Aims: Timely initiation of assessment for Autism Spectrum Disorder (ASD) is crucial as delays can significantly impact development of children and family well-being. This audit aimed to assess the adherence to National Institute for Health and Care Excellence (NICE) guideline recommendations of timely initiation of ASD assessment and follow-up care in the Greater Preston Area.

Methods: A retrospective observational study was conducted, using electronic patient records of patients referred to the ASD diagnostic pathway and listed for further investigation in 2022 in the Greater Preston area. Data on wait times between referral and first appointment and times between diagnosis and follow-up appointment were collected and analysed. Patients eligible for this study were under 18 years of age, living in the Preston area and had been referred to the ASD diagnostic pathway and listed for further investigation in 2022. 37 school-age and 48 preschool-age children were included in this study.

Results: It was found that 18.9% of school-age and 16.7% of preschool-age children were seen within the 13-week window between referral and first appointment recommended by NICE guidelines. This study also showed that 18.9% of school-age children and 20.8% of preschool-age children received a follow-up appointment within the 6-week guideline.

Conclusion: This study found significant delays in accessing the ASD diagnostic pathway and follow-up care which indicates the Greater Preston area is not in adherence with NICE guidelines. Changes are necessary to address these gaps and ensure timely support for children affected by ASD.

Aims: Rapid tranquillisation is a restrictive practice used to manage acute behavioural disturbance, where medication is given in the form of an IM injection. The first-line medication used is lorazepam. There is an increased risk of the emergence of serious side effects (sedation, loss of consciousness and respiratory depression/arrest) from giving lorazepam via the IM route. MPFT SOP states that physical observations must be checked at a specified frequency and duration and recorded on the restrictive interventions monitoring form found on the RIO IT system. The monitoring at Norbury House (PICU) in Stafford (MPFT) is often incomplete. This audit evaluates the current adherence to the SOP by reviewing the monitoring of physical observations after the administration of rapid tranquillisation, identifying some of the reasons for incomplete monitoring and areas of practice that require improvement. This audit aims to demonstrate the importance of physical health monitoring and focus on improving patient safety by ensuring stricter adherence to monitoring protocols.

Methods: Data was collected between 8 September and 8 November 2024. To assess the current compliance with the SOP, data will be collected from the EPMA and RIO IT systems to check that the physical observations have been recorded at the correct frequency and duration as per SOP. To identify some of the reasons for incomplete monitoring, a Microsoft form questionnaire will be sent to staff members at Norbury to complete anonymously. The collected data will be used to identify areas of practice that require improvement.

Results: From twenty-one cases, there was one case where monitoring was completed, five cases where no monitoring or documentation was recorded, eleven cases where monitoring and documentation were recorded but not completed and four cases where monitoring and documentation were partially completed. Based on the eleven questionnaire responses, three responses outlined the SOP correctly, four were unsure, and the remaining four were incorrect. Barriers to completing monitoring included patient agitation, time restrictions, forgetting to document, no computer access and low staffing levels. Suggestions for support included education, appropriate delegation of tasks, EPMA alerts, adequate staffing levels and frequent re-auditing.

Conclusion: There is evidence that the current adherence to monitoring protocols is below the set standard. The data collected demonstrates that monitoring is often incomplete. The questionnaire responses highlighted the gaps in knowledge of the SOP and the existing barriers to completing the monitoring. Measures that could be taken may include staff education, alerts and frequent re-auditing.

Aims: To assess whether current prescribing and monitoring practices for oral 'as required’ medications and Rapid Tranquillisation align with local and national guidelines.

To identify areas of non-compliance and enhance awareness of best practice guidance.

Methods: The audit included all patients at Rohallion Clinic, Perth, who had 'as required’ medications prescribed for sedation, anxiety, agitation, or behavioural disturbance at the time of data collection. Female, child, and adolescent patients were not included, as these populations are not present in Rohallion Clinic.

Data collection: Data were collected using an audit proforma during the period between 05/03/2024 and 04/09/2024 of 47 inpatients. Patients’ online drug charts and EMIS (electronic notes) were reviewed using MS Excel.

Standard:

1. 100% of patients should have a documented plan for oral and intramuscular 'as required’ medication in the notes, including if more than 1 medicine is required.

2. 100% of patients should be offered oral medication, if practicable, before administration of intramuscular medication.

3. 100% of patients should have side-effects monitored within 1 hour of rapid tranquillisation. If not possible, this should be documented on the observations chart and in the notes.

Criteria:

1. Multidisciplinary teams should develop and document an individualised pharmacological strategy for using calm, relax, tranquillise or sedate patients who are at risk of violence and aggression.

2. Oral medicines should be offered first, if practicable, before intramuscular medication.

3. After rapid tranquillisation, monitor side-effects, observations, level of hydration and level of consciousness at least every hour until there are no further concerns regarding physical health.

Results: NHS Tayside’s guideline on the pharmacological management of acute behavioural disturbance was updated in Oct 2024.

Total 81% (38) patients had 'as required’ medicines prescribed on the drug chart.

Lorazepam was prescribed most frequently. This is in line with NHS Tayside guidelines which consider lorazepam the first strategy for management of acute behavioral disturbance.

63% (24)of patients (who were on 'as required” medications) had a documented plan.

Standard 1 is not met.

The reasons for administering intramuscular as-required medications, along with documentation of side effect monitoring and observations, including any reasons for omissions, were recorded in electronic notes 25.42% of the time.

Therefore, standard 2 and standard 3 are not met.

Conclusion: One area identified as compliant with current NHS Tayside guidance is the frequency of medication administration, with most medicines prescribed every 4 hours.

