Seghabi v AAI Limited t/as AAMI

DETERMINATION OF REVIEW PANEL
CITATION:	Seghabi v AAI Limited t/as AAMI [2023] NSWPICMP 269
CLAIMANT:	Mary Seghabi
INSURER:	AAI Limited trading as AAMI
REVIEW Panel
MEMBER:	Susan McTegg
MEDICAL ASSESSOR:	Melissa Barrett
MEDICAL ASSESSOR:	Christopher Rikard-Bell
DATE OF DECISION:	15 June 2023
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; Medical Review panel; review of certificate of Medical Assessor (MA) Jones who certified any psychiatric condition had resolved; Held – Medical Assessment Certificate of MA revoked; accident caused relapse of post-traumatic stress disorder now in remission; not assessable; accident caused exacerbation of pre-existing persistent depressive disorder; 1% whole person impairment (WPI) for persistent depressive disorder; pre-existing WPI 0%; total WPI of 1% for persistent depressive disorder.
DETERMINATIONS MADE:	*MOTOR ACCIDENT INJURIES ACT 2017* WHETHER THE DEGREE OF PERMANENT IMPAIRMENT OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10% Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 The Review Panel revokes the Certificate of Medical Assessor Matthew Jones dated 21 June 2021 and issues a new certificate determining that the following injuries were caused by the motor accident: · relapse of past post-traumatic stress disorder, now in remission, and · mild exacerbation of pre-existing persistent depressive disorder. The Review Panel finds the following injury caused by the accident gives rise to a whole person impairment of 1% and which is not greater than 10%: · mild exacerbation of pre-existing persistent depressive disorder.

REVIEW PANEL REASONS FOR DECISION

INTRODUCTION

On 2 March 2018 Mrs Mary Seghabi (the claimant) was driving her vehicle on Henry Street, Penrith when the insured vehicle drove out of a car wash and collided with the front driver’s side of her car (the accident).
Mrs Seghabi was 63 years of age at the date of accident and is now 68 years of age.
Mrs Seghabi asserts she sustained the following injuries in the accident:
·        injury to neck;
·        radiation of pain into right shoulder, shoulder blade and arm;
·        injury to right hand and fingers, thumb and wrist;
·        injury to right shoulder;
·        injury to mid and lower back;
·        radiation of pain from back into right leg;
·        injury to right hip;
·        injury to legs and knees;
·        vertigo, and
·        psychological sequelae.
Mrs Seghabi has brought a claim for common law damages under the Motor Accident Injuries Act 2017 (the MAI Act).
AAI Insurance Limited trading as AAMI (the insurer) is the relevant insurer with liability to pay any damages to Mrs Seghabi under the MAI Act.
Section 4.11 of the MAI Act provides that there is no entitlement to damages for non-economic loss unless the degree of permanent impairment of the injured person as a result of the injury caused by the accident is greater than 10%.
This dispute is in relation to whether the degree of permanent impairment sustained by Mrs Seghabi as a result of the injury caused by the accident is greater than 10%. This constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.

A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[1]
[1] Section 7.20 of the MAI Act.
The dispute as to permanent impairment relating to psychological injury was referred to Medical Assessor Matthew Jones. Medical Assessor Jones assessed Mrs Seghabi and issued a certificate dated 21 June 2021 certifying any psychiatric condition caused by the accident had resolved and did not result in permanent impairment.
Mrs Seghabi sought a review of the medical assessment of Medical Assessor Jones.

REVIEW PROCEDURE

An application for review of the medical assessment of Medical Assessor Jones was lodged by Mrs Seghabi on 19 July 2021 within 28 days of the date on which the certificate of Medical Assessor Jones was made available to the parties.[2]
[2] Section 7.26(1)(b) of the MAI Act.
On 10 September 2021 the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect referred the medical assessment to the Review Panel (the Panel).[3]
[3] Section 7.26 of the MAI Act, AD2 p 6, AD7 p 189.
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 clause 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 Personal Injury Commission (Commission).[4] Accordingly, the President’s delegate referred the matter to this Panel to assess.
[4] Section 7.26(5A) of the MAI Act.
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.[5]
[5] Section 41(2) of the PIC Act.
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.[6]
[6] Rule 128 of the PIC Rules.
The review is by way of a new assessment of all matters with which the medical assessment is concerned. 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 accident, without those matters having to be the subject of assessment.
On 14 December 2022 the Panel agreed an examination was necessary.

RELEVANT LEGAL AUTHORITY

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 (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 (AMA4 Guides). The Guidelines are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.[7]
[7] Clause 1.2 of the Guidelines.
Causation of injury is addressed under Part 6 of the Guidelines dealing with permanent impairment:
“6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1.The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2.The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement.
6.7There 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.”

CERTIFICATE OF MEDICAL ASSESSOR JONES

The injury referred for assessment was psychiatric condition – the degree of permanent impairment resulting from the psychological injury caused by the accident.
Medical Assessor Jones issued a certificate dated 21 June 2021 in which he concluded that if Mrs Seghabi had a psychiatric condition caused by the accident it had resolved and did not result in permanent impairment.[8]
[8] AD7 p 23.
Medical Assessor Jones reported Mrs Seghabi was a 67 year old woman living with her daughter and son, a mother of five children, a grandmother to eight children and a great grandmother to one child. She was in receipt of a Carers Pension for her son with schizophrenia.
Mrs Seghabi sustained injury to her check, ribs/sternum, right leg and right big toe in a motor vehicle accident on 26 April 2003 (the 2003 accident) when her husband was killed. She had attended psychologists on and off and following the accident and consulted a psychologist for at least six months. Medical Assessor Jones reported
Mrs Seghabi was also involved in another motor vehicle accident in Blacktown which was “not major”.
Mrs Seghabi was prescribed insulin for diabetes and had a left hemicolectomy for carcinoma of the colon in 1984 and a total thyroidectomy in 2007.

