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.

The traditional ‘one size fits all’ model within secondary care mental health (MH) settings of regular appointments scheduled by a clinician at defined intervals isn't always responsive to an individual's changing needs. Previous reviews have shown significant levels of patient and clinician satisfaction with Patient initiated models of review in a variety of healthcare settings but its use within secondary care MH settings has been relatively limited. We describe the development and implementation of a Patient initiated follow-up (PIFU) pathway within MH services in NHS Greater Glasgow and Clyde (GG&C).

The pathway was developed by a small working group of clinicians with input from local management and eHealth colleagues with an emphasis on the principles of Realistic Medicine. There was input from peer support workers and the Mental Health network, a local service user organisation, into the development of the pathway. The pathway underwent a ‘test of implementation’ within three adult CMHT's with support from the development group. Feedback from the test sites was used to modify the pathway and ultimately support the wider rollout of the model across all seventeen CMHTs within NHS GG&C over the course of 2021. Formal evaluation of the pathway, including patient and clinician satisfaction, service utilisation as well as safety measures, is due to be undertaken at 12 months after full implementation.

The tests of implementation identified a range of factors that needed to be considered as part of the introduction of a PIFU model into MH settings.

Patient choice and shared decision making along with other clinical factors such as level of insight, availability of other supports, shared risk assessments and current clinical need were identified as relevant patient related factors. Clinician related factors included concerns about applicability within MH settings, perception of risk, increase in workload and appropriate identification of suitable patients. Regular meetings between the clinicians in the test sites and members of the development group as part of the implementation process helped address clinicians concerns and ultimately supported uptake of the model.

Our experience highlighted the potential for a personalised approach to care planning in empowering patients have a more active role in the way they access services as part of their recovery journey. It also highlighted patient and clinician related factors that need to be considered for a successful adoption of the model.

Clozapine has several effects on the genitourinary system including enuresis and an overactive bladder (OAB). However, little if any has been written about its effect in causing OAB and its prevalence. Typical feature of OAB is urinary urgency associated with urinary frequency in the absence of urinary tract infection or other obvious pathology. Having 8 voids or more in 24 hours in addition to urinary urgency is strongly suggestive of OAB. AB developed AOB while being treated with clozapine.

AB is 33 years old white lady with a well-established diagnosis of emotionally unstable personality disorder. She has been in mental health services from her late teens. She has had a trial of several antipsychotics, both oral and depot and has had a number of DBT sessions and one EMDR with limited effect. Prior to this episode, AB has had two successful trials of clozapine, one resulting in her longest period (9 months) of living in the community in 1998.

AB was started on clozapine again in 2021, she developed urinary frequency. She requested it to be stopped. Her condition deteriorated such that she needed intensive care unit. AB was again started on clozapine. She developed urinary frequency once more when the dose reached 250 mg. She did not have infection. For one week, her urinary frequency ranged from 36–66 in 24 hours. It was more evident in the day time. There was no incontinence. AB remained in her room close to her toilet. She stopped engaging in her therapy, she did not mix with others and did go out. She tried a number of medications-aripiprazole, oxybutynin and desmopressin with no benefit. Pseudoephedrine was started at 15 mg twice a day, eventually reaching 30 mg three times a day. Within two weeks, the urge disappeared and the frequency normalised. Six months on, AB remains well and has not reported any side effects.

Pseudoephedrine, an indirect alpha-adrenergic agonist successfully normalised AB's urinary frequency. It was evident so within few days though the maximum benefit was noted within two weeks. This is in agreement with what is reported in cases with enuresis

Very little is known about clozapine induced OAB. It had a severe negative impact on AB, who failed to engage in her therapy and her social life. Pseudoephedrine brought relief within a short period of time. In case of OAB and when stopping clozapine is not an option because of underlying severe mental disorder; think of pseudoephedrine.

The Royal College of Psychiatrists’ Fair Deal (RCPsych 2008) highlighted the far-reaching impact of stigma and discrimination on the lives of people with mental illness. The pervading nature of stigma has been acknowledged in recent national and international mental health policies (WHO). The World Health Organisation reiterates people affected by mental illness should not suffer social exclusion and marginalisation due to stigma.

A sixty-year-old gentleman presented to the Emergency Department following self-inflicted stabbing to the neck resulting in pharyngeal tear and surgical repair. Previous psychiatric history included inpatient admission on Section 2 following a major depressive episode. On this admission, inpatient psychiatric review elicited three months of psychotropic medication non-adherence due to difficulties the patient had encountered in acquiring repeat medications from his GP. He had relapsed into alcohol misuse as a coping mechanism culminating in a suicide attempt at home with a knife. Upon recommencing of sertraline and risperidone during admission, he was assessed as euthymic with low risk to self. The patient had been previously abstinent from alcohol and described religion as a protective factor. Prior to discharge, the patient's GP stated he must present to the surgery in person with a form of identification. This is despite CQC guidance stipulating practices should not refuse patients registration if proof of identity cannot be produced.

