Aims: Bruxism is a stereotyped movement disorder of tooth grinding or clenching. Unlike sleep bruxism, awake bruxism is not a sleep disorder, but is secondary to disorders of the central nervous system, such as Parkinson’s disease, stroke and advanced dementia. We report a case of debilitating awake bruxism that developed during the course of Alzheimer’s dementia, unrelated to neuroleptic use.

Methods: A 63-year-old man presented to our outpatient clinic of a tertiary care hospital in India, with a 4-year history of progressive short-term memory loss, increasing apathy and a constant audible teeth grinding in the day, which distracted him from social interaction. He was not taking any medications. Examination demonstrated phasic teeth grinding and extensive teeth wearing, but no extrapyramidal features or transient hypertonicity induced by distraction. Mini-Mental State Examination (MMSE) score was 15 out of 30. The psychometric testing was consistent with moderate dementia of Alzheimer’s type. Computed tomography revealed age-related cerebral atrophy.

Results: Donepezil 5 mg was initiated and subsequently increased to 10 mg for Alzheimer’s dementia improved MMSE to 20 three months after commencement. Quetiapine was prescribed for the bruxism. The patient reported a complete disappearance of awake bruxism at a daily dose of quetiapine 100 mg, with no occlusal appliances.

The biochemical origin of bruxism involves complicated interactions of various neurotransmitters. A central role of the dopaminergic system in awake bruxism was suggested from clinical observations in patients with Parkinson’s disease and attenuation of symptoms with dopaminergic medications. A favourable response to quetiapine in the present patient suggests that bruxism in dementia might also involve the dopaminergic pathway.

Conclusion: A 63-year-old male treated with 100 mg daily doses of quetiapine for Alzheimer’s dementia experienced a significant reduction of awake bruxism. More studies are needed to determine whether quetiapine has a long-term effect against awake bruxism.

Aims: This case study explores the assessment and management of ADHD in a 14-year-old patient seen in CAMHS, presenting with significant academic difficulties but excelling as a national-level athlete in netball. The challenges of balancing stimulant treatment for ADHD with optimal sports performance highlight the need for personalised care strategies.

Methods: A 14-year-old patient was referred to CAMHS for concerns regarding persistent inattention, poor focus, and declining academic performance. A neurodevelopmental assessment, including the NICHQ Vanderbilt and ACE scales, confirmed a diagnosis of ADHD (combined type). Symptoms such as difficulty concentrating on tasks requiring sustained mental effort, poor organisational skills, and a tendency to rush through assignments without completing them were particularly prominent. These difficulties impacted her performance in core subjects, including mathematics, science, and English, where her grades had significantly declined.

Despite academic challenges, the patient demonstrated exceptional athletic abilities, excelling as a netball player at the national level. Her coach praised her spontaneous, quick decision-making and high energy, attributes she associated with her ADHD.

After discussion, the patient was initiated on stimulant medication (methylphenidate). Following treatment, her focus, organisation, and overall academic performance improved, with notable achievements in her exams. However, the patient and her coach reported a decline in her sports performance, attributed to the loss of the “ADHD edge”, a concept supported in literature that highlights how ADHD traits, such as hyper-focus and spontaneity, can be advantageous in certain sports contexts. The patient felt her creativity and spontaneity, critical to her athletic success, were diminished.

Results: In collaboration with the patient, her family, and her coach, a flexible management plan was devised. The patient agreed to withhold methylphenidate on sports days while maintaining its use during school days. This approach allowed her to excel academically while preserving her peak performance in sports, achieving the best of both worlds.

Conclusion: This case highlights the nuanced challenges of managing ADHD in high-performing athletes. The combination of stimulant medication with a tailored regimen offers a balanced solution, enabling optimal academic and athletic outcomes. Further exploration into the interplay between ADHD and sports performance may guide future management strategies for similar cases.

