cm in height and weighed 105kg on 2 November 2023. She is right handed. In respect of her weight, Ms Mackay stated, “I weighed 80kg at the accident. My weight gain is from medicines and no exercise.”
In respect of her special senses, Ms Mackay stated:
“I have seen doctors about my eyes since I was little. I have a left eye strabismus. I have optic nerve atrophy in both eyes from birth that is still monitored.”
In respect of musculoskeletal issues, Ms Mackay stated, “I had an ankle niggle before the accident and was seeing a chiropractor.”
In respect of surgical procedures, Ms Mackay stated, “I had eye surgery in 2001 for strabismus but it has come back. I had wisdom teeth removed.”

Educational history

In respect of her educational history, Ms Mackay stated:
“I thought I was lazy at school because I couldn’t complete assignments in advance. I did OK overall. I remember problems paying attention in primary school. I was seen as a conscientious quiet achiever. In high school, I had problems doing the work. I was seen as not putting in effort. I was always late and forgetful. That continued. I had problems because of forgetting.
After my HSC, I started working. After I left my job at ING, I wanted to do Uni and did a university preparation course through UNSW. I started at Macquarie University in 2019. I took time off and returned to studies in 2020. I am enrolled for a degree in Cognitive and Brain Sciences. I have been unable to study this year since I can’t attend lab sessions because I can’t drive.”

Employment history

In respect of her employment history, Ms Mackay stated:
“I started working at Target when I was 16 or 17. I began work at ING when I was 19. I stopped working there when I was not promoted to the team leader job. Then I worked at Macquarie Bank for six months. That job was too much pressure. I found a customer service job at Macquarie University in September 2018. It was a year-long contract. After the accident, I had stopped working by the end of June 2019.”

Economic status

Ms Mackay’s current economic stress was evident. In this regard, she stated:
“I receive a pittance of $100 a week from the insurance company. The insurer has treated me badly. The insurer has been paying in the past year after they had stopped after the first year. I had to complain. The insurer delays my payments. They bully me.”
Ms Mackay’s husband works full-time.

Psychosocial history

Family history

In respect of her family history, Ms Mackay stated:
“My parents now live far away. They separated when I was 11. I don’t think I was affected by the separation. I grew up in the Blue Mountains. I am the youngest of 3. My mother is in Bundaberg and my dad is in Wattle Flat. I talk to mum on the phone. I have not gone to Bundaberg. I haven’t visited dad in 3 years. Scott drove me there. I keep in contact with my sister and brother. My sister is the oldest and lives in Port Stephens. Scott has driven me to visit her. She was diagnosed with ADHD in 2022. My brother lives in Penrith. Scott will drive me to see him. I see him once or twice a year. He has ADHD. My parents don’t have ADHD.”

Developmental history

In respect of her developmental history, Ms Mackay stated:
“I felt I was lazy. I wasn’t a cool kid but always had friends. I was not abused. I was bullied about my eye and being bigger. I don’t think about the bullying now. Because of it, I could have self-esteem issues.”

Relationship history

In respect of her relationship history, Ms Mackay stated:
“Scott and I got together when we were 20 and we lived together for four years before marrying in 2016. He is 45. He works for HCF in IT. He works from home and has a couple of days a week in the office. After the accident, I wasn’t caring for myself. It is not an ideal marriage in that Scott has to look after me. He is patient and understanding. Neither of us have children. I couldn’t have children now because of the medicines. I don’t think I could fall pregnant.”

Chemical dependency history

In respect of her chemical dependency history, Ms Mackay stated:
“I don’t smoke, vape or use recreational drugs. I don’t drink often. I have a drink every one or two months. Scott and I may share a bottle of sparkling wine. Before the accident it was only on weekends.”
Ms Mackay denied addiction symptoms or driving under the influence.

Forensic history

Ms Mackay now reports irritability. She does not have a history of legal problems. There is no history of a gambling problem. She denied any compensation claims before the motor accident.

