DETERMINATION OF APPEAL PANEL	
	
CITATION:	Canterbury Bankstown Council v Asmar; Canterbury Bankstown Council v Asmar [2024] NSWPICMP 553	
		
APPELLANT:	Canterbury Bankstown Council	
		
RESPONDENT:	Manal Asmar	
		
APPELLANT:	Manal Asmar	
		
RESPONDENT:	Canterbury Bankstown Council	
		
Appeal Panel		
		
MEMBER:	Catherine McDonald	
		
MEDICAL ASSESSOR:	Graham Blom	
		
MEDICAL ASSESSOR:	Professor Nicholas Glozier	
		
DATE OF DECISION:	8 August 2024	
		
CATCHWORDS: 	wORKERS cOMPENSATION - Workplace Injury Management and Workers Compensation Act 1998; Medical Assessment Certificate (MAC) was so brief as to be devoid of reasoning; re-examination required; Coca-Cola Europacific Partners API Pty Ltd v Pombinho; allowance for the effects of treatment; Zoric v Secretary, Department of Education; Held – MAC revoked.

BACKGROUND TO THE APPLICATION TO APPEAL
1.	On 28 February 2024 Canterbury-Bankstown Council (the Council) lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Medical Assessor Gerard Chew, who issued a Medical Assessment Certificate (MAC) on 31 January 2024. In her Notice of Opposition to the appeal dated 22 March 2024, Ms Asmar agreed that the matter should be referred to a Medical Appeal Panel, but for different reasons. The President’s delegate directed that Ms Asmar file an Application to Appeal and subsequently extended time for her to do so, determining that special circumstances existed. The delegate directed that both appeals be determined concurrently.
2.	Each of Ms Asmar and the Council relies on the following grounds of appeal under s 327(3)(c) and (d) of the Workplace Injury Management and Workers Compensation Act 1998 (the 1998 Act): 
•	the assessment was made on the basis of incorrect criteria, and
•	the MAC contains a demonstrable error.
3.	The President’s delegate was satisfied that, on the face of the application, at least one ground of appeal was made out – being that in s 327(3)(d) in each appeal. We conducted a review of the original medical assessment, limited to the grounds of appeal on which the appeal is made.
4.	Rule 128 of the Personal Injury Commission Rules 2021 (the PIC Rules) and Procedural Direction PIC7 – Appeals, reviews, reconsiderations and correction of obvious errors in medical disputes set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with r 128(1) of the PIC Rules.
5.	The assessment of permanent impairment is conducted in accordance with the SIRA NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 March 2021 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).
RELEVANT FACTUAL BACKGROUND
6.	Ms Asmar suffered a psychological injury in the course of her employment with the Council on 20 November 2020 as an Acting Team Leader, Fitness.
7.	Using the Psychiatric impairment Rating Scale (PIRS), the Medical Assessor assessed her in class 2 for self care and personal hygiene, travel and social functioning. He assessed her in class 3 for social and recreational activities and concentration, persistence and pace and in class 5 for employability, resulting in 19% whole person impairment (WPI). He added 1% for the effects of treatment, making a total of 20% WPI.
PRELIMINARY REVIEW
8.	We conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the Procedural Direction PIC7.
9.	As a result of that preliminary review, we determined that Ms Asmar should undergo a further medical examination because the MAC is so brief as to fail to disclose the Medical Assessor’s reasoning process.
EVIDENCE
10.	We have all the documents that were sent to the Medical Assessor for the original medical assessment and have taken them into account in making this determination.
11.	Medical Assessor Blom conducted an examination of the worker on 8 July 2024. His report forms part of these reasons.
12.	The parts of the MAC that are relevant to the appeal are set out below.
SUBMISSIONS 
13.	Both parties made written submissions. They are not repeated in full, but we have considered them.
14.	In summary, the Council submitted that the Medical Assessor made his assessment on the basis of “an incorrect criteria” and made a demonstrable error because he took a history which had not been given previously – that Ms Asmar was in an enclosed space when a manager was “hitting on her” and she feared she could be sexually assaulted. The Council also submitted that the Medical Assessor failed to provide reasons for his conclusions and that the justification given for the assessment under the PIRS is so brief that it does not allow proper consideration of “whether the rating of best fit has been selected”. The Council also submitted that the Medical Assessor had erred in the assessment of 1% WPI for the effects of treatment.
15.	In reply, Ms Asmar submitted that the assessment was made on the basis of incorrect criteria because the Medical Assessor should have assessed her in class 3 for self care and personal hygiene rather than class 2. In respect of the grounds relied on by the Council, Ms Asmar said that the additional history obtained by the Medical Assessor about the incident with the manager did not result in a material difference in permanent impairment and was consistent with the history obtained by Dr Kumar, who saw her at the request of the Council, and with the history of behaviour which led to the injury for which liability was accepted. Ms Asmar agreed that the Medical Assessor did not provide detailed reasons but said that it did not impact on the result, noting that the Medical Assessor made the same assessment as the doctors retained by each party, with the exception of self care and personal hygiene. Ms Asmar said that the Medical Assessor’s explanation met the requirements for an allowance of 1% for the effects of treatment.
16.	Ms Asmar made the same submissions with respect to self care and personal hygiene on her own appeal. In response, the Council repeated that the submission that the MAC was so brief that it did not allow for proper consideration of the PIRS assessment.
FINDINGS AND REASONS 
17.	The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made. 
18.	In Campbelltown City Council v Vegan the Court of Appeal held that an Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is required will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
