This audit was to assess and improve the organizational efficiency of referrals to Inverness Sector A Outpatient Service. The referrals were audited to measure the average waiting time from referral to first offered outpatient appointment and to assess the proportion of patients waiting longer than 12 weeks.

The audit included routine referrals to the CMHT Inverness Sector A, NHS Highland from GP practices: Kingsmills, Burnfield, Riverside, Fairfield, Foyers and Drumnadrochit Medical Practices. The number of referrals and the number and proportion of clients given appointments for assessments were calculated. Referrals were received directly from primary care and the Mental Health Liaison Team or following Out of Hours contacts at the Mental Health Assessment Team.

Data were collected retrospectively: referrals from 1 Jan 2020–31 Aug 2020. Sample size came to 160 patients aged 16–65 years. Data were collected via review of recorded documentation on the NHSH electronic patient record systems (SCIstore), from 5th–25th January 2021.

160 patients (male 82, female 78) were referred from 1 Jan to 1 Sept 2020. Of these, 140 (87.5%) were given an appointment for an assessment. The mean waiting time was 12 weeks for 103 patients (64%), with 57 patients (36%) waiting longer than 13 weeks. The bimodal distribution of waiting times prompted an analysis of those with longer waiting times. In some instances, appointments were delayed because patients either did not attend (DNA) or cancelled their appointments. Reasons for delays included: postponement until further information was available; cancellation of meetings or patients DNA. In 20 cases (12.5%), the referrals deemed inadequate, prompting further liaison with the referrer for clarification about the nature of the problem and previous psychological interventions.

The number of transactions (any amendment to a patient record) was higher than the number of patients affected, as several transactions can relate to one patients’ record.

Most referrals are vetted in advance via the daily Inverness triage huddle. Ways of improving the quality of information provided by referrers would be explored.

On receipt of each referral, the date of the 12 week deadline would be calculated and highlighted in a database.

The cross-sector (Highland wide) standardisation will add clarity about medical capacity, that does not involve use of excessive clinician time.

The objective of this report is to highlight the finding of a movement disorder caused by promethazine in a 16-year-old female and to alert other clinicians to a high index of suspicion of possible movement disorders in young people on promethazine.

I discuss a 16-year-old female (who presented to medics at 15) with low mood, lack of motivation, self-consciousness – at 15, she was over 6 feet tall and weighed 81.2 kg. She also self-harmed by cutting her thigh with razor along with poor sleep, anxiety, and panic attacks. She took an overdose of paracetamol and ibuprofen and a strip of vitamin D and irritable bowel tablets she found at home.

A clinical impression of moderate depression with anxiety and panic attacks and possible emerging emotionally unstable personality traits was made and she had begun psychological sessions with the therapist before referral to the medics. Fluoxetine 20 mg OD increased to 40 mg and Circadin 2 mg ON was commenced. Fluoxetine was later tapered off and Circadin stopped. Sertraline 100 mg OD increased to 200 mg was commenced and Promethazine 25 mg ON to improve sleep.

Within a month of commencement of promethazine, a sudden onset of extension of neck, blowing through lips and a high-pitched sound occurred whilst experiencing a panic attack and hyperventilating. She also stuttered and had difficulty in speaking, and her vision would go blurry. She initially refused to come off promethazine as it had helped her sleep. An impression of a tic disorder characterised by motor and vocal tics was made. There had been no recent infections or previous history or family history of tics. However, at this point, sertraline had helped with her motivation and she was able to come off promethazine and her sleep was improved by practising sleep hygiene with an accompanied cessation of tics.

Young person is currently on 150 mg of Sertraline.

The rationale behind reporting this case is that previous studies have pointed at SSRIs, as causes of tics disorders, but promethazine is one that does a good job in improving sleep and has a side effects of movement disorder.

Promethazine is one medication that can cause movement disorder and a high index of suspicion coupled with a prompt cessation of medication will reduce patient's distress and improve the therapeutic relationship between health professional and young person.

Written informed consent from patient and guardian was got.

Author declares that there is no conflicting interest, financial or otherwise.

To highlight the importance of appropriate diagnosis and management of severe mental illness in children. Awareness of rare diagnoses such as this will reduce the delay to treatment. A challenge in Ireland is accessing psychiatric inpatient treatment for very young children, with specialist units in Ireland designed to better cater for young people aged 12+.

