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PTSD Part 2, Dr Phyllida Roe

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Summary

Come join us for a medical teaching session on PTSD. We will discuss the core symptoms and their duration needed to diagnose PTSD, the increased risks that go with the diagnosis, the grief stage in the process, the natural approach to treatment and more. The discussion is not only on the medical side but the personal side too as we will reflect on the impact on the patient's physical health, cognitive abilities, self-esteem, and interpersonal relationships. Join us as we look deeper into the workings of the brain, specifically the Amygdala and its role in fear responses. Be brave, join in, and come learn more about PTSD.
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Learning objectives

Learning Objectives: 1. Understand the difference between PTSD and Complex PTSD 2. List the core symptoms of PTSD 3. Understand why watchful waiting is important, and the danger of interfering in the natural process 4. Identify the physical health risks associated with PTSD 5. Explain the function of the Amygdala is as it relates to fear responses and emotion regulation
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OK. And you should have some um slides for me, for my son. Yes. Shall I share them right now? Would you like me to share them? Yes, please. Yeah, first one. Ok. Just one moment, please. Can you see my great. Yeah, brilliant. Thank you. Ok, welcome everybody. Thank you for joining us today. If you need to get up, move around, get a drink, get something to eat, then please go ahead and be comfortable in my sessions. So for those of you who have come before, you know that I almost never use power points, it's more about thinking about what's going on. Ok? And you're all adult learners. So lists of things that you need to know. Those are very easy for you to look up. So we don't spend much time on that in my sessions. But I found this the other day which I thought illustrates actually quite nicely what we're trying to do here. So when you start your medical school journey, you've got a certain amount of data which gradually you start to fill in more information. Yeah, knowledge is where you start to see how these things join up. Yeah, insight you can see how things quite a long way apart on the system are related and with wisdom, you can actually follow that pathway. So a good clinician works within sight. A very good clinician understands how these things are related. An outstanding clinician works from this viewpoint, the impact that it's having on the patient. This is not just in psychiatry, this is on in every branch of medicine. So in my sessions, we spend a lot of time in this kind of area because this stuff you can look up and start to put together on your own. Ok. So that's why I hardly ever use power points cause I want you thinking not just copying stuff down. OK. Now, the great thing about psychiatry is that it's very difficult to be outright and wrong. Ok. People are so complicated that you can give the same patient to six different psychiatrists and the chances are they're gonna come up with four or five different plans and answers and the chances are that any one of those plans is gonna work fine. So really, I know it's intimidating but be brave jump in there, say stuff, we don't have wrong answers. In psychiatry, we have answers that promote more discussion and that's what these sessions are about discussion. OK. So be brave. Have a go I know it can be very intimidating when it's all strangers. But let's see how we get on. Can we push on to the next slide, please. Uh Oops, wrong one. Yes, that one. Thank you. Ok. And can you lovely moderator. Um Please, can you uh you should have that image as well as either a, a PDF or a word file. Can you put that in chat so that people can download it directly if they want to? All right, just the right head. OK. So this is the second session about PTSD and I hope at least some of you are in the first session. We talked about the core symptoms. Yeah. And that those core symptoms need to last a certain amount of time before we're going to give a diagnosis of posttraumatic stress disorder. Can anybody remember either shout them out or pop them in the chat? What the core symptoms are or even one of the core symptoms? Nightmares? Yeah. So reliving the experience. Ok. So that's one avoidance, avoiding situations that might trigger that recall. Good, well done flashbacks. Yeah, that's part of the reliving. Easily startles, avoidance, disturbed sleep. Yeah. Hypervigilance. Well done anxiety. So it comes with all sorts of things. Yeah, your core symptoms, I think you've got, most of them are reliving. Now, remember this is the bit that's hard to get your head around. This is not a memory. The brain doesn't recognize it as being a memory. The brain is right back in that moment of trauma. Ok. Avoidance, we've talked about well done. You pick that up. Um That kind of hypersensitivity, hyperarousal, all that goes