Aims: A patient with a diagnosis of schizo-affective disorder, characterized by a history of harmful substance use, was undergoing treatment in the Intensive Psychiatric Care Unit (IPCU). His medical journey, punctuated by numerous admissions since childhood due to various mental health crises, presented considerable treatment challenges. Key components of his therapeutic regimen included clozapine and sodium valproate. His treatment was complicated by a pattern of medication non-compliance, substance misuse, and recurrent hospital admissions. A recent transfer to an unrestricted smoking ward resulted in significant changes in his smoking habits, which notably impacted both his mental health and clozapine levels.

Methods: In the IPCU, a patient treated with clozapine for schizo-affective disorder faced notable challenges after the implementation of the Smoke-Free Perimeter Law. Initially permitted a regulated number of cigarettes each day, this allowance was curtailed due to the law’s enforcement requiring staff accompaniment for smoking breaks. The restriction led to reduced cigarette access. Following his transfer to an unrestricted smoking ward, the patient’s cigarette intake increased to 20–30 per day, reverting to his usual habit. This change precipitated a drastic reduction in clozapine levels from 0.46 mg/l to 0.28 mg/l, leading to heightened confusion, delusional thinking, and disorganized speech. Despite no change in medication, it was resolved to move him back to the IPCU under a restricted smoking regimen. As his smoking stabilized at 10–12 cigarettes daily, the clozapine levels fluctuated before eventually normalizing, correlating with a stabilization of his psychiatric symptoms.

Results: This case underscores the significant influence of lifestyle habits, especially smoking, on the efficacy of psychiatric medications in mental health care. The increase in cigarette use in the unrestricted ward led to a marked decrease in his clozapine levels, highlighting the interaction between smoking and medication metabolism. The situation points to the crucial role of healthcare providers in closely monitoring and adjusting treatment plans in response to lifestyle changes, ensuring patient well-being alongside adherence to public health policies.

Conclusion: This case illustrates the complex challenges posed by the Smoke-Free Perimeter Law in psychiatric care, particularly in terms of personalized care and medication management. The significant changes in the patient’s mental health and clozapine levels following increased smoking in an unrestricted environment underscores the need for careful planning in future transitions. Especially attempts to move the patient to a home or less restricted environment where smoking is more accessible, should be approached cautiously.

Aims: Catatonia can be secondary to psychiatric or medical conditions. Previous studies have reported associations between chemotherapy and catatonia, and between taxanes (a chemotherapeutic agent) and encephalopathy. However, there have thus far been no reports linking taxanes with catatonia. We present a patient whose catatonia emerged after receiving a taxane chemotherapy agent, docetaxel, while also suffering acute kidney injury and delirium.

Methods: Case report.

Results:

A 75-year-old housewife was admitted to a tertiary general hospital in Singapore for delirium followed by catatonia. She had a history of a right lentiform nucleus infarct in 2017 and of schizophrenia diagnosed in 1994, and treated with haloperidol. Her schizophrenia featured auditory hallucinations, delusions, and pressured speech; but no catatonia. In May 2024, she was diagnosed with stage III left breast carcinoma and commenced on neoadjuvant chemotherapy, consisting of docetaxel, pertuzumab, trastuzumab and filgastrim. Over the next 3 weeks, she developed poor oral intake and vomiting, resulting in acute kidney injury with metabolic acidosis, and requiring admission for rehydration. Initially, she was delirious, with drowsiness and inattention. However, on the third week of admission, she developed catatonia, with features of stupor, staring, echolalia, stereotypy, verbigeration, waxy flexibility, and perseveration. On the Bush–Francis catatonia rating scale (BFCRS), she scored 23. She did not exhibit any relapse of schizophrenia. To treat her catatonia, she was prescribed PO lorazepam 0.75 mg/day to 1.5 mg/day. Serial reviews before, and 30 minutes after the administration of lorazepam, demonstrated a significant reduction in catatonic symptoms. A week later, her catatonia resolved (BFCRS score 2) and she was discharged home. During clinic follow-up, she remained haemodynamically stable with good oral intake. Her BFCRS initially increased to 10, requiring further increase of lorazepam to 3 mg/day, which led to an improvement of the BFCRS to 2.