Psychiatric history prior to the motor accident

In respect of her psychiatric history prior to the motor accident, Ms Mackay stated:
“In 2016, I began to see Dr Angela Lam, my general practitioner about my feelings. I was having work problems with the office politics at ING. I was doing a manager role and was not given a team leader position, which was a problem. I used the EAP and that didn‘t have a massive benefit.”
Ms Mackay resigned from ING, worked briefly at Macquarie Bank and then took a time-limited position at Macquarie University in 2018 and stated:
“At the start of 2019, I felt extra emotional, stressed and thought talking to someone would help. I began to see Jackie Kingston. She picked up on ADHD because she noticed my thoughts were busy. My brother was diagnosed with ADHD as an adult.”
Ms Mackay was referred to Dr Anthony Levine, consultant psychiatrist, in March 2019. She stated:
“Dr Levine diagnosed ADHD with my symptoms. He also thought I had anxiety and depression. I had thought I was more emotional and anxious and had not thought of depression. He changed my medicine to escitalopram that I thought really helped after four to six weeks. Then we started on dexamfetamine. I remember the dexamfetamine was life-changing. I found I could focus on work and had not been able to do that before.”

Pre-accident functioning

Ms Mackay reported having no problems with personal hygiene or self-care.
Ms Mackay described no problems with social and recreational activities, had frequent contact with friends and had the ability to go to recreational settings.
Ms Mackay drove to work with no problem.
Ms Mackay felt her marriage was positive and that she related well to friends.
Ms Mackay had noticed focusing problems and felt she was doing better with prescribed dexamphetamine.
Ms Mackay worked at a less stressful job at Macquarie University but needed time off while starting the new medicines prescribed by Dr Levine.

History of the motor accident

Ms Mackay provided the following history of the motor accident:
“I was coming home from work with my husband driving. We were stopped at lights and without warning, we were hit in the back at moderate speed. They did not try to stop before hitting us.
I wasn’t immediately physically hurt. I was in shock. My husband seemed to have neck pain.
I had to call the ambulance. The ambulance came and I went with my husband to the hospital. I had no physical problems then. My husband was cleared. We both went home. The car was a week old. It was not written off. Now, I have had neck and back pain but nothing serious.
I didn’t have neck pain before and it appeared to be from the accident. I was aware of it and I continued to see the chiropractor for my right ankle injury. He also treated my neck. Now it doesn’t cause a problem. I get pain when I look down when I pick at my skin.”

History of mental health symptoms following the motor accident

Ms Mackay provided the following history of her mental health symptoms following the motor accident:
“I was in shock then and hyperventilated. Immediately after, I wondered what had happened. I think I was too distressed at first and I was more annoyed not to have a car over the long weekend. I had personal training appointments at the gym. It was a way to exercise. It was definitely to be healthy. Before the accident, I felt I needed to lose weight. I felt like it was a gradual thing that I had gained weight over the years.
After the long weekend, I drove a hire car to the gym and drove home. When I returned to work I drove there but couldn’t drive home. I was too anxious. I felt I couldn’t do it. That week I would drive to work and my husband would get an Uber so he could drive me home. (Ms Mackay began to cry as she talked about the driving problem)
The plan was to keep driving. I kept going to the gym even after stopping working. I could drive there and back. I was stressed about doing it and it made me anxious. I would have panic attacks. I kept driving until COVID. I have not done much driving since. It feels too hard.
Before the accident, I was seeing Dr Levine for treatment of ADHD and there was anxiety and depression there also. The anxiety and depression that was there before the accident worsened after it. I had constant low mood, low motivation and low hope. I was constantly anxious.”

