DETERMINATION OF REVIEW PANEL	
	
CITATION:	Marzifar v Allianz Australia Insurance Limited [2024] NSWPICMP 477	
		
CLAIMANT:	Amir Hussein Marzifar	
		
INSURER:	Allianz Australia Insurance Limited	
		
REVIEW Panel	 	
		
MEMBER:	Terence Stern OAM	
		
MEDICAL ASSESSOR:	Melissa Barrett	
		
MEDICAL ASSESSOR:	John Baker 	
		
DATE OF DECISION:	16 July 2024	
		
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; medical dispute as to whether the injuries sustained were threshold injures; Medical Review Panel conducted a medical examination; the somatic symptom disorder was accepted as causally related to the motor vehicle accident; Held – Medical Assessment Certificate confirmed; the injury referred for assessment and caused by the accident was a threshold injury.

DETERMINATIONS MADE:  	CERTIFICATE OF DETERMINATION
1.	The Review Panel affirms the Certificate of Medical Assessor Sidorov and certifies that the following injury WAS NOT caused by the motor accident on 19 September 2019: 
(a)	aggravation of post-traumatic stress disorder and secondary depression caused by 1 August 2018 motor accident.   
2.	The Review Panel further certifies that the following injury WAS caused by the motor accident on 19 September 2019:
(a)	DSM5 300.82 (F45.1) Somatic symptom disorder – persistent with predominant pain.	

STATEMENT OF REASONS
introduction
1.	On 19 September 2019, Amir Hussein Marzifar (Mr Marzifar) was involved in a motor vehicle accident (the accident), which he alleges resulted in both physical and psychiatric injury. 
2.	A complete description of the accident is provided below. 
3.	Allianz Australia Limited ABN 21 000 006 226 (Allianz) is the insurer. 
4.	Under the provisions of the Motor Accident Injuries Act 2017 (MAI Act) in force at the time of the accident the statutory benefits for treatment and care cease after 26 weeks if “the person’s only injuries resulting from the motor accident were threshold injuries”.
5.	Mr Marzifar submitted an Application for Personal Injury Benefits (APIB) dated 
23 January 2020. 
Threshold injury dispute
6.	Allianz determined that Mr Marzifar had sustained a minor (threshold) injury and denied liability for statutory benefits beyond 26 weeks after the accident. 
7.	Mr Marzifar subsequently filed an application in the Personal Injury Commission (Commission) in respect of the dispute. A treatment dispute was also filed.
8.	Pursuant to Schedule 2, cl 2 of the MAI Act, various matters are declared to be medical assessment matters, including whether an injury caused by the accident is a threshold injury.
9.	A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor. 
THRESHOLD INJURY- STATUTORY PROVISIONS
10.	Assent was given to the Motor Accident Injuries Amendment Act 2022 (the MAI Amendment Act) on 28 November 2022 with various amendments commencing on 1 April 2023. From 
1 April 2023 the MAI Amendment Act provides that a “minor injury” is known as a “threshold injury” and “minor injuries” are known as “threshold injuries”.
11.	The definition of what constitutes a minor injury has not been amended and continues to apply to a threshold injury.
12.	A threshold injury is defined in s 1.6 of the MAI Act and includes a “soft tissue injury” or a “psychological or psychiatric injury that is not a recognised psychiatric illness”. Section 1.6(2) of the MAI Act defines a “soft tissue injury” as:
“[A]n injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.”
13.	Section 1.6 provides that regulations may be made to exclude or include a specified injury from being a threshold injury. Part 1, cl 4 of the Motor Accident Injuries Regulation 2017 (the MAI Regulation) further defines threshold injury to include “an injury to the spinal nerve root that manifests in neurological signs (other than radiculopathy)”.
14.	Part 5 of the Motor Accidents Guidelines (the Guidelines) are made pursuant to s 10.2 of the MAI Act. The Guidelines contain the procedure for assessing whether an injury caused by the motor accident is a threshold injury for the purposes of the MAI Act. Version 9.2 of the Guidelines commenced on 1 April 2023 and applies to motor accidents occurring on or after 1 December 2017. In respect of the medical assessment of whether an injury is a threshold injury, the Guidelines relevantly provide:
“5.3 	The assessment will determine whether the injury related to the claim is a soft tissue injury or a threshold psychological caused by the motor accident.
5.4 	Insurers should not require injured persons to undergo diagnostic imaging for the purpose of the insurer determining whether the injury related to the claim is a threshold injury. Diagnostic imaging is not considered necessary to assess threshold injury.
5.5 	A diagnosis for the purpose of a threshold injury decision must be based on a clinical assessment by a medical practitioner or other suitably qualified person independent from the insurer.
5.6 	The assessment of whether an injury caused by the accident is a threshold injury for the purposes of the Act should be based on the evidence available and include all relevant findings derived from:
(a) 	a comprehensive accurate history, including pre-accident history and pre-existing conditions
(b) 	a review of all relevant records available at the assessment
(c) 	a comprehensive description of the injured person’s current symptoms
(d) 	thorough physical and/or psychological examination
(e) 	diagnostic tests available at the assessment. Imaging findings that are used to support the assessment should correspond with symptoms and findings on examination.”
15.	In Briggs v IAG Limited Trading as NRMA Insurance [2022] NSWSC 372, his Honour Justice Wright stated at [35]:
“The question of causation of injuries was not dealt with in Part 5 of the Guidelines but causation was addressed in Part 6, which related to assessment of permanent impairment. There is no reason to think that different principles were intended to be applied when a medical assessment was being made in relation to causation of minor injuries. Clauses 6.5 to 6.7 provided:
‘Causation of injury
6.5 	An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (or claims assessor) in considering such issues.
6.6 	Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
‘Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1.	The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2.	The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.’
This, therefore, involves a medical decision and a non-medical informed judgement.
6.7 	There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes’.”
ASSESSMENT UNDER REVIEW
16.	The injury referred for assessment to Medical Assessor Alexey Sidorov (the Medical Assessor) was: 
(a)	psychiatric condition – aggravation of pre-existing post- traumatic stress disorder and/or major depressive disorder and/or other psychological injuries yet to be diagnosed in accordance with DSM-5 criteria.
17.	At [3]-[4] in his reasons, Medical Assessor Sidorov noted the submissions made by both parties. 
18.	The Medical Assessor took a pre-accident medical history at [8].
19.	Mr Marzifar was born in Iran. He attended qualifications in cyber security and network engineering. 
20.	He came to Australia in 2010 with his wife. He stated that he studied a network security course at TAFE and subsequently worked as a network programmer. 
21.	He said that he was involved in a motor vehicle accident in 2018. He recalled that he felt very scared at the time and afterwards developed anxiety regarding driving. He saw a psychiatrist a couple of times. He was unable to recall whether he was prescribed or took any psychotropic medications, but said that he took some painkillers, the name of which he could not recall. He denied any psychiatric problems prior to 2018.
22.	The Medical Assessor took a history of the accident at [9] and a history of the symptoms and treatment following it at [10]:
“Mr Marzifar stated that the subject accident occurred on 18 or 19 September 2019. He described that, at the time of the subject accident, his wife and his daughter were in the car, his wife in the front passenger seat and his daughter in the rear passenger seat. Mr Marzifar was driving. Everyone was wearing a seatbelt. He stated that, as he was passing straight through an intersection, a vehicle that was turning right struck his car on the passenger side into the front passenger door. Mr Marzifar described that afterwards the other driver looked shocked, and Mr Marzifar came out of the car to assist the other driver. Mr Marzifar stated that his car was written off. Emergency services subsequently attended the scene of the accident. He did not attend the hospital after the accident and returned home by public transport.”
23.	Mr Marzifar told the Medical Assessor that he developed anxiety about driving. 
24.	He described nightmares relating to the accident and stated that he woke up at 3 or 4:00am. He worried about his future. There was no evidence of pervasive low mood and no evidence of mania or psychosis. He denied any thoughts of self-harm or suicidal ideations at any point. 
25.	Mr Marzifar told the Medical Assessor that he was involved in an accident in 2020 where his car turned over. He stated that this occurred when he attempted to avoid a pedestrian that ran across the road in front of his car and had to turn left very fast. He denied sustaining any physical or psychiatric injuries in that accident. 
26.	The Medical Assessor listed the current symptoms at [12]:
“Mr Marzifar stated that he continues to feel scared and hypervigilant all the time. His sleep is disturbed, and he experiences nightmares three or four times a week. He described his mood as often unstable and feels irritable and on edge a lot. There was no evidence of mania or psychosis. He denied any thoughts of self-harm, suicidal ideations, or harm to others.”
27.	The Medical Assessor set out the clinical examination at [14]: 
“Mr Marzifar presented as a man appearing of stated age. He was unshaven and was wearing a blue polo shirt. There was no overt evidence of self-neglect or poor personal hygiene. He did not exhibit any overt distress discussing the subject accident. He was generally cooperative and settled. There was no evidence of psychomotor disturbance or abnormal movements. His account of the subject accident and symptoms appeared to be embellished and he minimised the effect of other accidents before and after the subject accident. He presented it in an overdramatic way and was a generally vague historian. His affect was dysphoric, but with reactivity preserved. He described his mood as “not good”. There was no evidence of formal thought disorder. He denied any thoughts of self-harm, harm to others or suicidal ideations. There were no psychotic features present, such as delusions or hallucinations. He was oriented to time, place and person. He had good insight and a good degree of rational judgment.” 
28.	The Medical Assessor noted multiple inconsistencies in Mr Marzifar’s account and presentation. He did not report all the accidents that he has been involved in in the past, for example in 2017. When asked about that, he stated that he forgot about that accident as it was “not significant”. He appeared to minimise the effects of the previous accidents. He also minimised the effects of his workplace injury. I asked him that, as per the documentation, he experienced flashbacks, intrusive thoughts, poor sleep and nightmares after the workplace injury where he fell off the stairs and he appeared to minimise it and stated that it was “not serious”. His account was generally vague, and his presentation was overdramatic and embellished.
29.	The Medical Assessor provided a summary of relevant documentation at [17]. 
30.	In his diagnosis and reasons, the Medical Assessor opined that based on the account presented by Mr Marzifar, his presentation and review of provided documentation he did not meet the diagnostic criteria for a psychiatric disorder, as per the DSM-5, secondary to the accident. He was previously diagnosed with a post-traumatic stress disorder and associated depressive symptoms secondary to an accident in 2018, and his presentation appeared to be essentially unchanged since that accident. There was no evidence that he suffered a significant exacerbation of his symptoms or new psychiatric disorder secondary to the accident.
31.	He concluded that Mr Marzifar’s post-traumatic stress disorder was related to a previous accident in 2018 and had been further exacerbated by a fall in 2020. There was no evidence that the subject accident significantly exacerbated his symptoms.
32.	He determined that the following injury was not caused by the motor accident: 
(a)	post- traumatic stress disorder.
REVIEW PROCEDURE
33.	Mr Marzifar lodged an application for review of the assessment.
34.	On 28 March 2023, 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). 
35.	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. 
36.	The review is by way of a new assessment of all matters with which the medical assessment is concerned.
EVIDENCE BEFORE THE PANEL
37.	The Panel issued a Direction to the parties on 27 November 2023 (the first Direction) requiring each party to file an indexed, paginated bundle of documents. On 31 January 2024, the solicitor for the insurer uploaded to the portal a bundle of documents (Allianz’s bundle) and on 1 February 2024 the solicitor for Mr Marzifar uploaded its own paginated bundle of documents (Mr Marzifar’s bundle). 