Our data shows that lorazepam, promethazine, and haloperidol are the most commonly used medications, with fewer newer medications being prescribed.

Standards 1, 2, and 3 are not met.

Action plan:

Collaborate with the clinical team and pharmacist to improve the accuracy and completeness of documentation related to medication administration, including consent, administration records, and observed effects.

Add additional headers to online assessment templates to support more comprehensive documentation.

Re-audit once the action plan is implemented to assess any changes.

Aims: The At-Risk Mental State (ARMS), an attenuated psychotic syndrome, represents a critical period of vulnerability for the development of psychosis. Early identification and evidence-based intervention are crucial to reducing distress, improving long-term outcomes and public health costs. There are clear recommendations stated by National Institute for Health and Care Excellence (NICE) for the optimal management of ARMS in children and young people including early identification, access to psychological therapy and care co-ordination. Baseline audit data collected from Tier 3 teams within South West London and St George’s NHS Mental Health Trust (SWLSTG) highlighted significant variation in clinicians’ confidence and knowledge about ARMS, notably its identification criteria and optimal management. This audit sought to enhance clinician expertise of “At Risk Mental State” (ARMS) within Tier 3 Child and Adolescent Mental Health Services (CAMHS).

Methods: An educational intervention was developed to address the identified knowledge gaps. This included a 30-minute didactic teaching seminar covering ARMS diagnostic criteria, clinical challenges, and management guidelines, delivered during the CPD slot for four multidisciplinary teams across SWLSTG. Key topics included the Comprehensive Assessment of At-Risk Mental States (CAARMS), the role of psychological and family interventions, and current NHS England guidelines that included discouraging antipsychotic use in ARMS management.

Results: Post-intervention analysis showed improved clinician confidence in both ARMS identification and management. However, all participants indicated a need for additional support. Proposed ideas included specialist training (e.g. CBT for Psychosis and Family Interventions for Psychosis), access to validated assessment tools, appropriate funding for care co-ordination and/or the establishment of a dedicated ARMS service. Qualitative feedback also emphasised the diagnostic difficulty in this population and sociodemographic bias when identifying ARMS within CAMHS settings, highlighting the need for a public health approach to prevention of psychosis.

Conclusion: This project illustrates the effectiveness of a simple targeted educational initiative in improving ARMS-related competencies among Tier 3 CAMHS clinicians. It also highlights the importance of integrating structured tools and specialised pathways to optimise care for individuals at high risk of psychosis. Our next steps are to consider strategies to improve the standard of care provided for young people with ARMS. This includes further psychoeducation resources and a funding application for specialist training for Tier 3 psychologists.

Aims: Individuals with intellectual disabilities (ID) have a higher prevalence of psychiatric conditions, that can be linked to underlying genetic syndromes. Identifying these conditions early can enable tailored treatment, informed prognostic counselling, and improved long-term outcomes. There are established criteria for genetic testing in individuals with unexplained moderate, severe or profound ID. This audit aimed to assess the proportion of eligible patients under a Community Learning Disability Team’s psychiatry service who had genetic testing discussed, referred, or completed.

Methods: A retrospective audit was conducted in a Community Learning Disability Community based in London. The electronic health records for all patients under the psychiatry caseload as of November 2024 were reviewed. Data extraction focused on the ID severity, details of genetic diagnoses and mention of clinical genetics testing within the notes. Specific search terms were used including “gene*”,” genome”, “congenital”, “test”, “investigation”, “diagnosis”, “karyotype”, “screen”, “chromosome”.

Results: Of the 94 patients reviewed,1 had profound ID, 16 had a severe ID, and 22 had a moderate ID. Among these individuals, 20.5% had a confirmed genetic diagnosis, including conditions such as Trisomy 21, Costello syndrome, and inherited glycosylphosphatidylinositol deficiency. Mentions of genetic testing – such as prior referrals, discussions, or test results – were found in 25.6% of patients with moderate or severe ID. However, only one patient had been referred for genetic testing within this team, with others being referred whilst under Paediatrics or Child and Adolescent Learning Disability teams.

Conclusion: This audit highlights a gap in the discussion and referrals for genetic testing within the Community Learning Disability team. Given the prevalence of genetic conditions in this population, and the potential impact on mental and physical health and management strategies, increasing awareness and embedding genetic testing discussions into routine psychiatric assessments is needed. Future steps include providing targeted education for the Learning Disability Team on the importance of clinical genetics, sharing the referral protocol to the local Clinical Genetics team, and considering the addition of a prompt in initial assessments to ensure genetic testing is routinely considered. These measures will enhance early identification, optimise treatment approaches, and improve long-term outcomes for individuals with ID and co-occurring mental illness.

Aims: Discharge summaries are an essential part of patient care, ensuring that key medical information, including progress on the ward and treatment plans, is communicated to GPs and community teams. On functional old age psychiatry Wards 3 and 4 at The Mount, Leeds, ensuring timely completion of summaries is important for patient care and safety. The aim is to identify the key factors contributing to delays in writing and sending discharge summaries, providing guidance for implementing changes that support timely completion and help achieve the 7 day target.

Methods: We reviewed discharge summaries from January to December 2023 for patients discharged from Wards 3 and 4. The time from discharge to summary completion was recorded and compared against the 7-day target. Summaries were selected based on numerical randomisation, with 11 cases reviewed from Ward 3 and 13 from Ward 4. After data collection, we invited stakeholders to MDTs, where we identified nine key barriers, mapped the current process, clarified development regarding influence and interest, and prioritised two specific changes while exploring potential solutions.

