Could there be a non-psychiatric cause for S.T.’s physical symptoms?

Many migrants are not registered with a GP, for reasons described below. It is therefore common to encounter someone such as S.T. who, despite being at high risk for physical and mental illness, has not previously accessed healthcare since arrival in the UK and may have multiple undiagnosed and untreated illnesses. This adds significant complexity to the diagnostic assessment as, although asylum seekers are more likely to have physical symptoms as a result of psychological trauma, they may also have undiagnosed physical illnesses and physical injuries as a result of torture. It is therefore vital to complete a full physical health workup, including screening for tuberculosis and sexually transmitted infections where indicated, in order to identify and treat medical conditions. Extra care should be taken during physical examinations to avoid retraumatising the patient.

Dizziness and collapse are important features of S.T.'s presentation. Not only does he find these episodes distressing but his lack of awareness during the episodes renders him vulnerable to injury, exploitation and violence. When assessing patients who are in severe distress it is important to be mindful of the potential for diagnostic overshadowing and vital to identify possible medical causes for these episodes. These could include epilepsy, non-epileptic attack disorder, hypoglycaemia, dehydration and vasovagal syncope (fainting), and potentially substance misuse. If a neurological cause is suspected, referral to neurology may be indicated. Epilepsy is often difficult to distinguish from non-epileptic seizures and the two may both occur in the same individual. Important causes of non-epileptic seizures (particularly in people who have been severely traumatised) include panic attacks and dissociative episodes.^{Reference Perez and LaFrance1} Panic attacks are usually rapid but not immediate in onset and are associated with prominent autonomic symptoms such as palpitations, shortness of breath and tingling in the extremities. Dissociation is a psychological defence mechanism manifested as a perceived detachment of the mind from the emotional state and the body. It often occurs in the aftermath of severe trauma and may be triggered by reminders of the trauma. In our clinical experience, episodes of dissociative ‘unconsciousness’ are particularly common in people who have been subjected to sexual trauma and who have an overwhelming sense of shame and revulsion about what has been done to them.

A detailed history, including a collateral history (where possible), neurological examination and simple investigations (such as blood sugar and blood pressure, both during and after the episode) can be helpful to distinguish between these causes.

Psychotic phenomena in PTSD: a diagnostic challenge

S.T. was reported to be ‘responding to voices’. This might initially be thought to indicate a primary psychotic illness such as schizophrenia. However, it is also important to consider whether the voices might be a manifestation of post-traumatic stress disorder (PTSD). In PTSD, individuals may hear voices as part of a flashback to past traumatic events. Flashbacks may be triggered by reminders of the trauma or stressful situations and could therefore be intensified when the person encounters uniformed officers or is placed in a confined space (such as in hospital). Victims may find it difficult to distinguish these vivid phenomena from reality and may respond to them.

Ways in which flashbacks can be differentiated from primary psychotic experiences include: by their close relationship to the past traumatic experiences; by their transience; and by the preservation of some degree of insight. However, many experts believe that some people with PTSD also have more generalised psychotic experiences which are best understood as part of the PTSD process. This has been termed ‘PTSD with secondary psychotic features’.^{Reference Braakman, Kortmann and van den Brink2} A history of trauma is also common in people with psychosis. Therefore, it can be challenging to make a differential diagnosis of a psychotic illness in someone with comorbid symptoms of PTSD and it is common for clinicians to disagree on the primary diagnosis.

Distinguishing complex PTSD from PTSD and emotionally unstable personality disorder