with that. So, sleep, they might be easily irritated. Um, hypervigilance, they might notice problems with their concentration, things like that. Well done. So, if somebody comes to us, they've had a traumatic event maybe four or five days ago, it's been a traumatic event. They s, they tell you that they keep having flashbacks is that perhaps they were mugged somewhere. They, they're scared of going down that alley. Now, um Their sleep is all over the place. They've been really ratty with their partner. Are you going to diagnose PTSD? I've given you all the symptoms. Yes. Ask about duration. Well done. Heather. So we don't diagnose PT SS D until the patient has been experiencing symptoms for four weeks. Ok. Um Sorry about the terrible lighting. This lecture comes to you from a cupboard in the NHS literally. Um So the reason that we don't jump in and start treating too quickly, anybody remember that a grieving stage, like uh uh like you said in the last uh time, like, uh if a person is grieving, let them grieve, don't misinterpret it with posttraumatic stress disorder. That's right. So something that is a natural reaction, we don't jump in too quickly. Ok? Because if we interfere in the natural process, we can actually make things much worse. So most people who have a very traumatic experience will actually make a very good recovery with very little interference. Most people who are grieving will make a very good recovery with very little interference. So one of the things we bear in mind in psychiatry, it might look like a mental health problem and it is a mental health problem. But is it natural, is this a normal process that we should just give the patient a little bit of space to see how it settles PTSD is important because it carries with it. I don't think we talked about last time, increased risk of few different things. Anybody like to guess what? One of some of those increased risk things might be depression and anxiety, depression and anxiety, well done. Yeah, depression, depression, suicide, suicide. Yeah, it can be fatal. And that's why we do what's called watchful waiting. We don't just send the patient away. Yeah, we say we do what's called safety netting. We tell people to come back in about three weeks time, see how they go. But if things don't seem to be settling, you know, you offer them the opportunity to come a little bit earlier. So you make sure that they know but they can come back to you. OK. So we're not talking about risk of developing PTSD. Uh You're quite right though, women are twice as likely to develop PTSD. Uh There isn't such a good correlation with age. OK. So it, it, it increases the risk of a patient experiencing depression. Anxiety is part of the diagnosis of PTSD and that depression can lead to suicide. Yeah, because if the patient doesn't feel anything is improving and changing and they can become quite difficult people to live with if you can't sleep and you're always jumpy and you're always anxious. What kind of self-medication might you reach for alcohol drugs? Is it? Meditation? Uh Patients exhibits with patient with PT SS D are not at increased risk of meditation. Um Substance abuse, substance abuse, they might self medicate. People under a lot of stress, often reach for alcohol or for kind of drugs that they perceive as calming drugs. They might start off with a bit of diazePAM and, and get caught up in that cycle, then of dependence and substance abuse. And obviously, you don't want that to happen. It can have a serious impact on long term cognition and particularly memory. People can develop quite severe memory problems and remember this process, what's happening in PTSD is that an event and experience is not being processed by the brain into a memory. And so when the patients uh experience is triggered in some way, the brain doesn't know it's a memory, the brain takes you right back into that place. OK. So it can have long term effects on memory and cognition if the patient gets, gets too, if it gets too set in. Ok. And it is associated with physical health problems. Anybody have any ideas about why and how having PTSD might also reflect on your physical health. And start to impact on your physical health, uh, manner of weight loss, sorry, manner of weight loss could be, there could be weight loss. Yeah, weight loss. Most Westerners, to be honest, could do with losing a bit of weight. I wouldn't worry about that. Lack of activity. Yeah. People might put on weight. What happens when you put on weight, self injury? Yeah. What happens when you put on weight? You get depressed, you get depressed. Yeah. What does it do to your physical health? Putting on weight, hypertension diabetes, card stress, cardiovascular. Yes, you're right. It can. There is some association with, for people with very long term PTSD. Um, basically stress, any kind of stress pushes your BP up, it might push your heart rate up. Some people might eat um, to try to find comfort and that piles on the weight which puts them risk of diabetes. So again, there are physical health risks