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CRF 18.05.23 PTSD, Dr Phyllida Roe, Psychiatrist, SLAM

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Summary

This is a one-hour online teaching session on the topic of Post-Traumatic Stress Disorder (PTSD) that is relevant to medical professionals. The lecture will feature discussion on the criteria for a diagnosis of PTSD, examples of potential triggers and the earliest known record of the disorder dating back to 4000 years ago. Participants will be encouraged to ask questions, and be given the opportunity to explore the complexities of identifying and treating PTSD in different contexts.
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Learning objectives

Learning Objectives: 1. Understand the definition of Post Traumatic Stress Disorder (PTSD) 2. Recognize the differences between a fear reaction and PTSD 3. Explain how PTSD is described in different scenarios and contexts 4. Explain the earliest known records of PTSD, both pre- and post-industrial revolution 5. Analyze patient descriptions of PTSD symptoms and triggers
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So I hope that you can all see and hear me clearly. There is sometimes problems um work at the moment. If the stream goes down, then um the moderator or let the moderator know that you've got problems now, we can always switch to you just listening to my voice. Okay. Welcome everybody. Very happy to meet you all. Although I do of course, regret the circumstances that have made it necessary. So most of the names here I don't really recognize. But what I can see is that lots of you are from the Sudan um in all sorts of places. So you probably haven't attended sessions with me before. So I run things a little bit differently. I very rarely use power points. Could you excuse me? One moment? I am at work. Hello, different. I have any. So technically something like to do coming up through here, apologies as I say I am at work and but there there shouldn't be another interruption uh for the rest of the session. That was just something I needed to know about one of my patient's. So I don't normally work from Power points. You're all adult learners and uh, most of you are perfectly capable of looking up lists of things. So we don't, in my sessions, we don't spend time with me putting up power points that just have lists of information for you. All right. These are much more like discussion's, um, where hopefully we get you thinking a little bit about the patient experience with these psychological problems that, that I focus on and talk about. And so, yeah, a bit of a change of pace. It's been a long hard day for you guys already if you've been to all the lectures. Um, so originally I was just going to allocate one session, one hour to PTSD. But as I was working through it, I came to the conclusion that actually it's a very important topic and it's quite a complex topic. And so I do have a couple of sessions a little bit later in term where I thought I'd do another session on PTSD. Perhaps we put some of the more, more technical stuff and kind of the brain anatomy changes that happen. So a bit of a change of pace today. Don't be shy, speak up, put your hand up. We've got a lovely moderator with us today. So put your hand up and he'll let me know uh, that you want to say something. OK. Have a go in psychiatry. It's actually quite hard to, to give a wrong answer. All right. Put the same patient in with six different psychiatrists and those six different psychiatrists will come up with different plans and mostly all of those plans will work just as well as each other. It sometimes makes psychiatry feel a little bit complicated. Okay. But have a go do your best. So, we're talking about PTSD today and many of you sadly are in or have had to move away from your own homes because your home has become a war zone. So this is a very important topic for you both now and when you go back home and you're trying to help people back at home. Okay. So first question, what does PTSD stand for? There are no trick questions in my sessions. If they sound easy, it's not a trick. Okay. As I go for it, post traumatic stress disorder. Exactly. Well done. Thank you. And what does that mean? Who can say something about what PTSD is? Mhm. And again, I said the individual has already been through a traumatic experience. It could be anything, it could be like a physical or emotional. I don't know what the emotional traumatic disorders can be. Regurge date again again. But something the patient has experienced, which has led him into a shock manner in a complete state of shock. And even after that, the things are resolved, the person when he tries to remember those, uh, events or that episodes, they get into stress again. The very same physical experiences where they had at that time. They start to having and again and again, even though the same incident of the scenario is not the same yet, everything is fine but they will feel have the same physical um emotional reaction. Yeah. Excellent, excellent answer. Okay. So I see D 10 which is most commonly used in the UK for diagnosis and for understanding diagnoses says that the first condition for a diagnosis of PTSD, I'm just going to read this out to you because I haven't memorized. I see detail, a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress in anybody. Okay. So if you have a phobia about spiders and you go into your bedroom one night and there's a huge spider sitting on your pillow. Could this cause PTSD? Mhm. I don't think so. This would caught, this will cause a PTSD. Uh It's only a fear but uh it's not an incident where the like the spider has attacked the person