Dr Yasir Hameed (MBChB, MRCPsych, PgCert Clin Edu, FHEA) Psychiatrist and Honorary Lecturer Norwich Medical School

1. Post-traumatic stress
disorder (PTSD):
The new epidemic?
Dr Yasir Hameed (MBChB, MRCPsych, PgCert Clin Edu, FHEA)
Psychiatrist and Honorary Lecturer
Norwich Medical School

2. Warning
 Please note that this presentation will discuss cases and
topics that many will find very distressing. It will show
video content of violent nature.
 If you need to leave the lecture at any point, please do
so.
 If you need help or feel distressed afterwards, please
speak to your course organiser/tutor/personal advisor.

3. Kahoot! Quiz

4. Presentation outline
 My personal experience
 PTSD features and management
 PTSD in special groups (veterans, children, learning disability
and refugees)
 PTSD in films and media
 Case-based discussions based on my practice

5. Learning objectives
 Understand the features of PTSD.
 The importance of early recognition and management.
 Real-life scenarios will provide you with more insights into
the complexities of this condition and the dilemmas of
management.
 Resources for further reading and help for PTSD.

6. A bit about me
 I was born in Baghdad in 1978.
 Father was in army most of my childhood.
 Witnessed the Iraq Iranian war (1980-1988), first Gulf war
(1991), economic sanctions (1990-2003), second Gulf war
(2003) and its aftermath (until 2005)
 Grieved for many relatives and friends (cousin 2004,
father 2005, older brother 2006) and many others.

7. Al Wasiti Hospital, Baghdad: 9th April
2003
 I was working as a junior doctor in this hospital
in Baghdad during the war.
 We received many causalities and we struggled
to cope with the overwhelming number of
injured and dead.

8. NY Times journalist’s visit on the 10th
April 2003
 ‘Al Wasiti Hospital is a filthy, clattering thing,
but it is the best Baghdad can offer. There was
not enough of anything there, neither bandages
nor antiseptic nor beds nor doctors. Men with
terrible wounds walked the hallways; doctors
operated in the lobby on wailing patients.
Looters waited outside’.”
A NATION AT WAR: IRAQI CAPITAL; In Baghdad, Free of Hussein, a Day
of Mayhem. By DEXTER FILKINS. New York Times. Published: April 12,
2003

9. Canadian Medical Journal. 2009 Aug 4;
181(3-4): E40

10. The terrorist’s attack on the Iraq
Ministry of Foreign Affairs August 2009

12. History of PTSD (shell shock, soldier’s heart,
battle fatigue, combat stress)
 Cases of PTSD were first described thousands of years ago.
 Clearly documented during the First World War when soldiers
developed shell shock as a result of the harrowing conditions in the
trenches.
 But the condition wasn't officially recognised as a mental health
condition until 1980.

13. PTSD definition
 (PTSD) develops following a stressful event or situation of an
exceptionally threatening or catastrophic nature, which is likely
to cause pervasive distress in almost anyone.
 Around 25–30% of people experiencing a traumatic event may
go on to develop PTSD.
NICE 2005

14. Complex PTSD
 Complex PTSD: the experience of
multiple or chronic and prolonged,
developmentally adverse, traumatic
events, most often of an interpersonal
nature and early life onset.
 Bessel A. van der Kolk (Dutch
Psychiatrist) developed the concept of
developmental trauma disorder for
those experiencing the effects of
complex trauma.

15. Normal stress reactions after trauma
(Adshead & Ferris, 2007)
Short-term effects
 Immediate shock, numbness, disbelief
 Acute distress
 Dissociation and denial
 Short-term (1–6 weeks) high levels of arousal
 Intrusive phenomena: thoughts, flashbacks, nightmares
 Poor concentration
 Disturbed sleep, appetite, libido
 Irritability
 Persistent fear and anxiety, especially when reminded of trauma, leading
to avoidance behaviour

16. PTSD symptoms
 Re-experiencing symptoms: flashbacks, nightmares, images.
Triggers?
 Avoidance of reminders of the trauma: people, situations &
circumstances. Rumination may occur.
 Hyperarousal symptoms: irritability, poor concentration. Emotional
numbing may occur.
The onset can be immediate or delayed (less than 15%).