Conclusion: Breast cancer chemotherapy has previously been associated with cognitive deficits. Taxane-induced neurotoxicity can present with encephalopathy, ataxia, emotional distress, or cognitive impairment. Cerebral perfusion abnormalities in the motor cortex and frontal lobe have been previously described in catatonia, and after chemotherapy for breast cancer. In contrast, pertuzumab, trastuzumab, and filgrastim lack strong association with psychological symptoms. Therefore, while the catatonia is likely multifactorial in aetiology, with dehydration, acute kidney injury, and acidosis the probable culprits, we postulate that docetaxel significantly contributed to her catatonia. Notwithstanding the pathophysiology of catatonia, the case demonstrates good response to a benzodiazepine.

Aims: Munchausen syndrome by proxy, or “factitious disorder imposed on another” as per DSM–V criteria, is characterised by the falsification of signs or symptoms, or induction of injury or disease, in another individual. Despite its initial description over 60 years ago, the literature on its epidemiology, management, and prognosis remains limited, with most insights derived from isolated case reports.

Methods: We report a case of a 27-year-old woman charged with attempted murder after injecting her 7-year-old son with insulin multiple times. The patient’s actions were driven by a history of severe childhood trauma, including sexual abuse by her father and brother, which contributed to her distorted perceptions of her son’s behaviour. She falsely presented symptoms to healthcare providers, altered diagnostic tests, and fabricated medical histories, resulting in extensive and unnecessary investigations for the child on top of complications from being injected by insulin. Psychiatric evaluation diagnosed her with major depressive disorder, post-traumatic stress disorder, antisocial personality traits, and Munchausen syndrome by proxy. Despite being aware of the harm caused by her actions, the patient’s judgement was significantly impaired due to her mental illnesses. Treatment included antidepressants and psychotherapy, with partial improvement observed.

Results: This case illustrates the significant risks posed by Munchausen syndrome by proxy to victims and the complexities involved in its diagnosis and management. Early identification requires a high index of suspicion and meticulous investigation by multidisciplinary teams. Video surveillance and psychiatric evaluations are crucial tools in confirming such cases. Long-term management often necessitates pharmacological treatment and tailored psychotherapy for the perpetrator, alongside safeguarding measures for the victim.

Conclusion: Munchausen syndrome by proxy remains a challenging diagnosis requiring vigilance and interdisciplinary collaboration. This case underscores the importance of early recognition to prevent harm to victims and highlights the need for systematic research to explore common patterns and effective interventions in this rare condition.

Aims: Traditional Chinese Medicine (TCM) describes correlations between mental disorders, symptoms and physical organs, specifically identifying dominant emotions associated with specific organs. For example, in TCM sadness is correlated to the lung. TCM informs that psychological issues usually manifest as physiological dysfunction of the related organ. This encourages clinicians to consider the effects on various organs during management of mental disorders. This case study aims to explore the relationship and complexities between grief and idiopathic pulmonary fibrosis (IPF).

Methods: T was referred for grief counselling over her cats’ deaths and presented with respiratory symptoms which required further investigations. T is also a survivor of a horrific trauma 40 years ago, where an auntie wielded a knife at her and her mother. T’s mother died tragically while T bore scars across her arms, body, and the left side of her face visible till today. She was 6 years old. T reported that her father was deeply embittered, and never resolved his feelings of grief and anger. He died of lung fibrosis, which T attributes to his unresolved grief as she described how he would get breathless and could never talk about his late wife.

Results: Pulmonary fibrosis (PF) may be caused by many different things. IPF however is one type of PF where no cause can be identified.

Western literature concurs with TCM in that the link between disease and bereavement is strongest for the cardiovascular system. There are medical studies which investigated biological events that occur during the grieving process. They noted pathways through which grief might affect the immune system and increase vulnerability to physical illness.

T has no prior knowledge of TCM and no known family history of pulmonary fibrosis. However, T identified and believed that unresolved grief was a large contributor to her father’s lung condition.

Conclusion: Psychological issues as a potential risk factor to the development of lung diseases have not been studied in patients with IPF.

This case study highlights the importance of supporting T in her grief, if that may indeed reduce the probability of a lung pathology according to western literature and TCM.