Complex post-traumatic stress disorder (complex PTSD) is a new diagnosis included in the forthcoming ICD-11.³ Complex PTSD is more likely to develop following exposure to prolonged or repeated traumatic events from which escape is difficult (such as torture, slavery, human trafficking, prolonged domestic violence and repeated childhood abuse), whereas PTSD tends to develop following isolated traumatic events.^{Reference Brewin, Cloitre, Hyland, Shevlin, Maercker and Bryant4} Complex PTSD is also more likely to develop following interpersonal trauma than following events such as a road-traffic accident.^{Reference Brewin, Cloitre, Hyland, Shevlin, Maercker and Bryant4} Complex PTSD shares the same core features of PTSD (exposure to a threatening or horrific event, re-experiencing of the traumatic event, avoidance of traumatic reminders, sense of current threat and interference with functioning) but includes three additional features, all of which must be present for the diagnosis to be made. These are: interpersonal disturbances, affect dysregulation and a persistent negative self-concept. These additional features are believed to result from the degradation of the person's self-identity and autonomy. Functional impairment tends to be worse in complex PTSD than in PTSD, and standard PTSD treatment may be less effective.^{Reference Brewin, Cloitre, Hyland, Shevlin, Maercker and Bryant4}

It can sometimes be challenging to distinguish between complex PTSD and PTSD with comorbid emotionally unstable personality disorder (EUPD), since complex PTSD and EUPD may both stem from trauma in early life and share disturbances in affect regulation, self-image and interpersonal relationships. Although a pertinent feature of personality disorders is that, by definition, they develop in childhood, it can be particularly difficult to differentiate the disorders in someone who has experienced traumas at an early age or for whom we know little about their premorbid personality, like our patient S.T. However, there are some key differences: in EUPD, the person's self-image and interpersonal relationships tend to be unstable, whereas in complex PTSD the person is more likely to avoid relationships and have a persistently negative self-image.^{Reference Cloitre, Garvert, Weiss, Carlson and Bryant5}

Cultural idioms of distress

It is important to consider cultural idioms of distress when assessing patients from different backgrounds. For example, perceptual disturbances such as hearing voices might have a different significance or meaning to that assumed in a Western medical model. As with any symptom, asking the patient what it means to them is often illuminating. The section on cultural formulation in DSM-5 has some useful questions in this regard.⁶

A challenge for assessment: memory deficits are common following trauma

Trauma and its associated disorders, including PTSD and depression, are associated with relative deficits in autobiographical memory retrieval,^{Reference Schönfeld and Ehlers7,Reference Graham, Herlihy and Brewin8} and there is evidence that other aspects of memory may also be affected.^{Reference Brewin9} As a result, asylum seekers who have experienced trauma may tell a story that is convoluted and has an inconsistent timeline, which can make eliciting a clear history challenging. It is often helpful to check back frequently with the patient to make sure that you have understood correctly and to reflect with the patient on elements of the account that you find inconsistent or incomprehensible. The process of recounting may be distressing for the patient; thus, breaks may need to be taken and it is often not feasible to elicit a full account in a single session.

Of note, it is therefore possible that S.T.'s poor memory had affected his asylum claim, since an inconsistent story or inability to recall specific memories is often considered by immigration systems to indicate poor credibility, despite this link between trauma and memory deficit.^{Reference Herlihy and Turner10}

Decompensation since refusal of the asylum claim

S.T.'s mental health worsened following the refusal of his asylum claim. This is not surprising, since such refusals are often associated with being discredited and disbelieved and with the threat of imminent removal to a place where the individual believes themselves to be unsafe. Refusal of an asylum claim is also often associated with loss of accommodation and financial support. Even for those who are currently awaiting a decision, the research evidence indicates that prolonged immigration uncertainty is associated with a deterioration in mental health.^{Reference Laban, Gernaat, Komproe, Schreuders and De Jong11}

Many asylum seekers' claims are refused because of inadequate legal representation and/or lack of evidence to support their claim. These individuals may present in crisis and healthcare professionals are often unsure how to help people with such a precarious socio-legal situation. A number of useful charities that provide psychological, social and/or legal support are listed in online supplement 1 (available at https://doi.org/10.1192/bjb.2019.67).