19.	In Queanbeyan Racing Club Ltd v Burton the Court of Appeal held that an Appeal Panel is not limited to the ground held to have been made out by the delegate but may consider all grounds of appeal raised in the application. However, the panel is not permitted to look for errors which are not part of the grounds of appeal on which the appeal is made. We have only considered those grounds specifically raised by the appeal.
20.	The extent of history relating to the injury recorded by the Medical Assessor in the MAC was:
“She described significant difficulties in the workplace leading to the development of psychological symptoms. She described numerous difficulties. One particularly traumatic incident occurred when a manger was ‘hitting on her’ and she was in an enclosed space where she panicked and feared that she could be sexually assaulted.”
21.	Describing Ms Asmar’s treatment and symptoms the Medical Assessor said:
“Present treatment: She sees her psychiatrist. She sees a psychologist weekly. She reports that treatment has been helpful and there has been some improvement.
Present symptoms: ongoing low mood, anxiety and loss of confidence. She has become more avoidant and withdrawn socially. She has poor sleep. She described feelings of hopelessness and worthlessness.”
22.	The extent of the Medical Assessor’s history about Ms Asmar’s activities was:
“Social activities/ADL: she reports that tries to shower every day. She tries to walk daily. She has withdrawn from social activities. She has withdrawn even from seeing her family. She communicates regularly with her sister on WhatsApp. She does not do much housework. She relies on pre-prepared delivered meals.”
23.	The Medical Assessor described his mental state examination:
“Appeared her stated age. She was well presented and groomed. She had appropriate make up on with pencilled eyebrows, and slicked back hair. Flat affect. Nil abnormal psychomotor activity. Depressed and anxious mood. Oriented to time, place and person. Speech of normal rate, rhythm, volume and prosody. Nil formal thought disorder. Nil delusions or hallucinations. No thoughts of harm to others. No suicidal ideation today or immediate plan.”
24.	The Medical Assessor diagnosed persistent depressive disorder. He noted the assessments made by Dr Chow, who saw Ms Asmar at the request of her solicitors, and Dr Kumar, who examined her at the request of the Council. He highlighted the areas of disagreement:
“Self care – I agree with Dr Kumar. While there is impairment this is class 2 as she demonstrates ability to live independently
I agree with Dr Chow regarding treatment effect. She reports benefit from treatment which has had an impact on function.”
25.	In a report dated 15 September 2023, Dr Chow assessed 23% WPI. His PIRS assessments were the same as those made by the Medical Assessor with the exception of self care and personal hygiene for which he chose class 3. He added 1% for the effect of treatment though he recorded that Ms Asmar had seen a psychiatrist throughout 2022 and ceased medication due to side effects in February 2023. He recommended that she see a psychiatrist and consider restarting psychotropic medication.
26.	Dr Kumar saw Ms Asmar at the request of the Council and reported on 20 May 2021 and 15 August 2023. In his second report, he recorded that a manager made inappropriate remarks and tried to start a personal relationship with her, among other events. Dr Kumar assessed 19% WPI for the same reasons as the Medical Assessor but did not make an allowance for the effects of treatment.
The history taken by the Medical Assessor
27.	Turning to the first of the grounds relied on by the Council, we accept that the Medical Assessor made a demonstrable error in that he did not record an adequate history in the MAC.
28.	Even if the history of that event provided by Ms Asmar had been new, it was not a demonstrable error for the Medical Assessor to record it. He focused on one event only which Ms Asmar had described in different terms to Dr Kumar and has described in more detail to Medical Assessor Blom. She told him it took place in 2019. Ms Asmar also described the event to Dr Canaris, whom she saw for her solicitors in 2022.
29.	The fact that the Council may consider the emphasis on that event new does not make the recording of it wrong. As Ms Asmar’s submissions pointed out, the event is only one of the numerous incidents which led to the accepted injury for which she was referred for assessment, most of which occurred after the event described.
Failure to provide reasons
30.	The MAC is manifestly inadequate, which is a demonstrable error and necessitated a re-examination.
31.	The MAC is practically devoid of the history and the reasons for the Medical Assessor’s opinion. Section 325(2) of the 1998 Act sets out the requirements for a MAC:
“(2)	A medical assessment certificate is to be in a form approved by the President and is to—
(a)	set out details of the matters referred for assessment, and
(b)	certify as to the medical assessor’s assessment with respect to those matters, and
(c)	set out the medical assessor’s reasons for that assessment, and
(d)	set out the facts on which that assessment is based.”
32.	The Guidelines provide assistance to the Medical Assessor when they describe what is required by an independent medical examiner undertaking an assessment and preparing a report for the evaluation of permanent impairment. The principles apply to a MAC as much as a report prepared for one of the parties. The Guidelines provide:
“1.46 	A report of the evaluation of permanent impairment should be accurate, comprehensive and fair. It should clearly address the question(s) being asked of the assessor. In general, the assessor will be requested to address issues of:
•	current clinical status, including the basis for determining maximum medical improvement
•	the degree of permanent impairment that results from the injury/condition, and
•	the proportion of permanent impairment due to any previous injury, pre-existing condition or abnormality, if applicable.