17. Incidence and prevalence
 The majority of people will experience at least one
traumatic event in their lifetime.
 Nature: Intentional acts of interpersonal violence (sexual
assault, combat) are more likely to lead to PTSD.
 Gender: men tend to experience more traumatic events
than women, but women experience higher impact
events.

18. Risk factors for PTSD (Adshead & Ferris,
2007)
 Aspect of trauma
• Duration and magnitude of exposure to stressor
• Stressors are sudden and/or occur with no warning
• There is multiple loss of life, mutilation or grotesque imagery
• Criminal violence, especially sexual
 Experience during trauma
• Perceived own life to be at real risk
• Perceived lack of control of events, intense fear and helplessness
• Perception of grotesque imagery, especially of human remains or
children
• Witnessing or carrying out atrocities, e.g. murder, torture

19. Risk factors for PTSD (cont’d)
 Characteristics of the individual
• Previous psychiatric illness or neuroticism
• Previous exposure to trauma, especially childhood trauma
• Previous coping styles
• Denial of trauma and/or avoidance
• Female gender
• Previous acute stress reaction
 Post-trauma
• Denial of trauma by others or dismissal of experience
• Lack of social support

20. Statements make you suspect PTSD after
trauma
 “I’m just not the same anymore. I don’t fit in and I don’t
belong.”
 “I’m dead inside, I don’t feel anything anymore.”
 “You just can’t trust people or let them close.”
 “I can’t get close to my kids.”
 “I hate them for how we were treated when we got home.
I’ll never forgive them.”
 “I can only cope with life when I’m pissed.”

21. People at risk of PTSD
 Victims of violent crime
 Members of the armed forces, police, journalists and prison service,
fire service, ambulance and emergency personnel, including those no
longer in service
 Victims of war, torture, state-sanctioned violence or terrorism, and
refugees
 Survivors of accidents and disasters
 Women following traumatic childbirth, individuals diagnosed with a
life-threatening illness.
 Witnesses, perpetrators and those who help PTSD sufferers (vicarious
traumatisation)

23. Resilience, vulnerability and
controllability
 Important factors in development of PTSD.
 Resilience is defined as “'the psychological process developed in
response to intense life stressors that facilitates healthy
functioning”. (Ballenger-Browning & Johnson,2009).
 Vulnerability describes an inability to withstand the effects of a
hostile environment.
 It is important to recognise the person’s resilience and
vulnerability when dealing with stressors.

24. Factors promoting resilience
 Internal characteristics
• Self-esteem
• Trust
• Resourcefulness
• Secure attachments
• Sense of humour
• Interpersonal abilities
 External factors
• Safety
• Religious affiliation
• Strong role models
• Emotional sustenance: the extent to which others provide the individual with
understanding, companionship, sense of belonging and positive regard

25. Impairment, disability and secondary
problems
 Symptoms of PTSD cause considerable distress and can significantly
interfere with social, educational and occupational functioning.
 The resulting financial problems are a common source of additional
stress, and may be a contributory factor leading to extreme hardship
such as homelessness.
 Other possible complications of PTSD include somatisation, chronic
pain and poor health.

26. NICE guidelines for PTSD (23 March 2005)
 Initial response to trauma
 “Debriefing” is NOT recommended
 For mild symptoms lasting less than a month: watchful waiting (follow up
monthly). Use of hypnotics.
 Screening for PTSD
 Trauma-focused psychological treatment:
 Trauma focused Cognitive Behavioural Therapy (CBT): for severe symptoms.
 Trauma focused CBT OR Eye Movement Desensitisation and Reprocessing
(EMDR) for ALL patients with PTSD.

27. Video on EMDR

29. NICE guidelines (cont’d)
 Children and young people
 Trauma focused CBT
 Adapted appropriately to suit their age, circumstances and level
of development.
 Medication for adults:
 Not a first line treatment.
 Paroxetine or mirtazapine and amitriptyline or phenelzine.
 Information about side effects, suicide risk.

30. Screening of individuals involved in a major
disaster, refugees and asylum seekers
 Many refugees have experienced major trauma and may
benefit from a screening programme.
 Routine use of a brief screening instrument for PTSD as
part of the initial refugee healthcare assessment.
 This should be a part of any comprehensive physical and
mental health screen.