itself. So he might he or she might just be afraid or only look when the spider is gone. So it's not in the vicinity. If it's not in the vicinity, it's fine. Uh Axion or uh something would happen, then I don't know. I don't think so. The PTSD would cause such a lovely. Yeah. And I think, I think that's a good answer. The reason that it probably wouldn't satisfy that first diagnostic criteria for PTSD is that um most people, so people who don't have a phobia, it wouldn't bother them. So it falls down on that element. Okay. If you are, for example, in Australia, where they have a particularly nasty spider called a red back spider. A bite from that spider is life threatening. You will need hospital treatment and the resulting infection and skin changes can flare up a few years later. If you get bitten by a red back spider might that cause PTSD or not, the patient has survived and he or she has seen despite again then yes, this may cause because something has happened a physical yes, a life. It's a life threatening encounter with the spider. Yeah. So right away, we start to see that maybe the difference between PTSD and anything else. A fear reaction. It may not be as simple in psychiatric terms to identify and to manage. Okay. So more complications. What's the earliest known record? Rough date? Don't expect you to know the exact reference roughly when is the first recorded description of likely PTSD? Have a wild guess. Pop it in message is if you're a little bit shy to silence, we do have movements. Lena. Okay, Lena. Uh sorry, Lena 19 eighties. Why do you, why do you, why have you chosen that date? It's an important date. You're right. But why have you chosen that one school time? Okay. 1st, 1st description is a little bit sooner. Than the 19 eighties. Any advance on the 20th century. Yeah. So 19 eighties, you write lots of things starting to be recognized. Wild guess, fair enough, Lena Wild guess. I said wild guess. Okay. If I tell you that instead of 1980 A D, the common era, the first known description of PTSD actually dates from around about 1930 19 hundreds before the common era. So about 4000 years ago, we have the earliest known descriptions of something that that is almost certainly PTSD. And in fact, we would probably these days referred to it as battle fatigue. Um Not quite shell shocked because they didn't have shells in those days. Okay. So 4000 years we've known about it, Egypt is a great country. We have some of our earliest medical textbooks from about 2000 BCE. Okay. The date 19 eighties. That was a really interesting guess because would you believe after 4000 years? That's the first time there were formal diagnostic criteria turning up in that case in DMV. And it didn't appear in the ICD catalogs for another 12 years after that. So well into the 19 nineties. So pre industrial revolution, all of the descriptions that we've got of PTSD are in soldiers who've seen battle. So we've got several good accounts for example of soldiers following the battle of Marathon in about 400 BC. Um Herodotus wrote that we've got descriptions from Hippocrates of soldiers struggling with symptoms. Following battles. Okay. Come the industrial age, lots of things to change. So the industrial age we're kind of talking from the mid 19th century and then you start to get records of ptsd following industrial accidents, okay. So the nature of what people are describing, there's still the post battle traumas. But if I read you this comment from Charles Dickens, now, I don't expect you to know Charles Dickens, but if you do it's a bonus. Charles Dickens is one of the great literary figures of the uh 19th century. Um and he was involved in a train crash and he gives us this very, very clear description of the impact that it had on him. And he says the scene was so affecting when I helped in getting out the wounded and dead. That for a little while afterwards, I felt shaken by the remembrance of it, but I had no personal injury whatsoever. My watch which is curious was more sensitive physically than I for it was some few minutes slow for a few weeks afterwards, except that I cannot yet travel on a railway at great speed without having a disagreeable impression against all reason that the carriages turning on one side. I have not the least inconvenience left. No imagination can conceive the ruin of the carriages or the extraordinary weights under which the people were lying or the complications into which they were twisted up among iron and would and mud and water but in writing these scanty words of recollection, I feel the shake and I'm obliged to stop Oliver Twist. Yes. Absolutely. Right. Isaan, he wrote Oliver Twist. Um and lots of other excellent if somewhat weighty books since. So that description of PTSD following a train crash and the train, what happened, the train left the rails and lots of the carriages turned over and there were a lot of deaths and a lot of life changing injuries following that. So what he describes is actually a very clear description of PTSD at the time. He got on with the job of helping to sort things out, getting people out, rescuing people, getting people safe, okay and was fine about it. I didn't have any issues except he has this trigger event if he gets back on a train. And Charles Dickens traveled very widely mostly around Britain doing performances, uh sections of his books and monologues and things like that. He also traveled widely in the USA and he traveled in Europe. And for a man of that period, he spent a lot of time on trades and he describes being triggered by being back on a train. He's kind of all right. But even though he knows he's not being sensible about it, he's not being rational about