History of treatment following the motor accident

Ms Mackay provided the following history of treatment following the motor accident:
“I can’t remember all the medicines I have been prescribed. We first tried increasing escitalopram. I went through all the SNRI’s and SSRI’s and even tried antipsychotics. Perhaps four or five had a good effect but then I had an increase in a hormone that made me lactate. I have tried sertraline, lovan, pregabalin and quetiapine and I can’t remember what else. I didn’t take lithium. I had a rash as a result of taking lamotrigine. I began mirtazapine in December 2019 at 30mg and then it was reduced to 7.5mg.”
Escitalopram and sertraline are serotonin reuptake inhibiting antidepressant medicines. Lovan is a serotonin reuptake inhibiting antidepressant medication fluoxetine. Pregabalin is a pain modulating anti-convulsant. Quetiapine is an atypical antipsychotic medicine. Lamotrigine is a mood stabilising anticonvulsant. Mirtazapine is a serotonin and noradrenaline reuptake inhibiting antidepressant medicine.
Ms Mackay further stated:
“I have been talking to Dr Levine weekly since the start of 2020 when I started EMDR and COVID happened. I am still doing weekly online sessions for 45 minutes.
I continued to see my psychologist, Jackie Kingston, fortnightly face-to-face until COVID. I still see her fortnightly. She provides cognitive behaviour therapy that helps. She provided four sessions of EMDR. Then, I saw Dr Taggart Lidbury, a psychiatrist, who did eight sessions of EMDR from August 2021. There was some improvement from that but it was hard with the insurance.
I have done ‘This Way Up’ modules that were good.
I saw my chiropractor for a while.”

Details of relevant injuries or conditions since the motor accident

In respect of relevant injuries or conditions since the motor accident, Ms Mackay stated:
“Skin picking developed in July 2019. After some heal, I pick others. I have tried to stop. When I was a kid I scratched insect bites.
I developed rosacea after the accident. I don’t think I had issues before. I think it started around about the beginning of 2020. I have seen my general practitioner about it and she prescribed some cream but now I am using products I buy at the chemist.”

Current symptoms

In respect of her current symptoms, Ms Mackay stated:
“The driving has worsened. I haven’t driven for 10 months and drove 5-10 times last year. I haven’t taken public transport in one or two years. I didn’t like doing it. I feel this year is worse. I feel isolated with not driving and not seeing friends.
I am still enrolled in a degree in Cognitive and Brain Science. I started in 2020 and I have done one full-time year. I did one unit last year. I have not been able to study this year. I stopped studying after enrolling in semester 1 and 2 and dropped out. I want to complete the degree but have not done a semester this year. I should have attended at the campus for lab sessions but I could not attend.
I like spending time with my cat and husband.
The sadness is like waves. Most days it is there but not super obvious and I can get by OK. Then it goes down to feeling harder. It hurts. I can be distracted by something funny on TV. Occasionally, I talk to my nieces and I enjoy that. I think of suicide but I wouldn’t do anything. If I didn’t exist it would not be too much effort. It doesn’t feel worth it to be alive.
My sleep is broken and I wake easily with noises. I can’t get back to sleep quickly. I could wake because of anxiety. I have nightmares or bizarre dreams that wake me. I never used to be a light sleeper. Before the accident, the ADHD medicine didn’t affect sleep. I stay awake longer now before I go to sleep at 11.00pm. I usually stay asleep until around 7.00am to 8.00am, when I get up.
I think my weight gain is from not eating the best foods. I feel my body easily gains weight. I eat salad and protein but then have ice cream at night.”

Current and proposed treatment

Ms Mackay stated:
“I take mirtazapine 7.5mg at night, I take brintellix 30mg daily, escitalopram 30mg daily, guanfacine 3mg at night and dexamfetamine 15mg three times a day.”
Brintellix is the atypical antidepressant medicine (a serotonin modulator and stimulator) vortioxetine. Guanfacine is an alpha2A-adrenergic blockading medicine used in treating ADHD. Dexamfetamine is a stimulant medicine.
Ms Mackay consults Dr Lam monthly, Dr Levine weekly and Ms Kingston fortnightly. There are no physiotherapy or exercise programs in progress. She did not expect a change in her current treatment and stated: “I feel I am in survival mode.”