Medical Assessor Jones reported:
·        following the accident, she was shaking and felt faint;
·        the accident changed her, she stopped walking and has gained 10 kg;
·        she gets very emotional as she cannot do a lot of things around the house;
·        she became teary when she said she felt very lazy and in pain and said it was all “too much”;
·        she used to walk 30 minutes in the morning but now she does not feel like this;
·        she used to see a psychologist in Henry Street after the accident;
·        sleep is not the best; she wakes “thinking about things and feeling panicky”;
·        she felt very lonely;
·        she used to love food and now has trouble having breakfast, and
·        with respect to energy levels, she now has a nap on the couch in the daytime.
Medical Assessor Jones reported the following on examination:
·        when asked to describe her mood she was very upset and said she was going downhill with her health;
·        she is no longer actively social;
·        she was teary and emotional at times but otherwise was reactive, congruent and appropriate;
·        she was talkative and anecdotal;
·        her cognition, insight and judgment appeared intact;
·        she normally does not go out even when her daughter asks;
·        she has trouble if she drives for too long;
·        she loves cooking and continues to do so at home; there is a big family gathering every two weeks or so;
·        she cannot watch television for long;
·        she likes to read, and
·        she is very religious and goes to church every Sunday.
Medical Assessor Jones reported Mrs Seghabi had no ongoing active psychiatric disorder. Her psychological symptoms were consistent and proportional to her reported level of pain and physical dysfunction.

EVIDENCE BEFORE THE REVIEW PANEL

The Panel issued a Direction to the parties on 1 August 2022 (the first Direction) requiring each party to file an indexed, paginated bundle of documents. In response to this Direction the solicitor for the claimant uploaded to the portal a bundle of documents marked AD7 paginated from pages 1 to 1,334. The solicitor for the insurer uploaded to the portal a bundle of documents marked ‘Insurer’s bundle’ and paginated from pages 1 to 94.
On 10 February 2023 the Panel directed the claimant to upload to the portal on or before 24 March 2023 the following:
· up to date records of the claimant’s treating medical practitioners, and
· clinical records of any psychologist or psychiatrist consulted by the claimant over the last 12 months.
No records were produced but having regard to the history provided by Mrs Seghabi as to treatment the Panel felt it was appropriate to determine the matter in the absence of those records.

Photographs of the claimant’s vehicle

Two photographs of the claimant’s vehicle show significant damage to the front driver’s side of the vehicle over the wheel, including the mud guard, the bonnet and the right front headlight.[9]
[9] AD7 p 220.

Application for personal injury benefits (the application)

In the application dated 13 March 2018 the injures received as a result of the accident nominated by the claimant include “psychological sequelae”. [10] The claimant also nominated “psychological condition” as a pre-existing condition in the application.

[10] Insurer bundle p 17.

Treating medical evidence

On 16 September 2005 Mrs Seghabi attended Nepean Hospital with jaw, neck and back pain following her involvement in a motor vehicle accident as a back seat passenger.[11]
[11] AD7 p 616.

Penrith Mall Medical Centre

Dr Barich provided a report dated 23 August 2005 in relation to Mrs Seghabi’s claim arising out of the accident on 26 April 2003 when he diagnosed post-traumatic stress disorder and depression.[12]
[12] AD7 p 641.
On 26 March 2013 Mrs Seghabi had a fall in a car park and hurt her left ankle. On
8 April 2014 Dr Barich reported Mrs Seghabi had a fall at the club with shoulder and neck pain.
The clinical notes of Dr Barich show intermittent complaints of depression and/or stress and/or anxiety including on 24 January 2012, 19 March 2013, 29 October 2013,
2 January 2015, 27 March 2015, 4 December 2015, 16 December 2016, 6 March 2017 and on 19 May 2017.
On 2 March 2018 Mrs Seghabi consulted Dr Antwan Barich, general practitioner (GP) when he recorded “MVA today neck pain, right shoulder and hip pain, pain lower Tspine and right lower ribs”.[13] On 9 March 2018 Dr Barich also reported “more depression”.
[13] AD7 p 251.
Dr Barich completed a GP Mental Health Care Plan on 24 July 2018 which reported the following mental state examination:
“Appearance and general behaviour – quite anxious;
Mood – depressed-anxious;
Thinking – disturbances;
Sleep – insomnia;
Appetite – increased;
Memory – reduced:
Motivation/energy level – not motivated; and
Anxiety symptoms – anxious.”[14]
[14] AD7 p 38.
In his report dated 14 August 2018 Dr Barich reported the claimant’s anxiety/depression from 2007 had significantly deteriorated since the accident and that the accident was causing flashbacks to the previous accident.[15] He described her daily symptoms as “depressed mood all the time, nightmares, cries easily, reduced memory/ concentration/confidence, no interest, isolates herself, negative thinking, not sleeping, panic attach (chest pain)”.
[15] AD7 p 42.
On 11 October 2019 Dr Barich reported Mrs Seghabi was depressed and seemed to neglect herself. On 7 January 2020 Dr Barich diagnosed major depression and prescribed Apo-escitalopram and on 21 January 2020 he reported depressed mood, insomnia, tiredness and noted her son’s condition was affecting her mentally. [16] On
[16] AD7 p 51, 53, 54.
[17] AD7 p 56.
11 February 2020 Dr Barich recorded ankle pain and shoulder pain from a fall at McDonald’s on 18 December 2019.[17]
On 21 February 2020 Dr Barich recorded “depressed mood due to family problems”.[18]
[18] AD7 p 46.
On 27 November 2020 Dr Barich reported “depressed as started gambling and getting very upset”.[19]
[19] AD7 p 70.
On 28 May 2021 Dr Barich recorded “depression also aggravated by chronic pain”.[20]
[20] AD7 p 73.
On 10 December 2021 Dr Barich recorded “depression severe and easy crying”.[21] On
[21] AD7p 137.
[22] AD7 p 138, 139.
7 January 2022 Dr Barich recorded depression, and on 1 February 2022 he reported anxiety.[22] In May 2022 Mrs Seghabi consulted Dr Barich following a fall on wet grass.

