Somerset drew upon the Community Mental Health (MH) Service Framework, and local experience and recognised that too often service user experience of mental health was beset with artificial barriers, gateways and eligibility with people sometimes needing to deteriorate before they got the vital support they needed. In addition, we recognised that the gap between secondary care and primary care was experienced by service users as a “cliff edge”. The radical redesign of mental offers in Somerset aimed to deliver an experience of “no wrong door” and where, via a partnership between health, social care and Voluntary, Community and Social Enterprise (VCSE), people's needs could be met; both in terms of specific mental health offers as well as tackling the wider determinants of mental ill health.

OMH was launched early 2019, just before the pandemic, and so traditional project methodology did not always apply. Instead all partners focused on standing up the offer at pace in order to support the population within Somerset with the emotional and psychological consequences of the pandemic, and any pre existing challenges. The model was co-produced with Experts by Experience significantly contributing to the shape of the offers.

The model developed comprised of two key facets:

• • A mental health offer, where the needs of individuals, families and carers are met by a range of health, social care and VCSE partners (including the wider determinants of mental well being such as finance / housing)

• • A mental health eco system developed in collaboration with communities (including underserved communities), where support is available throughout geographical communities and communities of identity.

The project has delivered both quantitively and qualitatively. Over 4100 additional appointments are offered to people in Somerset per month and reported outcomes and evaluation has been very positive. Work is underway to collate further Patient Related Outcome Measures. Following a Realist Evaluation methodology, the researcher in residence has highlighted the culture changes that are key to delivering the aspirations of the Community MH Service framework. These include; the narrative of “no wrong door”, an increased and open range of offers and interventions, blended staffing models across traditional organisational boundaries, partnership working, the role of lived experience and the ambition of addressing inequalities.

OMH, the product of Community MH Transformation in Somerset, is a radical and co produced redesign of MH services in partnership with the VCSE and Local Authority that has improved access and support to all people in Somerset.

The National Institute for Health and Care Excellence guidelines state that benzodiazepines (BZD) should not be taken for longer than four weeks. However, there are no recommendations specifically addressing the use and misuse of BZD in inpatient settings and their prescription at discharge. A recent study (Panes et al., 2020) recommended aiming for BZD’ total withdrawal or, at least, dose reduction at discharge to reduce the risk of misuse in the community which can lead to dependence and serious side effects. Our study aimed to 1. describe BZD’ prescriptions on an acute female ward, before admission, during admission, at the time of discharge and at four and eight weeks post-discharge, 2. identify potential sociodemographic, clinical and therapeutic correlates/predictors of BZD’ prescriptions, 3. develop a strategy to reduce BZD’ prescriptions or, at least, to reduce the dose of BZD prescribed at discharge.

Data collection was done retrospectively through electronic medical and prescribing records and included admissions to Avocet Ward, between May and October 2021. Variables collected were age, ethnicity, length of stay, Mental Health Act status, diagnosis, comorbid drugs or alcohol misuse, Home Treatment Team involvement at discharge, community teams, prescriptions of regular and Pro Re Nata BZD and “z-drugs” prior to admission, during admission, at discharge, and at 4 weeks and 8 weeks post-discharge, maximum dose of regular BZD during admission and the dose at discharge.

Among the 59 admissions included, 25.4% had BZD before admission, 81.4% during admission (with a mean maximum dose of regular BZD of 38.8 mg (SD = 17.3) of diazepam equivalent), 50.8% at discharge (with a mean dose of 28.5 mg (SD = 18.5) of regular BZD), 35.6% 4 weeks post-discharge and 27.1% 8 weeks post-discharge. The odds of having regular BZD during admission were 7.4 times more likely for those on regular BZD before admission after controlling for other variables (95%CI: 1.1, 50). The maximum dose of regular BZD during admission was positively correlated with the dose of regular BZD at discharge (r(15) = .67, p < .01). Among the regular BZD prescribed during admission (N = 23), 26.1% were fully discontinued by the time of discharge and 43.5% were titrated down, while 30.4% remained at the same maximum dose prescribed during admission.

BZD prescriptions are common at discharge from inpatient settings and can be associated with BZD misuse in the community. We suggest strategies to avoid this issue.

Ekbom's syndrome (ES), also called delusional parasitosis, is a condition where the patient has an unshakable belief and a perception of being infested with parasites. ES is thought to mainly affect postmenopausal females and because patients are usually mono-symptomatic, they usually seek care from dermatologists. It is advocated to form a liaison between dermatology and psychiatry to ensure a full range of differential diagnoses, in order to form the most suitable management plan.