Michael (not his real name), age 10, was always described as a happy, calm child. He enjoyed school and loved playing outdoors. He had been progressing well with his life and neither his parents nor school had any concerns for him. Following the COVID-19 pandemic and school closures, Michael began to became more conscious of daily hygiene safety advice. However, things escalated to a very difficult level. Initially, he manifested extreme levels of anxiety with heightened levels of distress. He ran away from open doors or windows for fear he would catch the virus, insisted on changing his clothes several times per day, would become distressed if anyone touched him accidentally while he was outside and could spend hours afterwards crying and screaming.

In June 2020 he showed profound refusal to engage in basic care tasks and a dramatic social withdrawal, and ultimately required admission to hospital. He refused to eat and drink, stopped washing and toileting himself, lay in bed with the covers over this head, became non-verbal and refused to engage with any conversation or games. He showed prolonged periods of screaming. Ultimately this reached a level requiring TPN and PEG feeding and a low stimulation environment. Diagnosis of pervasive refusal disorder, secondary to severe COVID-19 related anxiety was made.

Pervasive refusal disorder is a rare and potentially life threatening condition in children. It is described as a profound psychological response to uncontrollable events such as grief, abuse, parental conflict and migration. In this case, it was the threat of the global pandemic. Through treatment in low stimulation environments, with consistent communication and rehabilitation and medication, followed by individual and family therapies when patients are more able, patients show a slow, but generally complete recovery. Happily for Michael, he has now recovered and returned home to his family, where he has returned to all his previous activities.

Michael and his parents have kindly agreed to allow us to tell his story, in the hope of teaching current and future psychiatrists about this rare condition. We send them our thanks and appreciation.

To highlight the importance of reviewing diagnosis and management of refractory psychosis and to share that with the scientific community; and to also shed some light on the dilemma and challenges that professionals may face to diagnose and treat organic psychosis. In addition, to look at the possible similarity/dissimilarity in psychopathology between organic and primary psychosis and differences in opinions through presenting the history and course of illness of this patient.

We present the case of a 51-year-old female who had a 28-year history of treatment-resistant schizophrenia. She did not report or display any seizure activity, and an extensive investigation was unremarkable. The unusual nature of her psychopathology, which was predominantly visual hallucinations and somatic delusions, and the difficult to treat nature of her symptoms, prompted investigation with Electroencephalograph which demonstrated bilateral temporal lobe epileptic activity.

Treatment with divalproex sodium and discontinuation of antipsychotic medication achieved an excellent response, where her visual hallucinations and somatic delusions were both remarkably ameliorated.

The differentiation between organic/secondary and functional/primary psychosis is an area of contention between psychiatrists and neurologists and also within each of these specialties.

The myriad of psychopathology and associated treatment resistant psychotic symptoms that patients with non-convulsive epilepsy may experience should result in building a long desired bridge between neurology and psychiatry to collaborate in managing such cases.

We report a case of a 58-year-old gentleman who was hospitalised intermittently for one year due to treatment resistant schizophrenia. Prior to hospitalisation he had been prescribed standard antipsychotics for decades without full resolution of positive psychotic symptoms. During his final admission lasting six months he was guarded, suspicious, irritable, constantly paced the corridor and displayed thought block and paranoid persecutory delusions. He would not enter the assessment room or allow any blood or ECG monitoring, however, he was compliant with oral medication. He was successfully treated with high dose olanzapine (40mg/day) and was discharged to the community. The aim of this study is to bring awareness and add to the body of evidence for the use of high-dose olanzapine in patients with treatment resistant schizophrenia in whom a trial of clozapine is not possible.

The patient gave written consent for this case report to be written and presented. An extensive literature review was performed and key papers were identified. Discussion focuses on the key areas in the literature.

This case demonstrates that high-dose olanzapine can be used effectively as an alternative to clozapine in treatment resistant schizophrenia.

This case highlights the need for further evaluation of high-dose olanzapine as an alternative to clozapine in patients with treatment-resistant schizophrenia.

There is limited research surrounding facilitated early discharge (FD) and Home Treatment Teams (HTTs). This study aimed to compare patients who received FD with patients who were discharged without FD to identify whether there were significant differences in terms of social demographics, illness characteristics, health outcome and treatment duration. Using this data we furthermore aimed to provide proposals to help advance the effectiveness of FD, as well as suggesting concepts of where future research should lie.

A randomised sample of patients who received FD and patients who were discharged without FD was obtained from a South London Hospital. This was manually narrowed down to patients specifically treated by the Wandsworth Home Treatment Team (WHTT). Socio-demographic and clinical data were then attained from the patients’ electronic records to compare and statistically analyse between the two groups.

Patients who received FD from the WHTT were found to have significantly less previous psychiatric admissions compared to those who were discharged without FD (p = 0.032). All other variables were found to have no association with FD.