it. He still has this sensation of the carriage starting to tip. So he's having his memory's triggered by what happened. And then when he describes the scene to us and although it's only one sentence, it's a very vivid description of what the scene was like. And he says, actually, I can't say anymore is making me anxious again. I'm not gonna write anymore. So that is a very neat patient description of their experience. Okay. So we know now a little bit about what PTSD is. There are essentially four criteria for diagnosis. So the first one is that there must be a trigger event. Now, here's a hard question. Can any of you see a problem with a diagnosis of PTSD? Mean that depends on a trigger event. Okay, I'll read you the ICD 10 description again, a delayed or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature later on. In, in, in the fine detail. It says that there must be an expectation of serious injury or death as well. Is there a problem with that description of a trigger event? Either pop your hand up or shout out or put something in messages. Why don't you think I'm seeing all the messages? But when I click on more, it just suggests I want to delete it, which I definitely don't. Okay as I'd go for it. What's the problem? Uh The problem is with the scenario where the first fatal incident happens. Yes, the incident has happened and just prior to the incident, the patient knows what he or she was doing. What was the situation? Whether he was sitting in the park traveling so he might, he or she might not just correlate the event, but this situation or the place or the thing with that, uh, with that fatal event, which is seriously not related, it's just a place or a time which it happened. The, some might say it was three o'clock in the, it was three o'clock in the afternoon and I was walking suddenly. So whenever after the events and many years after that, he might say three o'clock, oh, I remember that time. So it might be a simple situation on know situation at all, but just a prior events prior to the fatal event, they might relate to an event or a situation, time place or certain thing too, which could cause a triggering event which would completely normal or completely harmless. Yeah. So, so you're, you're right about trigger events and probably realistically in the next session, we'll talk a little bit about memory. Memory uh is central to what's going on. We don't really understand memory, but it is a very complicated aspect of understanding what's going on for the patient. Okay. So we'll probably do some more kind of anatomical stuff in the next session. So I have a lovely friend who is now retired from the service is he was a battlefield paramedic during the eighties and he served as a battlefield paramedic in many theaters of war that any of you who know your history. He was a battlefield medic in the Middle East in Afghanistan, in Bosnia. Uh, he was a professional soldier. He has the second worst PTSD I have ever seen. Do you think that his PTSD came from a single event? I don't think so. Maybe, don't think so. Why not? Because the situation this person might be, was a very hostile situation. Uh We get when you are in the battlefield, their signals there are signs or alarm which say, okay, we're in a situation, you know, if he's in a normal situation, peaceful home situation and he was still getting that uh triggers. So it is not the triggers. Maybe it is ingrained in the psyche itself. Mhm. But it's not, it will not be in a peaceful situation ever. Like it's a permanent state. Yeah. Okay. And Lamia says it's a continuous exposure to stress versus a single event. Yes. Okay. So, as you know, psychiatry, very young discipline, we've only defined PTSD in the last 40 years. Um And now we're recognizing and ICD 11 has a separate diagnostic set of criteria for what's called complex PTSD and complex PTSD arises where there are multiple stressful exposures that are cumulative in their effect. Okay. So my friend who was the battlefield paramedic, he's had multiple exposures to two events and occasions where his life has been under threat. Yeah, there is no single event. So what sorts of things, who, what sort of people, what sorts of experiences might be causing this continuous exposure or repeated exposures, who's vulnerable, who's at risk. Anybody going in Azad uh patient itself is at a risk because, uh, he might think that he, it's a fatal situation and he could, he could die. The other thing is people around him could also be in a dangerous one because he was in a baton field, which means he was trained in a manner which he could protect himself. And if it's, he's in a continuous state of stress, he might act out in a manner that he would think it's saving his life. But he doesn't know where the situation is, where he is right now. So you might hurt the people around him or his family members as well. Seeming they are the credits. Um, okay. So Valeria, I do apologize if I don't pronounce names correctly with a name like filler. You'd be amazed what people. Uh huh. And Lamia again, people in war zones, Children in abusive families, people in stressful occupations, doctors especially doctors in emergency department or for example, doctors who go out on helicopters, things like that. Okay, because what we now know is that repeated, quite small stresses in the scheme of things can mount up and result in PTSD complex PTSD. Okay. So don't forget that as doctors, you're actually in a high risk population, um, whatever you, whatever job you do in medicine because you're constantly making decisions in stressful situations. Some doctors often psychiatrists because, you know, by definition, our patient's are potentially