Case report

An 87-year-old widow was referred to the outpatient psychiatric clinic of King Abdullah University Hospital by a dermatologist because of generalized chronic pruritus that she believes is caused by a bug infestation. The symptoms started one year prior to presentation (soon after an ischemic stroke) with the perception that macroscopic parasites were crawling over her body, biting her face, head, and hands, and entering her eyes. She tried various strategies to eradicate the parasites with no benefit. Psychiatric examination findings included hypochondriac delusional ideas and dysphoria. When her general medical condition and her medications were reviewed, it was found that she had been diagnosed with hypertension and ischemic heart disease. She was taking anti-hypertensive drugs and blood thinners. After haloperidol 5 mg daily was added, she had a progressive clinical improvement.

ES is a neuropsychiatric syndrome that can follow primary psychotic or depressive disorders, dementia, or other organic diseases. Consultation-liaison by psychiatrists and dermatologists will be useful to assure timely referral. Better awareness of such an illness by general physicians, early recognition, good rapport, and empathic treatment are the cornerstones of management in such cases.

Mr AB is a 58-year-old male with diagnosis of Schizoid Personality disorder. An articulate and intelligent man, AB derived happiness and contentment from his work. Due to workplace conflicts, he was asked to resign several years ago and has not worked since. Mr AB then found a sense of purpose in life by looking after his elderly parents. His parents sadly died a few years ago and since then he has been living on his own. He has never married. AB has one brother who helps him with shopping and groceries. Prior to this admission, AB was admitted once a few years ago when he was diagnosed with Depressive Disorder.

Mr AB was admitted last year with profound self-neglect. He was detained under Section 2MHA as he wasn't eating and drinking and wasn't engaging with services. With the initial diagnosis being Recurrent Depressive Disorder, AB was commenced on treatment for the same and eventually received ECT, for which he had strongly opposed. Following 6 sessions of ECT, AB bargained with the team that he would start eating and drinking if ECT was stopped and did so as well. He then requested a transfer to a different ward and consultant, with whom he shared that he doesn't agree with our diagnosis of depression or Schizoid personality disorder. AB expressed that he doesn't find his life worth living and wants to be left alone. He strongly believed that his liberty to take decisions about his life is being unfairly taken away by the NHS and accused professionals of trying to protect themselves. No evidence of SMI found at this stage. Following several discussions, AB was discharged home. He however was readmitted within a couple of days’ time by his brother following disengagement, self-neglect and again, no evidence of SMI.

A capacitous patient, in the absence of Serious Mental Illness puts forth an argument that purely because his way of living and his opinions on life and death differ from that of the society, doesn't mean that his rights over his life can be taken away from him. He, however, struggles to acknowledge that as fellow humans we are strongly inclined to intervene and try to stop anyone from taking their own life.

A Challenging case that raises several questions surrounding Medical Ethics. The team is now looking into guardianship to ensure welfare of the patient.

The amended Mental Health Act (MHA) of 2007 gave Psychiatrists the right to detain, assess and treat individuals with mental health disorders, not only with a view to offer medical treatment but also to ensure their safety and that of the public, by containing them. This meant that patients diagnosed with disorders such as Antisocial Personality (APD), previously un-detainable under the MHA of 1983, would no longer be considered untreatable and could be sectioned, if appropriate. The idea was then generated, that Psychiatrists would now assume the role of custodians of potentially dangerous people and raised the concern that all persons with APD would be perceived as dangerous and find themselves at a dynamic risk of being sectioned under the revised MHA. The balance between the role of Psychiatrists as medical professionals versus this new, unpopular role as figures of public order was and still is, debatable.

We present the case of a patient with a background of Depression and Post-traumatic Stress Disorder with aggressive features, who during a consultation revealed a powerful homicidal urge and fantasies directed to an individual he believed had wronged him. The patient had access to the individual and had attempted to confront him. He had no forensic history, nor had he expressed criminal intent before. This triggered a safeguarding response, the consensus being that advice should be sought from the Forensics team, not only to protect the potential victim but also the potential perpetrator from the consequences of a criminal act.

Considering the lack of police involvement, plans, or weapons; the separation between patient and potential victim; and the patient's distress associated with the disclosure of the homicidal fantasies, the level of risk was deemed to not merit disclosure. Closer risk assessment with ongoing psychological and pharmacological interventions created a therapeutic alliance which allowed for open communication with regards to the dynamic nature of the risk and the potential for any further disclosure.

Within the definition of Duty of Care lie responsibilities beyond the strictly medical role of clinicians. Not unlike the duty to inform the DVLA about a patient's fitness to drive, breaking confidentiality for the purposes of patient or public safety is not a power that makes Psychiatrists figures of Authority, but a responsibility that is part of their role. At the same time, we should bear in mind that the license to disclose is also a license not to disclose.

Catatonia has an effective treatment: benzodiazepines. A first presentation of catatonia may present initially to an acute medical trust. It is important acute clinicians are familiar with its manifestations, medical differentials, and most importantly, understand the role of benzodiazepines in both the investigation and management of catatonia.