A follow up study to explore existence of complex grief in a cohort of patients with IPF would shed light on the possible correlation between grief and lungs, as described by the TCM perspective.

Aims: Aripiprazole, an atypical antipsychotic, is commonly prescribed for various psychiatric conditions including schizophrenia and bipolar disorder. It is generally considered to have a more favourable side effect profile compared with other antipsychotics, with a lower risk of metabolic side effects and hyperprolactinemia. We present the case of a 57-year-old male who developed marked hypersexuality and excessive spending following the initiation of oral aripiprazole.

Methods: Mr X was referred for psychiatric review within our drug and alcohol service due to concerns regarding worsening paranoid ideation. He had a history of alcohol dependency but had been abstinent for five months at the time of referral. He denied recreational drug use and was not on regular medication, aside from thiamine 100 mg three times daily. His past medical history was unremarkable, though he reported a family history of schizophrenia, with a brother diagnosed with the condition. Mental state examination revealed a complex paranoid delusional system, accompanied by auditory hallucinations, thought interference and somatic passivity. Blood tests were unremarkable, and a urine drug screen was negative. Aripiprazole was prescribed and titrated to 15 mg daily over a two-week period, with potential risks, including those of disinhibition, being discussed. At follow-up, Mr X recalled the discussion and reported a significant increase in his libido, spending over £1500 over the course of a week on online sexualised adult chat websites, a behaviour he had never previously engaged in. The aripiprazole was switched to olanzapine and the hypersexuality resolved over the following four weeks, with no further excessive spending.

Results: Whilst generally well-tolerated, aripiprazole is not without potential side effects, including issues with impulse control, such as hypersexuality and excessive spending. These behaviours are thought to arise from aripiprazole’s partial agonist activity at dopamine D2 receptors. Given the significant financial and social consequences these behaviours can have, it is essential for clinicians to proactively discuss the possibility of these side effects and ensure close monitoring, particularly during the early stages of treatment or following dose adjustments.

Conclusion: Whilst the appropriate prescribing of antipsychotics forms a key part of many treatment plans, this case report serves as an important reminder of the potential rare but significant side effects of aripiprazole. Clinicians must remain vigilant for these behaviours and proactively discuss them with patients, who otherwise may feel reluctant in doing so. It is essential to provide clear warnings and ensure appropriate follow-up to address any emerging side effects.

Aims: Progressive supranuclear palsy (PSP) typically presents with a constellation of motor symptoms, most commonly with frequent falls and gait disturbances. As the disease progresses, cognitive dysfunction and behavioural abnormalities may develop, however hypersexuality in the absence of the usage of dopaminergic agonists is rarely described. We report a case of a 70-year-old male referred to Consultation Liaison Psychiatry for inappropriate sexual behaviour on a background of Progressive Supranuclear Palsy with Predominant Cerebellar Ataxia.

Methods: He was admitted to hospital due to inappropriate sexual behaviours resulting in significant caregiver distress. There were increased sexual demands over the past year with other frontal lobe symptoms of hyperorality, apathy, distractibility and motor perseveration. His clinical history, previous investigations and treatments received were reviewed. He was subsequently diagnosed with Major Neurocognitive Disorder due to multiple aetiologies (PSP, Alzheimer’s disease and Frontotemporal lobar degeneration). He was started on trazodone and memantine with improvement and subsequently discharged home.

Results: PSP is known to cause frontal lobe deficits affecting executive function, with apathy, impulsivity and disinhibition, but rarely hypersexuality. Hypersexuality is more commonly associated with use of dopaminergic agonists that may be given to address motor symptoms in PSP. It is known that the use of dopaminergic agonists is associated with impulse control disorders such as pathological gambling, hypersexuality and compulsive eating. Further research into how progressive neurodegeneration from PSP affects brain function may shed more light on the emergence of behavioural changes such as hypersexuality.

In the management of hypersexuality, other contributing factors such as boredom, feelings of insecurity and lack of a sexual partner may need to be considered. Non-pharmacological options include behavioural interventions and education of caregivers. Medications may have potential side effects which need to be considered during prescribing. Serotonergic medications such as Selective Serotonin Reuptake Inhibitors are often used due to lower risks and have shown some benefit in reducing problematic behaviour. Other options include antipsychotics, cholinesterase inhibitors and hormonal treatments. It is also important to consider the wellbeing of family and staff looking after the patient as they may be victims of the patient’s sexual behaviour, and provide the necessary support.