31. Assessment instruments
 Impact of Event Scale (IES; Horowitz et al, 1979) and
Impact of Event Scale – Revised (IES–R; Weiss & Marmar,
1997)
 Post-traumatic Diagnostic Scale (PDS; Foa et al, 1997)
 Davidson Trauma Scale (Davidson et al, 1997)
 PTSD Checklist (Weathers & Ford, 1996).

32. Challenges of recognition in children
 Up to 30% of children attending the A&E for traumatic
injury may develop symptoms of PTSD
 Explain to the parents/guardian the symptoms and what
they need to do if they persist more than 1 month later
 Atypical presentation
 Ask about sleep pattern changes, sleep disturbances,
irritability and concentration problems.

33. PTSD in people with Learning Disability
(LD) (McCarthy, 2001)
 Presenting symptoms of post-traumatic stress disorder in people with
learning disability
• Aggression
• Disruptive/defiant behaviour
• Self-harm
• Agitation/jumpiness
• Distractibility
• Sleep problems
• Depressed mood

34. Assessment and coordination of care
 Primary and secondary care responsibilities.
 Using the Care Programme Approach (CPA) and involve the
patient and, where appropriate, their family and carers.
 Providing appropriate support for family and carers
(family trauma)
 Use of self-help groups and support groups

35. Practical support and social factors
 Identify the need for appropriate information about the
symptoms and give practical advice.
 Identify the need for social support.
 Use of interpreters and bicultural therapists
 Identify obstacles or resistance to seek help due to
cultural issues/barriers.

36. Treatment priorities
 First concentrate on management of risks.
 If there is severe depression, treat depression first before
offering trauma focused intervention.
 Management of alcohol and substance misuse is a priority
before other interventions.
 Prolonged treatment needed in people with personality
disorders.

37. Mental Health Act Code of Practice 2015

38. Mental Health Act Code of Practice 2015

39. Treatability Test
 Detention under Sec.3 requires that “appropriate medical treatment
is available for him”
 The Reference Guide (Para 1.16) adds that “medical treatment”
“includes nursing, psychological intervention and specialist mental
health habilitation, rehabilitation and care (as well as medication and
other forms of treatment which might more normally be regarded as
being “medical”)”.
 It goes on to say that this medical treatment is “for the purpose of
alleviating, or preventing a worsening of, the disorder or one or more
of its symptoms or manifestations”.

40. The refugees’ experience

41. The refugees
 Refugees present a particularly vulnerable group.
 Wide range of traumatic experiences.
 Sequential stresses: the process of migration, loss of
social role, stress of acculturation, change from a
majority to minority status, social isolation and lack of
knowledge about the norms of the new culture compound
over time.

42.  In 2015, according to the United Nations, the world held
244 million immigrants—people living in a country where
they weren’t born.
 The number of refugees who’d been forced out of their
birth country, 21 million, was higher than at any time
since World War II.

43. Useful websites
 Asylum Aid (www.asylumaid.org.uk): A charity that provides legal advice and
representation to asylum-seekers.
 Health for Asylum seekers and Refugees Portal (HARP) (www.harpweb.org.uk): A
public-sector research organisation providing social inclusion research and online
health information for health professionals and voluntary agencies working with
minority communities
 Information Centre about Asylum and Refugees (ICAR) (www.icar.org.uk): An
independent information and research organisation based in the School of Social
Sciences at City University, London.
 The Refugee Council Online (www.refugeecouncil.org.uk): An independent
organisation offering direct help and support to asylum seekers and refugees, and
acting to ensure that their needs and concerns are addressed

44. PTSD in war veterans

45. Mental health of veterans (Deahl &
Siddiquee, 2013)
 During 2010, 3942 new cases of mental disorder were identified within UK
armed forces personnel, representing a rate of 19.6 per 1000 strength.
 Rates were higher for women than for men, for other ranks than for officers,
and for those aged between 20 and 24 years.
 There were 315 admissions to the Ministry of Defence’s in-patient contractor
in 2010, including personnel based in Germany and treated as in-patients in
that country.
 In 2009, there were 164 medical discharges for a mental disorder out of a
total of 1363 medical discharges.