Here we describe a case of catatonia in a nineteen-year-old male, who presented acutely to the accident and emergency department with odd behaviour following inhalation of the synthetic cannabinoid ‘spice’. Initially, he was found to be rigid, mute and doubly incontinent, but able to follow vague commands. He was admitted to the acute trust for twelve days in which he was worked-up as a case of drug induced psychosis. As he was not improving, he was then transferred to psychiatric inpatient services for further investigation and management.

The acute medical team did not recognise this as a presentation of catatonia and did not conduct a lorazepam challenge, as suggested by specialist services. A lorazepam challenge is helpful in both diagnosing and treating catatonia. In this case, we believe this may have been missed, due to a lack of knowledge and understanding of the condition. Medical mimics of psychosis, such as autoimmune encephalitis, may be life threatening, but have a good prognosis if treated early. Here, these were not considered, which may have led to disastrous consequences had they been present. This case shows an opportunity for education into the differentials and management of catatonia.

We believe this case highlights a degree of poor understanding surrounding catatonia and its clinical work-up in the acute setting. There were missed opportunities to instigate treatment earlier and consider rarer alternative causes for the presentation. We hope this case will simplify diagnosis and management for acute clinicians, and highlight important medical mimics of catatonia. This case also shows the potential significant harms of synthetic cannabinoids such as ‘spice’ and highlights a need for further research and potential review for grading above Class B in the Misuse of Drugs act 1971.

Emotionally unstable personality disorder (EUPD) accounts for up to 20% of diagnoses in the inpatient psychiatry population. The assessment, diagnosis, and treatment of any personality disorder may be challenging, and its classification remains debatable. Here I will describe a case of a dual diagnosis of EUPD and schizotypal personality disorder. Through the case report I will also reflect on my first experience of working with a patient with personality disorder, as a Psychiatry Foundation Fellowship doctor with little previous exposure to the psychiatry specialty.

The patient was a female in her thirties, previously diagnosed with EUPD, who had not benefitted from a number of psychological treatments. She had a history of suicidal behaviour and previous admissions but presented differently this time. She had short hair that was dyed in a vivid colour, was paranoid that she was being spied upon from an alternative universe and had suicidal plans to join the alternative universe. She also had auditory and visual hallucinations. On exploration it became apparent that she had similar episodes in the past, each lasting no more than a day. An additional diagnosis of schizotypal personality disorder was made, and she responded well to risperidone. Unfortunately, she was transferred to another ward for bed management reasons, whereupon the diagnosis reverted to EUPD and antipsychotics were stopped.

This case highlights how in mixed personality disorders, features of one personality disorder may be more predominant than another at different times. It also contradicts the notion that people with schizotypal personality disorder rarely present to mental health services. The inconsistency of diagnosis and lack of continuity of care caused immense distress to the patient, prolonging the acute episode. This highlights the importance of a good formulation in order to tailor care for the patient.

As a newly qualified doctor, working with patients with personality disorders was a meaningful experience. Through ward rounds and the seemingly trivial conversations along the corridor, I thought about the effect of transference and countertransference for the first time, which is applicable to any interpersonal interaction. I witnessed the harm caused by the lack of continuity of care. I reflected on the intricate balance between the advantage of establishing a diagnosis for the patient, and the drawback of the diagnosis leading to labelling. It made me face the stereotypes I held and allowed me to learn about the patient as an individual.

Intern doctors are the backbone of the hospital infrastructure. While they are the first to provide patient care on an Emergency and Elective basis, they also happen to be the junior most. The interns of the year 2021–2022, apart from working in various departments of the hospital, were also the frontline workers in the 2nd and the 3rd wave of the COVID-19 pandemic. In the current global public health crisis, interns are more exposed to physical and mental exhaustion, owing to being overworked, along with carrying the burden of loss of patients, colleagues, and potentially infecting themselves and their loved ones to COVID-19. Burnout, a psychological syndrome that occurs due to work-related stress, includes emotional exhaustion (EE), depersonalisation (DP), and a sense of reduced personal accomplishment (PA). Intern doctors run a high risk of facing burnout—the prevalence of which is yet unknown. Hence, the survey was conducted.

An online survey was carried out using MASLACH BURNOUT INVENTORY (MBI) among interns with their voluntary participation. 22 symptom items pertaining to occupational burnout were assessed, with three-component scales: emotional exhaustion (9 items), depersonalisation (5 items), and personal achievement (8 items), with a 7-level frequency scale for all MBI scales and 0–6 scoring.

Responses were received from 180 interns (n = 180). Questions regarding current department postings and contraction of COVID-19 were included in the survey.

Burnout was prevalent in most interns who tested positive for COVID-19 = 60% (108), followed by those whose family members tested positive for COVID-19 = 23.8% (43).

Burnout was seen more in female interns = 30% (54) than in males = 10.56% (19).