Having a high number of previous psychiatric admissions seems to be an aspect that decreases the chance of being allocated FD. This variable can be seen as an indicator of severity of illness and a challenging social environment; it could therefore be valuable to take this variable into consideration when allocating FD. Furthermore, total treatment duration was found to not be significantly different for FD and non-FD patients, thus supporting the use of CRHTTs as an equivalent alternative for inpatient admission, however, national scale research should be conducted to strengthen and expand on these findings.

Obsessional slowness in OCD is a rare phenomenon on which there is minimal published literature. This is a particularly severe and atypical case of early onset OCD with extreme obsessional slowness and mutism. To the best of our knowledge, there have been no reports of similar severity published in this age group. This report seeks to provide discussion of important organic causes that may need to be considered as well as information on treatment approach.

An 18-year-old male was admitted to the National OCD Unit, Springfield Hospital with a history of autism and normal development until the age of 14, after which symptoms of OCD with fear of contamination emerged, followed by progressive motor slowness and mutism.

Due to the severity of OCD and self-neglect he had two previous admissions to CAMHS wards and required a course of ECT to treat catatonic symptoms age 17.

Pharmacological treatment has included Aripiprazole 5 mg and Fluoxetine 60 mg, which the patient was taking at admission. The latter was subsequently switched to Sertraline 250 mg and Aripiprazole increased. As it was hypothesized that his obsessional slowness stemmed from severe levels of anxiety, Buspirone was also added.

Therapy has been intensive, although communication difficulties have made targeting specific fears challenging as the exact nature of the intrusive thoughts remains unclear.

Following combined neurology and neuropsychiatry review, the patient spent four weeks in a general hospital for further investigation as it was initially felt an organic cause was likely. Initial differentials included Juvenile Onset Parkinson's or Wilson's disease. Both were subsequently ruled out and despite multiple investigations, no obvious organic cause was found. A markedly abnormal FDG PET scan showed findings usually seen in advanced dementia, but not necessarily clinically correlating to his current presentation.

The OCD unit have continued to provide intensive input and tailored treatment programme, encouraging actions against any rules he has in place. Prompting and pacing, verbal exercises and regular stretching exercises due to stooped posture which he attributed to needing to obey certain rules have been used.

It is important for clinicians to be aware of obsessional slowness in OCD and this report highlights a particularly rare and severe example in a young adult who has been difficult to treat. Organic causes may need to be considered and MDT approach to treatment is essential.

This poster aims to report an unregistered mutation in Transactive Response DNA Binding Protein (TARDBP) gene in a patient presenting young-onset dementia.

Hypothesis: Novel heterozygous mutation in the TARDBP gene is linked to a case of with young-onset dementia.

Pathogenic variants in TARDBP cause autosomal dominant fronto-temporal degeneration, characterized by TDP43-positive inclusions, dystonia, dyslexia, receptive dysphasia, and paraphrasic errors. In addition to the neurocognitive deficits, patients might suffer from cardiomyopathy and amyotrophic lateral sclerosis.

Molecular genetic analysis of whole-exome sequencing (WES) was carried out for a 45-year-old male patient presenting with cognitive decline and behavioural symptoms.

WES Identified the heterozygous variant c.527A > T p.(Lys 176lle) in TARDBP gene. To the best of our knowledge the variant has not been described in the literature so far (HGMD 2019.3). No allele frequencies in the general population have been documented.

We believe that we have identified a novel mutation in the TARDBP gene. This mutation is likely to be linked to this patient presenting with young-onset dementia.

This retrospective case series followed emotionally unstable personality disorder (EUPD) patients following initiation of clozapine on an off-licence basis, aiming to examine tolerance by determining side effect prevalence and treatment cessation frequency, as well as examining efficacy, by investigating number of hospital re-admissions and symptom control.

This case series captured the experiences of 11 EUPD patients under the care of Mersey Care NHS Foundation Trust, all of whom had, at some time in the past five years, been initiated on clozapine. All patients were white British females, with a median age of 31. The median daily dose of clozapine was 300 mg. Most patients had significant psychiatric comorbidities, as well as illicit substance and / or alcohol misuse.

Whilst prescribed clozapine, patients were only admitted to hospital once on average and this was commonly for clozapine re-titration. Whilst in hospital, rates of self-harm were low, but ligaturing and suicide attempts showed higher prevalence. Patients still demonstrated self-harming behaviour out of hospital leading to A and E presentations. In the community, contacts with the police were minimal, with only two patients undergoing Section 136 assessments or arrests.