46. Common presenting problems in
veterans
 Domestic and occupational breakdown
 Social exclusion
 Criminality
 Homelessness
 Self-harm
 Substance misuse

47. Help to servicemen in the community
 The Department of Community Mental Health or DCMH is responsible for
providing the support for the serving personnel in the region where the
serviceman is based. Contact should be made with the nearest DCMH, which
will ascertain exactly where and to whom the patient should be referred for
further treatment.
 The DCMH has considerably greater capacity than any NHS Community Mental
Health Team (CMHT)
 Patients with predominantly social problems should be reminded that entirely
independent organisations such as the Army Welfare Service can help.

48. Admission to hospital
 Compulsory: If detained, they will be treated in the NHS
similar to any other patient. However, the nearest
Department of Community Mental Health (DCMH) should
be contacted and made aware of the admission as soon as
possible.
 Informal admission: Should be referred to the DCMH to
arrange admissiom in a mental health provided contracted
with the MOD.

49. Where to get help for servicemen and ex-servicemen.
Martin Deahl, and Rehan Siddiquee APT 2013;19:268-275
©2013 by The Royal College of Psychiatrists

50. PTSD in media

51. Famous people with PTSD

52. PTSD and terrorist attacks
 Lack of systematic empirical research
 30–40%of people directly affected by terrorist action are likely to
develop PTSD
 20% are likely still to be experiencing symptoms 2 years later.
 Less is known about the mental health impact on children, but this
too appears to be considerable
Whalley MG and Brewin CR. Mental health following terrorist attacks. British Journal of Psychiatry
(2007). 190(2). 94-96

53. Normal individual reaction to terrorists’ attack
1- Emotional reaction: shock
2- Cognitive dysfunctions: disorientation, images,
memories, hypervigilance
3- Change in social interaction
4- Physical reaction: hyper arousal, insomnia
(Alexander and Klein, 2006)

54. Good kill (2014)

56. Shelter (2015)

58. Case Based Discussions

59. Case 1
 45 year old Caucasian male who is divorced, unemployed and lives
alone. He has PTSD symptoms following the suicide of his brother by
hanging 15 years ago. He witnessed a murder of a man in a local pub
last year which triggered worsening of his symptoms.
 He reported low mood with flashbacks of images and memories
related to these incidents (particular the later incident). However,
these symptoms are getting worse recently and he started to report
hearing two voices inside his head. The voices are two, one tells him
nice things and the other tells him nasty things (to harm himself, or
others).
 He was started on antidepressant and antipsychotic by GP with slight
beneficial effect.

60. Assessment
 Using the Posttraumatic stress disorder checklist-
civilians(PCL-C) which is a 17-item self-report scale for
diagnosis of PTSD, he scored 64 out of total of 85
suggesting moderately severe symptoms of PTSD. A cut-off
score of 50 for a PTSD diagnosis has demonstrated good
sensitivity (.78 to .82) and specificity (.83 to .86).
 He mainly scored high in symptoms of flashbacks,
avoidance, angry outbursts and mood symptoms and low
in autonomic hyperarousal and startle.

61. Risk
 Risk to self: He reported he has taken an overdose once in the
past (15 years ago). He reports having fleeting suicidal thoughts
but would not act on these. Protective factor is his daughter.
His brother also committed suicide.
 Risk to Others: He has been violent towards others in the past
whilst under the influence of alcohol. He reported constant
feelings of anger towards others and he tries to isolate himself
from others when he is feeling irritable.
 He has assaulted a total stranger about 8 weeks ago while in a
pub as he “didn’t like the way he looked at him”. He has been
in trouble with the police in the past but not currently due to
his aggressive behaviour.

62. Question
 The police brought the patient to section 136 suite after he had a verbal
altercation with a stranger on the bus. You are the duty AMHP and you asked
two doctors to attend the assessment, neither of them had prior contact with
the patient. You are trying to contact the Nearest Relative but there is no
answer.
 What are the issues?
 What clinical information do you want and why (must be specific)
 What bits of law are you going to think about?
 What are the clinical/legal options?
 What would you do?

63. Case 2
 52 year old lady from mixed ethnic background (Jamaican
mother and White father) who is divorced, unemployed and
lives alone.
 Reporting 7 years history of “anxiety”, following her divorce.
 Her symptoms include difficulty with breathing, nausea and
vomiting, palpitations and excessive sweating when she is
outside her house.

