Case Studies

Case 5 - A 19-year-old recently arrived from Uganda

Monica is 19 years old and has recently arrived in the UK from Uganda. She is claiming political asylum. She has been brought to the A&E department by a fellow resident at the hostel where she is staying because she has become increasingly agitated and fearful. She tells you that "the rebels are after me" and her agitation increases markedly each time there is a loud noise.

• a. What possible diagnoses are you considering at this point?

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  Correct answer:

  The presenting complaint about the rebels raises the possibility of a delusional disorder, but the fact that she is an asylum seeker (and therefore likely to be escaping from persecution) and her hyper-vigilance suggest the possibility of post-traumatic stress disorder (PTSD).

Monica tells you that six months ago her family home was broken into by rebel soldiers who killed her parents in front of her and then forced her to go with them to a military camp. She was made to be the ‘concubine’ of one of the rebel leaders who raped her repeatedly. She finally escaped with the help of one of the rebel soldiers.

• b. Does this history support the diagnosis of PTSD? What other questions would you ask to help confirm the diagnosis?

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  Correct answer:

  Yes, what Monica has experienced is clearly of an "exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone" You should ask Monica whether she experiences dreams or daytime "flashbacks", and whether she feels "numb" and less responsive than she used to be to other people or her surroundings. Does she avoid situations that remind her of her past traumatic experiences? Is her sleep poor? Has she ever thought of harming herself?

Monica says that she often thinks about killing herself, but thinks it would be wrong and that it would upset the friends who have supported her since she came to the UK.

• c. What other questions would you ask to assess her risk of suicide?

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  Correct answer:

  • Previous attempts and associated intent to die.
  • Current feelings of hopelessness.
  • Specific current plans (method, putting affairs in order).
  • Extent to which suicidal thoughts would be influenced by asylum status (threat of removal, granting of leave to remain).
  

• d. How would you manage Monica’s PTSD?

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  SSRI antidepressants, Eye Movement Desensitization and Reprogramming and trauma-focused psychotherapy have all been shown to be effective whereas the effects of anxiolytic drugs and of debriefing are less clear. Resolution of Monica’s symptoms will be difficult while her asylum status remains uncertain.