All patients reported side effects from clozapine - usually hypersalivation, over-sedation and constipation. All 11 patients experienced sinus tachycardia. Eight patients temporarily ceased taking clozapine at some point. In three patients, discontinuation of clozapine was as a result of intolerable side effects. Three patients experienced neutropenia, which subsequently resolved. Only two patients had a body mass index within healthy range.

Despite patients reporting clozapine to provide symptomatic benefit for their EUPD, and improved their engagement with mental health services, prevalence of self-harm and of A and E presentations remained high, indicating the importance of community support and concomitant psychotherapeutic treatment. Patients with more robust community support showed greater adherence to clozapine.

High prevalence of side effects and obesity in these patients, in addition to risk of developing neutropenia, highlights the importance of rigorous monitoring after initiating clozapine. It is reassuring that, despite development of neutropenia in some patients, this recovered quickly, and clozapine treatment could resume.

Clozapine may be an effective pharmacological treatment for enabling EUPD patients to engage more therapeutically with services. Clozapine may be of greater benefit to those with more stable, less chaotic lives. Although diminished, patients still show self-harming behaviour and need for A and E admissions and re-hospitalisation. Side effects of clozapine are common and regular monitoring is required.

The reason to share this case is to high light the lack of resources in mental health services which can delay the provision of appropriate care and this can have negative impact on child health outcomes.

A 10-year-old boy was referred to CAMHS. He presented with extremely challenging behaviours. After first appointment with CAMHS he attacked his father and nurses. He had to be restrained multiple times. He started to use wooden chair as a weapon, threatened to harm others and threatened to urinate on staff. He tried to kill him-self by ligature. Mental health act assessment was completed and when a decision was reached that detention under the mental health act was appropriate, no appropriate bed was available. He was admitted under Section II of MHA to paediatric ward where he remained for one week (with 2:1 CAMHS support). Then he was transferred to an inpatient CAMHS unit which was commissioned for children over 12 years of age. At a later date mental health tribunal panel upheld the section. After few days he was transferred to an age appropriate in-patient mental health bed. He stayed there for roughly 6 months and was discharged with a diagnosis of ADHD and Autistic Spectrum Disorder. There was a long delay in discharge, until appropriate specialist residential placement could be identified and he was transferred there. He is well settled now in the placement.

Legal advice was later taken on this case. MHA 1983, Human Rights Act, Children Act 1989, Criminal Law Act 1967 and Code of Practice 2015 were considered and it was agreed that it was appropriate to use MHA 1983. There was discussion whether the Children Act could be relied on instead, but in view of the fact that repeated restrain was required, he was in seclusion and possibility of need for rapid tranquilization post admission the decision was made to use the mental health act.

This case has highlighted a significant problem and calls for an urgent action to increase the number of inpatient age appropriate mental health beds and number of appropriate residential placements nationally. It has also been identified that application of legal frame work in children and adolescents can be a challenge and there is a need for targeted educational programmes for professionals on the use of legal frame work in children and adolescents.

To describe an unusual clinical presentation of Huntington's disease.

A 39-years-old married female, a homemaker, presented to the psychiatry clinic with her husband, with over a nine-year history of decreased sleep, suspiciousness, self-talking, agitation, anger outbursts, aggression, and social isolation. The patient was diagnosed with schizophrenia. Previously, she received various antipsychotics and Electroconvulsive therapy (ECT). The patient showed a partial response to treatment. Over the last 2-3 years, the patient had a progressive decline and later required supervision in her Activities of Daily Living (ADLs). She developed slurred speech limited to 1-2 worded answers, gait disturbance, falls, involuntary movements of the trunk and distal extremities, bowel and bladder incontinence, and severe weight loss. The patient's mother and older brother had a history of death in their early 40s due to an unknown cause.

At presentation, the patient was restless, irritable, self-talking incoherently, neither made nor maintained eye contact and tried hitting and biting upon approaching closely. She did not respond to any queries or followed commands. The patient showed poor personal hygiene. On examination, the patient was hemodynamically stable, had a loss of muscle bulk, broad-based gait, and choreiform movements of the trunk and distal extremities. We admitted the patient to the psychiatry ward and also consulted the neurology team. Her blood investigations showed ASMA antibodies positive, MRI brain was suggestive of Huntington's disease (HD), and her genetic test for Huntington gene confirmed the diagnosis of HD. We started the patient on Fluoxetine, Clonazepam, and Olanzapine. The patient showed a decrease in agitation, and her self-talking stopped.

HD is a rare genetic disease that has well-characterized symptoms. However, as seen in our patient, these symptoms can evolve and progress unusually in the early and middle stages. Psychosis in HD patients is rare but known. Psychosis is rare in HD and usually presents after a clear clinical picture of HD is apparent. Our case discussed psychotic symptoms in the pre-choreic stage of HD which adds to the existing evidence on challenging presentations and management of HD. Further research can help increase confidence in these outcomes and treatment guidelines.