1.47 	The report should contain factual information based on all available medical information and results of investigations, the assessor’s own history-taking and clinical examination. The other reports or investigations that are relied upon in arriving at an opinion should be appropriately referenced in the assessor’s report.
1.48 	As the Guidelines are to be used to assess permanent impairment, the report of the evaluation should provide a rationale consistent with the methodology and content of the Guidelines. It should include a comparison of the key findings of the evaluation with the impairment criteria in the Guidelines. If the evaluation was conducted in the absence of any pertinent data or information, the assessor should indicate how the impairment rating was determined with limited data.”
33.	In most MACs involving psychological injury, the material provided under the heading “Social activities/ADL” is detailed because it forms the basis of the PIRS assessment. It is important that detailed information be provided so that the parties and any Appeal Panel can understand the particular aspects of the history on which the Medical Assessor relied and why the relevant assessments have been made.
34.	In State of New South Wales (NSW Department of Education) v Kaur (Kaur) Campbell J said:
“In Wingfoot Australia Partners Pty Ltd v Kocak [2013] HCA 43; 252 CLR 480, the High Court of Australia dealt with the nature of the jurisdiction exercised by a medical panel under cognate Victorian legislation. The legislation is not entirely the same but it is broadly similar in purpose. Allowing for some differences, the High Court said at page 498 [47]:
‘The material supplied to a medical panel may include the opinions of other medical practitioners, and submissions to the Medical Panel may seek to persuade the Medical Panel to adopt reasoning or conclusions expressed in those opinions. The Medical Panel may choose in a particular case to place weight on the medical opinion supplied to it in forming and giving its own opinion. It goes too far, however, to conceive of the functions of the panel as being either to decide a dispute or to make up its mind by reference to completing contentions or competing medical opinions. The function of a medical panel is neither arbitral or adjudicative: It is neither to choose between competing arguments nor to opine on the correctness of other opinions on that medical question. The function is in every case to perform and to give its own opinion on the medical question referred to it by applying its own medical experience and its own medical expertise.’
Not all of this, as I have said, is apposite in the context of the New South Wales legislation. In particular it is obvious that approved medical specialists are required to decide disputes referred to them by the process of medical assessment. Even so, it is not necessary that approved medical specialists should sit as decision makers choosing between the competing medical opinions put forward by the parties. Essentially, the function is the same as that described by the High Court in Wingfoot Australia. That is to say, their function is in every case to form and give his or her own opinion on the medical question referred by applying his or her own medical experience and his or her own medical expertise. It is sufficient, as their Honours pointed out at [55], that:
‘The statement of reasons… explain the actual path of reasoning in sufficient detail to enable the Court to see whether the opinion does or does not involve any error of law’.”
35.	The MAC does not explain the Medical Assessor’s actual path of reasoning and a re-examination was warranted. We provide a reassessment under the PIRS below.
36.	We are mindful that it might be argued that there was only one of the PIRS tables where the class chosen by Dr Chow differed from that of Dr Kumar. But, as Campbell J highlighted in Kaur, the task of the Medical Assessor was to form his own assessment, not choose between the assessments of the parties.
37.	In Coca-Cola Europacific Partners API Pty Ltd v Pombinho, the Court of Appeal recently held that reassessment under the PIRS was appropriate to determine a s 323 deduction because the Medical Assessor had not considered material in the file about a pre-existing condition. Ward P said with respect to the deduction:
“The approach required by the Guidelines is a subtractive approach, requiring a deduction from the starting point of whole person impairment but it would make the exercise artificial if, having been required to consider all of the material that the Medical Assessor had failed to consider, the Appeal Panel could not then revisit the starting point of the assessment.”
38.	The position is analogous. It was necessary that a complete re-examination be undertaken because, as the Council submitted, the paucity of reasoning infected the whole MAC. Medical Assessor Blom undertook that re-examination and we adopt his report.
39.	Based on Medical Assessor Blom’s assessment, we consider that the appropriate assessments are:
Self care and personal hygiene	2	
Social and recreational activities	3	
Travel	1	
Social functioning	2	
Concentration, persistence and pace	3	
Employability	5	
40.	We consider that assessment in class 2 is appropriate for self care and personal hygiene. While Ms Asmar struggles to care for her son and manage the home, she does so with some deficits. On some days she is able to cook and she showers most days. She does some housework on most days. Though Ms Asmar does not attend to her personal hygiene as well as previously or as she would like, she is able to manage without outside support.
41.	The history Ms Asmar gave Medical Assessor Blom with respect to travel is different to that she has given before. Ms Asmar has shown she is able to travel to new environments without supervision, albeit she has done so on isolated occasions. She said that her impairment is no worse now than it was last year when she drove to Ballina. Assessment in class 1 is appropriate where there is “no deficit or minor deficit attributable to the normal variation in the general population”. The PIRS accepts that there is a variety of conduct which can be described as normal.
42.	The total of the assessment set out above is 16 and the median class is 2.5, rounded to 3. Under table 11.7 of the Guidelines, Ms Asmar’s WPI is 17%. There is no basis for a deduction under s 323 of the 1998 Act.