SUBMISSIONS
Claimant’s submissions, dated 8 February 2023
38.	Mr Marzifar submitted that Medical Assessor Sidorov’s certificate was incorrect in a material respect for the following reasons: 
(a)	failure to consider relevant documents; 
(b)	failure to disclose actual path of reasoning, and/or 
(c)	failure to provide adequate reasons.
39.	Mr Marzifar submitted that Medical Assessor Sidorov failed to consider the clinical records of doctors in particular at annexure 4 of Mr Marzifar’s original application which evidenced consultations relating to both 2018 and 2019 motor vehicle accidents and Mr Marzifar’s fall in 2020. 
40.	Mr Marzifar submitted that the vast majority of his consultations with his psychologist and psychiatrist occurred following the accident and Mr Marzifar submitted that there was overwhelming evidence that he sustained an exacerbation of his mental health symptoms following the accident. 
41.	Mr Marzifar submitted that Medical Assessor Sidorov failed to disclose his actual path of reasoning or provide adequate reasons for his conclusions that the subject accident did not exacerbate Mr Marzifar’s post-traumatic stress disorder, particularly in light of his findings that Mr Marzifar’s post-traumatic stress disorder had been exacerbated by the fall down the stairs in 2020.
42.	Mr Marzifar relied upon Allianz v Francica [2012] NSWSC 1577, where the Supreme Court held that Medical Assessors were required to consider and comment on the evidence produced in support of the central issues, and to provide sufficient reasons in support of their decision. Further, it was held that where certain evidence is important or critical to the proper determination of the matter, and it is not referred to by the Medical Assessor, it may be inferred that the evidence was overlooked or there was a failure to give consideration to it. 
43.	The obligation to provide reasons is also entrenched in common law. In AAI Limited v Fitzpatrick [2015] NSWSC 1108, it was held that a Medical Assessor’s failure to give required reasons is of itself a sufficient basis for concluding that there is reasonable cause to suspect that the assessment was incorrect in a material respect. Specifically, Schmidt J held at [30] that: “The conclusions expressed in the Certificate issued must then be explained by the Assessor in the accompanying statement of reasons. While the reasons given need not be {04151862} elaborate, they must disclose the actual path of reasoning by which the Assess or arrived at the opinions formed on each of the issues that had to be resolved”. (emphasis added). 
44.	Mr Marzifar submitted that Medical Assessor Sidorov failed to fully consider materials pertinent to the determination of minor injury including most notably the clinical records of Workers Doctors, Insightful Mind psychology and reports of Dr Nirenjen St George, and failed to provide a clear path of reasoning for his conclusion that Mr Marzifar’s post-traumatic stress disorder was not exacerbated by the subject accident. 
Insurer’s submissions in reply, dated 6 March 2023 
Failure to provide adequate reasons / failure to disclose actual path of reasoning
45.	Allianz submitted that recent decisions in cases such as Ali v AAI Limited [2016] NSWCA 110 and Insurance Australia v Milton [2016] NSWCA 156 demonstrate the continuing trend to construe the obligations of Medical Assessors to provide reasons for their determination very narrowly in light of the decision in Wingfoot. In both cases, it was indicated that so long as the reasoning provided evidence that the Medical Assessor considered relevant issues, the Court can infer that the assessor exercised his/her professional judgment in arriving at the ultimate conclusion without the need for further explanation.
46.	Allianz submitted that the reasoning provided by Medical Assessor Sidorov satisfied the abovementioned common law authorities governing the standard of reasoning required to be given in this context. 
Failure to consider relevant documents
47.	In the decision in Dunbar v Allianz Australia Insurance Limited [2015] NSWSC 119 it was held that there is no requirement for a Medical Assessor to address each and every report which offers a different opinion and explain how and why his/her own opinion differed. Having provided clear reasoning for his/her own decision, the Medical Assessor will have fulfilled their requirement of providing adequate reasons.
48.	It was evident that in his conclusion, Medical Assessor Sidorov had engaged with the relevant material as described in his certificate and excluded reference to material wherein the findings are not supported by the treating evidence and that of his own assessment.
49.	Although Medical Assessor Sidorov found that Mr Marzifar’s post-traumatic stress disorder did exist, consideration of the relevant documents provided to him, together with his own clinical examination, led him to conclude that the injury existed prior to the subject accident, was not caused by the subject accident and was not aggravated by the subject accident.