Results: The review of discharge summaries from Wards 3 and 4 revealed delays in completion. In Ward 3, none of the 11 reviewed cases had their discharge summaries completed within the 7-day target. In Ward 4, 23% of the 13 reviewed cases met this target. These delays can negatively impact patient care by slowing communication with GPs and community teams. Nine key barriers were identified, and two were prioritised: lack of uninterrupted time and delays in the allocation of a doctor to complete the discharge summary.

Conclusion: This audit identified nine key barriers, including a lack of protected time, unclear doctor allocation, and frequent interruptions due to ward acuity. To address these challenges, we propose implementing a dedicated 4-hour weekly slot for junior doctors to complete summaries, assigning a responsible doctor at the time of discharge, and providing a quiet workspace away from the acute ward but onsite to ensure they remain contactable in an emergency. These changes aim to simplify the process, reduce delays, and support both patient care and staff well-being, helping to achieve the new target of 14 days, extended from the previous target of 7 days.

Aims: A subset of patients assessed by the Liaison Psychiatry service at the Royal Infirmary of Edinburgh are transferred for inpatient psychiatric care. The aim of this audit was to investigate diagnosis concordance, length of stay and nature of follow-up in this cohort. A comparison was made with a previous version of this audit from 2019.

Methods: A review of the relevant cohort took place using internally recorded data from the liaison psychiatry service and inpatient discharge letters from Trak (an electronic notes system). The chosen time period spanned 01/01/24–28/06/24 (n=68). Patients were excluded if no clear working diagnosis was available, they were admitted to an inpatient facility not using Trak or if they were transferred from and subsequently returned to IP care (n=54). Diagnosis concordance was split into complete agreement/match to disorder/match to group of disorder/match with +/- 1 additional diagnosis/no match.

Results: Demographic overview: 82% of patients had been discharged from IP care by the end of the audited time period. 55% of transferred patients were male; 45% female. Patients were most commonly aged between 31–35.

Length of stay: Length of stay ranged from 1–260 days, with a mean of 65.82 and a median of 36 days.

Diagnosis concordance: 33% had complete agreement, 8% match to disorder, 26% match to group of disorders, 20% had a match +/- another diagnosis and 13% had no match. Therefore, 87% of patients had a match of some kind. The most common diagnosis group was a mood disorder, followed by neurocognitive disorders and primary psychotic disorders.

Follow up: 44% had mixed follow up (>1 discipline), 24% CMHT, 7% IHTT, 9% RRT, 7% CPN, 7% specialist and 2% solely primary care.

Conclusion: In a majority of patients there was an element of diagnosis concordance. Liaison psychiatry diagnoses can partly be a snapshot based on a shorter stay, and inpatient admission may allow further details to come to light influencing diagnosis (i.e. first presentation psychosis to schizophrenia). Notably, in comparison to the 2019 median audit IP length of stay had increased by 11 days. Hypotheses explaining this include a changing patient cohort overall or increased bed pressures leading to a different subsection of patients being admitted to IP care. The most common disorder group (mood disorder) is in line with a high percentage of patients presenting to the RIE secondary to intentional overdose with suicidal intent.

Aims: Establish the scale of the problem by collecting data on how frequently electrocardiogram (ECG) machines are not available, and the time doctors are spending searching for them.

Develop strategies for better monitoring and maintenance of available machines.

Methods: Initial data was collected from resident doctors within Leeds and York Partnership Foundation Trust (LYPFT) regarding incidents where ECG machines were not available over a period of 3 months beginning 01/08/2024 and ending 01/11/2024.

Data collection was facilitated by sending emails to resident doctors three times over the course of data collection. A reminder message was also sent out to the Resident Doctors WhatsApp group. Reports were received via email.

The data was collated and recorded on an Excel spreadsheet by SY.

Following data collection, statistical analysis was done on data received. This was via qualitative analysis such as calculation of the mean, median, mode; and through qualitative analysis via thematic analysis.

Due to the concerns surrounding early reports received and the implications for patient safety, concerns were escalated in the Trust senior leadership meetings and more ECG machines were sourced during the audit period.

Results were discussed at the Physical Health Team monthly meeting, to consider potential for improvements.

Results: A total of 28 reports were received over the three-month period, with the majority in August prior to escalating to senior leadership. Doctors spent a total of 490 minutes searching for a machine, with the mode and median being 10 minutes, and the longest being 120 minutes. 4 incidents reported of ECGs not being done. 89% of ECGs were required for routine monitoring, with 11% being due to chest pain. 46% of incidents were due to a missing machine, and 54% were due to a faulty machine. Faults were due to a paper fault, broken leads, missing clips, no charging cables, or the machine itself not working.

Conclusion: There are clearly significant issues with the availability of ECG machines across the inpatient facilities within the trust, leading to potentially significant delays both for routine and urgent ECGs. Issues highlighted within the trust meetings suggested that faulty machines were often not reported or fixed. To address this, it has been agreed to develop instructional flowcharts to streamline the escalation process and to implement this within the trust over the coming months.

Aims: Antipsychotic monitoring is crucial for identifying and managing side effects, improving treatment compliance, and reducing risks associated with long-term use. NICE guidelines recommend routine monitoring to enhance quality of life and prevent disengagement due to adverse effects. This audit assesses compliance with these guidelines within an Old Age Community Mental Health Team (CMHT). This was also discussed in MDT, as well as with patients and carers to have a better understanding of patient experience and how we can enhance antipsychotic monitoring.

Methods: We have registered our audit with Clinical Effectiveness Team at Cambridgeshire and Peterborough NHS Trust. We screened 101 patients under Ely Neighbourhood Team. We included patients with Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, or Delusional Disorder currently on antipsychotic medication. Of the 18 patients identified with these diagnoses, 17 were on antipsychotics. We have screened their notes in the last 12 months for Body Mass Index (BMI), ECG, Complete Blood Count (CBC), Electrolytes (U&E),Blood Lipids, HbA1c, Pulse and Blood Pressure, Liver Function Tests (LFT), Emergence of Extrapyramidal Side Effects (EPSE) or Movement Disorders.