Handwritten records of Dr Sanaa Barich

Handwritten records of Dr Barich appear to run concurrently with the typed records of Penrith Mall Medical Centre. The entries are not always readily legible.
On 10 November 2005 it was reported Mrs Seghabi had been involved in a motor vehicle accident when she was a passenger in the back seat. On 19 March 2020
Dr Sanaa Barich reported to Gerard Malouf & Partners that she had discouraged
[23] AD7 p 1018.
Mrs Seghabi from pursuing a claim for an accident on 16 September 2005 because of the stress associated with the earlier claim and because the accident was minor.[23]
On 24 January 2012 a GP Mental Health Care Plan was formulated for depression and anxiety and Mrs Seghabi was referred to Talking Point Psychology.[24] On 3 February 2012 Mrs Seghabi was referred to Mr Onuoha for depression.[25]
[24] AD7 p 1036, 1038.
[25] AD7 p 1042.
On 27 February 2012 it was reported Mrs Seghabi was involved in a rear end motor vehicle accident on 25 February 2012. Blacktown Hospital Discharge Referral notes Mrs Seghabi was brought in by ambulance complaining of headache, neck and shoulder pain.[26]
[26] AD7 p 1158, 1218.
Intermittent entries in 2009, 2010, 2012 and 2013 refer to depression, anxiety and stress relating to her son and her inability to see her grandchildren.
On 7 June 2012 Dr Antwan Barich provided a report in respect of the accident on
25 February 2012 noting she continued to complain of severe headache, neck pain, shoulder pain, and lower back pain.
On 15 September 2012 Dr David Bosanquet, clinical psychologist reported he had seen Mrs Seghabi for one session, noting she presented with symptoms of depression and anxiety.[27] She was primarily having problems caring for her mentally ill son.
[27] AD7 p 1069.
On 2 January 2015 a history of stress and depression related to her son’s injury is recorded.[28] On 6 February 2017 depression, insomnia and anxiety referenced. On
[28] AD7 p 868.
13 February 2017 it is recorded “severely depressed son injured”. On a date in January 2018 the record reads “some anxiety since knowing her son Bodwi had injury at childhood”.
On 2 March 2018 an entry reads:
“Car accident today at 1600 hrs.
Really emotional, legs feel numb.
Remembering prev. car accident with deceased husband. …”[29]
[29] AD7 p 853.
On 24 July 2018 the clinical entry reads:
“Depressed mood all the time. For weeks never stop thinking negative and old stuff since before MVA. Nightmare and easy crying remembering the recent & old accident. As flashback to old injury all time, isolated home, no interest. Thinking negative a lot, not sleeping, anxiety & panic attacks, (sweaty, chest pressure to level went to hospital as thought heart attack) …. Significantly mentally deteriorated since last MVA.”[30]

Dr Fred Nouh, orthopaedic surgeon
[30] AD7 P 851.

Dr Nouh initially saw Mrs Seghabi on 17 November 2021. In a report dated 24 June 2022 he diagnosed impingement and rotator cuff tendinosis of the right shoulder sustained in the accident.[31]
[31] AD7 p 1333.

Certificate of Medical Assessor Jonathan Herald

Medical Assessor Herald assessed the claimant’s physical injuries and issued a certificate in which he certified the following injuries caused by the accident gave rise to a permanent impairment which was not greater than 10%:[32]
[32] Insurer’s bundle p 83.
·        neck injury with vertigo and pain radiating to the right shoulder, shoulder blade and arm;
·        right hand injury;
·        injuries to fingers and thumb of the right hand;
·        right wrist injury;
·        mid back injury;
·        low back injury with radiation of pain into right leg;
·        right hip injury;
·        right leg injury;
·        left leg injury;
·        right knee injury, and
·        left knee injury.
Medical Assessor Herald reported Mrs Seghabi had a depressed affect but was not generally in distress during the examination. He reported she was taking Valium for anxiety. Whilst he stated Mrs Seghabi moved out of the granny flat into the main house with her daughter because she required more help with activities of daily living the need for assistance was related to the aggravation of her longstanding cervical and lumbar spondylosis.

Medico legal evidence

Dr Sikander Khan, general surgeon

Dr Khan assessed the claimant and provided a report dated 23 July 2019.[33] He reported physical symptoms relating to the neck, right shoulder and arm, back, right hip and leg. He also reported following the accident Mrs Seghabi had become very emotional, depressed and stressed.
[33] AD7 p 225.
He noted she sustained multiple injuries including to her neck and back in the 2003 accident in which her husband died and injuries to the right leg, neck and back in the 2011 accident, although Mrs Seghabi reported her neck and back had recovered by the time of the accident.
Dr Khan reported Mrs Seghabi had a mild depressed affect and became emotional during the interview talking about her deceased husband and family. He noted
Mrs Seghabi had been referred to a psychologist.

Dr Thomas Rosenthal, occupational physician

Dr Rosenthal provided a reported dated 13 June 2019.[34] Dr Rosenthal did not obtain any history of psychological symptoms. On examination he reported no obvious distress. He reported Mrs Seghabi functions reasonably well, sitting, standing and walking are not overly restricted, she can cook, hoovering aggravates her symptoms, and she has trouble hanging out the clothes.
[34] Insurer’s bundle p 60.
Dr Rosenthal diagnosed a whiplash injury with right arm symptoms of a non-radicular nature.

Additional evidence

The records of the treating psychologist for the period prior to the accident, as well as subsequent to the accident, were requested, but were not received.

SUBMISSIONS

Claimant’s submissions

The claimant provided submissions dated 19 July 2021 addressing the test to be determined by the delegate of the President, that is whether the assessment of Medical Assessor Jones was incorrect in a material respect.[35]
[35] AD7 p 9.
The claimant submits the conclusion reached by Medical Assessor Jones that her condition had resolved is inconsistent with the history he reported of her symptoms.
The claimant submits Dr Barich reported she had been suffering from post-traumatic stress disorder, major depression and severe anxiety disorder related to the accident which had “aggravated her pre-accident depression significantly”.
The claimant notes following the accident Dr Barich increased the claimant’s dosage of Lexapro from ½ tablet to a full tablet due to an increase in her symptoms.
The claimant also refers to the mental state examination reported in the GP Mental Health Care Plan dated 24 July 2018 and the report of Dr Barich dated 14 August 2018 where he reported significant deterioration in the claimant’s anxiety/depression since the accident.
The claimant submits if Medical Assessor Jones had assessed WPI he would have provided an assessment of greater than 10%.