Conclusion: Hypersexuality is rare in PSP and a thorough review of all possible causes is required. Management may involve both behavioural interventions and pharmacological treatment to aim to reduce inappropriate behaviours.

Aims: To present a case of refractory agitation in a patient with autism spectrum disorder (ASD) and explore electroconvulsive therapy (ECT) as a therapeutic option.

Supervision was provided by Dr Iyad Alazzeh (Halhul Community Mental Health Center).

Methods: A 14-year-old male patient with ASD presented to his psychiatrist after several failed attempts to integrate him into special-care schools due to increasing disturbance of behaviour. He has no other medical problems, and he lives with his father, who is diagnosed with schizophrenia, and his grandmother. His mother often visits him and helps take him to medical appointments. Several pharmacological agents have been attempted: Valproic acid, clonazepam, risperidone, olanzapine, and chlorpromazine, without improvement in his condition. The child’s condition further deteriorated as he stopped accepting medications, which disrupted his sleep and caused bursts of laughter and screaming. During an appointment, the patient attacked his mother and bit her causing an injury necessitating medical intervention. After a multidisciplinary evaluation, obtaining informed consent, and familiarizing the patient with the setting, electroconvulsive therapy (ECT) was initiated as a last resort. The patient underwent a series of eight ECT sessions under general anaesthesia.

Results: The only documented side effect was irritability at bedtime on the day of each ECT session, which disappeared with sleep. After he finished all his sessions, the patient had decreased laughter, started accepting medications again, was more responsive to directions, and didn’t exhibit aggression. However, his baseline agitation didn’t significantly improve, leading to the persistence of social integration challenges. It is difficult to determine if the cessation of physical aggression was the result of ECT or resuming medications.

Research on ECT use in paediatric populations is limited but growing, with studies indicating its potential to address severe neuropsychiatric symptoms, including catatonia, mood dysregulation, and treatment-resistant aggression. ECT has shown efficacy in managing specific refractory symptoms, particularly in cases where pharmacotherapy and behavioural interventions fail. However, ethical concerns, stigma, and limited clinical trials have historically restricted its use in this population.

Conclusion: Severe agitation in paediatric patients with autism spectrum disorder (ASD) presents a significant therapeutic and diagnostic challenge. This case highlights the potential of ECT to target specific refractory behaviours in paediatric patients with neuropsychiatric conditions. Further research into the role of ECT in managing treatment-resistant agitation in children with ASD is required.

Aims: Children with neurodevelopmental conditions, particularly ADHD, often face heightened vulnerability to adverse childhood experiences (ACEs), shaping their mental health trajectories. Trauma-informed care (TIC) provides a structured framework for understanding and addressing these vulnerabilities within clinical practice. Additionally, working with trauma-exposed children places significant psychological demands on mental health professionals, contributing to secondary traumatic stress (STS) and burnout. This study presents a complex case from CAMHS, illustrating the intersection of ADHD, trauma, and systemic care challenges, alongside an exploration of clinician well-being within trauma-intensive settings.

Methods: A single case study approach was employed, utilizing Bronfenbrenner’s Ecological Systems Theory to analyse the interplay between individual, familial, and systemic factors affecting an 8-year-old child’s mental health. A review of trauma-related clinician distress was conducted, drawing from literature on secondary trauma and workforce resilience within CAMHS services.

Results: The case study underscores the bidirectional relationship between trauma and ADHD. Despite medical and educational interventions, ongoing adversity exacerbated symptom severity, necessitating a trauma-informed, whole-system approach. Additionally, clinicians working within trauma-intensive environments demonstrate significant risks for STS and burnout, emphasizing the need for structured trauma stewardship interventions.