Our case highlights an unusual clinical presentation of HD, which can be challenging and lead to diagnostic delays. We recommend a thorough approach to history and revision of diagnosis in case of atypical presentations.

In this report, we present a case series of children with psychotic symptoms referred to a child consultation liaison psychiatric service within a tertiary paediatric hospital in Singapore. The purpose of this case series is to identify common symptoms at presentation, review the current practices in our hospital for investigation and treatment of first episode psychosis and short-term outcomes.

We identified 9 cases over a 1 year period, for which 7 were seen whilst admitted to hospital and 2 in the outpatient clinic. There were 6 females and 5 males ranging in age from 11 to 16 years old. The commonest symptoms on presentation were perceptual disturbance (88%) most commonly auditory hallucinations and altered behaviour (55%). Of the 7 children admitted to hospital, all were seen by the neurology team prior to the request for a psychiatric opinion. All admitted patients had blood and radiological investigations carried out. Most of the children were started on a short course of antipsychotic medication with the majority continuing to attend follow-up outpatient.

Only 9 cases were identified in this case series over a 1 year period highlighting that psychosis is not a common presentation in the paediatric population. From the history alone, it can be challenging to distinguish between primary and secondary causes of psychosis. Acute onset of symptoms and the presence of other neurological signs should raise the suspicion of an underlying organic cause. Out of 9 cases, only 1 case was treated for a presumed organic aetiology, which is consistent with findings from other authors who only found underlying organic factors in 12.5% of cases.

In this case series, we also noted that 45% of cases reported having symptoms for over 1 year before seeking help. This is also seen in the adult population in Singapore. Stigma, denial and lack of information about psychosis may all contribute to delay in seeking help. Although prolonged duration of untreated psychosis has been shown to be associated with poor long-term outcome, we found in our case series that even patients who reported a long duration of symptoms still responded well to medication.

There is room for collaboration with our neurology colleagues in the approach towards children with first presentation of psychosis, both in terms of investigations and management. Identifying reasons for disengagement from psychiatric care is an area for further investigations to improve outcomes in our patients.

To present a case of a 79-year-old male with frontal lobe dementia (following a cerebral abscess) who was referred due to inappropriate sexualised behaviour (ISB) in a care home setting.

To discuss the evidence base for the management of ISB in frontotemporal dementia.

79-year-old male patient who was diagnosed with frontal lobe dementia, following a craniotomy to aspirate and evacuate a cerebral abscess which affected the left frontal, parietal and temporal lobes. He then started to exhibit sexualised behaviour; he was using sexualised language towards female residents and care workers in the residential home, and was inviting residents to his room and asking them to touch him. This behaviour was felt to be due to inappropriate sexual behaviour which forms part of the spectrum of behavioural and psychological symptoms of dementia. Non-pharmacological interventions were tried but failed to manage his symptoms. He was started on Paroxetine which treated the symptoms for approximately 12 months. The symptoms reocurred and he was switched to Amisulpride which had a positive effect on his symptoms.

ISB is a behavioural and psychological symptom of dementia and may be seen in 7% to 25% of patients with dementia. ISB is distressing for the caregivers and also presents considerable challenges for the treating clinician. ISB presents with behaviour such as sexual language, implied sexual acts, and overt sexual acts. A differentiation should be made between whether the act was one of intimacy-seeking or disinhibition. However, there is a need to intervene when there are risks to the wellbeing and safeguards of the patient and also caregivers and residents. ISB can be difficult to treat, and there is limited evidence on the subject. It is often better managed by non-pharmacological interventions if possible, due to patients often being less responsive to psychoactive therapies and the risks involved with using medication. Non-pharmacological interventions include environmental, behavioural and educational approaches, and examples of these are discussed. Pharmacological interventions are also discussed, but there is a lack of evidence in this area; currently the evidence is from case series and case reports. The variety of drug classes illustrate the non specific nature of drug therapy.

Managing and treating ISB is difficult and complex.

The evidence suggests using non-pharmacological approaches as first line before considering pharmacological interventions.

However, there is a need for further research to develop robust non-pharmacological and pharmacological interventions in the treatment of ISB.

This case is presented to describe a rare psychopathology in which the patient hears her own voice speaking out loud all the texts that she sees in books or papers and she cannot read them inside her mind. This psychopathological phenomena has some features of reflex hallucinations, thought echo as well as of inner reading voices yet it cannot be categorized into either one.