Burnout was seen more in interns working in the Emergency and Trauma = 41.67% (75), and the least in Ophthalmology = 1.67% (3).

Burnout is significantly prevalent in intern doctors at the end of the academic year, especially due to the COVID-19 pandemic. Burnout can lead to increased medical errors, reduced patient satisfaction, which affects the quality of patient care. Understanding risk factors, improving workplace environment, limiting duty hours, workshops promoting healthy behaviours have been suggested to reduce burnouts and to prioritise both mental and physical health of interns so as to ultimately improve patient care.

Crystal House is a specialist CAMHS ID inpatient 5-bedded unit based in the Kingswood Centre, North West London - for children aged between 13 and 18 years with primary diagnosis of Intellectual Disabilities with or without additional concerns that warrant admission to hospital for purpose of assessment and management. Reporting this case, we wanted to highlight complexities of management of children presenting with neurodevelopmental conditions and history of trauma.

This is a case of a fourteen-year-old girl with established diagnoses of Moderate Intellectual Disability, Childhood Autism, Foetal Alcohol Syndrome and childhood trauma. She was admitted to our CAMHS ID Assessment and Treatment Unit with a nine- year history of self-injurious behaviour, suicidal ideation and voice-hearing experiences – after failed treatment in the community and in-patient treatment (including under restrictions of long-term segregation) on generic CAMHS unit. Her current treatment includes a person-centred Trauma- Informed Positive Behaviour Support Plan; individual and family therapy psychology sessions based on the principles of trauma-informed care and consultation with staff on trauma-informed care. She also undertook ADHD assessment, and we are in the process of optimising ADHD medication.

Trauma-Informed Positive Behaviour Support Plan was a new concept for the team. Therefore, this was supported by training and consultations with staff. The latter was introduced to create a psychologically oriented environment using trauma-informed care principals and helping the team understand what trauma means and how it affects the individual. ADHD assessment confirmed the diagnosis of ADHD which was followed by optimising ADHD medication.

Systemic and a person-centred approach is used for this child with concerning presentation and history of neurodevelopmental disorder and childhood trauma.

Traumatic brain injury during the war by shrapnel or bullet is lethal and life-threatening. The mortality rate from traumatic brain injury is more than 90%. Mrs. N (70) of Bangladesh is an exceptional and one of the luckiest women of the world. She is a war victim and has been living with shrapnel within her brain for the last 50 years.

According to the patient attendant, half a century ago, during the Liberation War of Bangladesh, one shell accidentally exploded in their backyard. Unfortunately, a few pieces of shrapnel penetrated her arm, leg and right side of the head. She lost her consciousness and immediately treated at war hospital as per level best. She forgets details of her treatment and has no treatment records. Last 50 years, she has been surviving with movement difficulties, weaknesses of the upper and lower limbs and occasional convulsions. Her sufferings have intensified day by day. Last few years she has been experiencing headaches, dizziness, vomiting and forgetfulness. Two months back, she drank some insecticide mistakenly. She also suffering insomnia and she often cried out from deep sleep. She complains about hearing unknown voices. The voices were talking about her. She also started to suspect her family members. She claims that her family members were conspiring to kill her. She has history of convulsions three times in the last 50 years, which were generalized and tonic clonic in nature. She didn't take any medication for convulsion. As her suspicion, irrelevant talk and oddity in behavior worsened, her family members took her to me for treatment. Considering her past traumatic brain injury, an X-ray skull was advised. Surprisingly, it showed a metallic foreign body (shrapnel) within her skull. Furthermore, a CT scan of the brain was done, and it showed there was an irregular bony gap at right parietal area, a shrapnel at right frontal area with extensive encephalomalacic Porencephaly communicating with lateral ventricle. Her thyroid and liver function are normal. She is non-diabetic, non-hypertensive. She was advised to take risperidone 2 mg daily at night. With this low dose antipsychotic medication her psychosis controlled.

Surviving with shrapnel within the brain followed by traumatic brain injury is very much rare. Shrapnel gradually damages the brain parenchyma and creates a large porencephaly.

Traumatic brain injury by bullet or shrapnel is always fatal. It is very much rare in medical to survive fifty years with shrapnel within the brain after shrapnel injury.

Lithium is an effective mood stabiliser for the treatment of the bipolar disorder. Its utility is not restricted to acute mania and prophylactic treatment of the bipolar disorder. Another well-known indication for its use is the treatment of refractory depression. Lithium can cause several adverse effects, and typically the side effects are dose-related. Unlike antipsychotic medications, lithium is rarely associated with drug-induced Parkinsonism.