Insurer’s submissions

The insurer provided submissions dated 10 August 2021 addressing the question to be determined by the President’s delegate, that is, whether the assessment of Medical Assessor Jones was incorrect in a material respect.
The insurer provided submissions dated 3 September 2020 in respect of the dispute as to permanent impairment.[36] The insurer submitted there was no evidence to suggest the claimant had been diagnosed with a psychiatric condition as a result of the accident in accordance with DSM-5.
[36] Insurer’s bundle p 4.
The insurer also submitted there was no evidence the claimant had undergone any psychiatric treatment as a result of the accident.

MEDICAL EXAMINATION

Mrs Seghabi was re-examined on 31 May 2023 Medical Assessor Chris Rikard-Bell and Medical Assessor Melissa Barrett. The assessment was conducted by video conference, using Microsoft Teams.
The claimant was present at the office of her lawyers Lionheart Lawyers and was unaccompanied.
An interpreter engaged by the Commission, Claudi El-Brihi, NAATI number 59150, was present for the duration of the assessment.

History

Psychosocial history and pre-accident history

Mrs Seghabi is a 69-year-old woman who lives with her adult daughter and son in a granny flat on the property which she owns. She supports herself on a Centrelink payment, previously a carer’s payment although it later transitioned to the aged pension. Her adult daughter is in receipt of a carer’s pension for caring for the claimant.
Mrs Seghabi was born in a mountain village in Lebanon. She described normal birth and achievement of milestones. She is the second eldest of a large family, with 12 siblings. Her father was a local taxi driver. She described a happy childhood and a, “beautiful close family”. She denied any childhood trauma. She attended a local school up until about 14-years-old. She displayed a particular talent for the French language.
Mrs Seghabi had an arranged marriage at almost 16-years-old, facilitated by her grandfather, to her husband who was an Australian citizen, then aged 26-years-old. After the marriage, she migrated to Australia with her husband. She had an uncle in Australia but otherwise had no family of her own in Australia. She and her husband lived with her in-laws. She learned English. She described the marriage in positive terms. Her husband was, “a bit gambler”, but he did not run up debts. Her husband had owned a fruit shop and later a takeaway shop.
In April 2003 her husband was driving a car in which she was a passenger, when a drunk driver failed to give way at an intersection and collided with their car. Tragically, Mrs Seghabi’s husband died at the scene. Mrs Seghabi witnessed her husband’s injuries and death. She suffered her own physical injuries for which she was hospitalised for two or three weeks and then treated with physiotherapy. The 2003 accident was the subject of the previous CTP claim which was settled. She expressed dissatisfaction regarding the financial settlement.
Mrs Seghabi had been assisting her husband in the takeaway shop and providing some care for their son but after her husband’s death she did not perform paid work. She continued to perform carer duties for her son, receiving a carer’s pension.
Mrs Seghabi’s daughter attempted to run the takeaway business but eventually had to sell it.
Mrs Seghabi has five adult children who all live in Sydney. Her eldest son, now aged 52-years-old, was diagnosed with schizophrenia and bipolar disorder at about 20-years-old. She reports a three year prodrome of social withdrawal prior to his first admission at 20-years-old. Two years ago, that is in about 2021, after watching a TV news item regarding a teacher at her son’s school having been charged with child sex offences, her son disclosed to her that he had been a victim of the teacher’s offences. When it was raised with her that the GP’s contemporaneous records indicate this disclosure occurred prior to the accident in May 2017 she acknowledged she was uncertain of the exact timing of the disclosure and there was a possibility her son’s disclosure had occurred prior to the accident.
Her son has continued to experience an ongoing relapsing course of schizophrenia. She estimates he has had about three periods of hospitalisation since the accident, the last in December 2022.
There was a possibility of post-trauma symptoms in her uncle, who she described as, “a bit mental” after an incident when he had a gun pulled to his head at a checkpoint in Lebanon.
Mrs Seghabi is a non-smoker, who does not use alcohol or other drugs. She denied gambling.
In the period before the accident, her physical condition had improved. She acknowledged she was, “not perfect” but states she was active and able to walk for periods of up to 40 minutes. She was not using regular analgesics. She had type II diabetes, treated with oral hypoglycaemics and subcutaneous insulin.
Her premorbid personality was “bubbly” and “happy”. She denied any experience of postnatal depression.
Mrs Seghabi first experienced a psychiatric illness after the 2003 accident in which she witnessed her husband’s death. She reported symptoms consistent with posttraumatic stress disorder, flashbacks when trying to initiate sleep for about a year, nightmares and disturbed sleep. She had not previously held a driver’s licence but after the 2003 accident, when travelling as a passenger she became very anxious, particularly if she was sitting in the rear of the car. She was referred to a psychologist who she saw for a few months. Her GP prescribed the benzodiazepine, alprazolam, but she states she did not want to take it. Instead, she used St John’s Wort for about six months, then ceased. These symptoms persisted for about four or five years, that is until about 2007 or 2008. In about 2013, with her children’s encouragement, she learnt to drive and attained her driver’s licence.
Mrs Seghabi acknowledged there was another motor vehicle accident, but she could not recall the exact timing of it, although she recalled it occurred prior to the subject accident. She was involved in a multi-car pile-up resulting in a collision to the rear of her car. She stated she had “not much injury” and was treated with physiotherapy. She acknowledged this had caused a resurgence of issues related to the 2003 accident, including intrusive memories of the 2003 accident, which she reports persisted for about a year. She stopped driving for a few months before resuming driving. She did not see a psychologist but saw her GP regularly and she regarded these regular GP sessions as, “like psychology”. There was a CTP claim for a physical injury only and she received a “very little amount of money”.
Whilst Mrs Seghabi stated she was uncertain of the relative timing of the disclosure of her son’s trauma she acknowledged that the disclosure may have occurred prior to the accident. She recalled that following her son’s disclosure, “I got very sick”. She blamed herself, as during her son’s schooling she had accepted the given explanation, that her son was required to remain back at school for detention, which she attributed in part to her inability to drive. She resumed St John’s Wort for a period of about six months. She found it of mild benefit, stating it, “calmed me down”.
In the period prior to the accident she, “didn’t have much issues” but acknowledged her mental health was, “not perfect”. She acknowledged she continued to experience a sense of loneliness and that she was, “missing something”. She maintained a sense of guilt regarding her son’s history of trauma. She acknowledged ongoing stressors about her son’s mental health, stating in the period before the accident her son was intermittently non-compliant with medication, that he would become aggressive towards her when unwell, she had found it necessary to call the police and he had been hospitalised a few times. In the period before the accident, she stated her son was, “all over the place”.
In the period before the accident her GP prescribed the SSRI antidepressant Escitalopram, but she states she ceased it after about two months due to side effects of nausea.
In the period before the accident, Mrs Seghabi was living in a granny flat with her adult daughter, on her own property. They were renting the main house out to another family for additional income. Her son was living on his own in a nearby flat. Her daughter did most of the cleaning and laundry. She would cook some meals for her son. She showered daily.
Her usual day consisted of making some tea and toast for breakfast, tidying up the house and shopping. She had a small dog, which she took for walks to the park. Her son would visit for some meals, usually breakfast, about three times a week. About once a month she would take her son to doctor’s appointment for his depot medication. She had enjoyed Anglicare Carer Respite Retreats, about twice a year, when she would go away, for example to Manly, with a group of other carers for about two days at a time. She was attending church once a week.
She was able to drive to the shops and further distances of about 45 minutes to familiar locations such as her sister’s home.
She had a good relationship with her adult children and grandchildren. They would visit her every two or three weeks. She had lots of friends. She would meet up with her friends for coffee about once a month. She had remained single after her husband’s death and expressed no interest in forming any relationship.