THE REVIEW BY THE PANEL
Context of the review
50.	Mr Marzifar was documented as having a motor accident on 23 August 2017. The complaint by Mr Marzifar was “Musculoligamentous spasm and pain.” The reason for attendance was Third Party CTP claim (Page 268 of Mr Marzifar’s bundle). 
51.	This report of the accident was associated with a complaint of back pain dated 
21 March 2018 (Page 267 of Mr Marzifar’s bundle). By this time, Mr Marzifar would be diagnosed with chronic pain disorder having sustained an injury in August 2017, and continued to suffer pain until March 2018, which was more than the six months minimum for a chronic pain disorder to reach criteria for diagnosis. 
52.	On 14 May 2018, Mr Marzifar was advised “pain clinic referral funding has been declined by insurance company”. The general practitioner noted “to submit dispute form to medical assessment authority, instructions given” (Page 271 of Mr Marzifar’s bundle).
53.	Mr Marzifar was diagnosed with post-traumatic stress disorder and secondary depression by Medical Assessor Enrico Parmegiani caused by a motor accident with the date documented on the Certificate as 1 August 2018. 
54.	The medical record shows that the accident was first said to have occurred on 31 July 2018 (Page 272 of Mr Marzifar’s bundle). The record stated that Mr Marzifar attended for his regular injection once every three months for maintenance treatment of his psoriasis. The complaint on 31 July 2018 was that Mr Marzifar was suffering from pain in his legs and thighs.
55.	The report dated 31 July 2018 recognised as the 1 August 2018 motor accident that is assessed by Medical Assessor Enrico Parmegiani. Medical Assessor Parmegiani documented, “He [Mr Marzifar] took analgesia for what he described as widespread pain”. (Page 425 of Mr Marzifar’s bundle).
56.	Mr Marzifar said he had another (subject) motor accident on 19 September 2019 (Page 278 of Mr Marzifar’s bundle). Mr Marzifar is not observed by the general practitioner to be in “shock”. The general practitioner documented likely minor soft tissues injury.
57.	A dispute was referred to Medical Assessor Alexey Sidorov whose Certificate is dated 
8 January 2023.  The dispute involved the assessment of “Psychological injury” (Aggravation of pre-existing post-traumatic stress disorder and or major depressive disorder, and/or other psychological injuries, yet to be diagnosed in accordance with DSM-5 criteria.)
58.	Mr Marzifar sought a review of the findings of Medical Assessor Alexey Sidorov’s Commission’s certificate dated 8 January 2023 as it related to the accident. Medical Assessor Sidorov had found: 
“The following injury referred to me for assessment has been assessed and determined to be not caused by the subject accident [19 September 2019].
(a)	Posttraumatic Stress Disorder.
A decision as to whether this injury is a minor injury is not required for the purposes of the Act.”
59.	Mr Marzifar reported and presented to medical services for the following:
(a)	motor accident in 2016 as documented in Medical Assessor Parmegiani’s certificate in relation to his subject motor accident on 1 August 2018;
(b)	robbery at his workplace two weeks prior to the 1 August 2018 motor accident;
(c)	subject motor accident dated 19 September 2019;
(d)	fall downstairs on 20 August 2020;
(e)	motor accident on 28 November 2020, and
(f)	motor accident on 24 January 2024 (first reported spontaneously by Mr Marzifar at the time of this review).
60.	The medical record as submitted was closely scrutinised by the Panel. There are marked differences in histories provided by Mr Marzifar at different times as to the nature of each event reported throughout the record.
61.	Pain is the main concern documented at both Worker’s Doctors and Merryland’s Family Centre.
62.	Chronic Pain Disorder has been redefined in DSM5 as Somatic symptom disorder with predominant pain 300.82 (F45.1). People with this disorder are noted in DSM5 as genuinely suffering. The diagnosis does not require the absence of all explainable medical conditions.
Mr Marzifar’s submissions
63.	Mr Marzifar submitted: 
(a)	As a result of the subject accident [19 September 2019], he sustained injury and/or aggravation of injury including the following:
(i)	Psychological injury (Aggravation of pre-existing PTSD and/or
(ii)	Major Depressive Disorder, and/or other psychological injuries, yet to be diagnosed in accordance with DSM-5 criteria.)
(b)	Since the accident occurred, he had undergone continued treatment 
due to the severity of injuries sustained in the accident.
(c)	Mr Marzifar continued to suffer from significant physical and psychological disabilities as a result of the accident.
64.	Mr Marzifar further submitted that Medical Assessor Sidorov’s certificate was incorrect in a material respect because of:
(a)	failure to consider relevant documents;
(b)	failure to disclose actual path of reasoning, and/or
(c)	failure to provide adequate reasons.
65.	He further submitted that Medical Assessor Sidorov had failed to consider the clinical records of doctors in particular at annexure 4 of Mr Marzifar’s original application which evidenced consultations relating to both 2018 and 2019 motor vehicle accidents and his fall in 2020.
66.	He submitted that the vast majority of his consultations with his psychologist and psychiatrist occurred following the accident and that there was overwhelming evidence that he sustained an exacerbation of his mental health symptoms following the accident.
Insurer’s submissions
67.	The insurer submitted that Mr Marzifar’s injuries as a result of the accident were threshold for the purpose of the Act.
Documents forwarded with referral
68.	All the documents forwarded with the referral were closely scrutinised.
69.	All late documents forwarded with the referral were closely scrutinised.
70.	The Panel noted that the documentation forwarded with the referral contains inconsistencies in relation to the histories provided by Mr Marzifar to the various services he had attended.
71.	The Panel placed before Mr Marzifar the various inconsistencies in the record to him at the review.
Relevant medical evidence
Medical Assessor: Enrico Parmegiani, Date of Certificate: 6 September 2021, Date of Accident: 1 August 2018
72.	Mr Marzifar had no forensic history. 
73.	Mr Marzifar was involved in a previous vehicle accident in 2016, in which he sustained spinal problems, and his wife lost a pregnancy.
74.	The Panel asked Mr Marzifar about the motor accident in 2016.
75.	Mr Marzifar said he was unsure whether the motor accident happened in “2014, 2015 or 2016”. Mr Marzifar said he believed the motor accident occurred in 2014. Mr Marzifar said he was driving alone in the Canberra region, at about 7.00pm. The road was “dark” and a kangaroo jumped out on the road. He said he was travelling at about 60kmph. The kangaroo hit his car. He was scared. He stopped in a rest bay. He said that he believed the kangaroo died.
76.	The Panel noted that Mr Marzifar had informed Medical Assessor Parmegiani that he was in the car with his wife. The Panel enquired with Mr Marzifar that at the assessment by Medical Assessor Parmegiani he reported that his wife was with him. Mr Marzifar affirmed that he was alone. 
77.	Mr Marzifar was asked about his wife losing a pregnancy in this motor accident. He said that her loss of pregnancy was in relation to the 2017 motor accident.
78.	Mr Marzifar was asked about whether he sought medical or psychological/ psychiatric treatment. He said he did not.
79.	The Panel noted that the motor accident related to 2016 is not further documented in the forwarded documents with this referral.
80.	Medical Assessor Parmegiani then documented: “He (Mr Marzifar) was eventually granted lump sum compensation for back pain”. 
81.	The Panel noted that Mr Marzifar’s first presentation to the Merrylands Family Practice on 
20 May 2016 was due to back pain. 
82.	Medical Assessor Parmegiani then documented: “He (Mr Marzifar) was involved in the subject accident in 2018, and in a further minor accident in 2019”.
83.	The Panel noted that Medical Assessor Parmegiani did not document any consideration in relation to Mr Marzifar’s motor accident in 2017.
84.	The Panel noted that Mr Marzifar was reported to have had “a further minor accident in 2019” - the subject motor accident for the Panel’s review.
85.	Medical Assessor Parmegiani then documented: “He (Mr Marzifar) has also complained of symptoms of chronic pain that have complicated his psychiatric recovery.”
Medical Assessor: Nel Wijetunga. Date of Certificate: 4 December 2020, Date of Accident: 
1 August 2018
86.	[Mr Marzifar] was involved in a motor vehicle accident on 1 August 2018. He completed a Personal Injury Benefits Form on 12 November 2018. Police report was 7 February 2019.
87.	Dr Sivakumar referred him [Mr Marzifar] to Westmead Hospital chronic pain clinic on 
21 March 2018 [in relation to 2017 motor accident].”
88.	The Panel noted documentation that Dr Baburam Bastakoti “referred Mr Marzifar to a pain clinic” for a second time as documented on the 12 April 2019 in relation to the 1 August 2018 motor accident.
89.	The Panel noted documentation that, Dr Baburam Bastakoti, stated on 15 September 2020 attendance, 
“fell from stairs 10 steps about 2 weeks ago… states that he [Mr Marzifar] is in significant pain taking panadeine forte…asking for something stronger advised to add celebres [sic Celebrex]…refused to prescribe ENDONE [Dr Bastakoti’s emphasise] - patient was pushing for it advised to speak to pain specialist.”
90.	The Panel asked did Mr Marzifar attend the pain clinic. He said he did not.
91.	Medical Assessor Wijetunga documented: “previous traffic accident on 23 August 2017. He [Mr Marzifar] had a previous traffic accident on 23 August 2017, which resulted in middle back and neck pain and the health summary from Marylands [sic Merrylands] Family Practice, reported on 21 March 2018, that he had been in constant pain since then”.
First Application Form for personal injury benefits dated 6 December 2019 (page 185 in 
Mr Marzifar’s Bundle) in relation to motor accident 19 September 2019
92.	The Panel noted that this handwritten form documented the following:
Have you ever made a CTP Claim for injury?  
93.	Mr Marzifar endorsed: Yes
94.	The date of injury was recorded as 9 August 2018. 
95.	The Panel interpreted this as 9 August 2018 as the injury date. 
96.	The Panel noted that the date of the 2018 injury was different.
97.	The Panel asked Mr Marzifar to confirm the date of the 2018 motor accident and he confirmed 1 August 2018.
Section 3. About the accident and your injuries.
98.	Date of motor accident, 19 September 2019.
99.	Where did the accident occur? Pitt Street near Walpole Street Merrylands.
100.	Mr Marzifar endorsed three passengers.
101.	The Panel noted that the number of passengers in the car was recorded as 3.
In your own words, please describe (or draw) the motor vehicle accident you were involved in
102.	Mr Marzifar drew an intersection of two roads. Mr Marzifar documented: “The other car past red light. Turning right red arrow.”
In your own words, please outline all Injuries you received as a result of the accident you have described above.
103.	Right Hand – finger – lower arms – right shoulder.
The Panel noted that Mr Marzifar had not claimed to be suffering from post-traumatic stress disorder at the time of this form being completed. Mr Marzifar had not stated that he had suffered from depression at the time this first application form was completed.
The Panel noted that Mr Marzifar had not stated that he had suffered from an exacerbation or aggravation of any psychiatric or psychological condition.
Were you suffering an illness or injury affecting the same or similar parts of your body at the time of the accident?	
104.	Mr Marzifar endorsed, Yes: Shoulder.
Documentation of the 19 September 2019 motor accident (page 19 of Mr Marzifar’s bundle).
Second Application Form for personal injury benefits dated 23 January 2020 - in relation to motor accident 19 September 2019.
105.	The Panel noted that this handwritten form documented the following:
Have you ever made a CTP Claim for injury?  
106.	Mr Marzifar endorsed: Yes.
Date of injury
107.	No day was endorsed by Mr Marzifar / 7 was endorsed by Mr Marzifar / 18 was endorsed by Mr Marzifar. 
108.	The Panel interpreted this as July 2018 as the injury date.
109.	The Panel asked Mr Marzifar when did the 2018 motor accident happen, he confirmed 1 August 2018.
Section 3. About the accident and your injuries.
110.	Date of motor accident:  19 September 2019.
111.	Where did the accident occur? Pitt Street near Walpole Street Merrylands.
112.	Mr Marzifar endorsed 2 passengers.
113.	The Panel noted that the number of passengers had decreased from the application form dated 6 December 2019 where the number of passengers was 3.
114.	Mr Marzifar reported at the time of this review assessment, that there was his wife and his daughter in the car at the time of this motor accident. 
In your own words, please describe (or draw) the motor vehicle accident you were involved in.
115.	Mr Marzifar wrote the following: “I was driving vehicle CI 62 QC in a northerly direction (when it) on Merrylands Road when it was struck in the passenger side by	 vehicle CVR 70R.  
116.	I consider the driver of vehicle CVR 70R was at fault for failing to give way at a T intersection and failing to stop to avoid the collision.
In your own words, please outline all Injuries you received as a result of the accident you have described above.
117.	Neck, right arm, right shoulder, right hand, left arm, left shoulder, abdomen, back, right leg, nervous shock.
Were you suffering an illness or injury affecting the same or similar parts of your body at the time of the accident?
118.	Mr Marzifar endorsed: Yes: Pre-existing injury to my right shoulder and back which was made worse by this injury.
119.	The Panel noted that Mr Marzifar had not stated that his “nervous shock” was made worse by the subject motor accident on 19 September 2019.
120.	The Panel asked Mr Marzifar how the subject motor accident had affected him emotionally. He said that he was worried for his wife and his daughter. He said his wife and his daughter each had claims regarding the motor accident.
121.	The Panel noted that claimant was vague when discussing his pain treatment.
Clinical Measurement Self-Assessment Tools from Worker’s Doctors
122.	Post-traumatic stress disorder checklist for DSM-5 (PCL-5) dated 12 November 2018 (page 249 of Mr Marzifar’s bundle). Score 59/80
123.	Post-traumatic stress disorder checklist for DSM-5 (PCL-5) dated 3 July 2019 (page 218 of Mr Marzifar’s bundle). Score 60/80
124.	The Panel noted that Mr Marzifar endorsed all but 4 of the 20 items in the range 3 to 4 out of 4, at the time of this review. The Panel noted that this was 3 fewer than Mr Marzifar had endorsed in the 12 November 2018 at 7 items endorsed as moderate.
125.	The Panel noted that Mr Marzifar’s post- traumatic stress disorder symptoms were essentially stable when assessed as a whole in relation to this screening tool. The screening tool results document a highly symptomatic claimant with severity of his post-traumatic stress disorder not significantly changing with treatment between these dates.
126.	The Panel notes that as Mr Marzifar had documented suffering from all symptoms on the PCL-5, it is not possible for him to acquire new symptoms related to his post-traumatic stress disorder after the 1 August 2018 motor accident.
NDI - Neck pain disability index questionnaire 12 November 2018 (page 247 of Mr Marzifar’s bundle) 
127.	Pain Self-report: 27/50,	54%.
ODI - low back pain disability index questionnaire 12 November 2018 (page 248 of 
Mr Marzifar’s bundle) 
128.	Pain Self-report: 23/50,	46%.
NDI - neck pain disability index questionnaire 3 July 2019 (page 219 of Mr Marzifar’s bundle) 
129.	Pain Self-report: 28/50,	56%.
ODI - low back pain disability index questionnaire 3 July 2019 (page 220 of Mr Marzifar’s bundle) 
130.	Pain Self-report: 28/50,	56%.
NDI - neck pain disability index questionnaire 6 December 2019 (page 183 of Mr Marzifar’s bundle)
131.	Pain Self-report: 34/50,	68%.
ODI - LOW BACK PAIN DISABILITY INDEX QUESTIONNAIRE 6 December 2019 (page 184 of Mr Marzifar’s bundle)
132.	Pain Self-report:  35 /50, 70%.
133.	The Panel noted that the self-report scales demonstrate a deterioration in Mr Marzifar’s pain after the subject motor accident on 19 September 2019 and before the fall on 
20 August 2020 and motor accident dated 28 November 2020.
134.	The Panel noted that the self-report is in keeping with the many attendances that Mr Marzifar has made to both services in relation to pain. The above scales are from Workers Doctors records.
135.	The medical record demonstrates a clear deterioration in the patient’s subjective experience of pain caused by the subject motor accident on 19 September 2019.
Worker’s Doctors regarding psychological treatment
136.	The medical record demonstrated that Mr Marzifar received treatment for post-traumatic stress disorder caused by the 2018 motor accident. The initial assessment by Dr Lim was on 12 November 2018 - page 264.
137.	Other than pain that was the primary concern of the assessment on 12 November 2018, the psychological symptoms documented were “trouble sleeping, flashbacks, anxious and cautious to drive.” 
138.	The Panel noted that these symptoms were insufficient to diagnosis post-traumatic stress disorder using DSM5 criteria. Dr Lim requested, “Psychologist - manage PTSD symptoms.” Page 265.
139.	The Panel noted that “trouble sleeping, anxious and cautious to drive” could be caused by chronic pain as well as posttraumatic stress disorder.
140.	Mr Marzifar received a total of seven attendances with three different psychologists. 
141.	Mr Robert Matek attended Mr Marzifar on 21 January 2020.  He recorded “Cognition: mood/ affect congruent, cheerful, polite, sleep hygiene broken, flashbacks and intrusive thoughts, ‘not comfortable with car anymore’, appetite fluctuates insight…” (page 40 of Mr Marzifar’s bundle) 
Psychologist Mr Neil McDonald
142.	Psychologist Mr Neil McDonald then attends for two appointments. The focus of treatment on 17 April 2020 was not in relation to posttraumatic stress disorder but for pain as documented: “[Mr Marzifar is] with a great deal of pain in hands and wrists, worries a lot about the virus in the community. Exercise is suggested as he is stuck i9nside [sic inside]. Having real problems with his sleep” (Page 50 of Mr Marzifar’s bundle).
143.	1 May 2020 - Mr Neil McDonald’s last attendance with Mr Marzifar was not focused on posttraumatic stress disorder. He documented, “Same as before no improvement. Only sleeping 2-3 hrs, can't watch the news. Little improvement. Exercise is recommended. Pain in the shoulder mainly in the morning. Feels lazy and tired in the morning. Low motivation. Low energy to do anything. client angry for himself. try and be motivated to exercise more” (Page 50 of Mr Marzifar’s bundle).
Psychologist Ms Duygu (Dee) Arslan
144.	The last psychologist, Ms Duygu (Dee) Arslan, was attended for two sessions:
(a)	15 May 2020 (Page 53 of Mr Marzifar’s bundle). This psychologist did document psychological symptoms. She did not report how severe the condition was, and
(b)	at the time of the last psychological session, the name of the provider is not recorded on 9 June 2020. (Page 55 of Mr Marzifar’s bundle)
Psychiatrist Dr Nirenjen St George
145.	Psychiatrist Dr Nirenjen St George first saw Mr Marzifar on 22 April 2020. Mr Marzifar attended on six occasions and the last attendance was on 16 December 2020.
146.	In the first report the psychiatrist documented a diagnosis of post-traumatic stress disorder. The psychiatrist stated that prior to the 2018 motor accident, Mr Marzifar did not have a psychiatric history. This is inconsistent with Mr Marzifar’s history of chronic pain. 
147.	The psychiatrist documented that Mr Marzifar had recovered from the 2017 motor accident writing “MVA (neck)(recovered) 2017”. He stated in his 22 April 2020 report the following, “[Mr Marzifar] was working a as a manager of Skin Laser Clinic prior to a motor vehicle accident on 19 September 2019…Prior to his accident, [Mr Marzifar] has no past psychiatric history… He reports the first MVA was when he was rear-ended while driving resulting in whiplash which recovered with physiotherapy…” (page 137 of Mr Marzifar’s bundle)
148.	However, on 25 March 2019, Dr Muhammad Ahmed at the Merrylands Family Doctors documented that Mr Marzifar had: “ongoing rt shoulder and neck pain for many months started after RTA in august 2017…” (page 276 of Mr Marzifar’s bundle).
149.	Whilst on 12 April 2019 Dr Baburam Bastakoti wrote: pain neck, shoulder, low back had car accident in 2018 August, “a lot of pain” and recommended referral to a chronic pain clinic. (Page 276 of Mr Marzifar’s bundle).
150.	Dr Gavin Soo in his 15 June 2020 report documented: “[Mr Marzifar] is a 35yo man who sees me in the rooms today with ongoing right shoulder pain following a motor vehicle accident on the 1 July 2017 and then again in September 2019.” (Page 102 of Mr Marzifar’s bundle)
151.	Psychiatrist Dr Nirenjen St George documented on 20 May 2020: “He reports ongoing significant pain…”( Page 129 of Mr Marzifar’s bundle).
152.	Mr Marzifar presents to Dr St George on 15 July 2020: Amir reports that his insomnia continues to cause him significant distress. He reports the pain and paratheses in his right hand wakes him. (Page 80 of Mr Marzifar’s bundle).
153.	Mr Marzifar had not continued in treatment with Dr St George or any other psychiatrist after 16 December 2020. Mr Marzifar had fallen on 20 August 2020. His pain increases after the fall. The recommendation of referral to hospital for treatment is not forwarded prior to the stopping of psychiatric treatment.
154.	Dr St George’s last report dated 16 December 2020 stated:
(a)	post-traumatic stress disorder (workplace fall), and
(b)	aggravation of post-traumatic stress disorder (motor vehicle accident).
155.	The Panel noted that whilst the psychiatrist documented this opinion, there was no supporting evidence to support his opinion of an aggravation of the subject motor accident. The PCL-5 was performed for the diagnosis of the 1 August 2018 motor accident, not the subject 19 September 2019 accident. It was not documented how the psychiatrist formed his opinion regarding Mr Marzifar having “two types of posttraumatic stress disorder at the same time”.
156.	The Panel recognised evidence-based research, and now common clinical practice, that the number of symptoms and self-reported severity of symptoms in the PCL-5 does not meet the minimum necessary diagnostic criteria for a DSM5 diagnosis post-traumatic stress disorder.
157.	Mr Marzifar when assessed by Dr Hong was documented at: “10. On 18 [sic 20] August 2020, he was at work and fell…Psychologically he said he is not sure if he [sic it] had any impact at all.”
158.	This finding in the forwarded documents excludes Dr St George’s 16 December 2020 diagnosis of post-traumatic stress disorder (workplace fall) as the fall at work, on 
Mr Marzifar’s report, did not meet the minimum necessary level of severity for Criterion A that must be met for a diagnosis of DSM5 post-traumatic stress disorder (309.81) (F43.10) - aggravation of post-traumatic stress disorder (motor vehicle accident). 
159.	The Panel noted that for the same reason, the fall at work on 20 August 2020 did not aggravate the diagnosis of post-traumatic stress disorder attributed to the 1 August 2018 motor accident. 
160.	The Panel noted that Mr Marzifar informed Dr Rastogi as documented in her report on 
26 October 2021 that the accident on 19 September 2019 “affected his wife but not him significantly”.
161.	For this reason, the accident on 19 September 2019 did not exacerbate the post-traumatic stress disorder attributed to the 1 August 2018 motor accident. 
162.	As the accident on 19 September 2019, on Mr Marzifar’s report, did not meet the minimum necessary level of severity for Criterion A that must be met for a diagnosis of DSM5 post-traumatic stress disorder (309.81) (F43.10).