This is a 26-year-old female with Schizophrenia for 3 years. While on medication 8 months before presentation she started hearing her own voice reading any text that she sees. When she sees a text she cannot read it in her mind and understand, but she hears it in her own voice to her ears. With this she also hears other voices talking about her and to her. She also believes that her father is the one who controls all her actions and the things that happen to her. In her mental state examination her mood was euthymic and she had delusions of control, thought broadcasting and in her perceptions she had visual perceptual abnormality where she saw the same object she would look at in another direction but they are under her control. She also had second and third person auditory hallucinations. She was admitted to start on clozapine because her voices did not respond to any medication.

Auditory hallucinations are the most commonly encountered type in schizophrenia with a prevalance of 70–80%. This patient hears the words that she sees which has some features of reflex hallucinations, however in the latter the hallucination is not a transformation of the perception. This also has some qualities of thought echo, where just as the patient thinks she can hear them. However in this patient she cannot read the texts in her mind. Inner reading voices are where a person talks to oneself while reading, however in the subjective mind. In our patient this phenomenon also proved to be the most difficult to treat as all her other auditory hallucinations responded to Clozapine, while still this phenomenon remained.

This case is presented to describe the rare psychopathology in this patient in the form of auditory hallucinations

This poster aims to report an unregistered mutation CSF1R gene in a patient presenting young-onset dementia.

Hypothesis: Novel heterozygous deletion–insertion mutation in the Colony-Stimulating Factor 1 Receptor (CSF1R) gene is linked to a case of hereditary diffuse leukoencephalopathy with spheroids (HDLS), presenting with young-onset dementia.

CSF1R mediates proliferation, differentiation, and survival of monocytes/ macrophages and microglia. Pathogenic variants in the CSF1R gene cause autosomal dominant diffuse hereditary leukoencephalopathy with spheroids characterized by variable behavioural, cognitive, and motor changes, usually presenting with young-onset dementia. The average lifespan after the start of the symptoms is often 6 years.

Molecular genetic analysis of whole-exome sequencing (WES) was carried out for a 49-year-old male patient presenting with rapid cognitive decline, behavioural symptoms and impaired sphincteric control.

WES identified the heterozygous deletion–insertion variant c.2356_2357delinsAC p.(Leu786Thr) (chr5:149435867-49435868; hg19) in the CSF1R gene. To the best of our knowledge the variant has not been described in the literature so far (HGMD 2019.3). No allele frequencies in the general population have been documented.

We believe that we have identified a novel mutation in the CSF1R gene. This mutation is likely to be linked to this patient presenting with young-onset dementia.

To demonstrate the increasing evidence for an aetiological role of cerebral mitochondrial dysfunction in neuropsychiatric disorders.

To raise awareness of the importance of frontline staff partaking in post marketing surveillance of medications.

We report the cases of two patients who developed worsening BPSD, coinciding with starting the factor Xa inhibitor DOAC medications Apixaban and Rivaroxaban respectively. Both patients required detaining under the Mental Health Act (MHA). Their symptoms improved significantly, within two weeks, on switching to alternative anticoagulant therapies and they were both discharged from the acute psychiatric ward.

Frontline healthcare staff in acute settings and the community manage a heavy workload. It is all too easy to overlook potential neuropsychiatric drug side effects, especially if they are not clearly listed. They may be easily missed amongst older patients and wrongly attributed to dementia.

Rivaroxaban is structurally related to the antibiotic Linezolid which has been reported to cause mitochondrial toxicity. Pre marketing In vitro studies concluded the risk of mitochondrial toxicity associated with this anticoagulant to be low. However a more recent in vitro study, using rat kidney mitochondria, reported evidence of mitochondrial swelling and a collapse of the membrane potential following exposure to low doses of Rivaroxaban. The effect of Apixaban, which is structurally related to Rivaroxaban, has yet to be investigated on mitochondrial function.

Recent research supports not only an association between reduced cerebral mitochondrial function and neuropsychiatric symptoms and disorders, but also the aetiological role it may play.

There is a need for a far greater awareness and understanding of the potential cerebral mitochondrial toxicity of drugs commonly prescribed to our older populations.

Cerebral mitochondrial toxicity can have a significant impact on the health and well-being of patients.

Older patients are particularly prone to experiencing neuropsychiatric side effects that may not have been apparent during preclinical trials.

Development of a rating scale of drugs that are potentially less toxic to cerebral mitochondria could inform national prescribing guidelines and enable safer treatments to be offered to older people, reducing the likelihood of them experiencing apparent behavioural and psychological symptoms of dementia.