History of the accident

The accident occurred on 3 March 2018. Mrs Seghabi was driving on her own in a Toyota RAV4. She was returning from the shop when another driver pulled out from the driveway of a carwash in front of her. She was unable to avoid the collision. She states the collision was to the side of her vehicle. A passer-by from the nearby carwash assisted to pull the door open to help her out of the car. She called police but they declined to attend. She did not wish to call the ambulance, telling passers-by that she would instead attend her GP the following day. She was uncertain of what happened to her car but thinks it must have been towed. Her car was subsequently repaired at a cost of about $6,000.

History of physical symptoms following the accident

Mrs Seghabi reported a worsening of lower back pain after the accident, and right shoulder and neck injuries. She stated she had physiotherapy once a week. She had surgery on her right shoulder on 2 December 2022 to repair, “three tears in shoulder”. Post-surgery, she continues to experience pain and now has some weakness in her right arm. She is hopeful and expects to see further improvement but states she was told by the surgeon that it may take a year post surgery to see maximum improvement. She uses Nurofen two bd and Panadol Osteo two bd, every day.
Her physical injuries continue to prevent her from walking or performing heavy household tasks. She has difficulty vacuuming, mopping, sweeping, reaching and performing some activities when getting dressed, such as reaching around to put her bra on. As a result, she needs some assistance from her daughter in dressing and some showering tasks. She states the restrictions, “upset me because I can’t do things any more”.

History of psychological symptoms following the accident

Mrs Seghabi stated the accident had “a big effect” upon her. She reports she experienced a relapse of flashbacks of the 2003 accident, rehearing the “hit” impact sound of the 2003 accident, which persisted for about a year after the accident. Her sleep was impacted, and she was waking twice a night due to both intrusive memories of the 2003 accident, as well as pain. She avoided driving for a period of six to seven months. She reported negative thoughts, “not another accident”, “why it happened to me?” When she resumed driving, she initially avoided the street where the accident occurred. For the first few months after she resumed driving, she said she was “scared” and she kept a distance between herself and other drivers.
Her mood has been impacted. She stated, “I’m very depressed”, “not happy like before, I don’t know why”. She states she had continued to socialise, attending coffee club every few months, up until about two years ago.
Mrs Seghabi saw a psychologist for about five sessions. The sessions involved addressing issues related to the accident, particularly related to her loss of independence and physical restrictions. She stated, “I like to do things” “I can’t do things”, as well as non-accident issues, including her sense of guilt regarding her son’s history of trauma. Subsequently, she saw her GP regularly.
She restarted St John’s Wort for a few months, which helped her to sleep and relax.

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

There have been no new injuries or conditions.

Current symptoms

Mrs Seghabi reported that the intrusive memories and flashbacks of the 2003 accident resolved within about a year of the accident. She resumed driving after a few months and although she initially experienced over-anxiety and overcautious behaviours when driving, these settled within a few months. She prefers not to travel on the street where the accident occurred but will do so if she must. She is currently able to drive about 40 minutes before she experiences fatigue.
She is less affected by her son’s trauma than she was when she first found out, but remains still troubled by it, “from time to time”. She still feels a sense of guilt but, “not like before”.
Mrs Seghabi reports a worsening of her mood over the last two years but could not describe why. She was still socialising at coffee clubs every few months up until 2021 but stated, “now I finish”. Since 2021 she has engaged in comfort eating and has gained about 20 kg. Her sleep is impacted by worrying. The content of her worries relates to her reduced physical capacity, “not fit like before”. She described sustained increase in appetite, craving sweet foods stating, “food relaxes me”. When asked whether her energy and concentration were affected, she responded, “don’t know what to say”, “not much”. Her attitude has changed, and she has been more irritable and, “not the same”. She denied anhedonia and reported she enjoys seeing her adult children and grandchildren. She does not report pathological guilt, stating, “I am a good lady, I know that” and recognises that others hold her in positive regard. She denied any suicidal ideation.

Current and proposed treatment

Mrs Seghabi recently decided she needed to return to see a professional and has seen a psychologist now on two occasions. Ongoing psychological treatment is proposed, and she had a further appointment with a psychologist the week after the review appointment. She is not using any psychotropic medications.