This case illustrates the socioeconomic factors increasing likelihood of suicide including forensic history, low financial status, unstable housing and lack of social support. Substance dependence is a risk factor that can be reduced by supporting patients in accessing specialist misuse input from inpatient and community teams. The patient reported fear of stigmatisation and criminalisation which led to the avoidance of seeking treatment, deterioration in mental health and severe clinical consequences. It is imperative marginalised patients with mental illness can access quality health care and this starts with GP registration.

Forensic mental health patients experience multiple stigmas impacting on well-being including social, institutional and media stigmatisation and high levels of internalised stigma. The Time to Change campaign focused on changing attitudes and behaviour however evaluation illustrated difficulties in tackling this issue. Healthcare professionals should be mindful to avoid stigmatising language and actions to ensure fairness in care. There is a need for the medical profession to continue striving for a tangible shift in attitudes. Advocating for those with mental illness can enhance quality of life for vulnerable patient groups.

Ataque de nervios is a culture-bound syndrome among individuals of Latin descent.The case study presents an ataque de nervios case triggered by unique stressors in a transgender female of Mexican origin. This case also highlights the critical features of ataque de nervios, and discusses the challenges in diagnosis, classification and management.

47-year-old transgender (male to female) woman was admitted to an acute female inpatient unit following a presentation of erratic behaviour and a collapse episode under mental health act. During her observation and assessment period, multiple ataque episodes were observed with characteristic features triggered by gender phobic comments. After ruling out the organic causes and ruling out other differentials, she was diagnosed with ataque de nervios. She completed her treatment and continues to remain on remission.

The case presents a rather recognized presentation of ataque de nervios, however, the unique triggers rooted from her gender identity are more relevant to the current 21st century social context which is also an important ongoing discussion topic in psychiatry. The themes are also good presentation of the evolving psychosocial context of the specialty.

Further study is needed to examine the relationship between ataque de nervios and gender identity, as well as the relationship to cultural, demographic, environmental, and personality factors.

A 46-year-old man has a diagnosis of schizoaffective disorder complained of intermittent abdominal pain for many years. Due to this, he had been reviewed by the GP and he was prescribed medication to help with his intermittent abdominal pain.

Over the years the abdominal pain gradually worsened. He also has communication issues due to language barriers and was unsettled for most of his assessment.

His past medical history includes a duodenal ulcer, infected swollen legs and recurrent urinary tract infections.

He continued to have pyrexia despite being on regular paracetamol. Following his second episode of pyrexia, he was referred to the hospital for further investigation.

This was found to be acute acalculus cholecystitis, with possible cholecystocolic fistula and pneumonia. He was managed conservatively with intravenous antibiotics and is awaiting cholecystectomy.

Behavioural change in people with mental illness need not necessarily be linked to their mental state as it can very well be the atypical manifestation of physical illnesses- some of which could be fatal. Prompt recognition and referral to acute medical or surgical services is essential. Staff need training in bias, diagnostic overshadowing and atypical presentations in those with mental illness which will help reduce rates of avoidable morbidity and premature mortality.

In any case physical illnesses may not present typically. Acalculous cholecystitis is a rare type of gall bladder inflammation and the cause in Mr X's case is not clear. At times of COVID-19, with the anxieties around exposure to hospitals and infections, it is important to be aware of this and ensure that people with worrying physical symptoms are promptly referred whether or not it is considered to be related to COVID-19.

Due to the pandemic, we were cautious on the ward and community about COVID-19 and preventing catching and spreading the infection. During all this, patients change of behaviour shouldn't be alluded to deterioration of mental health and mental health professionals should also consider ruling out physical causes for the change of presentation.

We present outcomes of a newly developed Community Rehabilitation team (MhIST) using the context of Jen's personal story. Jen is a 31-year-old student and freelance journalist. This story encompasses her journey from inpatient rehabilitation services to the community, completed with support from MhIST.

“For nearly four years, I was sectioned under the Mental Health Act as an inpatient in hospital. As I had been denied my fundamental liberties for so long, the prospect of leaving hospital for good and enjoying total freedom was both exhilarating and terrifying. How would I fare in the community, living on my own? Would I be lonely? Would I relapse? Would I survive?”

