Mental health symptoms-post conflict: a case series from West Belfast, Northern Ireland *Maneesh Gupta, Patricia Campbell, Elizabeth Schumacher Maneesh Gupta Patricia Campbell, Elizabeth Schumacher Email:
Abstract The impact of armed conflict on mental health is increasingly being recognised. Northern Ireland suffered from conflict for over 30 years. However, there is little qualitative clinical research on the long-term effect on those who had been exposed to prolonged conflict. We present a case series of patients who were,
and continue to live in, West Belfast - an area previously subject to the
long-standing conflict. All patients were directly exposed to the conflict. We
present different personal experiences and perceptions, different symptoms of
mental disorder and the different treatment modalities used. We will compare and
contrast the similarities and uniqueness of the complexity of this group of
individuals given the prolonged conflict exposure. FindingsIntroduction Northern Ireland had been the
scene of an armed conflict for thirty years (1969-1998). Approximately
3500 deaths and 40000 severe injuries are attributed to this conflict
[1] colloquially referred to as ‘troubles’. Of those killed 90%
were male. In addition the vast majority of prisoners and those seriously
injured have been male [2]. However, the impact of the troubles has
not been uniform across the whole of Northern Ireland. Over 25% of deaths
occurred in a small part of Belfast [1] particularly North and West
Belfast. The focus of post conflict
research in mental health has generally been on post-traumatic disorder.
Limited research in Northern Ireland has focused on psychological problems,
as measured by General Health Questionnaire (GHQ) [3, 4], failing to
provide any evidence for or against severe mental illness as a target
of public health intervention in the post conflict situation. Researchers
and clinicians have hopefully not overlooked the complex presentation
and needs of people who have a severe and enduring mental illness in
the post conflict scenario. This case series is aimed at
highlighting the varied presentations of severe mental illness in a
patient group who were directly exposed to a conflict situation in West
Belfast, Northern Ireland. This is a descriptive clinical account and
does not purport to be a representative study. Method MG conceived of the idea and
wrote to all West Belfast Community Mental Health Team (CMHT) team members
to contribute. PC and ES responded. All authors met and discussed the
aims of the paper and identified patients on their case load who had:
10 patients were identified.
Written informed consent was sought from them. All consented. For the ease of the reader
we have referred to all non-military armed groups as being ‘Paramilitary’
which is/was the frequently used description of both sides of the conflict.
It is by no means a reflection of the rights and wrongs of those groups. Results Case 1: Male
aged 53 years. Separated and living in local council (financially subsidized
accommodation owned by the government) flat. In receipt of state (govt
provided) benefits. Supported by ex-wife and daughter. In prison in 1970s during ‘internment’
(imprisoned without trial). He shared ‘cage’ with a senior paramilitary
man who later turned out to be a double agent. He was imprisoned when
Long Kesh prison was burnt down by the prisoners and was subjected to
attack by tear gas (O-chlorobenzylidene malonontrite.) due to the army’s
efforts at curtailing the prisoners’ attack on the prison. Subsequently
he was abducted, beaten by paramilitaries and shot at. In 2002, presented
to mental health services for assessment. Symptoms: Alcohol dependent. Hallucinations: Derogatory and command auditory hallucinations, which tell him to hang himself or harm himself in some way. Low self esteem and low
mood. Treatment: Risperidone depot
37.5mg every 2 weeks, fluoxetine 40 mg, diazepam 10mg. Case 2: Male
58 years. Separated and living alone. On own/work related pension. Supported
by both sisters. He was a council/local government worker in West Belfast for 30 years during the conflict. He reported negotiating blockades, barricades, burning vehicles and debris. He reported resistance from all sides and was stopped on a daily basis. He was tortured and witnessed torture whilst detained in the Palace barracks, Hollywood - which included sleep deprivation and beatings – he remembered the soldier to whom he was handcuffed to apologising for what he was about to do and explaining he only had 9-days to go before he was out of the army. He experienced ambushes and witnessed shootings and killings. He picked up dead bodies off the street. He had weekly house raids by the army at all times of day/night; on one day he experienced 3 raids. Whilst working he survived
an attack – paramilitaries entered his work premises and opened fire
with a machine gun killing dead two and injuring five co-workers including