mad. I've certainly been threatened by a patient with a knife, the person he'd knifed the night before. Ironically was in the intensive care unit immediately above our emergency department. So that's a very, really situation that could have resulted in PTSD. And it didn't, why can you have an experience where you're facing potential death? Right. This guy had already really seriously injured somebody else with his knife. I did not develop PTSD and it is not because I am virtuous, strong or anything like that. Okay. So I use myself as an example. I don't ever ask you to share your own experiences unless you want to, but you must remember to respect my privacy. Okay. So threatened by someone who had already succeeded in almost killing someone wanted me to admit him to the acute psychiatric ward thinking that if I did that, he wouldn't have to go to Courtney and face the consequences of what he'd done. So he threatened me with a knife to try to make me admit him. I knew how to get over the situation. Yes. OK. What I was able to do because I was working with a very good team when I went back over to the main unit to write up some notes and things like that. They didn't quiz me about what was going on. I said, you know, a bit of a grim night. Um, it was an absolute nightmare. The whole place was absolutely chaotic and normally you wouldn't see a patient on your own as a psychiatrist, but we just didn't have the staff who could be spared to come over with me. Okay. And what I had was a nice cup of tea and a biscuit. I'm British. We believe there is no problem that cannot be solved by a nice cup of tea. And if things are really bad, a biscuit as well, and I was able to sit quietly write up my notes, I was able to process what had gone on. And so that experience became a memory and what seems to happen to people who develop PTSD. As we heard Dickens describing at the time he just got on with helping out. Yeah. And you get the PTSD afterwards and you can actually develop PTSD some years after the initial trigger. So you help out, you do your best, your body and your brain is doing exactly the right thing. It is dealing with the situation that it's in right now. Yeah, adrenaline cortisol, all of those stress hormones, things like that. Okay. Then afterwards, the difference between people who develop PTSD and people who don't is that people with PTSD don't seem to be able to create recreate that experience, to encode it as a memory. So they don't process what's going on. Okay. And this is very important. So because they don't process it when they re experience it. So had I developed PTSD and I'm telling you about that incident with the patient. I wouldn't be treating it as a memory. I would be experiencing it as a current event. That's a bit tricky to get your head round. If you've not had an experience like this, sure, when you're thinking about this lecturer or any of the other lectures tomorrow, you know that it's a memory, you've processed it. You may not remember exactly what was said. You'll probably remember that I've forgotten my hairbrush and I look like a not brush my hair in several weeks. Um You may well remember where you were sitting. Maybe you were having a nice cup of coffee, something like that while you were listening. So it's a memory with all of those extra little bits tucked around it to give a vivid sense of that memory ptsd. They relive the situation. They do not understand in any meaningful way that this is just a memory. So my lovely friend Clive who was the battlefield paramedic. I have been walking along the street with him and there's been a bang and I've looked around and he's vanished and I've looked down and he's on the floor with his hands over his head because he is back in the moment when he was being shelled. Okay, that's not a memory for him. That's an experience that he's rehabbing because he hasn't processed it into a memory. Okay. I've seen him nearly kill someone. Remember he's a soldier. So he knows how to kill because building works were happening next door. And in the middle of the night, something fell off the roof next door. Something won't look him up with a loud bank. And he went straight back to believing that he was a soldier in a battlefield. And his wife who is an intelligent woman. She is, um, she's a judge, a high court judge. Um, so educated, intelligent, didn't know what to do. Called for an ambulance, ambulance crews wear a uniform. And sadly in the UK, that includes stab vest, it's a dark green. It's not got like military, um, uh, patterns on it or anything like that. But because he was in a battlefield and they were in uniform that he didn't recognize his brain told him that these were enemy soldiers and he tried to kill them. And so they're not unreasonably called the police. And so more people in uniform turned up. It was horrible, horrible to witness, horrible to try to cope with it. Fortunately because his wife is very well respected locally. Um, there weren't charges brought. Um, and in fact, nobody was seriously injured but perhaps a little bit of an insight into how horrible, you know, Clive was not having a good time. Clive was back on a battlefield in imminent danger of death. Yeah. And that modeled his behavior normally, he's the quietest, friendliest, calmest person who would never, you know, would be horrified if he could remember the events of that night. Okay. So it's a bad thing. It's really horrible and it's all to do with memory processing is ptsd related here. The campus abnormalities. It uh then maybe a little bit of vulnerability element in there. Okay. Um Complex ptsd um actually changes configurations in the brain and I'll talk more about that next time because