Further injuries
163.	Since the fall on 20 August 2020 and discharge from Westmead Hospital on 21 August 2020 Mr Marzifar presented to Ryde Hospital on 22 August 2020 and 28 November 2020.
164.	The presentation to Ryde Hospital on 28 November 2020 is reproduced here as it provides the single best independent contemporaneous record of Mr Marzifar’s behavioural pattern since presenting to Merrylands Family Practice in May 2016 with back pain. 
Ryde Hospital Discharge Summary Page 394 of the bundle
165.	The Panel summarised the information provided in the Ryde Hospital Discharge Summary. 
166.	Emergency Medicine, Admission Date: 28 November 2020, To be discharged: 
28 November 2020
History was derived from the patient who admitted he may be the most reliable informant
Driving in a Toyota Prius 
Saw pedestrian
Said swerved left to avoid
Could not recall if straight section or bend
Could not recall if mounted curb
Stated was going at ~50kmph
Was found with car upside down
Seatbelt in situ
Airbags NOT deployed
Was able to self-extricate
Stated however did lose consciousness so could not quantify number of times turned over. 
167.	Showed picture of car with undercarriage significantly damaged.
168.	Discussed with patient Acute stress reaction/post-traumatic stress disorder as noted to be quite anxious, edgy, verge of tears.
169.	Discussed nature of acute/chronic trauma and symptoms that may ensue.
170.	Discussed need for psychotherapy.
171.	I have advised that the patient should see a neurosurgeon/spinal surgeon if he has been experiencing intermittent numbness down both legs.
Psychiatrist Dr Michael Hong report dated 1 February 2022
172.	On 28 November 2020, [Mr Marzifar] had parked his car at the back of the clinic. A truck was reversing and struck his car and went away. He was not in the car and did not suffer psychological injury. (Page 471 of Mr Marzifar’s bundle).
Other significant inconsistencies in the medical record as listed by Psychiatrist Dr Hong report dated 1 February 2022:
173.	In 2015 [Mr Marzifar] was driving in Canberra and hit a kangaroo. He did not sustain any physical or psychological injury.
174.	The Panel notes that Mr Marzifar presents with pain in his back to Merrylands Family Centre on 20 May 2016.
175.	On 23 August 2017, [Mr Marzifar] was driving and had stopped. A female driver rear ended his car as she was on a cell phone. His wife was in the car and lost their 14-week-old pregnancy and she took a few months off work. He reported that psychologically he did not develop any symptoms and did not need any treatment. 
176.	The Panel noted that Mr Marzifar presented with pain in his back to Merrylands Family Centre frequently after this reported motor accident. 
177.	The 23 August 2017 and associated events is also associated with the 1 July 2017 date. 
178.	Mr Marzifar was assessed by Dr Gavin Soo and the 15 June 2020 report documented [Mr Marzifar] is a 35 year old man who sees me in the rooms today with ongoing right shoulder pain following a motor vehicle accident on the 1 July 2017 and then again in September 2019.
179.	On 31 July 2018, [Mr Marzifar] had dropped his children off at school and was driving in Carlingford on his own and on his way to work…The first psychiatrist appointment was by telephone around 2019 and the first psychiatric medication was in 2019 (the name could not be recalled) (Page 474 of Mr Marzifar’s Bundle).  
180.	The Panel noted that this date is referred to in both Medical Assessor Parmegiani’s certificate and Medical Assessor Nel Wijetunga’s report as their subject accident on 1 August 2018.
181.	The Panel noted the 1 August 2018 motor accident is determined to have caused post-traumatic stress disorder and secondary depression. The motor accident as reported by 
Mr Marzifar was not attended by NSW Police or Ambulance.
182.	The Panel noted there was no record of this assessment. Mr Marzifar reported all his psychological care was with Worker’s Doctors.
183.	On 11 April 2019, [Mr Marzifar] was driving and had taken his children to school and was on the way to work with his wife. They were in Merrylands. He was driving at about 50 kph. Another car was driving at 30 to 40 kmph and hit the left passenger side of his car and that driver was on the cell phone.
184.	The Panel noted that there was no other reference to this event.
185.	The Panel noted that a progress note, dated 12 April 2019 indicates a car accident in 
August 2018 with subsequent pain issues. There is no other reference than Dr Hong as to a 11 April 2019 motor accident. (pages 475 and 483 of Mr Marzifar’s bundle).
186.	On 15 May 2019, he was going through a construction area near the clinic when something fell on his head.
Dr Farouk Karhani, general practitioner
187.	Mr Marzifar attended the Merrylands Family Centre for follow up with Dr Farouk Karhani.
188.	The visit with Dr Karhani was summarised as: 
“Visit date: 27/05/2019. (Page 277 of Mr Marzifar’s bundle)
states unable to see from left peripheral visual field 
VA [visual acuity] 5/6 bilaterally 
VF [visual field] normal bilaterally
There are no further references to visual abnormalities in the medical record”.
189.	On 19 September 2019, he had a “big accident”. His wife and their 4-year-old daughter were also in the car. His daughter sustained a hand injury and recovered.
190.	The Panel noted the marked inconsistency between the documented history of Dr Hong as to Medical Assessor Parmegiani in his certificate dated 6 September 2021.
191.	Medical Assessor Parmegiani documented: [Mr Marzifar] was involved in a further accident in 2019 [subject motor accident 19 September 2019]. At the time he was driving in the company of his wife and second daughter, when they were hit at a traffic light on the passenger side. After this accident his wife had consistently refused to drive, while his daughter had experienced problems with her speech and emotions (Page 426 of 
Mr Marzifar’s Bundle).
192.	On 18 August 2020, he was at work and fell. Psychologically he said he is not sure if he [sic it] had any impact at all. (Page 476 of Mr Marzifar’s Bundle).
193.	The Panel noted that the fall at work, on Mr Marzifar’s report, did not meet the minimum necessary level of severity for Criterion A for DSM5 post-traumatic stress disorder (309.81) (F43.10).
194.	The Panel noted that the date of the fall in the documents was 20 August 2020 as documented at Westmead Hospital (Page 343 of Mr Marzifar’s Bundle).
Psychiatrist Dr Richa Rastogi report dated 26 October 2021
195.	Dr Rastogi documented: “He [Mr Marzifar] stated he had no mobile at that time as there was an armed robbery at his clinic two weeks ago when the robber confronted him with a knife whilst he was working...”
196.	The Panel noted that Mr Marzifar informed this psychiatrist on 26 October 2021 that he was “confronted with a knife” two weeks prior to the 1 August 2018 motor accident.
Medical Assessor Parmegiani Certificate dated 6 September 2021
197.	Medical Assessor Parmegiani documented:
“…he explained that two weeks before the accident [1 August 2018] his mobile telephone had been stolen by a man who broke into the clinic, while he was in the treatment room. He was not confronted directly by the robber, whom the security camera captured as being armed with a knife.”
198.	The Panel noted that Mr Marzifar informed Medical Assessor Parmegiani on 
6 September 2021 that, “He was not confronted directly by the robber, whom the security camera captured as being armed with a knife”.
199.	The Panel notes that this is an important difference in the record as to causation of the post-traumatic stress disorder attributed to the 1 August 2018 motor accident.
Psychiatrist Dr Richa Rastogi report dated 26 October 2021
200.	Dr Rastogi documented:
“Furthermore, he had another accident in 2019 where he was the driver, and his wife was the front seat passenger and his eldest daughter aged 6 years was in back seat. He had a collision on front passenger side at traffic light and since then his wife has refused to drive till date due to anxiety. His daughter experienced speech problems and speech regression and emotionally upset. He stated that this accident affected his wife but not him significantly.”
201.	The Panel noted that Mr Marzifar informed this psychiatrist on 26 October 2021 that the subject accident on 19 September 2019, “affected his wife but not him significantly.”
202.	The Panel noted that this report by Mr Marzifar would support Medical Assessor Alexey Sidorov’s finding that the 1 August 2018 motor accident diagnosis of post-traumatic stress disorder was not aggravated by the subject 19 September 2019 motor accident.
Psychiatrist Dr Richa Rastogi report dated 26 October 2021
203.	Dr Rastogi documented: “…medical assessment by Dr Parmegiani dated August 2021 stated a diagnosis of Post Traumatic Stress Disorder and secondary depression as a result of the subject accident which has remained untreated over time and the psychotic symptoms have persisted.”
Medical Assessor Parmegiani Certificate dated 6 September 2021
204.	Medical Assessor Parmegiani documented, “He [Mr Marzifar] demonstrated no evidence of delusions, hallucinations or disorder of thought form… He has remained untreated over time, and his psychiatric symptoms have persisted.” (Page 428 of Mr Marzifar’s Bundle)
205.	The Panel noted that Medical Assessor Parmegiani did not diagnose Mr Marzifar as having “psychotic symptoms”. The Medical Assessor stated, “He [Mr Marzifar] demonstrated no evidence of delusions, hallucinations or disorder of thought form…” which are psychotic symptoms.
206.	The Panel also noted that neither Dr Richa Rastogi nor Medical Assessor Parmegiani documented any awareness of the 28 November 2020 motor accident. This is important as the presentation at Ryde Hospital emergency department would indicate a serious accident that could produce the symptoms reported by Mr Marzifar.
207.	The Panel noted that Assessor Alexey Sidorov in the Medical Certificate under review documented: “He [Mr Marzifar] also explained that, also in 2020, a truck reversed into and damaged his car while it was parked in a car park. [Mr Marzifar] stated that he was not in his car at that time and just saw the video footage of the incident.”
208.	The Panel noted at the time of this assessment Mr Marzifar was asked about this event and said, “he flipped the car” which is similar to the history provided at the time of the attendance to Ryde Hospital on 28 November 2020.
209.	The Panel noted Medical Assessor Wijetunga’s assessment date was 25 November 2020, three days prior to the 28 November 2020 attendance to Ryde Hospital.
210.	Medical Assessor Wijetunga documented: “Despite attempts at clarifying several aspects of the history, [Mr Marzifar] was unable to offer suitable clarification and altered the chronological order of which his symptoms presented at different times”. (Page 417 of 
Mr Marzifar’s Bundle).
211.	The Panel concluded that this identified behaviour of Mr Marzifar continued at the time of this review.