64. Personal history
 She was born to a Jamaican mother and white father. She did not
know her biological father until she was in her twenties and he now
lives in Australia.
 Her mother fostered her privately to a white couple when she was six
weeks old. Her foster parents had four older children and the
youngest was ten years older than her.
 She found growing up in predominately white community in Norfolk
very traumatic because she felt very different. She remembers
scrubbing herself with bleach in an attempt to become white. She was
bullied and racially abused when she was in school and around her
home.

65. Personal history (cont’d)
 Her biological mother used to pick her up most weekends and it was
during that period that she sexually and physically abused her and
told her that if she told her foster parents then she would be taken
away from them permanently.
 At the age of fourteen, she was raped by one of her foster brothers
and she fell pregnant and was forced to give up her daughter for
adoption. She could not tell her foster parents because it would break
their hearts.
 Apart from her daughter she has not contact with the rest of her
family and she said that her husband turned the whole family against
her.

66. Current situation
 She stays in her bedroom for many days, she does not leave her house
for months. She only feels safe in her bedroom, with the curtains
closed. She has a friend who does the shopping for her.
 She is depressed. She said that she had no pleasure in life and could
not look forward to anything in the future.
 She refuses to see male professionals, particularly those from black
and ethnic minority, because she was abused by similar males when
she was younger.

67. Other symptoms
 She talked about different personalities living inside her. Each one of
them talks to her about their life, which is a reflection of her past in
different stage of her life.
 She stated that she sees her deceased mother when she goes outside
her home, she described a horrible picture of her mother with her
face filled with maggots and pointing at her.
 She also described periods when she will lose sense of time.
 She was very distressed when she talked about these symptoms.

68. Risk
 She has suicidal thoughts and took few overdoses over the years. She
also uses boiling water on her skin as self harm. She has a history of
cutting her arms. She uses self -harm as a coping mechanism. She said
that she has done so since the age of 5 years.
 She said that she has stored some tablets over the years just in case
she wants to “end it all”. She refused to hand them over. She also
mentioned a box she keeps in her room which contains some Heroine
and also a silver knife that she used to cut herself.
 She is an enduring risk of self harm and suicide due to the difficulties
in managing her emotions.

69. Question
 The patient took an overdose and her friend called the ambulance. She was
declared medically fit for discharge few days later. You are the duty AMHP and
her medical team called for a MHA assessment as she continues to voice
suicidal thoughts and refusing to engage with the community or crisis teams.
 What are the issues?
 What clinical information do you want and why (must be specific)
 What bits of law are you going to think about?
 What are the clinical/legal options?
 What would you do?

70. PTSD and self harm/suicide

71. Case 3
 19-year-old Caucasian girl who after a traumatic
childhood, began to deliberately self-harm at the age of
13, often by cutting her forearms. More recently,
swallowing inanimate objects has been her method of
choice.
 She has had over 150 A&E attendances, over 10
gastroscopies and a laparotomy. Knives, razors and six-
inch sewing pins have all been removed from her
gastrointestinal tract.

72. Personal history
 At an early age, she witnessed her parents fighting and her father was
often violent towards her mother.
 She was systematically physically and sexually abused over several
months by her eldest brother starting when she was 7 years old. This
abuse mostly occurred while her parents were at work and she was
alone at home with her brother.
 Her parents divorced when she was 8 years old. Her father moved
away with the eldest son and the patient and her other brother stayed
with their mother, who went on to have a string of violent and abusive
partners.

73. Psychiatric history
 She began abusing aerosols on a daily basis at school when
she was 13 years old and binged on alcohol sometimes up
to the point of unconsciousness.
 She ran away from home when she was 14 and at this time
it became apparent that she was cutting her arms and
legs.
 Due to the severe and repeated self harm, she spent 2 ½
years in various secure adolescent units, and was briefly
placed under section 3 of the Mental Health Act.

74. Current symptoms
 She had repeated admissions to psychiatric hospital to
“manage” her enduring risk of self harm and suicide.
 She described her feelings as follows: “I keep having
flashbacks of the abuse I suffered at the hands of my
brother when I was seven. I cut myself as a way of
releasing blood. My self-harm is a way of discharging
negative emotions and coping because my parents were
not able to support me emotionally when I revealed the
abuse. I cannot guarantee I will not do it again in future.”