associated with PTSD. Yeah. What's sorry? They just, there we go. That's better. What's C PTSD? We talked a little bit about this last week. Well, whenever it was, what's, what's that c consistent or chronic complex complex posttraumatic stress disorder. Remember the ICD 10 definition specifies that it is a single event that would cause distress to anybody. So complex PTSD is the situation where somebody is exposed to repeated continuous traumatic events and they can be in that sense, they can be comparatively small traumas, but they build up So ambulance drivers, people working in the emergency department. Yeah. People who are constantly put under stress, similar stresses, patterns of stresses. And we have a whole group of psychiatric patients, um, who are often, uh, people who've had a very abusive childhood and, or Children where there's been a lot of domestic violence in the household but they're witnessing and they can develop personality disorders which are very difficult to treat. And because these things stem from childhood, they become deeply ingrained in the brain. They actually cause physiological changes in the brain to a much more extreme extent than people suffering with simple PTSD. But there's been a single event. Ok. So we have this group of people with complex PTSD and this is from sustained or repeated trauma, um deeply ingrained and they usually have three additional core symptoms, which is that they have problems with emotional regulation, which is how they get a diagnosis of personality disorder. They have a very impaired sense of self-worth. Usually they have poor self esteem, very occasionally, they have excessive self esteem and they are often people with interpersonal problems. And if you ask them about friends, um they might tell you that at school, they sometimes had friends, but those friendships died quite quickly. And it's because um because they, they're emotionally unregulated. Yeah, people struggle to, to have them as friends and to maintain a relationship with them. So I've put on, on your blank spider as it were. I've included the Amygdala. Can somebody tell us what the Amy, the, apart from being a hard word to say what the Amygdala does? Yeah. Huh. Most of where the emotion regulators or emotions still comes in through specifically it's the area for fear responses. That's right. Process is fear and threatening stimuli. Well done. Sir, June and apologize, apologies randomly whenever I pronounce your names incorrectly. Ok. So the Amygdala is about the fear response and fear conditioning. So something happens, you hear a loud bang and you, you jump, you've got a startle reflex and then your brain says, oh yes, fireworks. Somebody's having a party down the block. They did tell me and your Amygdala steps down again. Ok. In PTSD, whether complex or simple, the Amygdala starts to struggle with that stepping down. And part of that is from the hippocampus, which is involved in that recognition and down regulation. And part of that is from the medial prefrontal cortex. I can't remember why I forgot to, to put um the other one on. So which also regulates fear responses. So once you start to impair those pathways between the hippocampus, the Amygdala and the medial uh prefrontal cortex, what you've got is you've got a situation where you, you've lost if you like the brakes on the emotional system. And so the patient is constantly on high alert, constantly hypervigilant, something to watch out for. If you do pediatrics, the, the child who sits quietly in the corner of the room watching very, very closely what's going on without any emotional response as a traumatized child. That's a hypo vigilant child. Yeah. A child who you do something painful to give trivial things, give an injection, take a bit of blood. Who doesn't respond emotionally? I think those Children are pretty stoic. But even so, you know, you'll, you'll get some response from them again. A hypervigilant child is a traumatized child and you won't get that emotional response from them. That's just a little side thing to when you're doing your pizza rotations to, to think about it is a child being very, very quiet and good because they're a quite good child or are they being very quiet and good because they're hypervigilant and they're terrified. So, just add that into the big blue blog about insight into the patient experience. Just to think about that. A good child is not always an emotionally healthy child. Mildly naughty is kind of the default setting for a child. Ok. So in complex ptsd, those changes in those pathways can actually be lost. And so now there's nothing to calm down the Amygdala. And so you've got somebody who is constantly producing particularly adrenaline and cortisol, the stress hormones. What happens if you've got lots and lots of adrenaline running through your system? How does that feel? We've all, we've all had experiences where, you know, adrenaline has been high, even if it's just in an exam room, for example, adrenaline goes up because you're in a stressful situation. How does it