him. He opted out of personal relationships
since 1994 due to concerns of getting “too close” to people –
he felt targeted as a council worker. Presented to mental health service
12 months later. Symptoms: History of alcohol dependence. Low mood. Interpersonal
difficulties. Hyper-vigilance. Overeating. Obese. Treatment: Started Psychotherapy/Trauma
Therapy. Venlafaxine 75 mg. Case 3: Male 50 years. Lives alone
in local council accommodation. He is in receipt of state benefits. He reports, aged 14, seeing his brother being shot at by the army and then being driven over by an armoured vehicle. He described seeing his brother’s head “burst” and the contents of the brother’s head “spraying the wall”. He reported picking up the parts of his bothers brain off the wall. At aged 16 he was ‘interned’ and was in Long Kesh and was there during the gassing and burning of Long Kesh. He described life as being constantly under threat, under siege and feeling the need to “be on the move”. In 1977 he was again in custody and placed in the H Blocks of Long Kesh, then released and re-arrested in 1983 for possession of explosives – it was during this period he reported having his first “breakdown”. He was then moved to the prison hospital where he was diagnosed as having schizophrenia (then 28 years old). Whilst serving his sentence, he reports he then faced an extra charge due to the “supergrass” trials. He was then charged with murder, which resulted in a life sentence, which was eventually overturned. He continues to sleep on the
sofa in the living room and describes the living room as a safe place,
likening it to his former prison cell. Symptoms: Delusional ideas
– fixated on the “suffering of children in the Middle East” and
also fixated on “God” – he often believes that other
people are God. Became socially isolated, some friends being killed
during the conflict or who later completed suicide as a result of the
conflict. He has also tried to end his own life on a number of occasions,
the most recent being last year where he attempted to hang himself. Treatment: Zuclopenthixol 500 mgs every 2 weeks, olanzapine 20mgs daily. He refused psychotherapy as
he feels he copes with life and does not wish to change his chosen coping
strategies.
Case 4:
Male
born 1958. Lives with wife and family in own home. Good support from
family. Unemployed. Subject to house raids, witnessed shootings and killings. He was imprisoned in the H
block during (for 10 years) the hunger strike. He was part of the ‘blanket’
protests and ‘dirty’ protests of 1980’s. During this time he reported
daily torture – strip searches, forced anal searches and general humiliation
and de-humanisation. Symptoms: History of alcohol dependence. Hallucinations-ordering
him to kill. Stabbing visions. Killing animals. Low mood. Insomnia. Treatment: Clozapine 500 mg, escitalopram 10 mg, venlafaxine 300 mgs. diazepam 10 mg. Case 5: Male
56years. Lives with wife in a local council accommodation. Has four
adult children (one child died when 2 days old). 12 grandchildren. Good
family support. In receipt of state benefits. He reports being taken to a holding centre by paratroopers and being held for a number of days. Witnessed a robbery and was
held at gunpoint up by the robbers who were paramilitaries (“men with
no faces”). He worked as a taxi driver and reports that he was hijacked
on 3 occasions during the course of his taxiing duties. The first time
he was held captive whilst his taxi was used to transfer a bomb. The
second he was forced to drive a bomb through the local area to a police
station and he saw children in the streets and was afraid the bomb would
explode and described fear. The third time he was called out to complete
a routine taxi duty – he ended up being forced to a take paramilitaries
to a shooting who intended to shoot the opposition forces. After this
he was arrested and taken to Castlereagh and interrogated. He reports
that the interrogators threatened to release his details to the opposing
paramilitaries and so he lived onwards following release in fear of
retribution. Repeated house raids throughout
the period of conflict by police and soldiers. First mental breakdown was in 1994. He reports that his personality changed he became introverted, suicidal and blackened the house windows. He had several hospital admissions and attempted suicide via overdose on 3 occasions. The final suicidal attempt he threw himself in front of a car and sustained injuries to his hand. He continues to sleep in day wear clothes. Brother and cousin were killed during the period of conflict. The house was reportedly taken
over by armed and masked paramilitaries and he was imprisoned upstairs
and forced to listen to the screams of his son whilst he was being beaten. Symptoms: Alcohol dependence. Sleeps in daily wear clothes. Depression. Hyper vigilance History of attempted overdosing. Difficult personal relationship with wife who also suffers with depression. Angina. Amputee. Diabetic.