We present a case of 78 years old gentleman who was assessed due to complaints suggestive of cognitive impairment. His past psychiatric history revealed that he was admitted to a psychiatric inpatient unit with a diagnosis of treatment-resistant depression in 1991. Lithium therapy was commenced during this admission, and he remained on lithium for 27 years. The patient was clinically stable in terms of the symptoms of depression; however, he reported bilateral postural tremors 20 years after the initiation of lithium therapy. Initially, he was diagnosed with lithium-induced tremor; however, in the following months, his symptoms had worsened, and he developed new motor disturbances, although the serum levels of lithium were within the therapeutic range. On examination, he had classic parkinsonian signs of shuffling gait, muscle rigidity in all four limbs and freezing of gait. DaT-SPECT imaging clarified the diagnosis as drug-induced Parkinsonism. As the daily lithium dosage was stopped, the patient's motor symptoms improved significantly; nevertheless, some of the symptoms persisted.

The pathophysiological mechanism behind lithium-induced Parkinsonism is unclear. The condition may develop with or without frank lithium toxicity and have diverse presentations. Literature suggests that the risk factors for lithium-induced Parkinsonism appear to be the patients' age, duration of lithium therapy, and serum lithium levels. It has been suggested that older patients have a more permeable blood-brain barrier and decreased renal clearance; hence, serum lithium levels can appear therapeutic, but brain lithium levels may be much higher. Pharmacokinetic drug-drug interactions might also contribute; thus, careful monitoring is essential.

Drug-induced Parkinsonism improves with discontinuation of the offending medication; however, 10% of patients will develop a persistent and progressive parkinsonian syndrome.

This report aims to emphasise the need to consider lithium-induced Parkinsonism when Parkinson Disease symptoms appear in chronic lithium users and close monitoring of lithium levels in geriatric populations. It is essential to recognise the condition, avoid misdiagnosis and prevent inappropriate use of anti-dopaminergic medications.

The authors intend to briefly review the literature regarding the progress of substance misuse rates and harms, the support available and reflect on the current national situation. We aim to better understand the changes in policies and services, and their impact to see what can be learned from the Portuguese experience.

A narrative literature review was carried out by the authors using the keywords “addiction” “drugs policy” “Portugal” “drug use”. The authors declare no conflicts of interest.

The end of the dictatorship in 1974, the reopening of borders, and the return of white Portuguese from former colonies, were all associated with a dramatic increase in substance misuse in Portugal. In the 1990's it is estimated that 0.5%-1% of the population was using heroin at the time, with extremely high rates of HIV and Hepatitis in intravenous drug users.

At the start of this period, healthcare services were poorly organized, resources for substance misuse services were limited, legislation was punitive, and there was a general understanding that drug addiction was a consequence of a moral failing. A change in paradigm occurred in the late 1990's and new legislation introduced in 2001, which along with the growth in services to support substance misusers dramatically reduced the rates and negative outcomes of substance misuse.

Of note, new HIV diagnoses due to injecting and overdose rates dropped significantly in the XXI century and decriminalization did not lead to an overall increase in substance misuse.

The pivotal shift in the understanding of the nature of addiction as an illness lead to a profound change in interventions to mitigate this overwhelming problem that affected Portugal by the end of the XX century. We hope that by sharing this experience this will improve interventions around the world to support substance misusers and public health.

Conversion disorder is common among children and adolescents, particularly in non-Western societies like in Bangladesh. Diverse presentation of the disorder makes it difficult to diagnose which ultimately may lead to poor prognosis.

Patient X is a 10-year-old girl, a 5th grade student, hailing from a District town, Bangladesh, attending child and adolescent consultation services with the complaint of sudden loss of vision in both eyes for 3 weeks. Earlier, she underwent thorough examination and investigation and intervention by the different specialists (GP, ophthalmologist, and neurologist). At one point she was given zero power glasses. Her symptom was then fluctuating. She was not attending school as she was away for treatment purposes. X complained of not seeing lines of books when her parents tried to persuade her to do schoolwork at home. Eventually she was referred for psychiatric evaluation after no improvement. Assessment was completed and parental discord, violent act of father towards mother, overprotective as well as inconsistent parenting, attention seeking behaviour of X were identified. General and systemic examinations were normal. Her finding was inconsistent with any physical disorder. Investigation was normal. Thus, diagnosis of conversion disorder was given. General treatment (reassurance, psychoeducation, adopting daily life programme) along with specific treatment (symptom reduction by suggestion, relaxation, and family therapy) were provided. Improvement was noted during the follow-ups.

The conversion disorder of this girl happened at her period of transition from childhood to adolescence. Psychopathology of hysteria still is not clear despite huge research efforts. Based on psychodynamic explanations, the core psychopathologies of her symptoms are primary gain - resolution of her witnessing severe parental discord that she failed to cope with happened through her presenting symptoms without awareness though later she does in awareness; secondary gain- she receives additional reinforcement in the form of extra care, parental help seeking behaviour, unnecessary interventions, demand fulfilment that mostly present in awareness. Other psychopathologies are conversion- the patient's psychological distress converted to presenting somatic symptoms through an intrapsychic process; repression-la belle indifference of the patient has developed through a process of displacing distressful experience, from awareness that gives relief to the distress.