Results: 17 patients were included in the audit. Patients were between ages 66 and 84. Of them 5 were males and 12 females. Of the 17 patients 6 (35%) of them had Schizophrenia, 3 (18%) of them had Paranoid Schizophrenia, 3 (18%) of them had Delusional Disorder and 5 (29%) of them had Bipolar Disorder. Within the last 12 months, all patients on antipsychotics were offered monitoring; 1 patient declined. 94% had blood work monitoring. 100% had pulse and BP recorded. 29% (5 patients) did not have an ECG, despite being on medications requiring ECG monitoring. 11 patients (65%) were not asked about EPSE/movement disorders. Of the 6 patients asked about EPSE, 66% (4) were asked in outpatient reviews, and 33% (2) were asked as inpatients in psychiatric units.

Conclusion: Despite good compliance with most aspects of antipsychotic monitoring, ECG and movement disorder evaluations require improvement in elderly CMHT cohorts. We recommend psychiatrists to work collaboratively with GPs to enhance antipsychotic monitoring.

Aims: Without a plan to support ongoing abstinence, detoxification (“detox”) could increase, rather than reduce, risks to a patient. Before referring for inpatient detox from alcohol or opioids, community teams are expected to discuss relapse prevention medications (RPMs) with patients, as part of their wider support plan.

This clinical audit examined whether RPMs were mentioned in referrals by community teams to our inpatient detox unit.

Methods: We examined referrals for patients admitted to The Level Nottingham inpatient detox unit between 1 January and 31 August 2024. Of a total of 215 patients that completed opioid or alcohol detox, a random sample of 50 were selected, stratified according to referring team. Referral forms and running notes were used to assess compliance with the following criteria:

1. Referring teams mention RPMs (whether to be considered or not considered).

2. Referring teams provide blood test investigations.

There was no previous literature or audit to specify a standard, so, given the importance of the issues under consideration, this was set as 100% for each criterion. We also extracted: whether patients were planned to go to residential rehabilitation after detox, and, where relevant, which RPMs were mentioned and time from blood test results to referral and to admission.

Results: 68% of referrals were for alcohol, and 24% for opioid, detoxification (2% were for alcohol and opioid, and 6% for other substances).

40% of referrals for alcohol, and 77% of referrals for opioid, detoxification did not mention RPMs.

29% of referrals for alcohol, and 31% of referrals for opioid, detoxification did not mention RPMs and were not planned to go to residential rehabilitation (considered as some of these settings do not accept patients on RPMs, focusing solely on psychosocial support).

48% of referrals for any detoxification did not have blood test results available. Where blood test results were available, median time from test results was 22 days to referral and 85 days to admission.

Conclusion: During the study period, an estimated one-third of referrals for alcohol or opioid detoxification did not mention RPMs (and were not going to residential rehabilitation post inpatient stay).

Approximately half of admissions did not have blood test results available.

The above is likely to delay the prescription of RPMs, and potentially increase the risk of relapse post-detoxification.

Recommendations to increase performance include discussions with referrers, changes to the referral form, and changes to referral screening.

Aims: Panic disorder, also known as paroxysmal episodic anxiety, is a severe, unpredictable, and debilitating form of anxiety that is characterised by sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). People that suffer from panic attack often have a secondary fear of dying or losing control. Like many other mental illnesses, the causes of panic disorder are unknown, but some predisposing factors have been identified including genetics, neurobiology, medications, psychiatric disorders, psychosocial factors and medical conditions.

Brucellosis is an infective medical condition caused by Brucella. In the UK, it is a very rare notifiable disease and transmission is usually from consumption of unpasteurised milk and cheese or from contact with infected animals. Brucellosis is considered a public health problem by many countries not only because of the economic loss it brings but it also causes chronic pain, anxiety, and depression, affecting the life quality of patients. Treatment for human brucellosis is based on combinations of antibiotics such as doxycycline, streptomycin, gentamicin, ciprofloxacin, and trimethoprim–sulfamethoxazole and rifampicin over a period of about 6 weeks. Rifampicin on the other hand has been implicated in worsening mental health conditions like anxiety and depression in many previous literatures.

The mechanism by which this occurs has been put to the drug-to-drug interaction that rifampicin might have with other medication patients are taking and the effect of rifampicin as cytochrome p450 enzyme inducers. This case report presents another perspective of rifampicin inducing and worsening panic disorder in a patient that has not previously been diagnosed with anxiety disorder.

Methods: This patient was a 70-year-old woman with background of depression, stable on sertraline, who contracted canine brucellosis from her dog. While on isolation ward in physical health hospital, she was commenced on rifampicin intravenously and oral doxycycline. She developed new onset panic attack five days into the treatment. was referred by the General practitioner following reports of new onset panic attacks. She continued to suffer from these panic attacks even when rifampicin was changed to oral after discharge from hospital. This affected her quality of life significantly. She was commenced on short course benzodiazepine after risk and benefit explained to her. Her sertraline was increased from 50 mg to 100 mg daily. Other psychological options were also explored. Patient reported good improvement within two weeks of commencement of treatment.

She reported good improvement during four-week follow up visit. She had not had panic attacks two weeks prior to the review. She had been tapered off the diazepam and she was one week left in completing her antibiotic regimen. Patient was followed up for two more weeks and discharged back to the GP.

