Natalia Wielgosz, CT3

Case Presentation Lewisham MHiLD

Estia 17th November 2015

Outline of presentation

Referral Clinical case

presentation Diagnostic

considerationsManagement /future

plans

Circumstances of Referral

Referred to MHiLD Psychiatry in July by social worker as “hearing voices telling her to self harm” & appearing low in mood

Whilst waiting to be seen: presented to A&E on 4 occasions within a couple of weeks c/o auditory hallucinations, thoughts of DSH & feeling unhappy with new placement

Appt arranged in OPD but was admitted to Maudsley Hospital following last A&E review. Had been offered HTT by liaison team in A &E but refused to engage with them.

Seen on the ward in August one day post admission

Review on the ward

unhappy with accommodation & restrictions Frustrated as no recent contact with son but did not

tell us why this was Reports of verbal & physical aggression – hit a support

worker in the facefelt angry and started hearing voicesTold us she had been given medication on the ward the

previous night and voices had disappeared- no longer felt suicidal & felt ready to return to residential home

became aggressive on the ward & asked to leave. Due concerns about risk of self harm, placed on Section 5(2) then Sec 2.of the MHA

keen to engage with the MHiLD services following discharge from the ward

Events since admission

Discharged after 1 week on the ward One further admission for one day -self d/cMultiple phone calls to a number of team

members –sometimes daily- and social worker asking to be moved

Has been taking Quetiapine regularly but sometimes asks to come off it

Mental state examination

A&B: 28 year old woman of mixed Ghanaian & Caucasian parentage wearing a bright top, vest & silver tights with sporty shoes, kempt,

hair in a ponytailgood eye contact, polite, no evidence of psychomotor retardation/

agitation, Speech: spontaneous, normal in rate, volume, rather monotonous,

deep voiceMood: S: “alright”, distressed about being on the ward. Objectively:

appeared euthymic with a slightly blunted affect. medication had helped her sleep (poor prior to admission), good appetite

Thoughts: no FTD evident, thoughts of self-harm before admission but not since

Abnormal perc: hearing voices telling her to self harm before admission - disappeared since she was started on Quetiapine the day before

Cognition: well orientatedInsight: keen to continue taking medication – as it had helped

voices asking to return home

Past psychiatric history

2005 (age 17): presented to A & E & seen by CAMHS c/o hearing voices

telling her to run away from home & memories of previous assaults/ feelings of sadness.

no evidence of psychotic disorder referred to MHiLD for psychometric assessment: determine level

of intellectual impairment & assess suitability for individual psychological treatment focussing on self-esteem/ assertiveness skills

d/c from MHiLD in 2007: no further concerns about mental health & not engaging with psychology team

2008:referred for therapy. felt to have mild LD, “traumatic experiences in her past which led her to develop the belief that the world is a dangerous place and people are not to be trusted and that she had very little control over what happens to her”

2010: re-referred to Lewisham MHiLD team – px Citalopram 20 mg for 10 months for mild depressive episode - postpartum low mood - related to her baby being taken into care- d/c in 2011 due to non –attendances

Past psychiatric history cont’d

2012: further referral: foster carer reported she had become upset about having to leave - agitated, pacing and talking to herself, isolating herself. - Assessment by Lewisham MHiLD team, did not meet full criteria of diagnosis of depression but ? EUPD traits with limited coping strategies when stressed.- not willing to engage and d/c

2013: referred for anxiety/ anger due to past experiences. C/o accommodation, frequent thoughts of self-harm for years but no hx of suicide attempt - admitted that making threats of self-harm was way of asking for help

engaged in problem-solving work & social skills enhancement. Felt that her emotional and other difficulties were the effects of trauma - conceptualised as PTS Disorder/Reaction. monitored in clinic & d/c

2014: re- referred – no features suggestive of any mental illness & no need for psychotropic medication –d/c from MHiLD until recent referral

Personal history

born in Ghanamother died when patient was 3 Spent childhood with her father – described him as an “alcoholic” who frequently beat herSchool attendance was poor - father unable to afford

school fees Spent most of her time assisting her grandmother with

cleaning/ housework- she took over her care Moved to the UK aged 13/ 14 to live with paternal aunt.

Difficult relationship- she beat her if she did not carry out household chores to high standards and reportedly hit her

Attended Tuke School, special school for people with I.D. Struggled academically - unable to converse properly in English

Personal History cont’d

Moved to foster care around this time – in number of different placements initially.

