This is a presentation on PTSD with real life clinical scenarios from my practice. I presented this seminar to the Approved Mental Health Professionals course in the University of East Anglia on 9th February 2016.

1. Post-traumatic stress
disorder (PTSD):
The new epidemic
Dr Yasir Hameed (MBChB, MRCPsych)
Psychiatrist and Honorary Lecturer
Norwich Medical School
9 February 2016

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

4. 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.

5. 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.

6. 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.

7. Then a NY journalist came into the hospital
on the chaotic day of the 10th April 2003
 “The looters surged through the city's streets. Having hit every
other hospital on the block, a mob came to AlWasety Hospital, and
began banging on the door.
 One of the doctors, a soft-spoken and overworked man named
Yasir, pulled a Kalashnikov rifle from a supply closet and fired a
single shot into the air. The crowd dispersed.”
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

8. Forgiveness.. The story of Nora and Lu

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.
 Intentional acts of interpersonal violence, in particular sexual assault,
and combat are more likely to lead to PTSD than accidents or
disasters.
 Men tend to experience more traumatic events than women, but
women experience higher impact events (i.e. those that are more
likely to lead to PTSD)
 Women are more likely to develop PTSD in response to a traumatic
event than men; this enhanced risk is not explained by differences in
the type of traumatic event

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 style
• 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. 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)

22. 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.
 The more uncontrollable the event appears to be, the more likely it is to be
perceived as stressful.
 It is important to recognise the person’s resilience and vulnerability when
dealing with stressors.

23. Factors promoting resilience
 Internal characteristics
• Self-esteem
• Trust
• Resourcefulness
• Internal locus of control
• 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

24. 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.

25. 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.

26. Video on EMDR

27. 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.

28. NICE guidelines (cont’d)
 If there is no or limited improvement with a psychological
intervention:
 Use another trauma-focused psychological therapy.
 Combine it with medication
 No convincing evidence for the following therapies
(supportive therapy/non-directive therapy, hypnotherapy,
psychodynamic therapy and systemic psychotherapy)

29. Recognition in Primary Care
 Presenting symptoms may vary. Ask specific questions in a
sensitive manner.
 Association with depression and substance misuse is high.
 Medically unexplained symptoms.
 Common trauma in civilian life: assaults, rape, road
traffic accidents, sudden death, domestic violence or
childhood sexual abuse.

30. Recognition in Secondary Care
 Maybe the first point of contact (especially in A&E,
Orthopaedic departments and plastic surgery)
 Opportunity of early recognition and identification of
PTSD.
 Similar principals to recognition in primary care.

31. 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.”

32. 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.

33. 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).

34. 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.

35. 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

36. 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

37. 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.

38. 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.

39. Mental Health Act Code of Practice 2015
 Page 26. Figure 1:
Clinically recognised conditions which could fall within the Act’s
definition of mental disorder
Neurotic, stress-related and somatoform disorders, such as anxiety,
phobic disorders, obsessive compulsive disorders, post-traumatic stress
disorder and hypochondriacal disorders
 Personality disorders – general points page 220
Many people may have a diagnosis of more than one personality disorder,
and they may also have other mental health problems such as
depression, anxiety or post-traumatic stress syndrome

40. Case presentation
 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.

41. 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.

42. 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.

43. What would be your management plan
for him at this stage?

44. Care for people affected by public care
or adoption
 On 31 March 2013, 68 110 children were in public care in England.
Their number had increased steadily each year.
 The number of children placed for adoption increased by 25% between
2009 and 2013, although their overall number remained small, at 3350
(Department for Education 2013a).
 Complex trauma presentations and higher rate of mental disorders,
hospital admission and suicide in adulthood.
Hillen & Wright (2015): Clinical work with people affected by public care or adoption. BJPsych Advances, vol. 21, 261–272.

45.  Maltreated children who returned to their parents were more likely to
experience further abuse or neglect and had poorer psychosocial
outcomes.
 A strong association was found between maltreatment and
behavioural problems/criminality, PTSD and obesity
 A moderate association with low educational/ vocational
achievement, depression, attempted suicide, alcohol problems and
prostitution/sex trading.

46. Problems with foster/public care
 High level of instability, transience and unpredictability.
 Multiple breakdowns of placements, high turnover of
social workers and last-minute changes to care plans
 Many children see multiple professionals stepping in and
out of their lives without effecting change for the better.

47. Prevalence of mental disorders in people
affected by public care
 In the US, the Casey National Study of more than 1000
foster care alumni found that the 12-month prevalence of
PTSD was 21%, exceeding that of US war veterans.
 The prevalence of drug dependence and bulimia nervosa
among care alumni was seven times higher than in the
general population.
 Rates of depression, panic disorder and social phobia were
also increased.

48. Case presentation
 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.

49. 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.

50. 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.

51. Current situation
 She stays in her bedroom for many days, she did 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.

52. 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.

53. 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.

54. What are your thoughts about
management of this lady?

55. Case presentation
 42 year old white British lady who lives with her adult sons and is
unemployed and has history of PTSD and emotionally unstable
personality disorder presented to the Crisis Team with “emotional
breakdown” and wanting to be admitted to hospital.
 Her son robbed an elderly lady in the street to buy illicit drugs. This
was reported in the national newspapers.
 She went to local drug dealers to “get the money back for this elderly
lady and apologise to her”.

56. Past history
 She was sexually abused from the age of 9 to 14 by her step-
father. She was sexually assaulted by a doctor while she was in
holiday in Turkey last year.
 She has flashbacks of these traumatic events and reported
chronic low mood. She reported recurrent intrusive violent
images, especially against males.
 She has been known for the mental health services for 16 years.