Medical examination 
212.	Mr Marzifar attended the assessment alone. He said he was at home. The assessment was conducted with Medical Assessor Barrett and Medical Assessor Baker in attendance.
213.	Mr Marzifar spontaneously offered at the beginning of the review that he was in another motor accident in January 2024. He was asked as to the date. Initially Mr Marzifar said it occurred on 15 or 16 January 2024, however later in the review when asking about details of this event he spontaneously offered the date as 24 January 2024. He said it was not a significant motor accident. 
214.	Mr Marzifar was asked to identify himself with his driver’s licence. Mr Marzifar said he did not have his driver’s license available to him. He said he was not told that he was required to identify himself. He was asked whether he had his Medicare card. He said he did not. He opened his wallet and showed a “Costco” members photograph card. The photograph of the person’s face on the card was the same as the person assessed. 
Pre-accident medical history and relevant personal details
215.	Mr Marzifar reported that he was born in Tehran, Iran. He stated that his father had died in about 2017, aged about 57 years. He reported that his mother was aged 64 years. She was a council worker in Tehran. He said his sister was a psychiatrist. Mr Marzifar was asked to clarify whether he thought his sister was a psychologist or psychiatrist and he confirmed that his sister was a psychiatrist. Mr Marzifar said his brother was aged 43 years and was also a medical doctor. Mr Marzifar said he was 40 years of age. 
216.	Mr Marzifar said he had attended and completed a Bachelor of Network Engineering and Cyber Security. He said he had completed his compulsory military training and was not injured during this time. He reported having worked in the Iranian nuclear industry prior to fleeing the country.
217.	Mr Marzifar said he married his wife in about 2010. They left Iran and transited to Indonesia on “fake passports”. He reported that he and his wife were detained on Christmas Island as refugees. He stated his detention was for a short time of two months. On his release into the general population Mr Marzifar reported that he lived with his wife in Sydney. Mr Marzifar said his wife was aged 30 years and was a nurse. He said he had three children; two daughters aged 12 and 9 years, and a son aged 2 years. 
218.	Mr Marzifar said he had worked in two jobs. One as a painter and the other as a director of a laser hair removal clinic in Merrylands. The clinic opened in 2015. The clinic continued to function at the time of this review. 
Prior motor vehicle accidents
219.	Mr Marzifar confirmed a motor accident in 2016 as documented by Medical Assessor Parmegiani in his Certificate dated 6 September 2021. He said his car was hit by a kangaroo. He said he was scared. He started attending the Merrylands Family Centre after this event on 20 May 2016 with back pain.
220.	Mr Marzifar reported he had been in a motor accident on 23 August 2017. He said he was not psychologically injured in this motor accident. He said he further exacerbated his pain syndrome due to the physical injuries he suffered in this motor accident.
221.	The date of prior motor accidents before the subject accident on 19 September 2019 was enquired about. Mr Marzifar was asked to confirm dates of his prior CTP claim applications as documented in the forwarded documents. The Medical Assessors noted two application forms for the same motor accident; one dated 21 November 2019 and a second dated 
23 January 2020, in relation to the subject motor accident on 19 September 2019:
(a)	CTP application dated 21 November 2019 was 9 August 2018 (page 186 of Mr Marzifar’s Bundle), and
(b)	CTP application form dated 23 January 2020, documented prior application date as July 2018 (page 18 of Mr Marzifar’s Bundle). 
222.	Mr Marzifar confirmed a date of 1 August 2018 in regard to the motor accident he was documenting whilst filling in the form.
223.	Mr Marzifar was asked about what had happened about two weeks prior to 1 August 2018. He reported that he was robbed, and that the robber was seen on his CCTV that monitored his shop. His mobile phone was taken.
224.	Mr Marzifar was asked about the motor accident on 1 August 2018. He provided a similar history to the medical record. He stated neither police nor ambulance were involved. He said he attempted to seek medical help for his pain that was aggravated in the motor accident. He said he was referred to a pain management clinic. He said he did not attend the clinic as he needed to keep his business open. He said he was attending two medical practices at the same time; Worker’s Doctors and Merrylands Family Centre.
225.	Mr Marzifar attended Workers Doctors and Dr Lim placed his first request for pain management and psychological treatment. He reported neck pain at 54% and lower back pain at 46% on 12 November 2018.  He completed a PCL-5. He reported having a score of 59/80. 
226.	The Medical Assessor noted that there are currently no empirically derived severity ranges for the PCL-5. This is understood to mean that the more symptoms a claimant has does not imply more impairment suffered by Mr Marzifar when the PCL-5 screening tool is applied. 
The accident on 19 September 2019
227.	The Panel noted that there were two CTP applications in the forwarded document; one dated 6 December 2019 and a second dated 23 January 2020. Numbers of passengers varied between the two applications. One application endorsed two passengers. The other three passengers.  
228.	The 6 December 2019 application documented less physical injury than the application of 
23 January 2020. The initial injuries were documented as, “Right Hand – finger – lower arms – right shoulder.” The subsequent CTP Application dated 23 January 2020 documented, “Neck, right arm, right shoulder, right hand, left arm, left shoulder, abdomen, back, right leg, and Nervous shock.”
229.	The Panel noted that it was after the subject injury dated 19 September 2019 that 
Mr Marzifar first used the term, “nervous shock”. The Panel understood the term “nervous shock” to imply traumatic psychological injury.
230.	The 6 December 2019 CTP application had the injury described as, “Mr Marzifar drew an intersection of two roads”. Mr Marzifar documented: “The other car past red light. Turning right red arrow”.
231.	The 23 January 2020 CTP application documented, 
“I [Mr Marzifar] was driving vehicle CI 62 QC in a northerly direction… on Merrylands Road when it was struck in the passenger side by vehicle CVR 70R. I consider the driver of vehicle CVR 70R was at fault for failing to give way at a T intersection and failing to stop to avoid the collision.”
232.	The Panel noted the description of the location of the motor accident did not match the photograph where the street sign for Walpole Road can be seen. The Panel noted it was not physically possible to be “heading north on Merrylands Road” as the road travels east to west from Villawood Road, interrupted by the southwestern rail corridor to re-commence on the western side of the rail line and continue to Cumberland Highway.
233.	The Panel asked Mr Marzifar where the motor accident happened. Mr Marzifar initially said that it happened on Merrylands Road. The Panel asked for Mr Marzifar to clarify. He corrected himself and said the accident happened on the corner of “Pitt Street and Merrylands Road.” The photograph did not support this response. On prompting, Mr Marzifar agreed the site of the motor accident was at the intersection of Walpole and Pitt Street.
234.	Mr Marzifar had documented that between two and three passengers were in the car. 
235.	The panel asked who was travelling in the car. Mr Marzifar said his wife and his younger daughter.
236.	Mr Marzifar during the assessment spontaneously said, “I want to say something important”. He said that he was “OK” after the 19 September 2019 accident. However, his daughter suffered from delayed speech and anxiety travelling in a car. He said his wife will not drive after the accident. 
237.	The Panel noted that this statement was similar to the information provided to Dr Rastogi at the time of her report in 2021.
238.	The Panel asked did he have any psychological or psychological symptoms. He reported pain at the time of the motor accident. He said he worried for his wife and daughter.  
Treatment post motor 19 September 2019
239.	Mr Marzifar said he immediately attended his general practitioner on the day of the accident, at Merrylands Family Centre. He reported pain in his back, neck, shoulders and other body parts. He received conservative treatment of his 2019 accident.
240.	Mr Marzifar presented to Workers Doctors for treatment of his 1 August 2018 motor accident. Mr Marzifar received a total of seven psychologist sessions.
241.	The Panel noted many symptoms documented by the psychologists. The symptoms were embedded in Mr Marzifar’s chronic pain syndrome. 
242.	Mr Marzifar was asked what symptoms he suffered. He said he suffered mainly from pain. He said he was also anxious about pain.
243.	Mr Marzifar said he saw a psychiatrist. He said he had side effects to quetiapine and mirtazapine. The psychiatrist documented various symptoms but no more symptoms than had been initially attributed to Mr Marzifar’s 1 August 2018 accident and the associated diagnosis of post-traumatic stress disorder.
244.	Mr Marzifar was asked was any of the treatment beneficial. He said that he did not think medication would work and he was not interested in any further psychological treatment. He was not recommended to attend psychiatric hospital.
245.	Mr Marzifar confirmed that his chronic pain syndrome increased after the 19 September 2019 motor accident. Mr Marzifar’s self-report for his chronic neck pain after the subject motor accident on 6 December 2019 was 68% significantly increased from up from 54% prior to the subject motor accident and the lower back pain score was 70% significantly up from the score prior to the subject motor accident on 19 September 2019 which was 46%. 
246.	Mr Marzifar said his general practitioner provided him with Panadeine Forte, two tablets daily and Voltaren, one tablet in the morning and one tablet at night. He had no other pain treatment.