Access and barriers to treatment in general practice

Data protection and confidentiality issues

An additional barrier is that refused asylum seekers and undocumented migrants may be afraid to give personal details to a GP practice in case these details are accessed by the Home Office, which could in turn lead them to be arrested, detained and/or deported. Some try to get around this by registering using an alias.^{Reference Roberts15} Their fears are well-founded. Non-clinical information about patients may be disclosed to the Home Office by NHS services in certain situations, such as if a patient who is ineligible for free treatment does not pay their treatment bill within 2 months. Their debt to the NHS may also affect their future immigration applications.¹² Previously, a memorandum of understanding (MoU) stated that NHS Digital could also disclose confidential patient information to the Home Office for the purpose of assisting immigration enforcement.¹⁶ However, this MoU was withdrawn for amendment in May 2018 and it has not yet been re-released.¹² At the time of writing, it is unclear how confidential information will be shared with the Home Office in the near future.

Access and barriers to treatment in secondary care (including community mental healthcare) and in-patient services

Which treatments are effective for someone in such a precarious social situation?

In an acute situation such as S.T.’s, the priority should be to allow the patient to feel as safe and comfortable as possible. Measures should be taken to provide a quiet and private space in which to talk to the patient. Short-term use of benzodiazepines should be (cautiously) considered if the patient is acutely agitated or anxious. If in-patient admission is thought to be indicated, clinicians should be mindful of how an acute in-patient psychiatric ward could be distressing for someone with a history of trauma.

Regarding longer-term management options for S.T., psychological treatments appear to have the greatest benefit in reducing PTSD symptoms.^{Reference Nosè, Ballette, Bighelli, Turrini, Purgato and Tol26} For example, there is robust evidence supporting the use of narrative exposure therapy (NET).^{Reference Tribe, Sendt and Tracy27} Although a sense of safety is often considered to be a prerequisite for psychological therapies to be effective, NET (which was developed for use in conflict zones) may be beneficial even for patients whose immigration status and social circumstances remain unstable. The humanising effect of having someone trusted to talk to regularly, in a safe space and without judgement, can be an especially helpful aspect of talking therapies. There is emerging evidence to suggest that arts-based therapies can be effective for those who find it more difficult to express themselves verbally about their trauma.^{Reference Beck, Lund, Søgaard, Simonsen, Tellier and Laier28}

Psychotropic medication can also be used to treat PTSD-related symptoms. Antidepressants can be helpful in treating depressive symptoms in people who have been severely traumatised: mirtazapine is often used because of its hypnotic effect. Antipsychotic medication (such as quetiapine, which is widely used) can be of benefit, particularly in the context of vivid flashbacks or hallucinations or in the management of persistent anxiety and agitation.^{Reference Cipriani, Williams, Nikolakopoulou, Salanti, Chaimani and Ipser29}

Practicalities and primary needs

S.T. has been made street homeless since the refusal of his asylum claim. This will also have implications for discharge planning if he is admitted to a psychiatric hospital for treatment. It is important to carry out a comprehensive needs and risks assessment as soon as possible and to generate a care plan in which these needs are prioritised appropriately.

If S.T. launches an appeal against his asylum application rejection, he would become eligible for support such as accommodation and certain other benefits; therefore, providing him with information on non-governmental organisations (NGOs) that provide legal advice may be a priority. A number of NGOs also support asylum seekers by providing therapeutic services, English language courses, social inclusion projects, housing and general advice. For example, NACCOM provides a useful list of charities/services that help destitute migrants across the UK (https://naccom.org.uk/projects/). Further information on some of these NGOs is given in online supplement 1.

Online supplement 2 gives advice on working with and assessing capacity via interpreters, which might help in further assessment of S.T.

It is also important to consider that, even if S.T. has a telephone, he might not have credit with which to make outgoing calls.

Suggested management plan for S.T.

• • Informal psychiatric admission for further assessment and formulation

• • Obtain collateral history from friends or relatives if possible (and if S.T. consents to this)

• • Thorough physical assessment to identify and treat any non-psychiatric illnesses

• • Early and proactive assessment of spectrum of needs: including prioritising housing, finances and referral to relevant charities for psychosocial and legal support

• • Consideration of short-term use of benzodiazepines if highly agitated

• • Consideration of anti-depressant and/or antipsychotic medication

• • Referral for talking therapy with a trauma focus (if available locally or via a charity)