1. Natalia Wielgosz, CT3 Case Presentation Lewisham MHiLD Estia 17 th November 2015

2. Outline of presentation Referral Clinical case presentation Diagnostic considerations Management /future plans

3. 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

4. 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 face felt angry and started hearing voices Told 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

5. Events since admission Discharged after 1 week on the ward One further admission for one day -self d/c Multiple 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

6. 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 ponytail good eye contact, polite, no evidence of psychomotor retardation/ agitation, Speech: spontaneous, normal in rate, volume, rather monotonous, deep voice Mood: 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 orientated Insight: keen to continue taking medication – as it had helped voices asking to return home

7. 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

8. 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

9. Personal history born in Ghana mother died when patient was 3 Spent childhood with her father – described him as an “alcoholic” who frequently beat her School 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Medical history No known physical health problems Peanut allergy- rash

16. Social Circumstance s Lives in 24 hour supported accommodation Moved 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

17. 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

18. 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

19. Questions/ Comments?

20. 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

21. 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 her Can be distrustful of people whom she previously trusted and relationships can be compromised by this ability to persevere with agreements / treatment is unstable

22. Diagnosi s Axis I: F70 Mild Intellectual Disability Axis II: nil Axis III: F60.3 Emotionally unstable personality disorder

23. Medicatio n Current medication: Quetiapine 25 mg om and 50 mg on -started in august whilst in hospital and increased in community Promethazine 25- 50 mg prn

24. Consideration s/ Plans Care co-ordination and CPA by MHiLD at present ? Referral to adult services Currently 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