247.	Mr Marzifar also attended his general practitioner for treatment of his psoriasis. He said that the injection of Stelara 90mg subcutaneously was once every three months, given at the clinic.
Mental state examination
248.	Mr Marzifar presented as an unkempt overweight man. He had long hair that he held in a tie behind his head. He was unshaven. He had no visible signs of psoriasis. He complained of pain during the assessment. He looked his stated age.
249.	Mr Marzifar was oriented in time, place and person. He presented as a vague historian. The panel asked how he understands his repeated motor accidents, fall and robbery. He replied that he is an “unlucky person”.
250.	Mr Marzifar did not report any delusions, visual or auditory hallucinations and he was not formally thought disordered. He was able to concentrate throughout the assessment. He reported his concentration was restricted by his pain. He reported working reduced hours depending on his pain. He had organised for an employee to do physical work.
251.	Mr Marzifar did not report a depressed mood. He did report anxiety about his pain, physical health, weight, and skin. Mr Marzifar’s affect was congruent with his mood. He was able to participate in the assessment. He did not report suicidal thoughts or plans. He was insightful into his condition.
252.	Mr Marzifar said he experienced anger as his neck injury, associated with the 2018 motor accident, was assessed as “minor injury”. 
Current functioning
253.	Mr Marzifar reported that his wife would assist him with his showering. He said he did not like to have his hair cut as he had difficulty with psoriasis that affected his scalp. He had not had a haircut since about 2019 on his report. He reported that his weight had increased and that he had used Duromine to reduce weight in the past. He had reduced his physical activity.
Mr Marzifar had been considered to have possible psoriatic arthritis by the Merrylands Family Centre medical team. He continued to experience pain.
254.	Mr Marzifar reported that he was less interested in his career. He said he knew he had financial difficulties as he was no longer able to earn income from painting due to chronic pain in his shoulders, arms neck and back.
255.	Mr Marzifar reported that his driving was restricted by pain. He reported he could drive to and from his home on Lane Cove Road, Ryde to Merrylands where the laser clinic he directs is located.
256.	Mr Marzifar reported that he could concentrate to be a director of the laser clinic. He reported he did not do the heavy physical work due to his pain. He reported that he could organise his finances to manage his business.
257.	Mr Marzifar reported that he was working up to eight hours per day and sometimes he had worked five days per week until the motor accident on 24 January 2024. At the time of this assessment, he was working about 2 – 3 days depending on his pain.
Consistency of presentation 
258.	There were multiple inconsistencies noted in Mr Marzifar’s forwarded documents regarding the specific details of events that Mr Marzifar is documented to have reported by different medical officers in various locations and centres within greater metropolitan Sydney. Most of the inconsistencies exist in the medical records as to how to formulate a psychiatric diagnosis.
259.	Mr Marzifar’s initial complaint in the medical record, and the last complaint Mr Marzifar provided at review, was that he is suffering from pain. Whilst the mechanics attributed to the onset of this pain appears to be related to various motor accidents, head trauma, robbery and falls, Mr Marzifar usually presents complaining of pain, commencing in the medical record on 20 May 2016 and persisting to the date of this review on 19 June 2024. 
Diagnosis
260.	The Panel noted a change in Mr Marzifar symptoms to include psychological symptoms and pain after the 1 August 2018 motor accident.
261.	The Panel noted the diagnosis of post-traumatic stress disorder caused by the 
1 August 2018 motor accident as diagnosed by Medical Assessor Parmegiani.   
262.	The Panel notes that Mr Marzifar could not acquire any new symptoms attributable to the diagnosis of post-traumatic stress disorder caused by the motor accident on 1 August 2018. The reasons for this is the finding of Mr Marzifar having endorsed all of the post-traumatic stress disorder symptoms as listed in the PCL - 5 symptoms as been caused by the previous motor accident, on 1 August 2018. Mr Marzifar did not report “nervous shock”, increased anxiety or any other symptoms related to post-traumatic stress disorder as listed in DSM5 at his presentation to the Merrylands Family Centre general practitioner soon after the motor accident on 19 September 2019.
263.	The Panel noted that the first CTP claim form completed by Mr Marzifar dated 
6 December 2019, is the first report and application for assistance, and does not document that he was suffering from any psychological symptoms caused this accident. The general practitioner documented in his notes soon after the 19 September 2019 motor accident, likely minor soft tissues injury and made no observation that Mr Marzifar was either in “shock” or suffered from anxiety as might be expected had Mr Marzifar suffered from an aggravation of the 2018 onset of post-traumatic stress disorder.
264.	The Panel asked Mr Marzifar how this accident had affected him emotionally. He said that he was worried for his wife and his daughter. He said his wife and his daughter each had claims regarding the accident.
265.	The Panel noted that this was consistent with Mr Marzifar’s report dated 26 October 2021 by Dr Rastogi where it was documented: “He stated that this accident [19 September 2019] affected his wife but not him significantly…”
266.	Medical Assessor Parmegiani in his certificate dated 6 September 2021, documented in relation to this accident, “further minor accident in 2019”. The Medical Assessor documented the following: “Despite his involvement in a further accident [19 September 2019] several months later, the symptoms of intrusive memories and flashbacks are restricted to the subject motor vehicle accident of 1 August 2018”. The Panel noted that this finding by Medical Assessor Parmegiani is consistent with the finding of Dr Rastogi and the findings by the Panel at this assessment when Mr Marzifar confirmed at the time of enquiry by the Panel, that he was concerned for his daughter and wife and not himself in relation to the injuries sustained in this accident.
267.	The clinical psychologist’s treatment was summarised by Dr Rastogi as “He saw a psychologist through telehealth session to help with setting goals, sleep hygiene and anxiety…” The focus of the anxiety is not documented. The report provided by Dr Rastogi attributes the anxiety to the 2018 motor accident and not this accident, where she confirms Mr Marzifar’s self-report of this accident affecting his wife and daughter but “…not him significantly.” Mr Marzifar confirmed this verbally at the time of review by the Panel when it was put directly to him.
268.	The initial request for psychological treatment was provided by Dr Lim at his initial assessment from Dr Eric Lim, general practioner dated 12 November 2018 noted from the accident [1 August 2018] Mr Marzifar suffered radiculopathy in his cervical and lumbar spine and post-traumatic stress disorder attributed to the [1 August 2018] motor accident.
269.	Mr Marzifar attended Dr Sebastian Calvache-Rubio about eight days after this accident. 
Mr Marzifar was assessed as having ongoing psychological distress in the context of: 
•	driving short distance due to pain causing less confidence when driving;
•	cervical spine and shoulder;
•	shoulder tendinopathy;
•	neck and shoulder discomfort, and
•	Mr Marszifar continuing to be able to continue working full time, after the 
19 September 2019 motor accident.
270.	The Panel noted that at this review eight days after this accident. The general partitioner did not note that there was an aggravation of post-traumatic stress disorder symptoms. The doctor did note that there was “ongoing psychological distress” in relation to the 
1 August 2018 motor accident and documented the aggravation of pain suffered by 
Mr Marzifar after this accident.
271.	The Panel does not find that this accident aggravated the post-traumatic stress disorder experienced by Mr Marzifar the 1 August 2018 accident. 
272.	Only the 2018 motor accident caused post-traumatic stress disorder as documented by Medical Assessor Parmegiani. 
The Panel notes that an aggravation of the clinical presentation of post-traumatic stress disorder requires more than the presence of symptoms or the continuation of symptoms, related to that condition. The PCL-5 self-reports prior to this accident provided support for 
Mr Marzifar endorsing all the presented symptoms for a diagnosis of post-traumatic stress disorder, except criterion A that was confirmed by Medical Assessor Parmegiani in his certificate dated 6 September 2021. The PCL-5 self-report measure cannot measure the severity of post-traumatic stress disorder. Whilst the psychologist attending Mr Marzifar did document symptoms related to post-traumatic stress disorder, they did not make comment regarding any documented symptoms being an aggravation of the symptoms of the post-traumatic stress disorder caused by the 1 August 2018 motor accident. 
273.	Importantly no PCL-5 self-report measure was completed to measure whether the claimant had improved on the patient’s self-report. 
274.	Mr Marzifar at the time of this review, on direct enquiry did not confirm any aggravation of post-traumatic stress disorder symptoms. 
275.	The medical documentation does provide evidence of an aggravation of Mr Marzifar’s chronic pain disorder. Mr Marzifar’s chronic pain disorder was considered clinically significant by both Dr Lim’s medical and psychological teams and Mr Marzifar as he documented a marked increase in his pain experience after this accident. 
276.	In conclusion, there is evidence for post-traumatic stress disorder symptoms prior to and after this accident. There is no evidence that the many symptoms suffered by Mr Marzifar have been aggravated by this accident. This finding made by the Panel is supported by the following reasons:
•	not all traumatic events clinically aggravate a pre-existing psychiatric or psychological injury;
•	the clinicians on the day of this accident did not note that Mr Marzifar was in “shock” a few hours after the motor accident;