Results: This patient presented with new onset panic attacks following commencement on rifampicin in the treatment of brucellosis. There have been reports that anxiety and depression are the commonest mental health conditions associated with brucellosis. It is therefore a possibility that the new severe debilitating form of anxiety is due to the infection with Brucella. On the other hand, there have been reports that patients treated for tuberculosis with rifampicin have increased incidence of anxiety. The mechanism of this has been linked to the inducing effect rifampicin has on liver enzyme cytochrome P450 which plays a crucial role in the metabolism of most medications. In the case of index patient, rifampicin might have had a drug-drug interaction with sertraline this patient was taking for depression. Though the sertraline was intended for treatment of depression, it is obvious that it was also helpful for premorbid anxiety for this patient. Once the beneficial effect of sertraline was reduced by the rifampicin, it led to the onset of severe and debilitating anxiety. Similar reports about interaction between rifampicin and citalopram have been reported.

Conclusion: The follow-up to this report would be to conduct a case series and observe the occurrence of drug-drug interaction between rifampicin and other common psychotropics.

Aims: We present a case of a 36-year-old patient on clozapine who was an inpatient in a mental health rehabilitation service diagnosed with Schizophrenia. During clozapine titration, the patient complained of chest pain and elevated temperature. The patient was subsequently transferred to the emergency department for further evaluation and management. Following the discontinuation of clozapine and the initiation of brief supportive medical therapy, the patient’s symptoms, ECG changes, and troponin levels fully resolved.

Methods: A 36-year-old Asian male diagnosed with paranoid schizophrenia, admitted to rehabilitation psychiatry. With no significant past medical history, clozapine was introduced in January 2024 using a slow titration protocol, resulting in minimal mental state improvement and physical deterioration. In February 2024, he developed a severe chest infection requiring a two-week hospitalization, during which clozapine was discontinued.

After discharge, clozapine was reinitiated with a slow titration protocol; however, in March 2024, the patient presented with tachycardia, elevated temperature, and chest discomfort during the titration process. ECG findings revealed sinus tachycardia with a heart rate of 112 bpm, a prolonged QTc interval of 470 ms, frequent premature ventricular complexes (PVCs), and ventricular bigeminy. Blood tests showed an elevated troponin T of 16 ng/L (normal range: 0–14). During an A&E evaluation, the patient was asymptomatic apart from the noted ECG abnormalities and was discharged within 24 hours with recommendations to reassess his medications. Clozapine was subsequently discontinued, and no antipsychotic therapy was initiated immediately.

A follow-up ECG performed one week later showed normalized findings, including a heart rate of 54 bpm and a QTc interval of 443 ms, while troponin T levels returned to normal at 14 ng/L. Clinical resolution of myocarditis-like symptoms was observed.

Results: In this case, the patient developed significant ECG abnormalities and elevated troponin levels within two months of clozapine initiation. These findings, combined with clinical symptoms, necessitated immediate discontinuation of clozapine. Subsequent resolution of cardiac abnormalities within one week strongly indicated clozapine-induced myocarditis or cardiotoxicity. This outcome aligns with existing evidence that supports stopping clozapine in the presence of significant cardiac derangements.

Conclusion: This case emphasizes the critical need for monitoring for any adverse effects from clozapine particularly in the titration phase. Regular monitoring, including ECG and blood tests, is essential to identify early signs of myocarditis or cardiotoxicity. If there are any symptoms indicating cardiac abnormalities, clozapine should be discontinued immediately and referral should be made to medical or cardiology specialist for further evaluation.

Aims: Genital self-mutilation (GSM) is a rare but severe form of self-harm often linked to underlying psychiatric disorders, particularly psychotic conditions. Approximately 54% of GSM cases occur in patients with psychosis, with substance use disorders being the second most common associated condition. Various triggers, including perceived rejection, lack of social support, and acute substance intoxication, have been implicated in GSM. When GSM arises from psychotic symptoms, it is referred to as Klingsor syndrome. Immediate psychiatric intervention is critical for managing such cases and preventing recurrence.

Methods: A 28-year-old divorced male was brought to the nearest hospital by his family following a penile self-amputation with a blade. Immediate surgical repair was performed. Three weeks later, he was admitted to Bethlehem Psychiatric Hospital for further evaluation and treatment. The patient had a history of self-harm that previously necessitated hospitalization. His psychiatric symptoms included commanding auditory hallucinations, delusions of reference, feelings of worthlessness, and psychotic features that emerged after cannabis use. In the weeks leading up to the self-mutilation, the patient exhibited insomnia, social withdrawal, and a growing preoccupation with self-castration. On examination, he appeared distressed, with an irritable affect and poor insight into his actions. He expressed a strong belief that his genitals were “the source of all problems” and reported suicidal ideations, stating he “needed to get rid of his penis or else would commit suicide”. He also exhibited persecutory delusions, delusions of guilt, control, and thought broadcasting. A comprehensive psychiatric assessment confirmed a diagnosis of Schizoaffective Disorder, exacerbated by substance use. He was admitted to the psychiatric ward following medical stabilization and was treated with quetiapine 600 mg/day, titrated as needed, and carbamazepine for mood stabilization. Supportive psychotherapy aimed at improving insight and addressing delusional distress was initiated, alongside family psychoeducation to prevent recurrence.

Results: During his four-week inpatient stay, the patient demonstrated gradual improvement in his psychotic symptoms. His insight improved significantly, and he ceased expressing delusional beliefs about his genitals. Upon discharge, he was referred to the Community Mental Health Centre (CMHC) and enrolled in an outpatient psychiatric programme, which included ongoing medication management and psychotherapy. At the few-months follow-up, he remained adherent to his treatment plan with no recurrence of self-harm behaviours.