Mental state examination

Appearance

Ms Mackay had evidence for recent skin excoriation on her left upper chest and healed excoriations on her arms. She stated that they were also on her legs. She wore glasses. She was neatly groomed. Ms Mackay stated that she washes her hair once a week. She has a haircut every three to four months and her husband drives her there or she walks there.

Clothing

Ms Mackay was dressed in an Activewear singlet top and Activewear leggings. She said:
“I have had an increase in pyjama days since the accident. It is once a fortnight or so. I am not in pyjamas today.”

Activity

Mrs Mackay sat through the interview moving only to search for papers when asked to name medicines. She stated:
“I have no specific schedule for exercise. I might use a treadmill or a mini exercise bike. I guess I last did that a month ago.”
No psychomotor retardation or agitation was observed.

Aggression

No hostile acts towards peers or property was reported.

Interaction

Ms Mackay was cooperative throughout the interview. Eye contact was good.

Facial expression

Facial expression was anxious and occasionally tearful.

Language

Rate was appropriate with no significant latency. Volume was average. Prosody was emphatic in the description of her problems.
In respect of coherence, Ms Mackay could describe her problems succinctly. There were no unusual word choices.

Affect

Ms Mackay’s affect was anxious and consistent with thought content. Affective reactions were appropriately moderated. There was no evidence for cyclic mood changes. Suicidal rumination was absent.

Phobias

Anxiety stops Ms Mackay driving a car.

Obsessions

Excoriation lesions were seen.

Dissociative

No dissociative behaviour was observed or reported.

Preoccupations

Recurrent self-injurious behaviour patterns with skin excoriation.

Perceptions

No delusions or hallucinations were reported.

Sensorium

Sensorium was clear.

Memory

Ms Mackay’s recall for timing of events and the names of medicines was normative.

Focus

Ms Mackay reported inattention before the prescription of dexamfetamine. She was not accident-prone.

Concentration

Ms Mackay’s concentration was not impaired as shown by clinical observation. Comprehension of commands was not impaired. She could focus throughout a two hour assessment interview.

Abstraction

Ms Mackay used abstract concepts without difficulty.

Attitude

In respect of her attitude, Ms Mackay stated, “It is hard dealing with the psychological issues I have had since the accident.”

Current functioning

Ms Mackay lives with her husband, Scott and they moved into their current unit after the motor accident. They have a cat and Ms Mackay stated:
“Scott will take our cat to the vet. I didn’t go with him last week. He follows me around. He is lying on my legs. He will sit next to me. I may play a game with him. It is good to have the contact.”
Ms Mackay described her daily routine as including picking at her skin. She stated:
“Showering and dressing takes a long time because I am skin picking or it feels like I can’t go faster. I shower every day. My appetite has not changed.
Scott cooks because I don’t want to do it. Mainly, he was the one to cook before. I don’t clean any more. I did that before the accident.
My husband does the shopping and takes the car shopping. Before, we both shopped or I would go to the shops.
Before the accident, I went out with friends for dinner or coffee. Scott and I would go out. I hear from a friend every week or so online. The pandemic did not affect me because I was happy to stay home. We used to be out every weekend before the accident. We saw people after work occasionally but not now.
Scott and I will go to visit friends, although, I have anxiety and I feel awkward visiting them. Two weekends ago, I went to visit a friend at her house and before that, it was the beginning of 2023 that I did it. I have met friends in a restaurant in Parramatta. I was fine, although, I felt awkward and it took a while to feel OK. The anticipation is a lot of the problem and I may want to cancel. I don’t go to visit Scott’s family. I’ve seen my brother and sister recently but not my mother and father. My mother visited in 2021 before lockdown. Because of the lockdown we visited her at her friend’s house. I may take a few days to recover from visiting.
During the day I watch TV or do washing. I may do admin stuff for the insurer. It may be a simple email and I find it hard to do that. I have to think about it forever.”
Ms Mackay does not undertake any sporting activities.
Prior to the motor accident, Ms Mackay drove to and from work. The week after the motor accident, although she could drive to work, she could not drive home. She drove to work despite her fears until early 2020 when the COVID pandemic began. She could drive to and from the Macquarie University campus in 2021. In 2022, she occasionally drove to the campus, although, driving was stressful. She could drive to exams. Since early 2023, she has not driven a car because of her anxiety. She has been able to walk to the hairdresser and a restaurant. She does not take public transport She is an anxious passenger.
Ms Mackay reported difficulties studying for her university course in 2023 because she could not attend laboratory sessions and withdrew from both semesters. She stated:
“I was always late for things and forget things before I started on dexamphetamine.
I try to read a book or listen to an audiobook or podcast. I don’t like psychology or self-help books. I read for 20 minutes at a time. I can listen to a podcast for 30 to 60 minutes. I may tune that out. I don’t watch new films but can watch a movie I know halfway or for 30 minutes. I am into Lego. I can manage half an hour once a month. I find the plans are helpful. It takes a lot of concentration and that is a struggle.”
Ms Mackay reported that she struggles to complete tasks. Her work pace has slowed significantly. She stated:
“I feel I was bored at work in 2019 and when I was diagnosed with ADHD, I worked part time for a couple of weeks and then I was full-time. After the accident, I stopped working by the end of June 2019. I have been unable to work because of the problems driving and getting out of the house. My anxiety and emotions are hard to predict. I don’t believe I could function as an employee. I don’t think I could function enough to work at home sitting at a computer.”
Ms Mackay reported that she does not meet her personal standards.
Ms Mackay reported that she has no regular religious observance because “I don’t believe in it”.

