MR SH is a 27-year-old gentleman from Afghanistan, referred by his GP for psychiatric assessment. He travelled from his home country over a seven-month period seeking asylum. He reported fearing for his life in Afghanistan having witnessed his father and brothers’ deaths, allegedly at the hands of the Taliban. He describes having suffered a gunshot wound at this time with shrapnel in his left shoulder.

He said his journey to Ireland from Afghanistan was long and arduous, involving travel by land, boat and ferry. He was placed in Mosney, Co Meath under direct provision for four months and was then transferred to St Patrick’s Accommodation Centre, Monaghan.

At the time of presentation, his symptoms included persistent low mood throughout the day for the past two months and a poor sleep pattern of approximately four hours per night, broken with initial insomnia. He reported poor appetite, often due to limited selection of food on offer in the accommodation centre. He described concentration, motivation and energy levels as low. He reported feeling irritable and angry at times. He described enduring daily headaches and being hypervigilant to loud noises. He described a frequent re-living of past events and having nightmares. He noted himself becoming more socially withdrawn. 

He has no psychiatric history of note but did seek help with regard to his mood symptoms while travelling through France and was prescribed antidepressants. He has no medical/surgical history. His medications at the time of review included duloxetine 90mg and alprazolam 0.25mg twice daily. He denies any alcohol or drug use.

Mr SH was born in Afghanistan. He described childhood as happy; he did well at school and proceeded to complete a degree in accountancy. He worked for some time as a social worker, youth advocate and with NGOs. Premorbidly, he reports being happy, socialising with friends, attending the gym regularly and enjoying running. He did not have any significant relationships. Since seeking asylum he stated having very little contact with his family in Afghanistan due to fear of compromising their safety. 

He presented as neatly dressed with good personal care, good eye contact and appropriate deferential rapport, carrying an envelope of documents. His speech was normal in volume and content, low in tone and he was fluent in English. His mood was subjectively low and objectively depressed. He reported no thoughts of self-harm or harm to others. No suicidal ideation. No psychotic symptoms. Cognition was good and insight present. 

His symptoms met criteria for PTSD and a diagnosis of this was made along with comorbid mild depression. ICD-10 diagnostic criteria include:

• Repetitive intrusive recollection or re-enactment of the event in memories, dreams
• Sense of numbness and emotional blunting, anhedonia
• Avoidance of situations/activities reminiscent of trauma
• Autonomic hyper-arousal with hyper-vigilance, enhanced startled reaction, insomnia 
• Anxiety, depression
• Acute outbursts of fear, panic, aggression triggered by reminders.¹

We increased his antidepressant medication and referred him for cognitive behavioural therapy/EMDR (eye movement desensitisation and reprocessing) with our psychology team. 

Discussion

ICD-10 defines post traumatic stress disorder as a delayed +/- protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.¹ It is a severe psychological disturbance characterised by involuntary re-experiencing of elements of the event, with symptoms of hyper-arousal, avoidance and emotional numbing. It can affect people of all ages. It is estimated that three in 100 of the general population will suffer from PTSD in their lifetime and up to 30% of those who experience a traumatic event will be affected.²

The diagnosis of PTSD is based on diagnostic criteria as described earlier. The ICD-10 and DSM-IV differ slightly in this. Characteristic symptoms to assess for, according to NICE guidelines, include re-experiencing phenomena. This involves involuntarily re-experiencing aspects of the trauma, often by intrusive flashbacks or nightmares. Another core symptom is avoidance of reminders of the event. Some patients will experience hyper-arousal including hyper-vigilance, startle response, irritability or poor concentration, sleep problems or emotional numbing. Comorbid conditions such as depression, anxiety, OCD and substance abuse may be identified.³ Symptoms typically occur immediately after the event but in some, < 15%, can be delayed. 

PTSD is a treatable condition, regardless of the time lapse since the traumatic event. However, recognition and diagnosis pose significant challenges. A recent Irish study identified that up to 40% of patients within psychiatric services had undiagnosed PTSD.⁴

NICE recommends routine use of a brief screening tool for any individual who has experienced a traumatic event. This should be performed one month after the event. It does not, however, recommend routine debriefing sessions. It also recommends that refugees and asylum seekers undergo PTSD screening as part of their comprehensive initial assessment.³

The management of PTSD is usually multidisciplinary and depends on the duration and severity of symptoms. For the patient presenting within one month of the traumatic event with mild symptoms, watchful waiting is the most appropriate approach with follow-up appointment arranged in the coming month. An empathetic manner and understanding is required to encourage recovery. For those presenting with symptoms beyond a month of the event treatment should be offered, including therapy and medication.⁵ The first line therapy recommended by NICE involves eight to 12 sessions of trauma-focused cognitive behavioural therapy or EMDR with a person adequately trained in providing same. EMDR involves thinking about aspects of the trauma while following the movements of the therapist’s finger.³

Antidepressant medication is indicated in the event of the patient refusing psychological therapy, if psychological therapy is ineffective or if there is severe depression or hypersensitivity symptoms. There is little evidence base about which medications are advised in PTSD. Paroxetine and mirtazapine are recommended if an antidepressant is required. Amitriptyline or phenelzine may be prescribed under specialist guidance. 