Adjustment for the effects of treatment
43.	The Medical Assessor made an adjustment of 1% because Ms Asmar “reports benefit from treatment which has had an impact on function”.
44.	Clause 1.32 of the Guidelines provides:
“Where the effective long-term treatment of an illness or injury results in apparent substantial or total elimination of the claimant’s permanent impairment, but the claimant is likely to revert to the original degree of impairment if treatment is withdrawn, the assessor may increase the percentage of WPI by 1%, 2% or 3%. This percentage should be combined with any other impairment percentage, using the Combined Values Chart. This paragraph does not apply to the use of analgesics or anti-inflammatory medication for pain relief.”
45.	The evidence in the file shows that Ms Asmar began to see Dr Tsang, psychiatrist, in April 2022. The notes produced under direction in April 2023 span the period from April to September 2022 at which time Dr Tsang recommended review in eight weeks. It is unclear from the file when Ms Asmar stopped seeing him regularly. She saw Ms El-Hassan, psychologist, until about six months before Medical Assessor Blom’s examination.
46.	Dr Kumar did not make an adjustment under paragraph 1.32. He said in August 2023:
“Ms Asmar reported that she is currently not on any psychiatric medications. She said that she was taking Pristiq at some stage, however she felt that it was not effective and stopped taking it a few months ago. She consults with a psychiatrist, Dr Ricky Zen, every 6 weeks and started around January 2022. She also consults with a psychologist, Houda, in varying frequencies from weekly to fortnightly to monthly since the last approximately 2 years.”
47.	Dr Chow saw Ms Asmar at about the same time, in September 2023, and he did not make an adjustment for the effect of treatment. He said:
“She advised that she has been engaging with a psychologist and has had a few sessions of EMDR. She has been seeing the psychologist every 2-4 weeks. She has been referred to psychiatrist. She last saw the psychologist last month and the psychiatrist a few weeks ago. She completed the STAIRs program at St John of God Burwood in November 2022.”
48.	He also noted that she had trialled many psychotropic medications. He said:
“Since ceasing work, she has been engaging in psychological and psychiatric treatment. She advised that she has been seeing a psychiatrist throughout 2022 and was prescribed medications, but ceased due to side effects in February 2023. She has also been engaging in regular psychological treatment.
Despite treatment, she continues to suffer significant psychological symptoms to warrant a diagnosis of major depressive disorder. She requires ongoing psychological and psychiatric treatment.”
49.	Discussing paragraph 1.32, Chen J said in Zoric v Secretary, Department of Education (Zoric):
“The clause may thus be understood to involve, and require findings about, the following ‘steps’:
1)	First, whether there has been effective long-term treatment of an illness or injury.
2)	Secondly, whether that treatment results in apparent substantial or total elimination of the claimant’s permanent impairment.
3)	Thirdly, whether the claimant is likely to revert to the original degree of impairment if treatment is withdrawn.
These steps largely align with the analysis of Adamson J (as her Honour then was) in Peachey v Bildom Pty Ltd (Quality Siesta Resort Pty Limited and Quality Hotel) [2020] NSWSC 781 at [57] (‘Peachey’), and both parties accepted that a proper application of cl 1.32 of the Guidelines requires these steps to be addressed.”
50.	His Honour went on:
“In relation to the first step, therefore, there needs to be a finding about the ‘illness or injury’ that results in permanent impairment and whether there has been effective long-term treatment of that ‘illness or injury’.
In relation to the second step, that enquiry involves a comparative exercise being performed, the nature of which was explained in Peachey at [52] as follows:
‘Clause 1.32 requires a comparison to be made between the claimant’s original degree of impairment as a result of the injury before the effective treatment and the claimant’s degree of impairment as a consequence of treatment to determine whether the treatment has resulted in apparent substantial or total elimination of the original impairment. The comparison is to be made between the respective impairments at those two relevant times. I consider this construction to be clear from the wording of the clause…’
Further, in relation to the comparative exercise required by cl 1.32, the clause neither requires, nor authorises, a comparison between respective WPI scores at those times, nor does there need ‘to be a post-injury pre-treatment WPI score for the purposes of undertaking the necessary comparison’: Peachey at [53] and [56]. The explanation for this lies, at least in part, in the language of the clause: the focus of cl 1.32 is upon ‘permanent impairment’, not on its degree expressed as a percentage: Peachey at [54] citing Hunter Quarries Pty Ltd v Mexon (2018) 98 NSWLR 526; [2018] NSWCA 178 at [67].
In relation to the third step, the question is whether the claimant’s impairment is likely to revert to the original degree of impairment if treatment is withdrawn. Plainly, the resolution of this question is likely to be informed, perhaps significantly, by the findings in relation to the first and second steps.”
51.	The parties did not refer to Zoric. The paragraph does not apply merely because there has been long term treatment or even some improvement. It requires a much higher criterion – that the treatment has resulted in apparent substantial or total elimination of her impairment. That is not the case for Ms Asmar, who continues to suffer a significant impairment. She has voluntarily reduced her treatment without significant change in her condition. An adjustment for the effect of treatment was not warranted.
52.	For these reasons, we have determined that the MAC issued on 31 January 2024 should be revoked, and a new MAC should be issued.  The new certificate is attached to this statement of reasons.