… in which clozapine tablets were dyed pink, to work around a delusion preventing treatment, and physicians tolerated and monitored an alarming early response to the drug.

56-year-old female with severe enduring Bipolar I Disorder, current episode manic with psychosis, already an inpatient for six months. When first seen by us, polypharmacy was evident including haloperidol 25 mg daily. Thorough trials of mood stablisers and second generation antipsychotics in various combinations had all failed. She had never had a clozapine trial.

Dishevelled middle-aged woman of European descent. Restless; shuffling gait; speech pressured, rapid and whispering, often to the point of unintelligibility. Affect labile: anxious and distressed, suspicious, angry, elevated and demanding. Thought form tangential+++ content paranoid persecutory themes, preoccupied with sexual trauma and delusional belief that yellow medication whether solid or liquid was poisonous. Risks of vulnerability, falls, aggression, neuroleptic malignant syndrome (NMS) and protracted psychotic mania requiring long term hospitalisation.

Change to clozapine.

All formulations are yellow.

Team discussion, ethical analysis, clozapine tablets dyed with red vegetable dye.

Potential benefit to patient great; current medications not effective and NMS possibly developing; she was fully informed about clozapine with no attempt made to hide the identity of the now crimson tablets.

Patient accepted the clozapine. Temperature, C reactive protein (CRP) and troponin were all normal at baseline but all rose above normal in week 1 of initiation. They peaked in week 3 and by week 4 were dropping, normalising completely within a few weeks. She was transferred to a medical ward for monitoring during weeks 2 and 3 of titration. There were no electrocardiogram changes, no chest pain, no signs of bowel obstruction and no evidence of agranulocytosis. Clinically, she remained well throughout except for the rise in temperature. Once the yellow medicine delusion receded she accepted undyed yellow tablets; the result was discharge home with her best mental state and level of functioning in 15 years.

There are no cases in the literature that we could find where tablets had been dyed, or where clozapine had been persisted with when such rises in temperature, CRP and troponin occurred. This case illustrates both. The risks in our view were outweighed by the simple fact that clozapine was her only hope of a life worth living.

After COVID-19 was declared as a pandemic, different countries have enforced lockdowns, and shielding to mitigate the spread of the virus as preventing loss of lives was the priority.

Our aim is to look for possible explanations for increased rates of visual hallucinations presented to Community Mental Health Teams for Older People during the period of lockdown.

A review of clinical cases presenting with new onset visual hallucinations to the Community Mental Health Teams for Older People during the lockdown period in 2020 was summarised in two case scenarios. One scenario represents cases with known background of dementia, while the other scenario represents new referrals during the lockdown period with no known psychiatric background. In those cases, the visual hallucinations started during lockdown with no clear cause, did not respond to psychotropic medications, physical health investigations were all normal and hallucinations improved markedly with the end of the lockdown and social isolation.

From clinical practice point of view, during the period of lockdown in the COVID-19 pandemic, visual hallucinations has been one of the commonest presentations reported to the Community Mental Health Teams for Older People. Families were calling frequently reporting that their loved ones were “seeing things”. Possible underlying causes include: social isolation, sensory and perceptual deprivation, visual impairment and Charles Bonnet syndrome, lack of cognitive stimulation activities with progress of dementia, superimposed delirium, in addition to depression secondary to loneliness, reduction in community support, increased alcohol consumption and negative effects of repeated media consumption.

There has been a marked increase in reporting visual hallucinations in the shielding older people population in the community during the period of lockdown in the COVID-19 pandemic. This shielded population was not exposed to COVID-19, so it didn't give an explanation to this new phenomenon. Though there are multiple possible causative factors, the effect of the lockdown itself with its resultant social isolation and sensory deprivation remains to be the most significant. Shielding the older people population throughout the COVID-19 pandemic came as an essential measure as the physical safety and preventing loss of lives was the priority; however the lockdown had significant negative effects on the mental health of the shielding population. It remains unclear if those negative effects are going to be reversible in the future, resulting in poor quality of life.

Hypnic Headache are is a very rare primary headaches that affect the elderly, with an average age of 60 years. Research in the areas of neurophysiology and treatment options for Hypnic Headache are necessary in order to better understand, and improve outcomes for this rare headache disorder.

Mr. X is a 70-year-old patient, has been presenting with the complaints of headache during sleep at night for the last 1 year. The Headache started after 3 to 4 hours after falling asleep. Due to headache, he wakes up from sleep around 03:00 to 04:00 am almost every night and his headache persist for 30 to 40 minutes. After waking up from sleep he keeps himself busy with religious activity and the headache gradually resolves. He then goes back to bed again.