that is a bit complicated and I might go wild and even give you a power point slide explaining it. Okay. So, so yes, that one of the core differences between complex PTSD and for one of a better term, ordinary PTSD is that the recurrent nature of complex ptsd can create physiological changes in the brain. Okay. The the physiology of this is very complicated and we're only just starting to unpack it, sorry, quick sort of coffee. Okay. So be aware, stop your patient is having a really horrible time. Mhm So the other thing to think back to the reason that I told you about how so much of our understanding has been built up by thinking about PTSD in the context of soldiers and wars. And so we have created a culture that tends to think of people with PTSD as being weak in world war one, the term they used was shellshock battle fatigue. And if a man had a breakdown and wouldn't engage in more and more activities, this was treated as cowardice. And the punishment for cowardice was execution. And that's created this kind of lasting feeling of negativity around people who experience ptsd. They can't cope, they're weak there, cowardly, they're not. It's all about what happens in that period after the trigger event and whether or not people have time and have the capacity to process what's going on, something interesting that has come out of um, serious accidents and terrorist events and so on in the west and particularly in the UK, is one of the things that they've discovered is that where people have been in a situation where they've been helping others. So a few years back, we, we had uh five attacks on our public transport system or all within was planned to, to be pretty well simultaneous. And so people were trapped in the underground, trapped in buses and, and so on. And one of the things that, that they found is that people do better if once they've been seen in hospital checked over and they're okay and they're going to be sent home. If they can meet up with the people that they've helped during the event itself, it seems to help them to process it so that it becomes a memory and they are less likely to develop PTSD, which I think is, is, you know, again, it's little bits of information all feeding into our understanding of what's going on in, in a really complicated mental situation. So one of the challenges is that one of the other diagnostic criteria and we'll look at this little bit more formally. Probably. Next, I think it's in about a fortnight's time. One of the other diagnostic criteria is that people with PTSD will consciously and subconsciously avoid triggers. So they were in a train accident, they'll avoid getting back on trains. They were mugged at a cash point, they'll avoid going back to cash points. They may even avoid going out of doors completely. Why does this create a vicious cycle of over mental health problem? Anybody see how that fits in with this idea of failure to process into a memory as as always got his hand up his great but lots of you are very, very silent here. So As'ad will come to you in a minute but let's have somebody else first and if you don't volunteer, I might pick you because sometimes I do that Julia newly a Petrova is that sometimes people pretend they're not there because they think uh Julia you're very faint. Can you turn your microphone up? I'm sorry. Do you hear me? Okay, Julia, what's the problem with people with PTSD avoiding trigger situations? Mm Any ideas when something happened? Uh What for example, some trigger uh people can like regress in this situation uh before uh they can feel the same feelings like here they can mm Lost. Where are they? Um For example, some hmm showered noise uh can cause uh this um flesh back and some people can start to hide or some, for example, soldiers who mhm who have this flashback, they can uh think that they are uh fighting now and they can cause some damage uh for the people who around them and they can uh sometimes they can't, can't recognize who are people around. Uh they recognize there like enemies. Yeah, you're absolutely right. Well done. Julia. Thank you. As I said, you put a note in saying reliving memory, remember, this is not a memory. Yeah, this is a repeating experience. So avoiding triggers can be very inconvenient. You're quite right. The problem is in terms of perpetuating your PTSD is yes. Thank you very much. Our med. That's a very good answer. You can't avoid it forever. Fear goes strong, gets stronger, affects daily life becomes stronger. So, so it's a spiral that people get into and because of avoidance tactics, they're actually avoiding processing the event so that it becomes a memory. And so people get tracked in this spiral of re experiencing the event over and over again and never make it into a memory. And so part of treatment is about processing and helping people to process what's going on. Okay. We're drawing near to the end. Um What I'll do is I've, I've got two sessions that I haven't allocated any topics to. So next session will be on capacity, okay. And that capacity will be taught obviously from a very Western British point of view because it's a legal concept in Britain. But I think is still a very important concept globally. The session after that, I haven't allocated a topic. So I'm going to talk some more about PTSD. I'm going to talk some more about consequences and I'm going to talk some more but very superficially about how memory works. In the meantime, if you'd like to come to that session, can I suggest that you look at a really excellent website and I just popped it into the chat. Very simple ptsduk. It is full of really excellent information. It's very carefully monitored. All of the information