WORKERS COMPENSATION DIVISION
APPEAL PANEL
MEDICAL ASSESSMENT CERTIFICATE
Injuries received after 1 January 2002

Matter number:	W8911/23	
Applicant:	Manal Asmar	
Respondent:	Canterbury Bankstown Council	

This Certificate is issued pursuant to s 328(5) of the Workplace Injury Management and Workers Compensation Act 1998.
The Appeal Panel revokes the Medical Assessment Certificate of Medical Assessor Gerard Chew and issues this new Medical Assessment Certificate as to the matters set out in the table below:
Table - whole person impairment (WPI) 
Body Part or system	Date of Injury	Chapter, page and paragraph number in NSW workers compensation guidelines 	Chapter, page, paragraph, figure and table numbers in AMA 5 Guides
	% WPI 	Proportion of permanent impairment due to pre-existing injury, abnormality or condition	Sub-total/s % WPI (after any deductions in column 6)	
Psychological injury	30.11.2020	Chapter 11	N/A	17	Nil
	17%	
Total % WPI (the Combined Table values of all sub-totals) 	17%	

Catherine McDonald
Member

Graham Blom
Medical Assessor

Nicholas Glozier
Medical Assessor
8 August 2024

PERSONAL INJURY COMMISSION 

APPEAL AGAINST MEDICAL ASSESSMENT

REPORT OF THE EXAMINATION BY MEDICAL ASSESSOR
MEMBER OF THE APPEAL PANEL

Matter Number:	M1-W8911/23	
Appellant:	Canterbury Bankstown Council	
Respondent:	Manal Asmar	