Mr. X also informed that, the headache is dull in nature and located in left temporo occipital region. It is not associated with photophobia, phonophobia, nausea, vomiting, tearing or discomfort in the leg. He gives no history of early morning headache or day time headache, sleep disorder, snoring or sleep apnea. He has no past history of trauma to the head, fainting attack, unconsciousness, weakness or paralysis of limbs, seizures or non-epileptic seizures. He is an non-smoker, non-alcoholic, non-hypertensive & non-diabetic person.

On general examination, his heart rate is 70 beats/min, blood pressure 138/68 mm of Hg. There are no anemia, jaundice or oedema present in him. His both lung fields are clear. On neurological examinations there are nothing abnormality detected. His Serological investigations, CBC (Complete Blood Count) FBS (Fasting Blood Glucose), lipid profile are within normal limit. CT scan of the brain is normal. There are no cerebral atrophy or volume loss compatible with age.

Mr. X was treated by several general practitioners with paracetamol, diclofenac sodium, mefenamic acid, tramadol hydrochloride. He used these drugs either singly or in combinations. But with this treatment there were no significant improvement occurs. Mr. X is scared and depressed for his sleep time headache.

Hypnic headache is a very rare headache disorder. It occurs in age groups over 60 years. It is occur at night during in sleep and waking the patient up, hence the name of it “alarm clock headache”. It is commonly unilateral and lasts for 15 minutes to 4 hours. Hypnic headache commonly dull or throbbing in character and does not make the patient restless, unlike in Cluster Headache. After waking up from sleep, most patients engage in some activity. Hypnic headache is not associated with rhinorrhea, tearing and ptosis. Diagnosis is mainly clinical. Secondary causes headache must be excluded. International Classification of Headache Disorders 3rd Edition (ICHD-3)-beta provides diagnostic criteria for hypnic headache. Pathophysiology of hypnic headache is not clearly identified. Usual treatment options of Hypnic headache includes bed time coffee, lithium carbonate, indomethacin. Our patient fulfil all the criteria of Hypnic headache and he fells improvement with Indomethacin 50 mg in devided doses.

Hypnic Headache is a very rare type of primary headache. It should be diagnosed only after other secondary causes of headache have been excluded. Caffeine, lithium carbonate, flunarizine, indomethacin, used to treat the patient of Hypnic Headache. Lack of study and awareness about these disorders can lead to delays in diagnosis and treatment. Clinical trials are needed to find out proper treatment, but it will be difficult to perform because of the rareness of this disorder.

A growing body of research evidence shows that individuals with Obsessive Compulsive Disorder (OCD) have been negatively affected by the COVID-19 pandemic including deterioration of OCD symptoms plus relapse from previously well-controlled OCD. The impact of the COVID-19 pandemic is discussed in a single case study of a patient with OCD consisting of contamination concerns. In addition, the effectiveness of providing Exposure and Response Prevention (ERP) virtually is evaluated with regards to the treatment outcome in COVID-19 related OCD.

This study describes a 41-year-old, single, employed female with OCD consisting of concerns of contamination and infecting others thereby causing harm. The total duration of the disorder is 32 years with the most recent presentation being of three years duration. Relapse during the pandemic resulted in OCD symptoms being solely concerned with COVID-related contamination. The questionnaires routinely completed at the time of assessment and treatment were the Obsessive Compulsive Inventory (OCI); Yale Brown Obsessive Compulsive Scale (YBOCS); Beck Depression Inventory (BDI). Clinical data were collated and analysed prior to and during the pandemic. Treatment consisted of ERP and was adapted for provision via a virtual platform. ERP involved exposure to a graded hierarchy of COVID-specific anxiety-provoking situations modified to take government guidelines into consideration.

Prior to the COVID-19 pandemic the patient's response to treatment with cognitive behavioural therapy (CBT) including ERP indicated a 79% improvement in OCD symptoms on self -rated measures. The impact of the pandemic led to a significant 65% deterioration in OCD symptoms, regarding COVID-19 contamination concerns. Intervention with ERP resulted in 73% improvement over a three-month period. Measures of depression symptoms indicated an 80% improvement pre-COVID, with a 78% deterioration at relapse. Following treatment, the patient also showed a 65% improvement in depression symptoms. Improvements have been maintained at one month follow-up.

The case study supports literature indicating the exacerbation of OCD symptoms due to the COVID-19 pandemic for patients with contamination fears and washing compulsions. The promising results support the use of ERP as an effective treatment for COVID-related OCD symptoms. It also validates the provision of CBT interventions virtually to ensure accessibility of treatment to OCD sufferers.