Arthritic. Treatment: Diazepam 6mgs, lithium 400mgs daily, risperidone 4mg, venlafaxine 75mgs daily, zopiclone 7.5mgs daily Refused talking therapy for
fear this would “open a can of worms” Case 6: Female aged 57. Lives with husband in local council accommodation. Has four adult children (the fifth child died when 2 days old). Has 12 grandchildren. Good family support. In receipt
of state benefits. Repeated House raids. Cousin and brother-in-law killed. She is married to case 5. During the 1970’s she took part in a women’s march to an area under curfew, which was imposed by soldiers. She reports being beaten by soldiers when pregnant and lost the baby. She reported that she lived under siege at the time of the ‘Ballymurphy massacre’ - the local community demolished the walls of adjoining terraced houses to create a passage for safe movement to maintain human contact with friends relatives and neighbours and share resources. Reports repeated house raids and continue to sleep in her daywear clothes. The house was reportedly taken
over by armed and masked paramilitaries and both herself and her husband
were imprisoned upstairs and forced to listen to the screams of their
son whilst he was being beaten. Symptoms: No history of alcohol dependence. Difficult personal relationship with husband who also suffers with mental health difficulties. Depression Lupus. Arthritis. Ongoing back pain Treatment: Trauma therapy to
good effect. She has also completed a course of anti-depressants. Case 7: Male
54 years. Lives alone in local council property. Supported by ex-wife
and daughter. In receipt of state benefits. Father was shot dead by paramilitaries in the early 1970’s – he had to identify the dad’s body. Shortly afterwards he was shot at and wounded by paratroopers. He reports witnessing his friend being shot dead – this friend was shot in the jugular and the room was described as being full of blood and he described the smell of burning flesh. Frequent house raids and detentions. During the conflict he slept
on the sofa, as he was afraid of being shot in his bed. He continues
to sleep on the sofa meaning he would be ready if there was another
house raid. Symptoms: History of alcohol dependence. Auditory hallucination. Microphone coming out of walls. Feels bugged by British. Hyper vigilance. Olfactory hallucination-burning flesh. Visual hallucinations – blood on the floor in relation to witnessing a friend being shot and he was also shot during the conflict. Could not do trauma therapy. He continues to remain hyper
vigilant and sleeps on the couch in fear of being under siege or attack. Treatment: Chlorpromazine 200mgs
daily, venlafaxine 150mgs daily and quetiapine 300mgs, diazepam 10 mg. Case 8: Male
aged 45. Lives alone in local council flat. Supported by ex-wife and
mother. He has 3 teenage children who live with the mother. Was detained in the young offenders’ prison for 2 years. He reports paratroopers and paramilitary forces repeatedly beat him during the conflict. He also experienced house raids. In the late 1970’s he was
imprisoned in Long Kesh during the H-block protest for “political”
offences Symptoms: History of alcohol dependence. Previous overdoses. Suffers with paranoia and feelings of low mood and hyper vigilance. He continues to live in
fear of para-military/military beatings especially due to the fact he
has lasting physical scars to remind him of previous beatings. He has
been known to the mental health team for approximately 10 years. Treatment: Risperidone depot
50mgs every 2 weeks, diazepam 15mgs, venlafaxine 150mgs daily, Case 9: Male
62 years. Lives alone in local council flat. Support from sister and
brother-in-law. Plus another daughter who also assists. 1971 he was arrested on his way home from work due to a random selection process. Reportedly was placed in an army jeep and used as a human shield to ensure safe passage through a nationalist area. Was taken to palace/police barracks and interrogated. He reports being beaten, stripped naked, hood placed over his head, and had a snooker queue inserted in his rectum. Held under water for short periods of time – resulted in repeated drowning sensations, subjected to sleep deprivation and subjected to burns. Imprisoned in Maidstone, a prison ship. He was also interned in Long Kesh for 4 years - and reports being sprayed with gas. He presented to services 2
years post release 1978, the initial presentation was precipitated by
what he described as a “mental breakdown”. Symptoms: History of alcohol dependence. Recurrent flashbacks, paranoia,
psychotic symptoms. Low mood and depression. Poor memory. History of
over doses. Phobia of dogs. Treatment: Venlafaxine 75mgs
daily, haloperidol 10mg, risperidone 4mg, lithium 800mgs, diazepam 15mg,
zopiclone 7.5mgs nocte. Case 10: Male
born 1960. Lives with mother. At age 17, put in prison for
inappropriate behaviour towards the British Army. He was attending a
day training centre when the army took over the building. Saw people
being killed by the army. Re-imprisoned in 1988 for attempted murder.