Examination Conducted By:	Graham Blom	
Date of Examination:	8 July 2024	

1.	The workers medical history, where it differs from previous records
	Ms Asmar began working with Canterbury Bankstown Council in 2017 initially working permanent part-time. She transferred after approximately one year to a casual position eventually taking a role as a sports liaison officer and then subsequently worked as the bookings officer. Soon after taking this role she began to be subjected to bullying, harassment and hurtful remarks by co-workers. As well she felt she was being micromanaged and on occasions felt humiliated in front of other co-workers. She managed to continue in the role although submitted a formal complaint about her treatment – this was subsequently upheld.
As well, in late 2019, she was supervised by a man, Steve, who began to send her inappropriate texts, attempting to form a romantic relationship with her. She repetitively refused these overtures, but this did not appear to deter Steve. He began not only texting her but also attempted to engage her in conversations about a possible romantic relationship. Over the Christmas break in late 2019, she was working on a Sunday, alone in the office. Steve was aware that she was alone and attended the office, using the opportunity to try to persuade her again to engage in a relationship with him. This uncomfortable situation was exacerbated when he refused to let her leave the office until she had given him a hug. She found this intrusive and humiliating but complied as the only way to get away from him. It was this episode that the Medical Assessor referred to in his report. I noted with Ms Asmar that this had not been mentioned in the lengthy statement included in the brief of evidence. She said that at the time she found it too uncomfortable to talk about it as the statement was being taken by a male. She also stated that whilst this episode was very distressing, it was not the main issue in her injury but rather part of an ongoing process of mistreatment, bullying and harassment that she experienced while working at the Council.
In 2020, she became the acting team leader, but again found this difficult as she was working with some of the people with whom she had had difficulties in the past, and the workload was quite intense. In mid-2020 she was obliged to attend a work meeting which she experienced as being personally intrusive and inappropriate. She had understood the meeting to be related to work but it was in fact a team building exercise and members were encouraged to share deeply emotional material. Ms Asmar found this a disturbing as she felt forced into a position of emotional vulnerability with which she could not cope. Afterward she became intensely anxious, and this continued over the following months, to the point that she eventually consulted her general practitioner. She continued to consult him on a regular basis and in about November 2020 was initiated on the antidepressant, fluoxetine. Despite this her anxiety continued and was made worse when she was placed on a team to transfer the workplace onto new software. She said that she was not given sufficient training and that the timeframes for this were unrealistic. She was working exceptionally long hours felt stressed, overwhelmed and increasingly unable to cope. She was unable to take her planned annual leave during this time which meant that her son, who was 14 and suffered from autism spectrum disorder, had on multiple occasions to come into work with her because no one was available to mind him. This further added to Ms Asmar's stress.
In February 2021, she took annual leave but during the break, she was repetitively contacted by her supervisor, asking for assistance with the initiation of the new software program. She became angry and anxious, feeling increasingly harassed and overwhelmed. This culminated in her experiencing acute, impulsive suicidal ideation, associated with panic attacks and a sharp drop in her mood. She said she was also experiencing substantial insomnia with both difficulty getting off to sleep and waking during the night, nightmares which caused her to wake in panic and episodes of out-of-control crying. Her appetite was poor, and over a period of a couple of months she lost about 5 kg in weight she was irritable and experienced ongoing conflict with her son. She felt overwhelmed and struggled to care for him which further exacerbated her distress. She became withdrawn, and increasingly was struggling to manage her personal hygiene and care for the house.
Her general practitioner around this time increased her fluoxetine, she thought to 40 mg/day. Subsequently he referred her to a psychologist and also a psychiatrist although it took considerable time before she was actually able to gain a psychiatric appointment. She began seeing her psychologist on a regular basis, although eventually she was forced to switch psychologists as her original psychologist was not SIRA trained. Nevertheless, she attended psychological appointments regularly up until about January 2024. She stopped at that time because she felt that the psychological input was no longer assisting her and in fact was causing her increased distress. This was related to the introduction of EMDR therapy as well as the increasing feeling that she was being pressured to return to work. She also felt that her psychiatrist, Dr Tsang, was able to provide sufficient psychological input. Her psychiatrist, arranged for her to undertake an eight week St John of God Hospital in Burwood in late 2022. She hopes to do the second part of this course at some future date, although nothing has been arranged at this stage.