Mental State examination

Mrs Seghabi presented as a neatly groomed woman of stated age, wearing appropriate casual attire. She had a full range of facial expressions and gestures. Her facial expressions were animated. There was no evidence of any psychomotor agitation or retardation. Her speech was normal in rate, volume, and rhythm.
She described her mood as depressed. Her affect was reactive and appropriate to the content. When discussing negative life events, she was appropriately serious. She became briefly tearful when discussing the 2003 accident causing the death of her husband but was able to quickly contain her emotion. When talking about her family, particularly her grandchildren, she was able to smile easily and warmly.
Mrs Seghabi continues to experience a sense of loss regarding the death of her husband, and intermittent guilt regarding her son’s history of trauma, but she denies excessive preoccupation with guilt and there was no evidence of pathological guilt. She described a sense of loss regarding her restricted physical functioning and independence. She described a change in attitude, becoming less patient and less tolerant of people who lie. She retains some hope and optimism regarding the outcome of her December 2022 shoulder surgery. There were no delusions. The previous re-experiencing flashbacks have resolved. There was no formal thought disorder. There were no perceptual abnormalities.
She denied any suicidal ideation. She did not express a risk to others.
She was able to concentrate well for the duration of the interview which extended for approximately 1 hour 40 minutes. She could provide a clear history of recent and past events.
She has some insight into her difficulties and has intermittently engaged with her GP, has used St John’s-Wort and has attended brief periods of psychological treatment.

Current functioning

Self-Care

Mrs Seghabi states that since her shoulder surgery in December 2022, aged care services have provided her a referral to a cleaning service, which she pays for once a week. She can perform some light cleaning tasks and tidying. She can perform some simple cooking but it is too painful for her to make complex traditional Lebanese foods. Her daughter cooks dinner. She showers daily. She needs some physical assistance in the shower. She wears a small amount of makeup, lipstick, consistent with her pre-accident habits. At assessment she had neat painted fingernails, which she stated she did herself.

Social and Recreational Activities

In the last two years Mrs Seghabi has relocated to a church nearer to her home. She continues to attend church once a week and will have coffee with the nuns after church. Her adult children and grandchildren visit her regularly, about once every two weeks. She acknowledges she enjoys the visits, “love it”, “one thing made me happy”. She will talk occasionally with her friends.

Travel

Mrs Seghabi can drive independently for periods of about 40 minutes before she becomes fatigued.

Social Functioning

Mrs Seghabi has maintained a good relationship with her adult children and grandchildren. She is still close with her family. She described herself as still having, “heaps of friends”. She described herself as less patient with people who lie and has distanced herself from some friends for this reason.

Concentration, Persistence and Pace

She can concentrate adequately for the one-hour church service.

Work and Adaptation

She is now on the aged pension. Mrs Seghabi continues to assist her son. She reminds him of his appointments and accompanies him to some appointments when he asks her to. Her son is now on the NDIS and performs most of his own chores. Mrs Seghabi manages her own finances independently.

Comments of consistency

There were no substantial inconsistencies.
There was an issue regarding the timing of her son’s disclosure of trauma relative to the timing of the accident. The contemporaneous records of the GP were raised with Mrs Seghabi. She accepted that she was uncertain of the exact timing and that it was possible that the disclosure had occurred prior to the accident.