feel? You feel palpitations and a bit sweaty sometimes? Yeah. It activates that, that flight, flight or freeze? Yeah. Remember there's three s, you're overwhelmed. You might be sweaty, you might be shaky. Your brain might be a bit all over the place. Even when not being actively triggered. That's how someone with ptsd feels with a complex or simple or the time they are not having a good time. So, what are you gonna do about it? So let's go back to our patient who's come to us three or four days after a traumatic event, they went to get cash from the cash point and they were threatened by a thief with a, with a knife, um, and had not just their card but anything else of any value at all on them was stolen, their watch the rest of their wallet, things like that. Three or four days in, they've got the core symptoms. What are you gonna do? Are you going to debrief them? Are you going to get them to talk about it? No, a trick question because we will make, try to make them sure, like, uh, assure them that right now they are safe. Like it's not a, they just got Jack, they just, it's not a fatal situation. They might be in shock but not in a manner like, uh we have to calm them down first. Yeah. So try to take a little bit of the heat out of it. Reassure what you don't want is you don't want to get yourself into a situation where the patient is going over and over the information over and over again because they're not dealing with it that just perpetuates rumination rather than helping people to transfer that into a memory. Ok. So your first instinct as a doctor and as a psychiatrist, I start nearly all my sessions, I say it something really simple. Like, so what's going on? How is it going? How are you getting? Yeah, real simple. Open questions. You don't want to stop your patients from talking. Normally, what you don't want with this patient is you do not want them to get into that spiral of telling you over and over again. Ok. Maybe hear it once and say yes, I, you know, I understand that must have been really frightening for you. What a horrible experience. And actually it's quite normal. You know, you've had this horrible experience, I'm not surprised but the stuff you're telling me that's a normal response. And I know it's very frightening, but for now we're just gonna let your brain settle down and sort out that experience a little bit for itself. So you're giving them very clear information. You've got a plan. Yeah. And what I want you to do when you, when you go back to reception, can you make an appointment to come and see me. Tell, tell reception, I'd like to see you in about three weeks time and we'll have another chat and see how you're getting on. Um, come and see me. Even if you feel things are settled, I, I'm expecting they will. But I still want to see you. So, you've told them this is a normal reaction you've told them for. Now, we're just gonna let your brain see if it can sort itself out. You've also told them that you've acknowledged that this is frightening and that even if they're feeling better, you, I'm going to see them again. Ok. So that's your first management. Ok. When we talk about watchful waiting, we mean it, we are waiting, but we're still paying attention. Ok? And most people, we'll come back to you in three weeks time and they will still have some of those symptoms. They might be getting nightmares, ok? They might, well still be a little bit jumpy. They might still be a little bit anxious, but it's not controlling their life anymore. So the normal process is working, even if they're not completely fixed for want of a better term, the normal processes are working. And so maybe you'll see the minimum if it's not working, if they're still really poorly or if they've come back to you a little bit early, still really poorly with no signs of improvement, then you're starting to think about having to do a bit of active management and certainly realistically, it's very difficult to provide that because the best evidence is not for medication. Remember, we're trying to get people back into a normal response pattern. And so talking therapies and the ones with the best evidence are trauma focused. C BT. Don't worry about getting all this done. I've, I've got a completed spider for you with all this information. OK? Um or E MD or eye movement. Um, some desensitization. Ok. Um And actually the evidence for, for that, the evidence for EMDR is the best. However, even in northern Europe, we have very few properly trained practitioners and the waiting lists are very long. So although talking therapies are our best option for the long term outcome, they may not be available in a good enough time frame to prevent all of this abnormal response becoming completely ingrained and therefore much harder to treat. So, if you're just in general practice, if you're not a specialist psychiatrist, there's no reason why you can't manage this with medication and you'd probably be wanting to look at an SSR I, it's one of the very few conditions for which paroxetine is your first choice. SSR I, there are