Manifestations of conversion disorder can simply be explained as cry for help, give indication of the problem areas, help in understanding personality traits, making intervention and prevention plans. Early identification of stressors is crucial for the treatment of this disorder.

Fahr's disease is a rare neurodegenerative disease with radiological findings of symmetrical and bilateral idiopathic calcifications of the cerebellum, periventricular white matter, and basal ganglia, characterized by the presence of neuropsychiatric symptoms.

We report a case of a 46-year-old male who presented with psychomotor agitation, aggression, restlessness, irritability, decrease need for sleep and psychotic symptoms including grandeur and mystical delusions. He had a previous history of an admission 4 years prior with a similar presentation. Computed tomographic scan of the patient demonstrated a bilateral calcification of globus pallidus. Laboratory investigation was unremarkable. Due to agitation, the patient started treatment with Haloperidol 10 mg and Levomepromazine 25 mg presenting resulting in important extra-pyramidal symptoms (EPS), namely marked motor rigidity. Subsequently, a switch was made to Olanzapine 5 mg with persistence of clinically significant EPS. A final switch was made to Aripiprazol 15 mg (gradually titrated) and a mood stabilizer was started (Sodium Valproate), with full clinical remission within a month and no signs of EPS.

The age of onset of manic symptoms in this patient is not suggestive of bipolar disorder (average age onset 25). On the other hand, Fahr's disease usually presents within the 4th and 5th decade of life. The clinical presentation usually involves motor symptoms (movement disorder and Parkinson like symptoms) and dementia, but purely psychiatric presentations have been described. The localization of calcifications also seems to have a clinical correlation, as Pallidal calcifications as the ones identified in our patient have been associated with manic symptoms. Idiopathic forms in which no metabolic or other underlying causes are identified, treatment is usually symptomatic, but one has to be cautious because these patients have an increased sensitivity to neuroleptics and can thus easily develop EPS.

Psychiatrists should consider Fahr's disease as a differential diagnosis in a manic episode, especially with a late age of onset, which is not suggestive of a bipolar disorder. This case also further emphasizes the importance of neuro-imaging in psychiatry and underlines the importance of a careful treatment approach in this type of patients because of an higher risk of developing EPS.

Lyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixode. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves regardless of antibiotic treatment. It may result in a range of clinical manifestations involving different organ systems, and can lead to persistent sequelae in a subset of cases.

We describe a case of a 47-year-old male, with severe intellectual development disorder (IDD), who presented with behavioural changes, aggressiveness, psychomotor agitation and confusion. 15 days prior to admission in the psychiatry ward he had recurred several times to the emergency department with similar clinical presentation, and had been discharged following adjustments to his medication. After showing no improvement and no response to treatment he was admitted. He then presented fever and laboratory study (LS) revealed increased inflammatory markers. His family also informed he came from a rural area and had contact with wild dogs. No tick bite or erythema was identified during physical examination. Nevertheless a serologic study for Borrelia burgdorferi was performed and turned out positive. An antibiotic regimen was administered and and the patient's symptoms fully remitted 48 hours after treatment was initiated.

Borreliosis usually presents erythema at the site of the tick bite which could have already resolved when the patient was examined. It was first assumed that the clinical manifestations were part of his psychiatric condition. An infectious etiology was presumed after the onset of fever and increased inflammatory markers were identified. Given the patient's context, Borrelia in particular was considered a likely hypothesis. This case illustrates the difficulties of differential diagnosis inherent to patients with IDD, both because of the pathology itself, which can mask such clinical manifestations as delirium, and of the stigma associated with mental health patients, which frequently cuts the diagnostic work-up of organic causes short.

This case highlights the clinical challenge patients with IDD represent. Differential diagnosis can be elusive, especially in the context of infectious diseases like borrelia, as they can present with unspecific clinical manifestations in this subgroup of patients, and hence why a complete and thorough clinical evaluation is essential. This case also illustrates that mental health patients suffer from stigma: Being branded a “psychiatric patient” created a 16-day delay between onset of symptoms and appropriate treatment initiation- antibiotics.

Chronic mania is variably defined but classically recognized as the presence of manic symptoms for more than 2 years without remission. The reported incidence ranges between 6–15% among all patients with bipolar disorders. Although it has been described in psychiatry literature for a long time, it has not yet found a place in current nosological systems

We present a 32-year-old single and unemployed man who is supported by his family and living with a sudden-onset, continuous illness of 12 years’ duration characterized by a resistant and markedly euphoric and expansive mood with grandiose delusions. Other features such as distractibility, pressured speech, racing thoughts and psychomotor disturbance remain significant but vary and are more responsive to medical interventions. Psychotic symptoms are largely confined to mood-congruent delusions, grandiose and religious, and are reported to have followed the mood disturbance from early on. There is no history of substance use, past psychiatric or medical illness, or head trauma and no evidence of a neurological cause on workup. This gentleman has been treated with a range of mood stabilizers and antipsychotics and two courses of ECT over the years. In the recent years, he has been on a combination of Clozapine, Valproate, and Pregabalin with relatively favorable but inadequate response and limited functional improvement.