57. Risk assessment
 She has history of taking overdoses and self-harm by
cutting her arms. She currently reporting thinking of
ending her life by taking an overdose and has very violent
images of harming other people.
 She reported recurrent suicidal thoughts of taking an
overdose of her medication. There are plans and intention
and she felt unsafe to stay alone in her flat. The
protective factor is her family and ex-partner who works
off shore but supports her.

58. Would you offer hospital admission to this
lady? If she refused, would you consider the
MHA to detain her?

59. PTSD and self harm/suicide

60. Case presentation
 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.

61. 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.

62. 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.

63. 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.”

64. 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

65. 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

66. 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

67. 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

68. What is the role of psychiatric hospital
admissions for this patient? Will it reduce the
risk of suicide/self harm?

69. PTSD and cognitive impairment

70. Case presentation
 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.

71.  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.

72. 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.

73. What do you think are the main risks in
this case?

74. The refugees’ experience

75. 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.

76. Case presentation
 18 year old man refugee from Eriteria who lives alone in a council flat
presentated 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.

77. 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.

78. 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.

79. How to support him after his discharge?

80. 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

81. PTSD and chronic mental health
problems

82. Case presentation
 52 year old war veteran who lives with his wife and
daughter and is unemployed. GP referred him due to short
term memory problems for two years.
 Repeatedly forgets his passwords, wallet & recent
conversations. He took an accidental overdose of his pain
killer.
 “strange” behavioural changes (looking for a spoon while
he was not eating and then his wife found him on the floor
looking for a spoon under the sofa).

83. Past psychiatric history
 Chronic insomnia and sleep pattern reversal where he
would stay awake at night and sleep most of the day.
 He had features of PTSD related to his previous childhood
experience of abuse and also to his time in the Falkland’s
war.
 He refused any previous psychological interventions.
 He is on antidepressant.

84. Risks
 He is putting himself in danger due to his behaviours
(climbed on the roof)
 Driving: he had an accident about two years ago and
recently there was another incident during which his
daughter was very concerned because his reactions were
slow.
 Accidental overdose

85. Management
 He scored very poorly on the cognitive testing.
 All his investigations, including brain MRI were normal.
 No specific cause was found for his cognitive impairment.
 He remained adamant that he will not seek psychological
help.

86. What would you do if patients refuse
help?

87. PTSD and advanced decisions

88. Case presentation
 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.

89. Would you treat her or respect her
advanced decision?

90. PTSD and dissociation

91. Case presentation
 18 year old Caucasian male, lives with family or three
younger half siblings, stepfather and mother.
 Admitted to the psychiatric unit due to self harm.
 Allegation against him regarding rape of two minors (his
ex-girlfriend and her sister)
 Heavy substance misuse.

92. Past psychiatric history
 Throughout his childhood: History of witnessing domestic violence
when growing up in. Sexual and physical abuse by his father for many
years. Frequent moves.
 Diagnosis of ADHD and autism spectrum disorder (Asperger’s
syndrome) and PTSD.
 Reporting that he has a second personality which takes control over
his body (Philip)
 ‘Philip’ is antisocial, psychopathic and does nasty things. ‘Philip’
fantasies about hurting people sexually.

93. What are your thoughts on the diagnosis
of multiple personality disorder?

94. Dissociative Identity Disorder
(DID)
 “Most often—personalities have proper names.”
 “Often personalities are disparate and may even be opposites”
 “DID is consistently linked to childhood trauma [sexual
abuse].”Kaplan & Saddock (1998)
 PTSD present in “majority of cases” (Vermetten et al, 2006).

95. How would manage his risks?

96. PTSD in war veterans

97. 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.

98. Common presenting problems in
veterans
 domestic and occupational breakdown
 social exclusion
 criminality
 homelessness
 self-harm
 substance misuse

99. 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.

100. 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.

101. 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

102. Domestic violence and PTSD (Howard,
2012)
 Domestic violence is as serious a cause of death and incapacity among women
aged 15–49 as cancer
 There is a strong association between domestic violence and mental health
problems but a very limited evidence base on interventions to address this
violence and its consequences
 Prevalence of isolated domestic violence incidents is comparable for men
(one in five) and women (one in four).

103. PTSD in media

104. Famous people with PTSD

105. Princess Diana and PTSD

106. Reading about trauma to others
 Following the reports of her death, there was an apparent increase in
consultations with general practitioners for depression (Morris,B 1997: GPs called
into action to help nation recover from shock of Diana's death. Brirtish Medical Association News Review, September 24, 18).
 The administration of the Impact of Events Scale to an opportunity
sample of 205 respondents three weeks after the death showed that
28-32% had a "clinically significant reaction" to this event. (Shevlin, M.,
Brunsden,V., Walker, S., et a1 (1997) Death of Diana Princess of Wales. British Medical Journal. 315, 1467)
 This is replicated now in studies about people watching violent videos
from areas of conflict or terror attacks.

107. PTSD by proxy
 Witnessing the trauma of another person is often enough to create
post-traumatic effects in the witness as well, especially if that person
is still young and impressionable.
 ISIS use “secondary traumatisation” to create empathy and sparking
an identification with victims elsewhere, and then seduce them into a
violent movement to strike out at anyone they perceive as the
enemies of Islam.

108. The Power of Graphic Violence

110. 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

111. 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)

112. Long term effects

113. In the Valley of Elah (2007)

114. Brothers (2009)

115. The Messenger (2009)

116. The Impossible (2012)

117. Good kill (2014)

118. Shelter (2015)

119. 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.

120.  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.

121. 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.

122. 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.