lots of potential problems with paroxetine but it does seem to have a very slight edge over, um, over other SSRIS. Remember with SSRS, any hint of heart disease, you're gonna go for surgery. Yeah, surgery means your safe one. Ok. The other thing that, that some patients benefit from is mirtazapine. And that's because a low dose of mirtazapine is, is quite sedating. It's one that we tell people to take at night. And so if they're being bothered with poor sleep in particular, and if their appetite has been affected and they've got poor appetite, then mirtazapine might be a very good choice for them and has fewer common unwanted effects than paroxetine. The evidence base for both is, is pretty poor really. But something to take the edge off, the anxiety would be a good place to start. If you're really not getting anywhere with it, then you probably like any other mental health problem. You need to pass it on to a psychiatrist and psychiatrists. We might look at um using a monoamine oxidase inhibitor there. Again, the evidence is poor but there is some evidence that phenelzine, for example, or even amitriptyline. Um, it can be helpful for some people. Ok. So when you hit the four week mark, if people are still really struggling, you wanna get in there and try to get things a bit sorted in grade. Ok. So big question for you to at least think about and think about really seriously. Lots of people here sadly have had very traumatic experiences. You have come from a war zone. Some of you, some of you have come from areas where there's been natural disasters. How would you recognize in yourself if you were developing PT SS D don't give me real examples if you are struggling with PTSD, but you could give me some general hints about what you might be looking for in yourself. Mhm. Weight changes and sleep changes. Yes, sleep changes, sleep changes, we all notice those. Yeah. And sleep changes can be associated with all sorts of mental health problems as well as some physical health problems and nightmares. Ok. Remember PTSD is about reliving the memory. Ok. So yeah, triggers be aware of loud noises and surroundings. Yeah. And so if you've come from a war zone and you hear a loud bang, if your brain doesn't immediately say to you, Crikey that made me jump. It was somebody dropping something heavy if your brain says you've got PTSD. Yeah. If you're not processing it as a memory associated with things that commonly make that loud noise, what can you do to help yourself? You can't prevent it. You've had the experience, you notice that you're sorting down that slightly ptsd kind of pathway bearing in mind that doctors, ambulance staff are also vulnerable to this because of the nature of our jobs. So it might be if you're working in the emergency department, it may actually be quite subtle. So what are you gonna do about it? So what question? So, really low cholesterol because one of the things that we talked about and the reason that we talked about history is that PTSD is very much still stigmatized as somehow being a weakness. Mhm. Yeah. Remember all of our early descriptions are really based on soldiers experience of battle either during or after the battle. Um, in World War One, which was in the early part of the 20th century, you can actually be shot for having what in those days they called shell shock because it caused and the phrases lack of moral fiber. And so it really comes even now how people feel about it. And so one of the reasons that I wanted a second session is to say if you're feeling that well done, somebody said go to the GP, don't give up on yourself. Value yourself, care for yourself, be kind to yourself. If you're struggling with either Frank PTSD from a single event or complex ptsd because of multiple small events. The GP is gonna be your first stop. Yeah. And hopefully there you'll, you'll get on a pathway where people will be able to give you some help. Be kind to yourself is always your first duty. OK? We've talked about nightmares. So we've got some terms that are very close together and are actually quite important as part of our diagnosis of PTSD. So we all dream, even though we don't remember our dreams, sometimes we have vivid dreams, sometimes we have nightmares and sometimes we have night terrors. Anybody want to explain, maybe not explain the difference between all four. Somebody can explain the difference between maybe two of them night terrors are consistent whereas nightmares are single or one or two times, but night terrors are consistent. That's, you mean consistent content, uh, not consistent, like, consistent as in will happen again and again, they're happening whenever the person is trying to sleep. Like, uh, it is there, but it's nightmare is a single event. Like, um, nightmares can, can be repetitive as well. Nightmares are during rem sleep, night terrors during non rem. Remember? Give you a hint here. PTSD is an issue about memory and memory encoding night terrors. You'll get lots of sympathetic and parasympathetic activation. But the person experiencing night terrors