Chronic mania lasting for 12 years, in the absence of an organic cause, despite the use of a wide gamut of modern psychotropics, alone and in combination with ECT, and with adequate compliance is an exceptionally rare entity. It poses manifold challenges both in terms of diagnostic considerations and therapeutic approaches. The overlap of symptoms of mania, schizophrenia, and schizoaffective disorders along with chronicity adds a particular layer of complexity. The hallmark of chronic mania is euphoric and expansive mood along with grandiose delusions and the presentation is relatively less centered on sleep disturbance, hypersexuality, and psychomotor agitation as compared to an acute manic episode. It is distinguished from schizophrenia spectrum disorders as it lacks flat or inappropriate affect, incongruent delusions and disorganized thought. Course of illness, prior mood episodes and family history are important in differentiating from a schizoaffective pattern of disease.

Unremitting mania of this duration is unique in its psychiatric morbidity and devastating in its impact on the individual in terms of psychosocial functioning, quality of life, physical health and safety. It also brings unprecedented stress on the family and other support systems.

Paracetamol is a commonly used antipyretic and analgesic over the counter medication. In acute or chronic overuse it is associated with dose-dependent hepatic injury. There is a narrow therapeutic margin and that consistent use of as little as 7.5 g/day may be hazardous. Unintentional overdose with paracetamol is the most common cause of acute liver failure in the United Kingdom Here we present an unusual case of a 60-year-old lady with a reported chronic history of self-medicating with an above daily recommended dose of paracetamol without evidence of hepatic injury.

A 60-year-old Caucasian lady known to psychiatric services for 20 years with Recurrent Depressive disorder, Obsessive Compulsive Disorder (OCD), Dependent Personality Disorder with Borderline personality traits. She reported consuming 32 tablets of paracetamol (16gm per day) every day for the past 11 years. She experienced obsessions of fear that if she did not take a particular number of paracetamols in a day then her friends will come to harm and her anxiety was relieved by the compulsion of consuming supratherapeutic doses of paracetamol. There was no evidence of misuse of any other medications other than paracetamol. Her blood investigations revealed liver function tests within normal limits and ultrasound of the liver was unremarkable.

A literature search of “paracetamol or acetaminophen” and “no liver or hepatic” and “damage or injury” found only one case report. The case reported that studies of paracetamol metabolism were performed in a 58-year-old female with rheumatoid arthritis who had consumed 15–20 g paracetamol daily for 5 years without developing liver damage and data were compared with results in seven normal volunteers. The report concluded that a combination of slow paracetamol absorption, enhanced detoxication of paracetamol (by sulphation) and reduced metabolism to potentially cytotoxic metabolites may have reduced the risk of liver damage in this patient.

In OCD, misusing medications can be an uncommon presentation of compulsive acts to relieve anxiety. The diagnostic dilemma of factitious illness is probable, however supratherapeutic use of paracetamol without physical harm is rare but possible.

The association of ADHD with mental health and medical conditions is commonly encountered in clinical practice. Interestingly there are patients with congenital conditions who present with features of ADHD and little is known about their association and neurological basis. There is no strong literature but anecdotal reports that indicate children with congenital heart disease are more likely to suffer from mental health conditions including ADHD. The clinic however is unable to analyze such hypothesis and instead decided to evaluate cases related to Neurofibromatosis (NF1), Arnold Chiari Malformation, Transposition of great arteries, Di George syndrome to understand the longitudinal history, symptom persistence and functional impact of ADHD.

• A. Index patient aged 45 years referred for possible association of ADHD and Neurofibromatosis with issues related to long-standing trouble with sleep and movement disorder.

• B. Index patient aged 41 years received a surgical repair for a Chiari malformation hoping it would improve the cognitive functioning but still suffers lot of symptoms that are consistent with clinical picture of ADHD.

• C. Index patient aged 19 years referred for ADHD assessment reported history of transposition of great arteries and VSD that warranted emergency operative procedure before age 3. The behavioural symptoms that were suspected as related to physical illness and frequent attendance to hospital however did not resolve and were noted to be in line with possible ADHD.

• D. Index patient aged 40 years admitted to general psychiatry following episode of psychosis and during examination presented history of Di George syndrome with brief input from Cardiology. It was apparent that patient struggled with poor understanding, lack of consistency, disorganization, distractibility, learning difficulties and the features suggested a pattern of Attention deficit disorder.

Focused on

1. 1. The qualitative analysis of developmental history, childhood rating scale, symptom comorbidity and functional impairment of such cases.