75. Endoscopy photographs clockwise from top left, showing sewing needles in the fundus of the
stomach, a pen in the cardia of the stomach, a knife in the distal oesophagus, and a cigarette
lighter in the fundus of the stomach.
Mohammed Rashid, and Ishaan Gosai BMJ Case Reports
2011;2011:bcr.07.2010.3136
©2011 by BMJ Publishing Group Ltd

76. CT of the neck showing the right limb of an open safety pin extending through the posterior wall
of the pharynx and lying just 7 mm away from the internal carotid artery.
Mohammed Rashid, and Ishaan Gosai BMJ Case Reports
2011;2011:bcr.07.2010.3136
©2011 by BMJ Publishing Group Ltd

77. Abdominal radiograph showing a knife and a lighter in the stomach.
Mohammed Rashid, and Ishaan Gosai BMJ Case Reports
2011;2011:bcr.07.2010.3136
©2011 by BMJ Publishing Group Ltd

78. Abdominal radiograph showing a lighter, multiple sewing needles and pieces of glass in the
bowel.
Mohammed Rashid, and Ishaan Gosai BMJ Case Reports
2011;2011:bcr.07.2010.3136
©2011 by BMJ Publishing Group Ltd

79. Question
 The patient was discharged recently from the inpatient ward to a supported
accommodation. Few days later, a member of public called the police after he
found her on a bridge, threatening to jump off. Police brought her for assessment
in section 136. She reported recurrent suicidal thoughts of taking an overdose of
her medication and jumping off a bridge. She wanted to be re-admitted as she
doesn’t feel safe in her flat. The crisis team are experiencing staff shortages and
they said they are unable to attend the assessment.
 What are the issues?
 What clinical information do you want and why (must be specific)
 What bits of law are you going to think about?
 What are the clinical/legal options?
 What would you do?

80. Case 4
 51 year old war veteran who lives with his wife and children
presented with gradual change in his personality, becoming more
withdrawn, and “behaving as a child”.
 He is presenting with irrational obsessions, for example, not eating or
even touching certain foods and wanting to do things in certain order.
 He is totally dependent on his wife in every aspect of her day to day
life.
 He also sometimes misidentifies his wife and his children and gets
mixed up about that.
 His appetite has changed and he has strong cravings for sugars and he
gained a significant amount of weight over the last year due to this
and poor exercise and mobility.

81.  He has labile mood and he can be very tearful one minute and then
very angry and shouting the other (emotional dysregulation suggestive
of poor executive function). He also gets very repetitive in his speech
and behaviour, for example, he talks about his heart operation nearly
every day and about his time in the Gulf War.
 He has significant rigidity and literal interpretation of things that are
said to him and his wife has to explain things in simple language for
him to comprehend.
 He also developed fears of spiders and other insects and there may be
evidence that he is having visual illusions as he described huge spiders
crawling on the floor.

82. Past psychiatric history
 He has a history of post-traumatic stress disorder of PTSD resulting
from his time in the first Gulf War in 1991 and the traumatic
experiences he had endured there.
 He did have a history of anger management problems prior to this
presentation but this became significantly worse recently.
 He gets flash backs from the war when he sees certain TV programs so
his wife has been trying to avoid that. He was feeling very guilty
about his time at war and he said things like “I’ll go to hell” due to
the things he believes he has done there.
 His first admission to psychiatric hospital was last year due to threats
of self harm.

83. Question
 The patient assaulted his wife and son and was admitted to a psychiatric hospital.
The family said that they are unable to cope with his behaviour and the team are
considering the option of discharging him to a nursing home. The patient would
like to go back home. Cognitive testing during his hospital admission showed a
significant impairment in his short-term memory and frontal lobe (executive)
functions. You were allocated to be his social worker and you are invited to a
multidisciplinary meeting to discuss his discharge plans.
 What are the issues?
 What clinical information do you want and why (must be specific)
 What bits of law are you going to think about?
 What are the clinical/legal options?
 What would you do?