PANEL DELIBERATIONS

Taking into consideration the documents provided, as well as the information conveyed by Mrs Seghabi during the assessment, the panel considered that Mrs Seghabi had a past psychiatric history of post-traumatic stress disorder following her husband’s death in the 2003 accident. Based on her history she would have fulfilled the DSM-5 criteria for post-traumatic stress disorder, fulfilling Criteria A by having directly experienced a motor accident causing her serious injury and her husband’s death. She fulfilled Criteria B by experiencing nightmares and flashbacks, Criteria C, avoidant symptoms, with avoidance of distressing memories when seated in the back seat of the car, Criteria D symptoms, persistent fear of the risk of another accident, and Criteria E symptoms being alterations in arousal and reactivity with hypervigilance and difficulty sleeping. She fulfilled the complete criteria for post-traumatic stress disorder for a period of about a year and then had some attenuated but persisting symptoms for about four or five years in total.
The symptoms of post-traumatic stress disorder resolved after about four to five years, after a period of about six months treatment with St John’s Wort, a natural preparation which acts as a mild SSRI antidepressant, and a few months of psychological treatment, as well as the passage of time. Mrs Seghabi then reached remission, such that about 10 years after the accident, in about 2013, with the encouragement of her children, she was able to learn to drive for the first time.
Following another motor accident, of unclear timing but occurring before the accident, Mrs Seghabi experienced a relapse of post-traumatic stress disorder symptoms, a return of memories of the 2003 accident, and avoidance of driving for a few months. She saw her GP regularly but had no formal treatment and the symptoms again reached remission after about a year.
The panel accepts that the past post-traumatic stress disorder was in remission at the time of the accident.
The panel also considers that Mrs Seghabi had a pre-existing diagnosis of chronic adjustment disorder, described by DSM-5 as persistent depressive disorder.
Mrs Seghabi had experienced the loss of her husband in 2003, after which she reported a sustained sense of loneliness and of something missing. Furthermore, she experienced ongoing stressors regarding her son’s relapsing psychiatric condition, and she had experienced a sense of loss and grief due to the significant emotional trauma of discovering her son had been a victim of trauma as a child. Mrs Seghabi acknowledged she was uncertain of the timing of the disclosure and the panel noted the contemporaneous records of the GP show the disclosure occurred by May 2017, before the accident. Further, in the period prior to the accident Mrs Seghabi acknowledged she was still experiencing residual physical symptoms in relation to the earlier accident, although she was not reliant on regular analgesics.
Mrs Seghabi acknowledged that while she did not have significant psychiatric symptoms in the period before the accident she was, “not perfect” and described feelings of loneliness, intermittent guilt, and anxiety regarding the impact of her son’s psychiatric illness. These symptoms were of a severity that led her to see her GP.
The contemporaneous records of Dr Barich confirmed longstanding pre-accident symptoms of anxiety and depression, from at least 2012 and continuing to be intermittently recorded on two occasions in 2017, and again in January 2018, just two months prior to the accident. Mrs Seghabi acknowledged she had been prescribed the SSRI antidepressant Escitalopram before the accident but had ceased it after two months because of side effects of nausea. The GP clinical notes on 30 January 2018 note the GP, “suggested proper counselling under care plan”, although a GP mental health care plan was not documented as completed. The GP’s medical certificate dated 25 July 2008 acknowledged, “her pre-accident depression”.
Thus, the panel was satisfied that Mrs Seghabi had experienced longstanding symptoms of anxiety and depression, where the contemporaneous notes of the GP record symptoms of anxiety, depression and sleep disturbance, causing significant distress. The Panel finds Mrs Seghabi would have fulfilled the diagnostic criteria for an adjustment disorder and, noting the chronicity of her symptoms without remission for more than two years, she would have fulfilled the DSM-5 diagnosis for persistent depressive disorder.
On this background, the accident would have had greater salience to Mrs Seghabi than a person without her history of trauma resulting from the 2003 accident and the earlier diagnosis of post-traumatic stress disorder. The accident as described would not have fulfilled DSM-5 criteria A for post-traumatic stress disorder, noting she declined to call the ambulance and decided she would see her GP the next day, indicating
Mrs Seghabi did not consider the accident was one in which she was seriously injured. However, noting the significant damage to the vehicle, that the accident would have been frightening, that Mrs Seghabi would have been primed to the effects of the accident as a result of her involvement in the 2003 accident and the resultant post-traumatic stress disorder, and her history of relapse of post-traumatic stress disorder following the earlier rear-end collision, the Panel considers the accident was a plausible trigger for relapse of post-traumatic stress disorder. After the accident, Mrs Seghabi reported the following symptoms:
·        a relapse of flashbacks of sounds from the 2003 accident;
·        avoidance of driving for a period of six to seven months;
·        exaggerated negative thoughts about the world, “not another accident” and blaming herself for the trauma, “why it happened to me?”, indicative of negative alterations to mood and cognition;
·        alterations in arousal and reactivity, with poor sleep, waking twice at night impacted by pain as well as intrusive memories of the accident, and
·        increased vigilance and anxiety when she returned to driving, keeping a greater distance between herself and other drivers.
After a period of a few months of treatment with St John's Wort, which acts as a mild SSRI, the relapse of post-traumatic stress disorder reached remission after about a year and has remained in remission since. There were no persisting symptoms of post-traumatic stress disorder described at the assessment and Mrs Seghabi’s pattern of driving is now broadly in line with her pre-accident driving habits.
The accident is also reported to have caused physical injuries, resulting in chronic pain and pain-related restrictions to her independence. The Panel notes Medical Assessor Herald considered Mrs Seghabi suffered an aggravation of the underlying spondylosis of the cervical and lumbar spines in the accident resulting in a WPI of 10%. Because of the psychological effects of chronic pain, as well as the further loss of her physical independence, the Panel finds this is a plausible cause of the exacerbation of the pre-existing persistent depressive disorder.
Mrs Seghabi has reduced interest in some tasks, increased depression, reduced interest in social engagement, reduced interest in some activities, comfort eating has resulted in weight gain, and worry about her physical condition impacts her sleep and causes irritability. The panel accepts the GP’s account of a worsening of her depressive symptoms after the accident and notes the symptoms are documented in the contemporaneous records of the GP.
In addition, Mrs Seghabi has continued to experience the impact of the pre-accident stressors related to her son’s ongoing relapsing condition and issues related to his trauma disclosure. It appears there has been a further worsening of her symptoms in the last two years, for unclear reasons. However, the accident need not be the only cause of her current condition, as long as it is a more than negligible cause.
Regarding treatment, Mrs Seghabi has been seeing her GP regularly, but has recently decided to return to psychological treatment.
Regarding diagnosis, the Panel have therefore formed a different view to that of Medical Assessor Jones. The panel considers that the accident-related relapse of past post-traumatic stress disorder is in remission and has resolved.
The panel also considers that Mrs Seghabi had an ongoing, pre-existing persistent depressive disorder at the time of the accident and that her description of her current functioning compared to her pre-accident functioning is only minimally different. Nevertheless, based on her account of increased depressive symptoms, the GP’s contemporaneous records and the slight worsening of functioning after the accident, the panel accepts there was a mild exacerbation of the pre-existing persistent depressive disorder as a result of the accident-related stressors of chronic pain and pain-related restrictions to independence.

REVIEW PANEL DECISION

The Panel found the accident was the cause of the following injuries:
· relapse of past post-traumatic stress disorder, now in remission, and
· mild exacerbation of pre-existing persistent depressive disorder.
The accident-related relapse of post-traumatic stress disorder persisted for about a year after the accident but has been in remission since 2019. Therefore, there is no current accident-related post-traumatic stress disorder and no assessable permanent impairment.
The Panel finds the exacerbation of the pre-existing persistent depressive disorder continues and is capable of assessment for permanent impairment.

Psychiatric Impairment Rating Scale (PIRS)

Degree of whole person impairment (WPI) of the injuries caused by the accident was calculated as follows:

Psychiatric diagnoses	1. Mild exacerbation of pre-existing persistent depressive disorder	2.
Psychiatric diagnoses	3.	4.
Psychiatric treatment description	Previous psychological treatment in about 2020, regular sessions with the GP, a few months of treatment with St. John's Wort, a natural mild SSRI.