Got on well with her latest foster mum (2004) but ran away a few times- max for 1 month – reported being repeatedly sexually assaulted by various men on the streets

Attended Lewisham & Bromley College - reports of abuse by older peers- forcing her to take drugs & to have sex against her will (court case ongoing) Claimed to have sold drugs for one of the men

Has a 5 year old son who is in care of his father, her ex-partner -no contact but it unclear why not

Became pregnant over 1 year ago and had a termination. ?subject to pressure from the father as he threatened her & unborn baby if she did not get an abortion.

Living in supp. accommodation over past 3-4 yrs- moved to a new placement in spring/summer 2015

Safeguarding arrangements

2013: subjected to sexual and financial abuse by a group of men in Catford

As appeared unable to protect herself: protected firstly by a Deprivation of Liberty (DoLS) authorisation, then by an order of the Court of Protection which is still in force

Part of restrictions: accompanied by support staff at all times when out of the house

Family History

No known history of mental illness in her family

Mother died when patient was age 3- cause unknown

Father had issues around alcohol intake

not in regular contact with her relatives back in Ghana

does not get along with her aunt who resides in the UK

Substance misuse

History of cannabis/ cocaine/crack use in the past

smoked cigarettes - during the recent review, she reported smoking when stressed

not known whether she has been using drugs and drinking alcohol recently but she denied either when seen in A&E prior to admission

Recently admitted over the phone she has one beer most evenings- often talks about wanting to get drunk but staff can talk her out of it

Forensic History

a lot of police involvement regarding her

vulnerability

Past reports: involved in drug dealing -does not

appear that she has been charged with an offence

Assault on two members of staff at the

residential placement- phone had been taken

from her by the police who investigated this

incident - outcome of this is unknown

Medical history

No known physical health problems

Peanut allergy- rash

Social Circumstances

Lives in 24 hour supported accommodationMoved there in summer 2015 –triggered by

long term unhappiness in her last placement DoLS arrangements: escorted by the care

home staff for up to 7 hours per day whenever she goes out due to ongoing concerns about her vulnerability

Level of functioning / IQ assessments

capable of managing her daily living skills independently (enjoys going shopping, able to travel on her own and is able to use the computer very well as she browses the web without assistance)

WAIS III assessment in 2005: Full Scale IQ below 55 “severe impairment in intellectual functioning across verbal and visuospatial tasks”

We feel: helpful to understand this in context of upbringing in a different psychosocial environment, poor schooling, poor English language skills at the time and history of traumatic life events

Her independent living skills and adaptive function have been noted to be relatively good

Structure of week

spends a lot of time watching TV and using the computer to check her Facebook account and play online games

did some cleaning work in past which she described as a work experience and reported that she did not enjoy it

Questions/ Comments?

Summary

28 year old woman with mild I.D. with a recent admission due

to repeated presentations to A&E (auditory hallucinations and

thoughts of self-harm)

managed under the DoLS secondary to concerns re exploitation

social stressors: moving to a new accommodation, court case

regarding her allegations of abuse and lack of contact with 5

year old son

risk of aggression to others especially staff due to her

frustration at restrictions

Psychological formulation

long hx of instability in emotional state & relationships - early childhood disruption (lack of attachment formation)

More recent trauma: financial/ sexual abuse, having child taken permanently into care, a later termination

Currently: experiences of negative emotions & ongoing difficulties in maintaining interpersonal relationships

suspicious of other peoples’ intentions- ? Due to experiences of being manipulated/ exploited/ abused by others

often personalises other’s behaviour, interpreting it as harmful

Can perceive meetings as forms of conspiracy against herCan be distrustful of people whom she previously trusted

and relationships can be compromised by thisability to persevere with agreements / treatment is

unstable

Diagnosis

Axis I: F70 Mild Intellectual Disability

Axis II: nil Axis III: F60.3 Emotionally unstable

personality disorder

Medication

Current medication:Quetiapine 25 mg om and 50 mg on -started in august whilst in hospital and increased in communityPromethazine 25- 50 mg prn

Considerations/ Plans

Care co-ordination and CPA by MHiLD at present? Referral to adult servicesCurrently receiving specialist psychological therapy for

trauma-related difficulties –provided by Respond- is suspicious of them

Previously not offered specialised interventions for personality disorder –This appears more appropriate and therefore referred to IPTT

One of goals: become able to protect and manage herself well enough to be allowed to live without the current restrictions of her liberty

Continue Quetiapine- despite ambivalence has been taking it regularly and feels it helps voices

Develop Resource book with goals/decisions/interventions/rules