will have no recall at all of what cause that terror. It's quite common in small Children and then it just goes away. It can still happen in adults. A nightmare. You can remember that you had a nightmare. You were aware that you had a nightmare at night. Terry, you wake up in this very agitated state. Um And as an adult, as a child, you're very distressed as an adult. You're pretty distressed as well, but you really don't know why you have no record of what happened except that you are terrified terror. So no reflection of no recollection of the event. So nightmares are bad dreams. They're scary dreams. Do you, do you think people with PTSD get nightmares or night terrors? They may get both but only one of them is part of the diagnosis of PTSD well, the the events in which they have come from like such as a traumatic event. So it will be rewired, rewiring of the brain. So they might have a recollection. So it's a nightmare compared to nightmare well done. It's a nightmare because they will recall a fair amount. Ok. Um They may not recall every detail. So they're, they're recalling, their nightmares are not just a recalling, they are a reliving. Remember, this is an experience that has not been properly encoded into memory. So they're nightmare probably is on that borderline between a nightmare and a vivid dream. A vivid dream is a dream that feels so real that you could almost be reliving a real event except that a vivid dream is rarely about a re a real event. They have elements from real events in it and a vivid dream doesn't have to be frightening. It's not necessarily a nightmare, it's just a very intense dream. Whereas in a dream, most people have some sort of awareness that it is just a dream, they're not living out anything there. So there's fairly fine division, divisions between different sorts of brain activity at night. What we do know is that a really excellent way of torturing people and causing psychosis is to prevent them from dreaming. We don't understand what the function of dreams of any level of intensity is, but we know that it's vital. So what you're not gonna do too quickly is to jump in and give people sedation. That means that they won't dream at night or that will reduce their dreams because that is going to lead them down, down towards the psychotic kind of areas where their experiences then become paranoid and where it's not just that something can trigger them, but the, the thought of something can trigger them. Ok. So it's a tricky topic and there are more and more ways as we lived through the 20th and, and now well into the 21st century, more and more ways where trauma can be caused because we have industrialization. No, has become industrialized. Yeah. World war one, people were still fighting hand to hand but starting to get things like cannons, tanks and things like that. By the time we get to the wars in the Middle East in the sixties, seventies, eighties and nineties war has a very different look to it. We have trains that go much faster than trains did in the past. We had that horrendous train crash in India just a few days ago. Chances are there's going to be a lot of ptsd coming out of that. The death toll was very high. The injury toll was absolutely massive. It took time to evacuate people from the scene. Ok. So not just people experiencing war or natural disasters, industrialization and the way we live um in northern Europe with um you know, the breakdown of what used to be called the extended family system, the extended family is actually quite protective of PTSD and it's one of the things that we've lost um certainly in much of Europe. OK. So we're coming to a close now. So if we can have the final um slide, please, and if you can also put the image on the chart, my lovely moderator. Uh There we go. So just little bit of more detailed notes of just the material that we've covered in the last two sessions. Remember for those of you who are interested um and want to read a little bit more. There's an excellent website which is uh if you just Google PTSD UK, it's a very good website. It's very up to date. Lots of interesting information, including some, some, some of the real kind of technical physiological stuff. Ok? Anybody like to ask any questions? I think we've got a minute or two more. Yeah, we've got a little bit more time. Anybody got any questions. No, if you want to contact me, please don't send me a friend request. Um I never look at them. Ok? If you look me up on Facebook under my full name, which is Do ro um you should have that somewhere. Um There aren't many of us around. Um And I've got a question from beer. If a patient has PTSD and somatic symptoms, would you add C BT to the treatment plan? Um Yes, C BT trauma focused C BT. Uh Would would work towards managing all of that. How can you help someone with the process of making a certain event, a memory that's a very skilled task. And one of the key things that tends to, to limit people making a memory is the avoidance ironically. So by avoiding situations, so somebody got mugged. So they