If there is no response, another class of antidepressant may be trialled, or adjunct therapy with olanzapine. The patient should be advised of potential side-effects and risk of withdrawal symptoms. Often a short course of sleeping tablets or benzodiazepines may be required to assist with poor sleep, anxiety and irritability.³

In terms of prognosis, up to 50% will recover within one year, but 30% will have a chronic course. Outcome may depend on initial symptom severity. Recovery may be helped by good social support, absence of maladaptive coping mechanisms (ie. avoidance, denial, thought suppression, rumination), and no further traumatic life events.²

One particular group of note in PTSD is asylum seekers and refugees. As we see higher numbers seeking asylum in Ireland, recognition and knowledge of PTSD is important. An asylum seeker is someone who is seeking to be recognised as a refugee (a person who has fled their own country in fear of persecution due to race, religion, nationality, social group or political opinion). While awaiting their application to be processed by ORAC (Office of the Refugee Applications Commissioner), they are housed by the Government’s Reception and Integration Agency (RIA) in direct provision accommodation centres around the country. They have no choice in location. Adults receive a weekly allowance of €19.10 and €9.60 per child. Children are permitted to attend primary and secondary school, but are not entitled to free fees in college. They are not permitted to work. With no employment opportunity, little social engagement/integration, crowded conditions and future uncertainty, the risk is significantly high for mental illness.⁶

In a recent report on the experiences of women in direct provision by AkiDwA, ‘Am Only Saying it Now’, it was found that the majority of the women interviewed had been in direct provision accommodation for more than two years. The report noted that the female participants felt they were ‘pushed to their limits from stress’ as a result of a number of conditions out of their control, including: ‘enforced inactivity, overcrowding and other difficult living conditions in accommodation centres.’⁷

An interesting Irish study: ‘Trauma and PTSD rates in an Irish psychiatric population’ was conducted by researchers at the School of Psychiatry at UCD and the Department of Adult Psychiatry at the Mater Hospital.⁴ They found that up to 67% of Irish patients and 80% of migrants attending a general psychiatry outpatient clinic had experienced at least one traumatic event in their lives which would satisfy criteria for PTSD. Prior to this, only 31% Irish and 3.5% of migrants had a formal diagnosis of PTSD, highlighting the fact that PTSD is most likely significantly under-diagnosed.The trauma in this study experienced by migrants included witnessing murder of a family member, violent attacks, rape, lack of basic essentials, kidnapping and forced labour. Given that migrants are less likely to present to or access mental health services, mental illness and trauma rates in the migrant population is likely to be much higher.

Looking to the future, it would appear that we will see more and more patients presenting with symptoms consistent with PTSD, making it an important health matter. Awareness, recognition and appropriate management of PTSD will pose a challenge to us as healthcare providers and to society in general. Interestingly, Einstein was a well- known sufferer of PTSD. 

References

1. World Health Organisation. ICD10 International Statistical Classification of diseases and related health problems. Volume 2. 10th Revision. 2010 Edition
2. Semple D, Smyth R. Anxiety and stress related disorders. Oxford Handbook of Psychiatry 2009. Oxford University Press. Second edition
3. National Collaborating Centre for Mental Health. NICE Guideline. March 2005. Post traumatic stress disorder: Management. Available at https://www.nice.org.uk/guidance/cg26/chapter/1-Guidance
4. Wilson F, Hennessy E, Dooley B, Kelly B, Ryan D. Trauma and PTSD rates in an Irish psychiatric population. Disaster Health Journal 2013; Volume 1, Issue 2, pages 74-83
5. PubMed Health. National Institute of Mental Health. Post traumatic stress disorder. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024667/
6. Direct Provision and Dispersal: Is there an alternative? 2013. Irish Refugee Council on behalf of the NGO Forum for Direct provision. Available at http://irc.fusio.net/wp-content/uploads/2011/09/Direct-Provision-and-Dispersal-Is-there-an-alternative.pdf
7. AkiDwA, ‘Am Only Saying it Now’, 2010 p12. Available at http://www.akidwa.ie/AmOnlySayingItNowAkiDwA.pdf