Patient’s documentation: Name: Kieran Holt Age: 16 Height: 6’2” Build: Very tall, broad-shouldered, physically strong

Background: Kieran was admitted following multiple violent outbursts at his residential placement. He assaulted a staff member during a restraint after becoming triggered by perceived “disrespect.” Police were involved before hospital admission under the Mental Health Act.

Diagnoses (Working Formulation): -Conduct Disorder (with emerging Antisocial traits) -PTSD (history of chronic childhood physical abuse) -ADHD (combined type) -Emotional dysregulation -Possible emerging Personality Disorder traits (under assessment — not formally diagnosed due to age)

Triggers -Feeling challenged or “talked down to” -Loud male voices -Sudden physical proximity -Being told “no” without explanation -Perceived loss of control

Presentation: -Quickly escalates from calm to aggressive -Paces when agitated -Clenched fists, jaw tightening -Shouting, swearing -Can become physically intimidating (standing very close, towering over staff) -Has damaged property before -Deep down: hypervigilant, expects betrayal, struggles with trust.

Start of role play:

It’s late afternoon. Kieran has just been told he can’t access the gym because he refused medication earlier. He is pacing the corridor outside the nursing station. His breathing is heavy. His fists are clenched.

He suddenly kicks a chair across the room.

Kieran: “This place is a joke! You don’t control me! I said I’m going to the gym!”

He turns toward you, towering over you slightly.

Kieran: “You think you can just take stuff off me whenever you feel like it?”

He steps closer. His posture is tense but he hasn’t touched you.