Since consulting her psychiatrist, she has been trialled on a variety of antidepressants, as well as clonidine, Periactin, and for a brief period of time olanzapine. She was also trialled on a combination of modafinil and dexamphetamine for treatment of her long-standing narcolepsy. She believed that this reduced her excess sleep and assisted her concentration and focus but cause considerable side effects so that eventually she ceased this combination and is currently only taking modafinil.
About 1 to 2 months ago, she decided to cease all of her psychotropic medication, except for her narcolepsy treatment. That is to say, she has been on no active medical treatment for her depression and anxiety for over one month. She said that she has not noticed any deterioration as a result of this but has been freed of the prior side effects that were troubling her. At the time that she ceased her medication she had been taking duloxetine and clonidine. She initially ceased the duloxetine, about two months ago, and then the clonidine a month ago.
2.	Additional history since the original Medical Assessment Certificate was performed
There have been no significant changes in her circumstances since the Medical Assessment of January 2024. As mentioned above, she has ceased all of her medication previously prescribed but has not noted any change in her level of symptomatology or impairment following this.
3.	Current Treatment.
Ms Asmar is currently not receiving any active treatment for her disorders. She had been seeing her psychiatrist regularly and intends to keep in contact with him on an “as needs basis” in the future. She has ceased all of her medications as mentioned above. She is not consulting her psychologist having ceased this about six months ago.
She continues to be treated for other long-standing illnesses, both Crohn’s disease and narcolepsy.
For her Crohn’s disease, she is treated with ustekinumab injections on a monthly basis. She also takes azathioprine, 50 mg/day and allopurinol, 100 mg/day. The latter is taken as the azathioprine has raised her blood urate level.
For her narcolepsy she currently takes modafinil 200 mg twice daily.
4.	Current Symptoms.
She continues to experience anxiety on a daily basis. This is characterised by feelings of tension, worry, episodic feelings of doom associated with the awareness of her heart pounding, feelings of helplessness, dry mouth, tremor and distress. She says that she experiences various aches and pains associated with her tension. She is regularly fearful of a full-blown episode of panic. She said that these episodes are worse when she has re-experiencing phenomena which occur reasonably regularly. She continues to experience nightmares and occasionally wakes from these in extreme anxiety.
Her mood is persistently low, and she feels sad most of the time. She is episodically tearful. She also experiences increased levels of irritability and frustration, and this has impacted her relationship with her son. She has little pleasure in life and little interest in the things that previously engaged her. Her motivation is low and she experiences regular fatigue. She continues to have difficulty with sleep with both initial and interval insomnia. As mentioned sometimes her sleep is disturbed by nightmares or bad dreams. Her daytime fatigue is exacerbated by her narcolepsy - she often has periods of enforced sleep during the day. She has regained her appetite to some degree although it has not returned to normal. She regained the weight that she had lost in the initial phase of her illness, probably as a result of the medications that she had been taking where she said that she often ate even when she wasn’t hungry. She forces herself to eat regularly now. Her concentration is poor, she struggles with memory and complained bitterly of experiencing “brain fog”. She continues to experience, on a reasonably regular basis, feelings of helplessness and hopelessness and sometimes feels overwhelmed and experiences impulsive thoughts of self-harm – such as driving her car into a tree whilst driving. She said that she would never act on this, however because of her concern for her son.
5.	Review of ADLs.
Ms Asmar lives with her son in a rented unit in Bankstown. Her son is now 18 and continues to struggle with Autism Spectrum disorder. He has gained a position as an apprentice electrician recently.
Ms Asmar says that she struggles to care for her son and manage the home. She usually has her groceries delivered to the home and cooks some days although on other days will feel unable to and will eat easy food on these days. She showers most days and attends her personal hygiene although not as well as previously or as she would like. She struggles to clean her unit every day but does do some housecleaning or other housework most days. She continues to care for her son, although given that he is working, he is clearly more independent, but she feels guilty that she is not doing a good enough job as a mother.