2. 2. It studied the family history of physical and mental illness including predisposition to ADHD or neurodevelopmental conditions.

3. 3. It also evaluated the treatment response to stimulant/non-stimulant therapy.

Clinically there was no typical co-relation of increased mental illness or genetic predisposition for ADHD in the family history and qualitatively the presentation did not differ from other ADHD patients and the treatment response was not variable, however it still draws attention towards the need for regular screening of all nervous and cardiac origin congenital conditions for an early intervention.

Treatments without robust evidence are not recommended. However, some patients detained in secure hospitals might need novel approaches such as: off-license use of medication, use of psychological (rather than their biological) effects of drugs. In addition, some detained patients may request for unconventional treatments they believe in. In community and capacitous patients, the clinician's role is advisory and the burden is on the patient to make the final decision and access such treatments privately. However, in a detained patient (with or without capacity), it may fall on the Responsible Clinician (RC) to deny or facilitate access to such interventions. Currently, there is no guidance for such circumstances. We have presented three real cases followed by proposing a flowchart to guide RCs.

Case 1 (2019–2020): X with mild Learning Disability (LD) and mixed personality disorder detained under Section 3 with no leave to community. X asked for Hypericum which has been helpful with her headaches in the past. X had capacity to make that decision.

Case 2 (1996–97): Y with mild LD and aggressive behaviours responding instantly to any injection. Y lacked capacity so injections of distilled water was tried in his best interest, with equal positive effect. The question was about using distilled water as rapid tranquilisation with no side effects.

Case 3 (2020–21): Z with a treatment-resistant psychosis who has been unwell for months and detained in four different PICUs. Z's father requested N Acetyl Cysteine which had historical calming and sedative effects for Z.

The main issue in case 1 is the conflict between the patient's Human Rights and RC's Duty of care. Here the patient could be potentially deprived of their right to make an ‘unwise decision’ should the RC bar her access to a treatment which lacks evidence but is privately available to public. This can be construed as an infringement of Article 8 of Human Rights.

The issue in case 2 and 3 is rather different. Here the conflict is between the RC's duty of care to provide evidence-based treatments and the patient's “best interest” which seems to be an intervention without robust evidence.

We have developed a flowchart to help RCs by navigating amongst several competing/ conflicting legal and ethical concepts such as: Patient's wish/Human rights, Patient's capacity, Bolam test, “Medical Treatment” Under Section 63, 62 or 58 of Mental Health Act 1983, Best interest, Second Opinion (SOAD) and advice from court.

Creutzfeldt-Jakob disease (CJD) is a rare, progressive, fatal neurodegenerative disorder caused by an abnormal glycoprotein known as the prion protein. The core features include progressive cognitive decline, cerebellar dysfunction, personality changes, and visual disturbances. Although psychiatric symptoms are rare, they can be the primary symptom of CJD, and such presentations can pose diagnostic difficulties. In this paper, we describe the case of Ms. R, who manifested psychotic symptoms as the first signs of CJD.

Ms. R, was a 49-year-old white British female not previously known to psychiatric services, who presented with acute onset of florid psychotic symptoms. Her symptoms included auditory hallucinations, paranoia, and thought disorder. She was treated with antipsychotics for over four weeks, following her admission, but no improvement was seen. Instead, her psychosis worsened with cognitive decline, mutism, and the appearance of neurological symptoms such as jerky body movement, ataxia, and falls. All screening blood tests, chest X-ray, and CT abdomen were normal. The MRI, however revealed few patches of high T2/FLAIR signal in the deep white matter. Cerebrospinal fluid showed increased protein. Neurologist reviews suggested the possibility of sporadic CJD (sCJD) as a probable diagnosis. As her condition deteriorated, she became comatose and died four months after the appearance of the first psychiatric symptoms.

It can be challenging to diagnose CJD since the clinical picture overlaps with other neuropsychiatric and neurodegenerative conditions. It requires the presence of relevant clinical findings along with positive CSF, EEG, or MRI findings to make a probable diagnosis. Regarding our case, some noteworthy observations were psychosis as the initial symptom, relatively delayed onset of neurological signs, rapid deterioration with brief duration of illness. The MRI findings were typical of those seen in sCJD, although the EEG did not suggest sCJD. A differential of variant CJD was considered because of her age, prominent psychiatric symptoms, and delayed neurological signs.

Creutzfeldt-Jakob disease course is rapidly progressive, and majority of patients die within one year. Therefore, awareness of early clinical features is of great significance. Among other things, this would enable patients and their families time to understand the nature of CJD, prognosis and prepare advanced directives. This case adds to the growing number of atypical presentation of CJD as well as pointing to an expanding spectrum of the disease. Therefore, clinicians should consider CJD in the differential diagnosis of new-onset psychosis, particularly if symptoms persist and worsen despite standard psychiatric treatment.