don't like going down a particular street anymore. Comparatively trivial example, but a very real one. So they're avoiding going down a particular street. And so what you can do is you can work with them. Two, go down the street, you know, choose on well lit time of day when it's a busy street. You know, if it's a shopping street, someone who shops, if the trauma happened when it was busy, then she use a quieter time. Yeah. Um So by helping people with that avoidance very gently and very gradually and this is expert work. OK? This is, I wouldn't do it. I would ask one of the specialists in my team to do it. Ok. So really what it comes down to is dealing with the avoidance because it's the avoidance, which is the, the psychological thing that's present, that's preventing that experience from becoming a memory. OK? The other things, the the the cortisol, the adrenaline and so on. If you can deal with the avoidance, the other stuff will start to resolve. So that's the key. OK? Dealing with the avoidance. So there was another question here that I've now lost. Where's he from? Can somebody? Uh No, I've lost. There was another question there and I can't find it if you're still here, maybe put it back on or shout out in the meantime, iad, you've got your hand up. Uh Yes, it's regarding the same thing and uh related to the topic. Uh Previously we discussed with us previously before the PTSD was capacity. Yeah. Can we say that person who is suffering from PTSD even though when we calm them down? And we explain and everything, there's something with the capacity uh it's affected or it's just, it's the memory which is near so engraved in the memory and the neurons that it's affecting the capacity or the capacity is there in the patient to deal with it. I would normally start with the point of view that a patient with PTSD has capacity except where they're actually in a phase where they're reliving the experience. Ok. So my lovely friend Clive who has very, very bad ptsd second degree to being a battlefield medic. Um when he is reliving being under fire, he does not have capacity when he's not in that mind, space, he has capacity to make decisions and have discussions about how we might move forward and how we can manage it. So the fact that bless him, he rejects even the idea that there's a problem which I'm afraid is very common amongst military and ex military again, because of this perception of weakness. Yeah. Um And so you often find that military from anywhere in the world, not, not just northern Europe are, are quite reluctant to, to engage with the idea that they have PTSD and need treatment. So, while they're back in the event, in the traumatic events, they're not with you at all, they are absolutely back in the trauma. They do not have capacity to make decisions when they're not in that state. When they're not having an episode where they're reliving, then there is no reason to doubt their capacity. Remember, Clive bless him. I'm sure a bit of E MD R would be massively helpful to him, but he has capacity to say no, he doesn't want any treatment that he's coping fine and most of the time he is coping fine. Ok? So capacity, you're right is an absolute minefield. Remember it is time as well as decision specific and that if you believe a patient doesn't have capacity, then you need to ask yourself is the is whatever is causing the loss of capacity, is that likely to resolve within the near future? And for most people reliving that trigger event is quite shortlived. And so therefore, you can assume that they will come out of that state within a reasonable time frame. OK. Any more questions if you want to contact me, as I say, Facebook, um send me a message at the moment. I've just moved home and I don't have wifi. So I'm even slower than usual to respond. Um I never look at friend requests, but you are most welcome to contact me via messaging on Facebook. If there's something you feel I can help you with. All right. So we'll leave it there. It's a long day if the, if you go to all the lectures. So let's leave it there. You've got five minutes or so before the next session and I hope wherever you are that you're having quite a nice day. Thank you very much for joining us and you should now have copies of both the blank Spider and the one with a bit more detail on in the chat and you should be able to access um the, the slides. Uh We are putting talks, we're recording them and, and then I'm going on the website um when, when our admin have time. So thank you very much for coming the next session. Um I haven't allocated a particular topic. Uh I think I've put it down as a general case discussion, so it'll be chatting about common cases that might turn up when you're on duty in the emergency department. Ok. So lots of thinking for that one. Enjoy. What's left of your day. Thank you very much for coming. Bye, lovely. Thank you very much for the lecture. Can I have everyone to fill out the feedback form us? It's very crucial for us and we'll sure have a lecture from 53 o'clock. Have a lovely day, everyone.