Comment on consistency

There was consistency between the history of current psychiatric symptoms, presentation at the assessment interview and findings on examination.

INJURIES

The Panel is satisfied that, following the motor accident, Ms Mackay developed psychiatric symptoms that have continued and were present at the time of the assessment on 2 November 2023.
The Panel is satisfied that the injury listed by the parties as major depression can be redefined and incorporated into a diagnosis of persistent depressive disorder with anxious distress.
The Panel is also satisfied that Ms Mackay has suffered an excoriation (skin picking) disorder.
The Panel is satisfied that the persistent depressive disorder with anxious distress and the excoriation (skin picking) disorder were caused by the motor accident and give rise to a permanent impairment for the reasons referred to below.

STABILISATION

The Panel considered the question of stabilisation and is satisfied that Ms Mackay’s psychiatric disorders caused by the motor accident have stabilised.

DSM-5-TR PSYCHIATRIC DIAGNOSIS AND REASONS

Persistent depressive disorder with anxious distress

Ms Mackay had symptoms of a major depressive disorder with comorbid attention deficit/hyperactivity disorder with an inattentive presentation before the motor accident. The major depressive episode was aggravated by the motor accident and because the episode has lasted for more than two years, the diagnosis has changed to one of a persistent depressive disorder.
Ms Mackay fulfills the following DSM-5-TR criteria for a persistent depressive disorder with anxious distress:
A.    depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least two years;
B.    presence, while depressed, of the following:
(a)insomnia;
(b)low energy or fatigue;
(c)low self-esteem, and
(d)feelings of hopelessness;
C.    during the two years of the disturbance, the individual has never been without the symptoms in criteria A and B for more than two months at a time;
D.    criteria for a major depressive disorder may be continuously present for two years;
E.    there has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder;
F.    the disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder;
G.    the symptoms are not attributable to the physiological effects of a substance or another medical condition, and
H.    the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The onset of the condition is late, with onset having been at the age of 21 years or older.
As Ms Mackay’s symptoms of a major depressive episode have lasted for more than two years with an exacerbation of symptoms after the motor accident, the DSM-5-TR diagnosis is of a persistent depressive disorder. Her anxiety symptoms can be incorporated into the persistent depressive disorder diagnosis rather than separately listed as a generalised anxiety disorder. Based on the history and documents, the major depressive episode has continued since the motor accident. As she is taking three antidepressants, has weekly psychiatric consultations and fortnightly psychological therapy, she meets the criteria for a severe disorder.
The Panel is satisfied that the unchallenged circumstances of the motor accident as described by Ms Mackay and referred to in [163] and [164] above could have caused or contributed to Ms Mackay’s persistent depressive disorder with anxious distress and further, the Panel is satisfied and finds that it did cause such injury.