Conclusion: This case highlights the interplay of psychosis and substance use in GSM and underscores the necessity for early intervention and psychiatric care. A multidisciplinary treatment approach including pharmacotherapy, psychotherapy, and family support is essential for prevention of future episodes.

Aims: Idiopathic Regression in Down Syndrome (IRDS) is reported to be present in 16% of people with Down syndrome however the clinical presentation is heterogeneous with no universal diagnostic criteria. It often presents in adolescence or early adulthood and there are often no known triggers. Common symptoms include language regression, mood symptoms, psychotic phenomena, motor symptoms and loss of previously acquired cognitive skills.

We present a case series of two patients who presented to the West Norfolk Community Intellectual Disability Service with symptoms suggesting IRDS.

Methods: AB (F; 34 years) has the diagnoses of Mild Learning Disability, Down syndrome, Bipolar Affective Disorder following a manic episode at the age of 18 and obsessive-compulsive disorder with predominantly compulsive acts. She was described by parents as a very sociable, active, and high achieving before she developed acute regression. Around the age of 12 years following an episode of profoundly serious pneumonia, she became catatonic, anorexic, and doubly incontinent. Clearly described episodes of depression and mania, obsessional behaviours and speech deterioration were also noted.

The diagnosis of IRDS was raised by parents in 2023 and AB is currently being assessed for immunotherapy.

XY (M; 46 years). Following a gastrointestinal infection aged 18 years, the family noticed he became more housebound, obsessional about symmetry, and depressed. No specialist investigations were done but he was managed for depression with several antidepressants with no improvement. He was also diagnosed with dementia and started on donepezil but nothing changed. He is currently psychotropics-free and following a retrospective diagnosis of IRDS and discussion with family, they were relieved that the correct diagnosis of XY’s condition has been found.

Results: A physical illness appears to have triggered the regression in both cases. Personality and mood changes especially a manic presentation which is uncommon in people with Down syndrome were also reported. Psychotropic medications were not beneficial in at least the second case. In both cases, the diagnosis of Idiopathic Regression in Down Syndrome was an acceptable explanatory model for the family.

Conclusion: We hope clinicians will make the diagnosis more promptly thus facilitating quick access to adequate treatment.

Aims: Presented is a 33-year-old gentleman with a diagnosis of emotionally unstable personality disorder (EUPD) well-known to mental health services, including inpatient, community, liaison, and psychological care teams, with a long-standing history of self-harm and suicide attempts, which included deliberately placing himself in high-risk public areas which have at times resulted in detention under mental health legislation.

Methods: Over the past several years, this gentleman has fabricated claims of a cancer diagnosis, terminal prognosis, and multiple surgical procedures – assertions refuted by his medical records – while leveraging these falsehoods on social media and through a crowd sourcing campaign to raise funds by misrepresenting his physical health. Furthermore, he has strategically leveraged medical admissions to access medications, including strong analgesics and for a self-reported diagnosis that remains unverified.

During conducted assessments, he has expressed a desire for psychological therapy and enhanced crisis support yet consistently avoids engaging with the planned, regular support offered by teams who are familiar with his history, including appointments scheduled after episodes of self-harm.

While services have considered a factitious component in his presentation others contest it aligns more strongly with malingering. Consensus with professionals is that given his presentation there are difficulties in developing and maintaining a safe therapeutic relationship due to his disingenuity, threats of complaints, and his active avoidance of any meaningful, structured, recovery-focused work.

Results: Factitious disorder is driven by an internal need to assume the sick role and receive attention or care, with patients intentionally producing symptoms rooted in psychological need rather than for external rewards where the behaviour is characterized by a willingness to undergo invasive tests and treatments, reinforcing their patient identity. Factitious disorder is recognised as a psychiatric diagnosis warranting treatment, whereas malingering is motivated by external incentives and is not considered a mental illness but rather a behavioural strategy. Individuals who malinger tend to avoid procedures that might expose their deception and selectively engage in behaviours that yield tangible benefits.

Conclusion: This case underscores the importance of comprehensive, multidisciplinary assessments in achieving accurate diagnoses by clarifying key differences in motivation, behaviour, and clinical classification. Enhanced diagnostic clarity not only improves patient care, but also safeguards healthcare resources. Despite evident secondary gains in this case, the long-standing emotional instability and interpersonal dysfunction associated with EUPD still necessitate a balanced, empathetic therapeutic approach.

Aims: Dissociative Identity Disorder (DID) is a complex psychiatric condition that is often misdiagnosed due to its overlapping symptoms with other disorders such as mood and psychotic disorders. The presence of psychotic features, including auditory and visual hallucinations, disorganized behaviour, and memory gaps, can make the diagnosis of DID particularly challenging. This case study highlights a 27-year-old female whose DID diagnosis was delayed due to misinterpretation of her psychotic symptoms, which were initially attributed to other psychiatric disorders.

Methods: A 27-year-old female with a 15-year history of psychiatric care began experiencing symptoms at the age of 13, initially presenting with anxiety and panic attacks. Over time, her symptoms escalated to include episodes of auditory and visual hallucinations, disorganized speech, and erratic behaviour, leading to multiple hospitalizations. During one hospitalization, she displayed regressive behaviours, mutism, aggressive outbursts, hypomania, and dissociative amnesia. Despite extensive workups, including MRI scans and lab tests, no organic causes were found. Her diagnosis fluctuated between psychotic disorders, mood disorders, anxiety disorder, and dissociative disorder. Her mood and psychotic symptoms were initially treated as schizoaffective disorder, but the patient experienced adverse reactions to antipsychotic medications, including galactorrhoea from risperidone and weight gain from amisulpride. These medications were ineffective, prompting a reassessment of her diagnosis. A thorough review of her clinical history, including reports of memory gaps, identity disturbances, and dissociative episodes, led to the reconsideration of DID as the primary diagnosis.