Released in 1998 as part of the agreement between the two ‘warring’
sides. Symptoms: History of alcohol dependence. Anxiety and depression.
Insomnia. Unable to socialize. Poor memory. Treatment: Counselling from
voluntary sector. Citalopram 60 mg, diazepam 30 mg, zopiclone 15 mg. Discussion Of the ten patients we have
mentioned, nine are male, seven are separated and yet their primary
support appears to be from the ex-wives and/or the daughters. Seven
have been (or are) dependent on alcohol. Six live in local council property.
It was also noted that of the 9 males, 8 are ex-prisoners and all of
the 9 males experienced varying forms of torture. Any armed conflict leads to
a situation of fear, helplessness and danger for the civilian population
in the area. Mental illness has been found to be highly prevalent in
such areas [5, 6]. It is surprising that despite the exposure to sustained
conflict, Northern Ireland has been reported to have psychiatric morbidity
rates almost similar to other parts of UK [7]. Is the prevalence diluted
by the localised nature of the conflict or is it influenced by the instrument
(GHQ-12), the nature of psychological problems studied or the small
sample size (3163 respondents from Northern Ireland)? [7]. Situations of conflict, adversity and sustained exposure to trauma are likely to influence presentation of severe mental illness. Sustained and cumulative trauma has been reported to influence the presentation of psychosis [8]. Mullholland et al have written about the effect of exposure to ‘troubles’ influencing the presentation of schizophrenia [9]. More recently Maguire et al have found exposure to trauma (in Northern Ireland) predicting hospital admissions and quality of life in patients suffering from bipolar disorder [10]. We cannot deny that a post
conflict situation will lead to a complex presentation of mental illness
and would need specific qualitative research to look at the nature of
morbidity. In this case series, the complexity
of presentation and needs associated with the different qualitative
nature of mental illness in a post conflict situation is highlighted. Alcohol dependence: Seven of
ten patients reported present or past symptoms of alcohol dependence.
Mental illness especially chronic and complex has been reported to be
associated with increased alcohol use [11]. Added to that is the ‘distinctive’
drinking pattern in Northern Ireland (a mean consumption of 43.21 units
a week) [12]. It is reasonable to say that
alcohol dependence was not a strikingly unique feature in this case
series. Overdoses/Suicidal acts:
Suicide is a key problem in Northern Ireland. West Belfast has a very
high rate of suicide (16.2 per 100,000 in the period 2000-2004) [13].