Excoriation (skin picking) disorder

Ms Mackay fulfills the following DSM-5-TR criteria for an excoriation (skin picking) disorder:
A.    recurrent skin picking resulting in skin lesions;
B.    repeated attempts to decrease or stop skin picking;
C.    the skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning;
D.    the skin picking is not attributable to the physiological effects of a substance (for example, cocaine) or another medical condition (for example, scabies), and
E.    symptoms of another mental disorder do not better explain the skin picking.
The excoriation (skin picking) disorder commenced after the motor accident. There is a temporal connection.
The Panel is satisfied that the unchallenged circumstances of the motor accident as described by Ms Mackay and referred to in [163] and [164] above could have caused or contributed to Ms Mackay’s excoriation (skin picking) disorder and further, the Panel is satisfied and finds that it did cause such injury.

Attention deficit/hyperactivity disorder, inattentive presentation

Ms Mackay fulfills the following DSM-5-TR criteria for an attention deficit/hyperactivity disorder, inattentive presentation:
A.    a persistent pattern of inattention that interferes with functioning or development, characterised by:
(a)often fails to give close attention to details;
(b)often has difficulty sustaining attention in tasks;
(c)often avoids tasks that require sustained mental effort;
(d)is often easily distracted by unrelated thoughts, and
(e)is often forgetful in daily activities;
B.    several inattentive symptoms were present prior to age 12 years;
C.    several inattentive symptoms are present in two or more settings;
D.    there is clear evidence that the symptoms interfere with the quality of social, academic, or occupational functioning, and
E.    the symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.
Attention deficit/hyperactivity disorder is a neurodevelopmental disorder. Accordingly, the Panel is satisfied and finds that the disorder was not caused by the motor accident.

PERMANENT IMPAIRMENT

The degree of whole person permanent impairment of the injuries caused by the accident is calculated as set out below.

Current permanent impairment

In accordance with the Guidelines, the PIRS does not assess impairment for somatoform disorders or pain.

Psychiatric diagnoses

Persistent depressive disorder with anxious distress.
Excoriation (skin picking) disorder.

Psychiatric treatment description
Psychiatric consultations.

Psychological counselling.
Psychotropic medicine.

Category Class Reason for decision

Self-care and personal hygiene 2 Mild impairment. No problem in personal hygiene with regular showering. Skin picking, missing meals, irregular preparation of meals with reliance on her husband for cooking and household chores results in a mild impairment.

Social and recreational activities 2 Mild impairment. She can attend family functions, visit friends, and go out for meals occasionally. She has attended functions independently and visited all family members since the motor accident.

Travel 2 She has not driven in 2023, although, she could drive alone until late 2022. She now travels in a car only when driven by her husband. However, she has been able to walk alone to a restaurant and to have a haircut. She does not take public transport. She is an anxious passenger. Clinically, this is a mild impairment for travel because she can leave her home without a support person.

Social functioning 2 She has continued contact with her family. She contacts friends by telephone and rarely visits. So, she lost some friendships. Her husband is supportive but there is marital stress. Clinically, this is a mild impairment.

Concentration, persistence and pace 2 She can listen to podcasts for up to an hour, read for 20 minutes and follow instructions to build Lego structures. She can follow a movie to halfway or for 30 minutes. She could not study at university in 2023 because she could not travel to the necessary laboratory sessions to complete the semesters. She has residual adult attention deficit/hyperactivity symptoms. Clinically, this is a mild impairment.

Adaptation 3 Because of her depressive anxiety she has stopped driving, does not use public transport and would need to work from home. Her depressed mood and anxiety result in reduced motivation. She could work less than 20 hours a week in a less skilled and less stressful positions but is now unmotivated. Clinically, this is a moderate impairment.