Results: The psychotic features in this patient, such as hallucinations and disorganized behaviour, were secondary to her dissociative episodes, occurring during times of identity disturbance. This case underscores that psychotic symptoms in DID can easily be misinterpreted as part of a mood or psychotic disorder, especially when dissociative episodes are not initially recognized. The prolonged misdiagnosis delayed appropriate treatment, but a more comprehensive understanding of her symptoms led to the correct diagnosis and tailored management.

Conclusion: This case highlights the diagnostic challenges in identifying DID, particularly when psychotic features overlap with other psychiatric conditions. Early recognition of DID, with a thorough longitudinal assessment of both dissociative and psychotic symptoms, is crucial for accurate diagnosis and improving patient outcomes. A more targeted approach, including trauma-informed care and psychotherapy, would have been beneficial and should be considered in similar cases.

Aims: Miss X, a 39-year-old postpartum mother with a strong family history and previous diagnosis of Huntington’s disease, was admitted to mother and baby unit three months after delivery due to psychotic symptoms and delusional disorder. Initially admitted informally, her deteriorating mental state necessitated detention under Section 2 of the Mental Health Act. Her symptoms significantly impaired her ability to care for herself and her children.

Methods: Her psychiatric history included past depression and anxiety, previously managed with counselling, but no prior inpatient admissions. Family history was significant for Huntington’s disease in her mother, maternal aunt, and grandfather, as well as schizophrenia in her paternal aunt.

Miss X presented with persistent paranoid delusions, believing she was being stalked by both a male and female figure whom she could see and hear throughout the day. These hallucinations interfered with her sleep, appetite, and self-care. Additionally, she reported intrusive thoughts of accidentally harming her baby, further affecting her ability to meet the needs of her children. She lacked insight into her condition and was treated with risperidone for her psychotic symptoms and mirtazapine for depressive symptoms, given the history of Huntington’s disease and the distress following the loss of custody of her baby.

Investigations revealed no acute intracranial abnormality on CT Head, but there was mild diffuse cerebral and hippocampal atrophy disproportionate for her age. Cognitive assessments included a Frontal Assessment Battery score of 16/18 and an ACE-III score of 78/100. Urine dip on admission was negative. Blood investigations and ECG were largely unremarkable. Differential diagnoses considered included Post-partum psychosis, Schizophrenia, Schizophreniform disorder.

Results: Miss X’s lack of insight into her Huntington’s disease has contributed to a significant breakdown in her caregiving ability. The persistence of her paranoid delusions, particularly the belief of being stalked, suggests a deeply entrenched belief system that may have been reinforced over time, making it more resistant to treatment. The overlap between neurodegenerative and psychiatric symptoms presents a challenge in management, requiring a tailored, multidisciplinary approach.

Conclusion: This case highlights the complex interplay between Huntington’s disease and severe psychiatric manifestations, particularly delusional disorder. Her enduring psychotic symptoms, compounded by cognitive impairment, significantly impact her functionality and caregiving capacity. Early intervention, close psychiatric monitoring, and integrated neurological care are essential to improve patient outcomes.

Aims: Individuals with learning disabilities (LD) have a higher rate of mental health disorders and behavioural difficulties.

Conventional interventions may be limited in addressing non-verbal emotional expression.

Art therapy offers a creative, structured medium for self-expression, emotional regulation and social skill development.

Methods: Case Report

A 42-year-old lady, Ms X, with moderate LD with challenging behaviour, paranoid schizophrenia and past history of mixed anxiety and depressive disorder and impact of art therapy in her treatment and quality of life.

Ms X has gone through a series of unfortunate events, for example, her brother committed suicide by jumping off a bridge. She lost her mother and her father had been diagnosed with Alzheimer’s dementia. Considering her level of LD and the trauma that she has gone through and the past history of risky behaviours including verbal and physical aggression, requiring inpatient admission and intensive support, she has been doing well.

There are times she tends to become increasingly anxious needing reassurance, however, these are more infrequent now. In general, she has been compliant with the prescribed medications, Depakote and olanzapine. She goes out for swimming quite frequently and also she enjoys walking along the beach with staff. She keeps herself active.

A significant improvement in her presentation is attributed to the art therapy she has been having regularly since September 2024–January 2025. She has completed 12 sessions and a remarkable positive change has been noted by staff supporting her.

Results: Discussion.

1. Improvement in Psychosocial Functioning.

A systematic review (37 studies) indicated that art therapy interventions significantly enhanced psychosocial well-being.

Key therapeutic factors included varied artistic mediums and therapist-guided sessions.

2. Reduction of Aggression.

Ms X had reduced episodes of aggression which is also supported by a quasi-experimental study (Egypt) that found 85% of participants exhibited reduced aggression.

3. Alleviation of Mental Health Symptoms.

Art therapy provides a non-verbal mode of expression, effective in treating patients with learning disabilities and comorbid anxiety/depression. Shown to improve emotional processing and engagement in therapy.

4. Enhancement of Social Skills.

Studies indicate that art therapy significantly improves social interactions, particularly in patients with learning disabilities.

Conclusion: Art therapy is a valuable adjunct that provides alternative communication channel, especially for non-verbal or emotionally withdrawn individuals.

Clinical Implications and Future Directions:

Incorporate art therapy into multidisciplinary-treatment plans for patients with learning disabilities.

Investigating neurobiological mechanisms underpinning art therapy’s impact could optimise therapeutic approaches.