She is very withdrawn and avoidant and says that she rarely socialises although she continues to maintain contact with both her sisters and a few old friends. She has on occasions been encouraged to attend social events such as a barbecue with family but said that this is very rare. She maintains social contact with both her sisters and friends via WhatsApp, although said that sometimes she is unable to even engage with this. She occasionally will go for a walk on her own, but only when she has driven to a different suburb where she is unlikely to meet people from the Council.
She drives to her appointments and occasionally to go shopping. She can drive out of the local area, although prefers not to do this. However, she attended a conference in Ballina associated with a course that she did last year. She decided to drive there and back and managed this. She has not driven such a long distance since (the conference was about 15 months ago) but her level of impairment is no worse now than it was then. She said that recently she drove as far as Sutherland after attending a psychiatrist appointment, although felt that she did not pay close attention to her driving.
Her relationship with her son remains close although because of her irritability and symptomatology there has been conflict and strain in the relationship at times. She feels guilty that she does not provide sufficient care for her son and that at times he has to look after her, but clearly the relationship remains reasonably strong. Her sisters remain in regular contact with her usually through WhatsApp as she does not like talking on the telephone. She also has contact with a couple of close friends and whilst the relationship with them is strained they are still engaged with her. She has lost some however due to her illness.
She complained bitterly about her capacity to focus and especially to remember past events. She said that she regularly experiences “brain fog” and this causes her to struggle to be able to think clearly. I raised the issue of her having undertaken a course last year. She said that this was an online course undertake at her own pace. She said that her psychologist had strongly encouraged her to do it as she had paid for it whilst employed and was unable to gain a refund. Nevertheless, she did complete the course. She said however that she did not believe that she would be able to do this now as, at that time, she was taking  a combination of dexamphetamine and modafinil both in high doses to manage her narcolepsy and that this had helped her concentration. She had to cease this combination however because of the significant side effects that she experienced.
During this she interview maintained focus for a period of 100 minutes although she clearly had difficulty with her memory of chronology and timing of events. She was also quite preoccupied with her symptoms and impairment as well as the unfairness of what she had experienced while working at the Council. This led to her being somewhat distractible and occasional difficult with focus.
She has not worked since leaving the Council in early 2021. She continues to experience substantial symptoms of both anxiety and depressive symptomatology. She is avoidant and withdrawn and struggles with concentration and focus. Were she to return to employment, even with limited hours, it is likely that her symptoms and level of impairment would deteriorate further.
6.	Findings on Mental State Examination
Ms Asmar was seen via teleconference from her unit in Bankstown. She was alone throughout the interview. The quality of the reception was reasonable, and the interview progressed without any significant difficulties.
She appeared as a woman of her stated age. She was somewhat tense throughout the interview and on one or two occasions became slightly tearful. She was dressed in a robe which she said was a bathrobe but looked neat and tidy. She was not wearing makeup.
She persisted with a lengthy interview of approximately 100 minutes. There were difficulties however with her memory particularly of chronological order of events and she was somewhat distractible. She tended to be highly focused on her symptoms and their impact on her overall function. She also expressed considerable amounts of guilt particularly in relation to her mothering of her son.
There was mild flattening of her affect, but nevertheless she was able to respond in an emotionally appropriate way. She expressed feelings of hopelessness and helplessness, on several occasions, associated with guilt and spoke of occasional impulsive suicidal ideation.
She was not psychotic - in particular she did not display hallucinations, delusions or formal thought disorder.
She described re-experiencing phenomena, characterised by nightmares and intrusive re-experiencing thoughts and feelings.
Her cognitive function was consistent with her psychological disorder and there was no evidence of organicity.
7.	Diagnosis.
Using the DSM 5 diagnostic criteria, Ms Asmar meets the criteria for:
I.	Persistent Depressive disorder – with episodic Major Depressive disorder, no current episode.
II.	Anxiety disorder – Not otherwise specified. This diagnosis is applied because of the existence of traumatic anxiety characterised by intrusive re-experiencing, avoidance, a degree of hypervigilance with panic but absent the criteria A required for diagnosis of PTSD.
8.	Results of any additional investigations since the original Medical Assessment  Certificate
There were no other investigations since the original MAC.