Table 1 shows that six of the patients in this case series had taken
overdoses or attempted suicide and 3 had ongoing suicidal thoughts. Mental state: Low mood and psychosis was the key finding in our patient group. 8 patients have low mood and are on antidepressants. Case 6 has stopped antidepressants though she has had them in the recent past. Four patients have psychotic signs (hallucinations/delusions) and two more have unreasonable fear and paranoia. Apart from case 6, others are on high doses of psychotropic medications with community mental health team support. We note that there is no consistency in the medication prescribed. Patients have been prescribed various permutations and combinations of anti-psychotics, anti-depressants, anxiolytics and hypnotics (table 3). In this patient group high
medication, combination treatments and offering psychotherapy has not
made a substantial difference in their functioning. Do we need a new
paradigm of treatment for such a client group? Do we need to recognise
that patients with this presentation and an exposure to conflict will
need complex interventions that might have to be innovative and bold? Trauma Therapy: Psychological treatment has often been used in post conflict situations. It is useful for a range of post-exposure (to conflict/trauma) situations and improves not only PTSD symptoms but also associated depression and anxiety [14]. Mental health services in Belfast started to provide specialist trauma therapy over the last 3-4 years. This was in response to the local demand and recognition by local services of the need to provide specialist therapies. However, of our 10 patients 6 declined to engage with the therapy (Table 3) because they felt ill-at ease in altering their current coping strategies. Some also stated not wishing to “open a can of worms”; others identified trust issues with the service providers. In other post conflict areas
it was noted that people did not wish to explore their difficulties.
De Jong et al [15] highlight that during their research into the trauma
of ongoing conflict in Chechnya there were a significant number of patients
who felt that their primary modality of coping would be to deny a problem
exists. Interestingly the 2nd and 3rd most popular
form of coping was to seek solace and guidance in prayer or from family
members. Case 7 started therapy but was unable to complete this due to the suffering the therapy caused. Case 6 on the other hand was able to complete and benefit from the therapy; case 2 is presently in therapy and reports finding this very useful. Case 10 prefers to have therapy from the voluntary sector in his own area – despite the fact that our service is able to provide specialist trauma therapy he hints at trust issues and prefers to remain with a non-specialised but culturally accessible service. His symptoms do not include
psychosis. A better illness profile in
those with strong sense of national identity was reported in 2007 [16],
where PTSD rates were higher in those for whom national identity was
unimportant. Most of the patients in this case series, however, have
a much closer and ideological involvement with the conflict. Case 4
was in prison at the time of the hunger strikes in 1980s and took part
in the ‘blanket’ and ‘dirty’ protests, which are major events
in the struggle of republicans/nationalists against the government.
Yet, he suffers from the most severe mental illness, is on clozapine
(reserved for treatment resistant schizophrenia), and poses the greatest
risk to others due to the stabbing visions he has had. Conclusion We have presented a descriptive account of the nature of mental illness in 10 patients in West Belfast. The limitation of our presentation is that the cohort of patients cannot be deemed to be representative. We have presented those we know have been in conflict and are associated with our community mental health team’s support. One of the future goals of further research would be to study more rigorously and scientifically the patient group in West Belfast for the nature of mental illness in a post conflict situation. The strength of our paper is,
however, the qualitiative description of complex mental illness that
we have presented along with the difficulties of treatment that these
patients have and are facing. Perhaps researchers and clinicians need
to look at new ways of helping complex mental health needs in a post
conflict situation. Competing Interests Maneesh Gupta has not had any
(direct or indirect) exposure to the conflict in Northern Ireland. He
holds an Indian passport. Patricia Campbell has been
born and brought up in Northern Ireland. She has had direct exposure
to the conflict. She holds an Irish passport. Patricia Campbell is the
President of Independent Worker’s Union, which is a union of all workers
in Ireland (Northern Ireland and Republic of Ireland). The IWU is an
apolitical organisation, and is not associated or affiliated with any
political or religious organization. Elizabeth Schumacher has not
had any (direct or indirect) exposure to the conflict in Northern Ireland.
She holds a British passport. No funding has been sought
or provided to the authors in planning or writing this paper. Authors contributionsManeesh Gupta conceived of
the idea, sought regulatory approvals, contributed to the collection
and analysis of data, and wrote the draft manuscript. Patricia Campbell contributed
to the collection and analysis of data, assisted in gaining regulatory
approvals, seeking consent, and wrote the draft manuscript. Elizabeth Schumacher contributed
to the collection and analysis of data, assisted in gaining regulatory
approvals, seeking consent, and wrote the draft manuscript. All authors collectively finalised the paper and approved the final version.
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Table 2: Mental
state
Table 3: Treatment
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