% WPI = percentage whole person impairment.

List classes in ascending order Median Class Value

2 2 2 2 2 3 2

Aggregate score Total % WPI

+ + + + + = 13 7%

Current % WPI = 7%

Apportionment

A major depressive disorder and a comorbid neurodevelopmental disorder of attention deficit/hyperactivity disorder with inattentive presentation pre-dated the motor accident.

Pre-existing impairment

Psychiatric diagnoses Major depressive disorder with anxious distress.
Attention deficit/hyperactivity disorder, inattentive type.

Psychiatric treatment Description Psychiatric consultation.
Psychological counselling.
Psychotropic medicine.

Category Class Reason for decision

Self-care and personal hygiene 1 No deficit. The claimant described no deficit in this domain of functioning.

Social and recreational activities 1 No deficit. She described going out for dinner with friends and her husband, going out for coffee and spending time out of home with her husband. She also visited her family.

Travel 1 No deficit. She drove to work with no difficulty and reported no problems in other areas of travel in the year before the motor accident.

Social functioning 1 No deficit. Her relationships with her husband, family or friends had no problems.

Concentration, persistence and pace 2 Mild impairment. She had problems with focus and persistence before the motor accident. Although she reports a significant improvement with prescribed dexamfetamine, the later dosing increases do not suggest there was a significant improvement. Clinically, this was a mild impairment.

Adaptation 2 Mild impairment. Because of problems in her previous employment, she took a full-time job in customer service at Macquarie University which was easier than her previous work. Clinically, this was a mild impairment.

List classes in ascending order Median Class Value

1 1 1 1 2 2 1

Aggregate score Total % WPI

+ + + + + = 8 1

Pre-existing % WPI = 1%

Adjustment for the effects of treatment

There is no adjustment needed as there is no measurable treatment effect from the combined psychiatric consultation, psychological counselling and psychotropic medicine.

Assessment of permanent impairment

The Panel assesses Ms Mackay’s permanent impairment as follows:
(a)    current WPI: 7%
(b)    pre-existing WPI: 1%
(c)    WPI adjustments for the effects of treatment: 0%
Accordingly, the Panel assesses Ms Mackay’s final WPI as 6%.

TREATMENT DISPUTE

Causation

The Panel's findings in relation to whether the treatment to be provided was related to the injuries caused by the motor accident are the same as the findings made in Medical Assessor Roberts certificate dated 13 June 2022.
AHRR 4 listed symptoms of depression and anxiety as having been caused by the motor accident. Attention deficit/hyperactivity disorder was listed as a diagnosis but symptoms were not recorded as caused by the motor accident.

Reasonable and necessary

The Panel's findings in relation to whether the treatment to be provided is reasonable and necessary in the circumstances are the same as the findings made in Medical Assessor Roberts certificate dated 13 June 2022. Ms Mackay continued to need treatment with psychiatric consultation, psychological counselling and psychotropic medicine as listed in AHRR 4.

Improve recovery

The Panel's findings in relation to whether the treatment will improve recovery are the same as the findings made in Medical Assessor Roberts certificate dated 13 June 2022. The Panel finds that the proposed treatment is expected to improve recovery.

FINDINGS

The Panel adopts the re-examination findings and conclusions of Medical Assessor Newlyn and Medical Assessor Chew based on their examination and specific findings pertaining to diagnosis, causation, assessment of permanent impairment and assessment of the treatment dispute.
The Panel, comprised of two specialist medical practitioners, is not required to choose between competing medical opinions and is required to form its own opinion: Insurance Australia Group Ltd v Keen[43] and Insurance Australia Ltd v Marsh.[44]
[43] Insurance Australia Group Ltd v Keen [2021] NSWCA 287 at [40], [41] and [45].
[44] Insurance Australia Ltd v Marsh [2022] NSWCA 31 at [11], [21], [64].
The Panel determines that Ms Mackay’s attention deficit/hyperactivity disorder with an inattentive presentation was not caused by the motor accident.
The Panel determines that Ms Mackay sustained a persistent depressive disorder with anxious distress and an excoriation (skin picking) disorder caused by the motor accident.
The Panel revokes the certificate issued by Medical Assessor Roberts dated 13 June 2022.
The Panel determines that the persistent depressive disorder with anxious distress and excoriation (skin picking) disorder caused by the motor accident gives rise to a WPI which is not greater than 10%, that is, 6%.
The Panel determines that, the 10 weekly psychological counselling sessions proposed in AHRR 4, relate to the injury caused by the motor accident; are reasonable and necessary in the circumstances; and will improve Ms Mackay’s recovery.