•	the first CTP claim form signed by Mr Marzifar did not include the term “Nervous shock” whilst it did state that Mr Marzifar was aware that his chronic pain disorder had been immediately and ongoingly exacerbated which is subsequently supported by self-report scales of increased neck and back pain;
•	about eight days after the accident, the general practitioner did not report an aggravation of posttraumatic stress disorder symptoms. He did report ongoing psychological distress, whilst Mr Marzifar continued to report working fulltime at the laser clinic, and
•	his loss of function is related to the claimant’s chronic pain disorder.
277.	For the above reasons it is the Panel’s opinion that on the preponderance of the evidence the 19 September 2019 did not aggravate the post-traumatic stress disorder that was caused by a prior event.
278.	The Panel acknowledges that Mr Marzifar reported many psychological symptoms that could be related to post-traumatic stress disorder however neither his clinical team nor himself on self-report acknowledged an aggravation of the posttraumatic stress disorder caused by the 1 August 2018 motor accident. 
279.	The Panel recognises that Mr Marzifar was suffering from chronic pain syndrome prior to the 2018 motor accident. Chronic pain syndrome is described in DSM5 300.82 (F45.1) as Somatic symptom disorder – persistent with predominant pain commonly clinically affirm many symptoms offered for endorsement by a clinician that include both physical and psychological symptoms. This is seen with Mr Marzifar’s completion of the PCL-5 checklist endorsing all 20 items prior to the psychologist or psychiatrist review. The presence of various post-traumatic symptoms alone does not meet DSM5 criteria for post-traumatic stress disorder. For the establishment for a DSM5 diagnosis of post-traumatic stress disorder there must be significant clinical loss of functioning and impairment in social, employment and other impairment areas of functioning. After this accident Mr Marzifar was focused on continuation of his fulltime work until he suffered further aggravation of his DSM5 300.82 (F45.1) Somatic symptom disorder – persistent with predominant pain (chronic pain disorder).
280.	The Panel acknowledges that a wide range of psychological symptoms can present, including depression-like symptoms, in relation to either post-traumatic stress disorder or DSM5 300.82 (F45.1) as Somatic symptom disorder – persistent with predominant pain. The concept of a “secondary depression” is documented by Medical Assessor Parmegiani’s Certificate in relation to the 1 August 2018 accident. The concept of a “secondary depression” is however not a DSM5 listed condition. 
281.	The symptoms of depressed mood, anxiety and poor concentration due to pain are frequently clinically part of DSM5 300.82 (F45.1) Somatic symptom disorder – persistent with predominant pain.  
282.	The reporting of depressive disorder symptoms does not clinically define an exacerbation of a depressive disorder. Whilst there are depressive symptoms documented in the medical record. These symptoms are not related to any specific event and are not graded as to severity. Importantly at the time of the first psychologist clinical note documented, “mood/affect congruent, cheerful, polite”. Mr Marzifar was not documented as having deterioration in functioning related to an aggravation of depressive disorder symptoms. This clinical note is consistent with no aggravation of a depressive disorder, about four months post motor accident, a clinical time frame well outside the usual presentation of major depressive disorder or aggravation of depressive disorder conditions that may present from as early as two weeks from onset of symptoms. For these reasons there was no evidence of an aggravation of depressive disorder caused by this accident.
283.	Mr Marzifar has had other somatic symptoms described in the medical record documents at Merrylands Family Centre that includes: “tongue freezing”, loss of left sided peripheral visual fields, and right iliac fossa pain. DSM5 300.82 (F45.1) Somatic symptom disorder – persistent with predominant pain commonly includes symptoms that affect neurological functioning. This is well documented by Dr Farouk Karhani, general practitioner during his close examination of Mr Marzifar during the patient’s attendance at the Merrylands Family Centre for follow up with Dr Farouk Karhani. The visit with Dr Karhani was summarised as: Visit date: 27 May 2019 (Page 277 of Mr Marzifar’s bundle). Mr Marzifar, “states unable to see from left peripheral visual field, VA [visual acuity] 5/6 bilaterally, VF [visual field] normal bilaterally”. There are no further references to visual abnormalities in the medical record.
284.	To conclude the PCL-5 checklist is not a diagnostic tool. The PCL-5 is a screening tool and does not validate Criterion A for post-traumatic stress disorder. The reporting of any psychological or psychiatric symptom related to any condition is insufficient for the diagnosis of either depressive disorders or posttraumatic stress disorder. The presence of depressive disorder symptoms, anxiety and stress related symptoms commonly present in the clinical setting. DSM5 300.82 (F45.1) Somatic symptom disorder – persistent with predominant pain is a well-known clinical presentation where there can be many reported psychological or physical symptoms.
285.	The diagnosis of DSM5 300.82 (F45.1) Somatic symptom disorder – persistent with predominant pain is defined using the following DSM5 Diagnostic Criteria: 
A.	One or more somatic symptoms that are distressing or result in significant disruption of daily life.
This criterion is evidenced by the chronic pain disorder Mr Marzifar had suffered that was aggravated by the subject accident. 
B.	Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1.	Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
This criterion is evidenced by Mr Marzifar’s inability to be reassured by medical staff, resulting in frequent attendance soon after initial events best evidenced by Mr Marzifar’s frequent attendance at Merrylands Family Centre with complaints of pain and the presentation to Ryde Hospital on 22 August 2020, one day after discharge from Westmead Hospital for the same event (a fall on 20 August 2020).
2.	Persistently high anxiety about health or symptoms.
3.	Excessive time and energy devoted to these symptoms or health concerns.
C.	Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
(a)	The criterion is evidenced by somatic symptoms in the medical record documents at Merrylands Family Centre that includes: “tongue freezing”, loss of left sided peripheral visual fields, right iliac fossa pain and numbness without nerve conduction studies validation of loss of nerve function.
Specify if: With predominant pain (previously pain disorder). This specifier is for individuals whose somatic symptoms predominantly involve pain.
(b)	This specifier is evidenced by the ongoing predominant pain for many years since the motor accident in 2017
Specify if:  A persistent course is characterised by severe symptoms, marked impairment, and long duration (more than 6 months).
(c)	This specifier is evidenced by the ongoing predominant pain for many years since this accident.
286.	Mr Marzifar was suffering from chronic pain disorder as documented by the Merrylands Family Centre, commencing on about the 23 August 2017 motor accident.
287.	The motor accident on 1 August 2018 was diagnosed as post-traumatic stress disorder.
288.	The accident on 19 September 2019, aggravated Mr Marzifar’s DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain. Mr Marzifar suffered from many symptoms, and predominant pain.
Causation 
289.	Mr Marzifar has suffered from a chronic pain disorder since the motor accident in 2017.
290.	Mr Marzifar was diagnosed with post-traumatic stress disorder in related to the motor accident in 2018.
291.	Mr Marzifar had a further motor accident on 19 September 2019. Mr Marzifar self-reported that he did not suffer from worsening of the symptoms of his post-traumatic stress disorder due to this motor accident.
292.	Mr Marzifar, on his pain severity self-reports, did report in documentation forwarded with this referral for review, a lower pain score before the subject motor accident on 19 September 2019 and a markedly increased pain score after the accident in December 2019, prior to the fall on 20 August 2020.
293.	Mr Marzifar self-reported that his post-traumatic stress disorder was not exacerbated by the fall during whilst assessed by non-treating psychiatrists as independent medical examiners. 
294.	Mr Marzifar reported he had increased somatic symptoms as well as psychological symptoms after the accident. This is consistent with the diagnosis of DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain. The fall further exacerbated Mr Marzifar’s DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain. His presentation to Ryde Hospital on 22 August 2020 is clinically expected in a claimant that suffers from DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain.
295.	The transition from chronic pain to DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain commonly occurs after a significant life event such as a motor accident and Mr Marzifar cannot be reassured by his treating team. The clinical path from symptom to disorder is well documented. The nature of the motor accident affecting his wife and child more than him, psychically is commonly part of the clinical presentation.
296.	The accident could cause Mr Marzifar to suffer from DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain.
297.	It is the finding of the Panel that the accident on 19 September 2019 did cause the psychological condition defined as DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain.
Determination 
298.	The Review Panel affirms the Certificate of Medical Assessor Sidorov and certifies that the following injury WAS NOT caused by the motor accident on 19 September 2019: 
(a)	aggravation of post-traumatic stress disorder and secondary depression caused by 1 August 2018 motor accident.
299.	The Review Panel further certifies that the following injury WAS caused by the motor accident on 19 September 2019:
(a)	DSM5 (300.82) (F45.1) Somatic symptom disorder – persistent with predominant pain.