there is correct and is up to date. So do choose your sites carefully. But that would be a good one to look at. And if you have time and inclination do have a look at the formal diagnostic criteria because we'll talk a bit more about those in ICD 10. And if you're very keen, have a look at the information on complex PTSD in ICD 11. Okay. That leaves me with one further session, which I haven't allocated a topic too. And um, so if anybody has a topic that you would especially like covered, um Does Psychological aid also include the PTSD? So we have a few minutes left. So this is, this might be viewed as a trick question. Somebody turns up to you. And last week there was an incident that has created PTSD. We won't talk about diagnosis and so on. Your absolutely content in your own mind. This patient has ptsd. Okay. Can I make a session about schizophrenia and mania? Um, certainly we could do a session about mania if you forward these questions on to, um, to the lecture, add mons and they'll let me know if, if lots of people are asking for the same thing. All right. Um, so patient has had a trigger event comes to you says come sleep. I'm getting nightmares. I'm anxious about going out and you think, yeah, you might be developing PTSD. You've had the trigger event. Are you going to treat them? Now? I know because of the names. I think only one of you came to my session on depression. Are you going to treat a patient who's had a trigger event a week ago? We should say someone says, no, someone says we should, someone says, yes, nothing for yes, yes. Another for yes. No, no, we are not going to treat them because for the same reason that we do not treat people who are depressed because they have lost someone close to them that they've loved very much because this is actually a normal reaction. They need to grieve. So grief is about processing the loss of someone you love. Not getting PTSP is about processing your experience. And if you do something to interfere with that process, either grieving or people who've had a potential trigger event for PTSD. What you're doing is you're preventing them from processing the experience normally. So, yes, girlfriend, well done. You monitor their condition, we say okay, that was very scary for you. Let's see how you go for a few days. Let's see if things get a bit better for you. Why don't you make an appointment to come back and see me in about three weeks time and if a month after the event, people are still experiencing symptoms, that's when you start to think about treating. So remember if it's a normal reaction, you don't treat you sit tight, you let people monitor what's going on and reach their own understanding of what they're experiencing. If you interfere in those processes, you massively increase the risk of triggering serious psychiatric problems and abnormal responses. Okay. So sometimes, and it's the hardest thing for an inexperienced doctor to do. And I know right, I've been there. I've been an inexperienced doctor to sit and say to somebody who is in distress. Actually, we're not going to do anything for a bit. We're just going to see what happens. Not doing anything is the hardest decision you'll ever have to make doing something makes us feel better. See, I'm a doctor, I've done something I've helped sort this person out. Not always. And that's a very important part of your education, not just in psychiatry, but, but it is very common in psychiatry that you do. Just wait a little bit and see what happens. Okay. If you've gone to all of these sessions, you must be absolutely exhausted. I'm gonna finish here. Do, do a little bit of reading if you would like to and if you want to come to the next session and that means that you'll have a solid foundation. As I say, I, I found, um, PTSD UK, a really helpful website when I was thinking about what to talk to you about today. Okay. So go get up, walk around a bit, get yourself a drink and enjoy the final session of the day. And um I hope I will see at least some of you again soon. So next session will be capacity and then after that, we'll come back and you've had time to process. So hopefully none of you get PTSD from this lecture, you have time to process it and come back in a couple of weeks time and we'll talk a little bit more about PTSD and the patient experience. Okay. Stay safely. Thank you very much professor for such an amazing presentation. Um Hope no one has any more questions for the doctor. If not, I do wish you an amazing, remaining lovely day and hope to see you in a fortnight. Thank you very much again just before you switch us off. Yes, if people want to contact me, yes, you've got my name Phillip. I'm on Facebook. It's mine. That's just my name on Facebook there. Aren't many of us. You'll find me easily. My picture is a little yellow flower. Um, don't send me friend requests. I never look at friend requests. I get dozens of them every day for, for a completely different reason. Um, but do send me a message. I can be a little bit slow as you, you've seen, you know, constant interruptions. Um, so I can be a little bit slow to answer but, but I do usually every few days try to look at my messages. So if you, I wish to do so, you are most welcome to message me directly. All right, do your best to stay safe. Do your best to look after yourself. Thank you some of you soon. Okay. Thank you very much, professor. Lovely, good bye. Bye bye. Can I just have everyone else to complete the feedback form as is very crucial for us to continue? Thank you very much and I hope to see you guys in couple minutes in the last lecture for today. Thank you very much for everything else.

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