CONCLUSION

The Panel’s determination is set out in the Certificate of Determination attached to this Statement of Reasons.

Psychiatric diagnoses	Persistent depressive disorder with anxious distress. Excoriation (skin picking) disorder.
Psychiatric treatment description	Psychiatric consultations. Psychological counselling. Psychotropic medicine.
Category	Class	Reason for decision
Self-care and personal hygiene	2	Mild impairment. No problem in personal hygiene with regular showering. Skin picking, missing meals, irregular preparation of meals with reliance on her husband for cooking and household chores results in a mild impairment.
Social and recreational activities	2	Mild impairment. She can attend family functions, visit friends, and go out for meals occasionally. She has attended functions independently and visited all family members since the motor accident.
Travel	2	She has not driven in 2023, although, she could drive alone until late 2022. She now travels in a car only when driven by her husband. However, she has been able to walk alone to a restaurant and to have a haircut. She does not take public transport. She is an anxious passenger. Clinically, this is a mild impairment for travel because she can leave her home without a support person.
Social functioning	2	She has continued contact with her family. She contacts friends by telephone and rarely visits. So, she lost some friendships. Her husband is supportive but there is marital stress. Clinically, this is a mild impairment.
Concentration, persistence and pace	2	She can listen to podcasts for up to an hour, read for 20 minutes and follow instructions to build Lego structures. She can follow a movie to halfway or for 30 minutes. She could not study at university in 2023 because she could not travel to the necessary laboratory sessions to complete the semesters. She has residual adult attention deficit/hyperactivity symptoms. Clinically, this is a mild impairment.
Adaptation	3	Because of her depressive anxiety she has stopped driving, does not use public transport and would need to work from home. Her depressed mood and anxiety result in reduced motivation. She could work less than 20 hours a week in a less skilled and less stressful positions but is now unmotivated. Clinically, this is a moderate impairment.

List classes in ascending order						Median Class Value
2	2	2	2	2	3	2
Aggregate score						Total	% WPI
+	+	+	+	+	=	13	7%

Psychiatric diagnoses			Major depressive disorder with anxious distress. Attention deficit/hyperactivity disorder, inattentive type.
Psychiatric treatment Description			Psychiatric consultation. Psychological counselling. Psychotropic medicine.
Category			Class		Reason for decision
Self-care and personal hygiene			1		No deficit. The claimant described no deficit in this domain of functioning.
Social and recreational activities			1		No deficit. She described going out for dinner with friends and her husband, going out for coffee and spending time out of home with her husband. She also visited her family.
Travel			1		No deficit. She drove to work with no difficulty and reported no problems in other areas of travel in the year before the motor accident.
Social functioning			1		No deficit. Her relationships with her husband, family or friends had no problems.
Concentration, persistence and pace			2		Mild impairment. She had problems with focus and persistence before the motor accident. Although she reports a significant improvement with prescribed dexamfetamine, the later dosing increases do not suggest there was a significant improvement. Clinically, this was a mild impairment.
Adaptation			2		Mild impairment. Because of problems in her previous employment, she took a full-time job in customer service at Macquarie University which was easier than her previous work. Clinically, this was a mild impairment.
List classes in ascending order								Median Class Value
1	1	1		1		2	2	1
Aggregate score								Total	% WPI
+	+	+		+		+	=	8	1

[2023] NSWPICMP 695

21 December 2023