Upon leaving hospital, I immediately received intensive support from MhIST. They were the bridge between the gulf that was hospital and the community. Since leaving hospital, I have been relishing my freedom. I enjoy meeting up with my friends after so long apart. I have volunteered at The Storyhouse, a local arts venue. The Spider Project – a non-clinical community mental health service in Chester - has also provided me with fulfilling activities from yoga to creative writing. The MHIST team have not only kept me well but, most importantly, helped me thrive. Leaving hospital has been an adventure. It has been a joy to regain my independence and freedom. To live rather than to exist. Life is amazing. Long may it continue.”

MhIST provides an intensive rehabilitation and recovery service, delivering bespoke packages of care to individuals. This is achieved using key working and a shared team approach, outcome focused goal-based interventions, weekly reflective/formulation meetings, and a focus on social rehabilitation. Patients referred to MhIST will have a high level of complexity plus severe, treatment refractory symptoms, with impaired social, interpersonal and occupational function and high support needs. They may have co-occurring mental health conditions including substance misuse or neurodevelopmental disorders.

MhIST is a new service and has been active for around 6 months. The first 10 patients referred have been from acute wards (3), community mental health teams (1), and inpatient rehabilitation wards (6). 60% of patients are currently housed in independent accommodation.

Jen's story narrates the experience she encountered during transition from inpatient rehabilitation services to the community. This was completed with support from MhIST, a new community rehabilitation service which provides an intensive rehabilitation and recovery service.

The National Institute for Health and Care Excellence (NICE) guidance on the management of behaviour that challenges in autism, is that medication should be considered when psychosocial or other interventions cannot be delivered because of the severity of the behaviour. In our experience of working in Secure and Specialist Learning Disability, there are also times when challenging behaviour continues despite non-pharmacological interventions being optimised. There is (limited) evidence that clozapine should be considered for the management of aggression in patients with autism not improved by first-line antipsychotic drugs.

We present two cases of female patients with autism and learning disability, both of whom had been detained for a long period under the Mental Health Act 1983. Both continued to present with significant aggression despite non-pharmacological treatment being optimised. The aggression did not respond to first-line antipsychotic drugs, nor other psychotropic medication. They were started on clozapine.

In the first case, that of a 32-year-old, aggressive incidents reduced from a mean of 15 per month to 5 per month. The use of physical restraint reduced from 10 episodes per month to 5 per month. Staff reported that aggression was less severe than previously. Due to the improvement, the patient began having access to escorted community leave.

In the second case, that of a 31-year-old, incidents of aggression requiring floor restraint reduced from a mean of 30 episodes per month to 15 per month. The average monthly duration of restraint reduced from 29.5 minutes to 18.5 minutes. Although difficult to quantify, the staff team consistently reported that her level of arousal at times of incidents was less. Her engagement levels also increased. She became more tolerant of people being in her living space and actively sought out contact with staff.

Clozapine resulted in a reduction in aggression and arguably, improved quality of life, for the two patients described. We make recommendations on when clozapine could be considered for treatment resistant aggression in autism and what should be done before this. We also provide guidance on how a therapeutic trial should be conducted, in line with Stopping Over Medication of People with a Learning Disability, autism or both with psychotropic medicines (STOMP-LD).

It is reasonable to consider clozapine for aggression in autism when all other interventions have failed. It may result in meaningful change and improved quality of life.

The aim of this audit is to look at the presentation of women who were pregnant or less than one-year post-partum presenting with psychotic symptoms in the A&E Department, general hospital and calls to crisis line, particularly with the fact that the pandemic impact remains on the nation. Our aim was to ensure that all referred patients were assessed within the first 24 hours, all the assessments were completed face-to-face, a biopsychosocial assessment was completed for each patient and an outcome was agreed on and clearly documented in the notes.

All referrals to West Essex access and assessment team from the A&E department, the general hospital and calls logged to crisis line were included. Data were collected prospectively over a six-month period from mid-November 2020 to mid-April 2021. For the purpose of this audit, an identification form was designed and disseminated to access and assessment and crisis teams to identify illegible patients. Our data collectors then used the main audit tool to gather the data.

In total, our sample included sixteen patients who met our criteria over the six months period. There was only one patient who was out of area. Most of the patients were of white British ethnicity (ten out of sixteen) and other six patients were five white other and one of Asian origin. The mean maternal age in our sample was 27.3 years old and the majority of the referrals came from the labour ward in Princess Alexandra hospital (57%). The two main outcomes of our audit were to check the response time and the way the initial assessment was carried over. Our results show that the team responded to all referrals on the same day with no delays. All the assessments were carried out in a face-to-face fashion in the general hospital apart from one assessment that came through the crisis line and this was carried out in the patient's home.

From our data we can identify that the access and assessment team met the standards we set for this audit. This fulfills the recommendations of MBRRACE-report and the RCPsych. One of our recommendations was to provide educational sessions to the emergency department in the general hospital to raise awareness on psychotic presentation during perinatal period.