Aims: Dissociative Neurological Symptom Disorder (DNSD), also known as Conversion Disorder, is a common diagnosis among mental health patients in Pakistan. Despite its prevalence, research on DNSD, especially regarding patient experiences, is limited. Family-related stressors are significant contributing factors in its development, with familial discord playing a key role in triggering symptoms.

Methods: A 24-year-old female was referred by a neurologist after presenting to the outpatient department in a wheelchair due to a fear of falling. She reported symptoms including jerky body movements, episodes of apparent loss of consciousness, diarrhoea, weakness, visual disturbances, headaches, and palpitations, which had persisted for over two years. Despite multiple consultations, no organic cause was identified. She had been prescribed various medications with no improvement. Upon evaluation, a diagnosis of DNSD was made, compounded by significant emotional stress, particularly familial discord. A multidisciplinary approach, involving specialists in neurology, ophthalmology, ENT, and gastroenterology, helped rule out underlying physical conditions. Her pre-morbid history indicated high academic achievement but chronic familial stress.

Results: This case emphasizes the importance of recognizing psychosomatic presentations in patients with unexplained neurological and physical symptoms. Despite extensive negative investigations, the patient’s psychological stressors, such as familial discord and fear of stigma, were key contributors to the onset of her symptoms. The patient’s fear of walking further exacerbated her physical disability. Treatment included sertraline, mirtazapine, and short-term benzodiazepines for anxiety and depression. Psychological therapies such as Cognitive Behavioural Therapy (CBT), deep breathing, safe-place visualization, imaginal exposure, systematic desensitization, and gratitude journalling were used to address emotional issues and reduce disability. This comprehensive approach resulted in symptom resolution, and the patient was symptom-free within 18 months, now pursuing an MPhil degree.

Conclusion: This case highlights the value of a multidisciplinary approach in diagnosing and treating complex physical symptoms with unclear aetiology. Addressing underlying psychological stressors and utilizing appropriate psychosocial interventions significantly improved the patient’s condition. Early identification and holistic management combining medical, psychological, and emotional support are crucial for effective treatment of DNSD.

Aims: Sodium amytal is a barbiturate medication, first synthesised in Germany in the 1920s to treat anxiety and sleep disorders; as well as being used as an anaesthetic. This case report discusses sodium amytal prescription and subsequent dependence in an 82-year-old female with a history of anxiety and agoraphobia. It aims to highlight historical indications, mechanism of action of and potential dangers of cessation. As such, clinical management of withdrawal is discussed including the initial use of a more commonly prescribed barbiturate in place of amobarbital; with the ultimate aim being to cease such dangerous medication and to consider safer alternatives – pharmacological and psychological.

Methods: Mrs F was referred to Older Persons Psychiatric Services in 2024. At this time, her GP reported that she was ‘one of only 30 patients in the UK’ to be prescribed sodium amytal, and that it was ‘no longer being produced’. At the time of referral, Mrs F had just a 7-day supply of medication left.

Guidance from the local Medicines Information team had been sought prior to admission. They recommended a phenobarbital taper for seizure prophylaxis when discontinuing other barbiturates, where 100 mg amobarbital was roughly equivalent to 30 mg phenobarbital. Phenobarbital is a long-acting barbiturate which would be more commonly found in practice, given its use in management of epilepsy.

As such, an attempt was made at the safe withdrawal of sodium amytal in the inpatient setting. This was due to the significant risks associated with abrupt withdrawal, including seizure, hallucinations and cardiovascular collapse tending to occur after 16 hours of cessation with such risk remaining up until approximately 5 days.

Mrs F had run out of medication on the day that she was admitted, and given the aforementioned risks, a thorough plan was developed to ensure close monitoring. She was commenced on 1:1 special observations initially due to the risk of seizures. Her clinical observations were performed on a regular basis and a CIWA (Clinical Institute Withdrawal Assessment for Alcohol) score was also performed hourly to monitor withdrawal severity. To this end, lorazepam was prescribed at a dose of 1 mg every 6 hours, as well as an ‘as required’ dose of 1 mg prescribed for when CIWA score was >8.

At consultant review the following day, Mrs F was commenced on phenobarbital at a dose of 30 mg QDS + 30 mg PRN to a maximum of 150 mg/day, continuing on regular lorazepam at 1 mg QDS. Of note, this is slightly lower than the aforementioned recommendation which would equate to 162 mg/day. Subsequently, owing to increasing agitation and anxiety, Mrs F’s dose was increased to 60 mg mane, 30 mg TDS plus 30 mg PRN and her dose of lorazepam was reduced to 1 mg TDS. She was discharged on both medications, 9 days after admission.

Results: The treating team discussed the preferred option to follow on from the withdrawal of amobarbital with subsequent tapering of phenobarbital, given that it shares many of the same risks as the former. Mrs F however was not keen to change medications again at present, owing to her age and ongoing anxiety. In fact, at a subsequent outpatient review, Mrs F reported that she felt that she would require more lorazepam to cope with ongoing anxiety, however this was not facilitated. In terms of patient safety, it should be highlighted that the patient was discharged on 2 addictive, sedative medications (even if the lorazepam was a short-term measure), which could prove challenging to rationalise moving forward and perhaps gives an insight into the ongoing difficulties faced by outpatient teams in terms of cessation of addictive medicines. Importantly, the patient would not however experience the same supply issues currently with phenobarbital. It should also be noted that she had declined psychological therapy with the Community Mental Health Team for Older Persons.

Conclusion: The aims of this report were to highlight the use and action of the barbiturate class of medications, whilst also discussing difficulties with supply issues, dependence and the associated potential for withdrawal. Ensuring patient safety is paramount, and in many cases patients who are prescribed this class of medications for a prolonged period of time require inpatient management to allow for a safe transition to an alternative medication.