Category	Class	Reason for Decision
1. Self-Care and Personal Hygiene	1	The panel excluded impairment due to pain according to Guideline 1.214 of the PIRS. The certificate of Medical Assessor Herald acknowledges accident-related physical conditions causing ongoing impairment and thus her experience of pain and physical restriction for activities of daily living appear completely explainable by the physical condition alone. Within her physical restrictions she performs some tidying, she can prepare some simple meals, particularly breakfast, she showers daily with some physical assistance, and wears some light makeup as was her pre-accident habit. On examination, she presented as a neatly groomed woman. She had made some effort with her appearance, having freshly painted fingernails, and she certainly did not look unkempt. Thus, the panel considered, that when the effects of the physical condition are excluded, there was no impairment due to the psychiatric condition.
2. Social and Recreational Activities	2	Mrs Seghabi reports a reduction in her interest in activities. Nevertheless, she continues to attend church weekly, consistent with her pre-accident habit, and continues to enjoy visits by her extended family once every two weeks, consistent with their pre-accident frequency of visiting. However, she reports in the last two years she has not been attending other social activities, such as coffee with friends, although she still talks occasionally with her friends. Accepting that this represents a reduction in her socialising, but that she still enjoys regular contact with her extended family and regular attendance at church, consistent with the pre-accident pattern, this is consistent with a mild impairment. She would not fulfil PIRS criteria for a moderate impairment as her pattern of socialising is only mildly reduced from her pre-accident habits.
3. Travel	1	Although there was a period of heightened anxiety when driving, she reports this resolved within a few months of resuming driving. She no longer avoids driving and can drive on the same road that the accident occurred on if required. She can drive on her own for periods of about 40 minutes before she gets fatigued, which is broadly consistent with her pre-accident capacity of driving 45 minutes to familiar places. Therefore, when comparing her current travel capacity with her pre-accident capacity, there is no impairment.
4. Social Functioning	1	Despite some irritability and reduced patience, this predominantly relates to an intolerance of lying which most likely is a consequence of her reaction to her son's traumatic experiences, rather than the accident. In any case, she reports a close relationship with her family. She continues to live with her daughter, as she did prior to the accident, and states she has “heaps of friends”. Therefore, despite some irritability, she does not describe tension in her relationships and there is no impairment.
5. Concentration, Persistence and Pace	1	She can focus on the church service for one hour, which is consistent with a normal capacity to concentrate in the population. Further, objectively at assessment she was able to concentrate well, managing the demands of an assessment conducted in English with the use of an interpreter, for over an hour and a half. Therefore, based on both history and objective findings on examination, there is no impairment.
6. Work and Adaptation	1	Restrictions to her capacity to engage in pre-injury duties and care for her son relates to her physical restrictions and pain, which is excluded from assessment under PIRS Guideline 1.214. Excluding the effects of her physical condition Mrs Seghabi continues to perform chores that she is physically capable of, she engages in personal care and presents herself as she did pre-accident; she continues to provide some care for her son, reminding him of appointments and accompanying him to some appointments and she remains independent in attending to household bills. Isolating the effects of the psychiatric condition, there is no impairment.
List classes in ascending order: 1, 1, 1, 1, 1, 2
Median Class Value: 1
Aggregate Score: 7
% Whole Person Impairment: 0%

*%WPI ^{= Percentage Whole Person Impairment}

Pre-existing/subsequent impairment

The degree of WPI of the pre-existing persistent depressive disorder was calculated as follows:

Psychiatric diagnoses	1. Persistent depressive disorder	2.
Psychiatric diagnoses	3.	4.
Psychiatric treatment description	She had previously seen a psychologist and had treatment with an SSRI antidepressant, escitalopram, which she ceased after a few months due to nausea. She was seeing her GP regularly.

Category	Class	Reason for Decision
1. Self-Care and Personal Hygiene	1	Mrs Seghabi was living in the same granny flat with her daughter. Her daughter had performed most of the cleaning and laundry but Mrs Seghabi prepared some food for her son, often cooking him breakfast, and showered daily. Therefore, there was no impairment.
2. Social and Recreational Activities	1	She did some shopping, took her dog for a walk to the park, would see friends for coffee about once a month and attended church weekly. She enjoyed going on Anglicare Carer’s Retreats for a two-day respite, on average about twice a year. She enjoyed her children’s visits every two to three weeks. Therefore, there was no impairment.
3. Travel	1	She was able to drive for periods of about 45 minutes to local areas, the shops, and to familiar areas, including her sister’s home. She denied any persisting anxiety when driving. Mrs Seghabi had attained her driver’s licence later in life, in about 2013, and it had been her habit to only drive in a restricted manner. It had not been her habit to drive long distances or outside of familiar areas. Therefore, although she only drove in a limited manner, there was no impairment due to a psychiatric condition.
4. Social Functioning	1	Mrs Seghabi reported a good relationship with her adult children, grandchildren, and she had maintained lots of friends. She had no interest in forming a new relationship after her husband's death. Therefore, there was no impairment.
5. Concentration, Persistence and Pace	1	Mrs Seghabi was acting in a carer’s role for her son, reminding him of his appointments and accompanying him to some appointments. There was no evidence of impairment.
6. Adaptation	1	Mrs Seghabi had been a long-term carer for her son and was in receipt of a carer’s pension. She would prepare meals for him, visit him, remind him of his appointments and accompany him to his medical appointments. She was therefore fully engaged in non-work roles, living with her daughter, engaged in regular attendance in church activities, and was performing carers duties. Therefore, there was no impairment.
List classes in ascending order: 1, 1, 1, 1, 1, 1
Median Class Value: 1
Aggregate Score: 6
Pre-existing Whole Person Impairment: 0%

*%WPI

Apportionment

There is no apportionment for subsequent impairment.

Effects of treatment

The panel accept Mrs Seghabi’s account that the post-accident psychological treatment addressed both accident and non-accident-related issues including her sense of guilt regarding her son's traumatic experiences, as well as issues related to the accident and her inability to perform pre-injury tasks. Further, she reported a few months of treatment with St John's Wort, acting as a mild SSRI, helped her sleep and relax.
The Panel finds the combination of these brief treatments would have resulted in a mild treatment effect upon the accident-related post-traumatic stress disorder, noting
St John's Wort acts as a mild SSRI and SSRIs are evidence-based treatment for post-traumatic stress disorder.
The psychological treatment as described did not include evidence-based treatment for post-traumatic stress disorder and therefore the psychological treatment is unlikely to have had significant impact upon the post-traumatic stress disorder symptoms.

The predominant reason for remission of the post-traumatic stress disorder symptoms was likely the passage of time, consistent with the previous history of remission of the previous accident induced relapse of post-traumatic stress disorder without formal treatment, and the effects of informal exposure with return to driving.
Therefore, although there was likely some improvement in post-traumatic stress disorder with St John’s Wort, the remission of post-traumatic stress disorder was neither due to St John’s Wort nor the psychological treatment.
The Panel finds the treatment has not been effective in treating the persistent depressive disorder. There has not been any consistency in treatment for the persistent depressive disorder and the Panel considers it is not appropriate to make any adjustment for the effects of treatment.
The Panel assesses a 1% WPI for the following injury caused by the accident:
· mild exacerbation of pre-existing persistent depressive disorder.

[2023] NSWPICMP 269

15 June 2023