84. Case 5
 18 year old man refugee from Eretria who lives alone in a council flat
presented with severe persecutory delusions about his neighbour and
the authorities.
 He carried out series of shoplifting offences and assaulted a police
officer and his neighbour.
 He was detained under section 2 MHA after the neighbour reported
that the patient was burning letters in his flat.

85. Personal history
 He arrived to the UK when he was 14 years old as an Unaccompanied Asylum
Seeking Child (UASC) and received support from the county council services
under section 20 of the Children Act 1989 and later under the Children
(Leaving Care) Act 2000.
 He reported that he witnessed the murder of his pregnant mother when he
was in Eretria and was subjected to slavery.
 He initially lived with a foster carer then moved to a council property.
 He faced many difficulties in the education system in the UK and dropped out
of school.

86. Progress on the ward
 He remained lacking insight and refusing to accept medication.
 He was detained under section 3 MHA and was put on depot antipsychotic
injection.
 He later said that he couldn’t remember his mother or the cause of her death
as he was very young when she passed away.
 He denied exposure to direct trauma and didn’t have PTSD symptoms.

87. Question
 The patient is nearing his discharge from the hospital. The consultant is
thinking of placing the patient on a CTO. You are the AMHP responsible for
organising the CTO. You conclude that the patient has capacity but is refusing
to consent for a CTO.
 What are the issues?
 What clinical information do you want and why (must be specific)
 What bits of law are you going to think about?
 What are the clinical/legal options?
 What would you do?

88. PTSD and advanced decisions

89. Case 6
 47 year old lady with history of emotionally unstable personality
disorder and long standing PTSD symptoms due to abuse during her
childhood. She is divorced, lives alone and unemployed.
 She took an overdose and called her GP surgery to tell them that they
don’t need to worry about her anymore and she won’t be bothering
them again.
 On arrival to the hospital, it was found that she had an advanced
decision to refuse medical treatment should she chose to take her
own life. This has been documented in a detailed report by her
psychologist and Lead Clinician from the community mental health
team few months ago.

90. Question
 You were asked to organise an MHA assessment. However, the medical team
would like to know if they can treat her on not? The legal team are
unavailable to provide advice. The Site Manager asks you about your opinion.
 What are the issues?
 What clinical information do you want and why (must be specific)
 What bits of law are you going to think about?
 What are the clinical/legal options?
 What would you do?

91. References
 Post-traumatic stress disorder: NICE guidelines (2005).
https://www.nice.org.uk/guidance/cg26
 Post-traumatic stress disorder: The management of PTSD in adults and children in
primary and secondary care. National Clinical Practice Guideline Number 26.
National Collaborating Centre for Mental Health. commissioned by the National
Institute for Clinical Excellence. The Royal College of Psychiatrists & The British
Psychological Society, 2005.
 Ahmed A S (2007) Post-traumatic stress disorder, resilience and vulnerability
Advances in Psychiatric Treatment, 13 (5), 369-375.
 Adshead, G. & Ferris, S. (2007) Treatment of victims of trauma. Advances in
Psychiatric Treatment, 13, 358–368.

92.  McCarthy J (2001) Post-traumatic stress disorder in people with learning
disability. Advances in Psychiatric Treatment, 7 (3), 163-169.
 Deahl M, Siddiquee R (2013): What civilian psychiatrists should know about
military psychiatry. Advances in Psychiatric Treatment, 9 (4), 268-275.
 Howard L (2012). Domestic violence: its relevance to psychiatry. Advances in
Psychiatric Treatment, 18 (2), 129-136.

93. Charities
 Rape Crisis – a UK charity providing a range of services for women and
girls who have experienced abuse, domestic violence and sexual
assault
 Victim Support – providing support and information to victims or
witnesses of crime
 Lifecentre. Adult and under 18s helplines (lifecentre.uk.com):
Telephone counselling for survivors of sexual abuse and those
supporting survivors. Also offers face-to-face counselling and art
therapy groups in West Sussex.

94. Charities (cont’d)
 First Person Plural (firstpersonplural.org.uk): Survivor-led organisation
for people living with complex dissociative conditions after
experiencing abuse in childhood.
 Freedom from Torture (freedomfromtorture.org): Provides direct
clinical services to survivors of torture who arrive in the UK. Has
access to interpreters.