A dual-focused approach in CAMHS – addressing both patient needs and clinician well-being – is critical for sustaining high-quality care. Conceptual frameworks such as the Biopsychosocial Model and the Boundary Seesaw Model provide strategies to navigate the competing demands of care provision and workforce resilience. Reflective practice, clinical supervision, and organizational support emerged as critical factors in maintaining a sustainable mental health workforce.

Conclusion: Trauma-informed care is essential for managing neurodevelopmental conditions within adversity-laden contexts. Optimizing CAMHS services requires integrating trauma-responsive strategies at both patient care and workforce levels to ensure sustainable, high-quality mental health support. This study underscores the urgency of workforce resilience policies within trauma-informed mental health systems.

Aims: Bipolar depression remains a major therapeutic challenge, particularly in elderly populations where treatment options are constrained by comorbidities and medication tolerability. Despite pharmacological advancements, many patients experience persistent depressive symptoms, even after multiple trials of mood stabilizers, antipsychotics, and antidepressants. Lithium, while effective, is associated with nephrotoxicity, limiting its use in the elderly. Modafinil, a wakefulness-promoting agent primarily used for narcolepsy, has emerged as a potential adjunctive treatment for treatment-resistant bipolar depression (TRBD). Its broad neurochemical effects, targeting multiple pathways, suggest promise in addressing refractory mood symptoms. However, its role in elderly patients remains underexplored.

Methods: We report the case of a 74-year-old Caucasian male with a long-standing history of bipolar disorder and multiple comorbidities, including hypertension, pulmonary fibrosis, cerebellar ataxia, and chronic kidney disease (CKD). His psychiatric symptoms began in 1995 with depression, progressing to a bipolar diagnosis after a manic episode in 1997. Initial treatment with lithium and venlafaxine stabilized his mood for several years. However, lithium was discontinued after nine years due to worsening renal function, leading to recurrent depressive episodes characterized by anhedonia, hypersomnia, and cognitive decline. Multiple pharmacological trials, including olanzapine, lamotrigine, fluoxetine, aripiprazole, quetiapine, and lurasidone, failed to achieve symptom remission. A retrial of lithium proved ineffective and was discontinued due to further renal deterioration. Given the lack of effective options, modafinil was introduced which improved his Montgomery–Åsberg Depression Rating Scale (MADRS) score from 29/60 to 6/60, reflecting enhanced mood, motivation, and wakefulness without adverse effects.

Results: TRBD in the elderly is complicated by age-related pharmacokinetic changes, comorbidities, and sensitivity to side effects. Standard mood stabilizers like lithium are often contraindicated due to nephrotoxicity, while atypical antipsychotics can introduce metabolic or cognitive risks. Modafinil’s unique neurochemical profile offers a novel approach to addressing treatment-resistant symptoms. While concerns regarding potential side effects, such as cardiovascular risks or mania induction exist, recent studies suggest modafinil is generally well-tolerated with minimal mood switch. This supports emerging evidence that modafinil may serve as an effective adjunctive therapy in TRBD, particularly when conventional treatments are limited.

Conclusion: This case highlights the successful use of modafinil as an adjunctive treatment in an elderly patient with TRBD. The patient’s significant improvement in depressive symptoms and overall functionality, without adverse effects, suggests that modafinil may be a viable option for elderly patients unresponsive to conventional therapies. However, further research, including randomized controlled trials, is needed to establish clear guidelines for its use.

Aims:

Gender variance is a prevalent yet complex phenomenon that continues to generate significant academic and clinical interest. Historically, the diagnosis of Gender Identity Disorder was classified under Mental and Behavioural Disorders in the International Classification of Diseases (ICD). This has since been revised to 'Gender Incongruence’ and relocated to the Conditions Related to Sexual Health section in ICD–11. Despite these advancements, the psychopathology of individuals experiencing distress related to gender incongruence remains insufficiently understood. Countries like Pakistan where sex reassignment procedures are illegal, provide a unique lens through which to explore the psychological experiences of individuals with gender incongruence.

Methods: This report details the case of a 20-year-old woman who presented with a testosterone-secreting tumour. Previously identifying and living as a heterosexual female, she reported experiencing homosexual encounters, emotional distress, confusion regarding her gender identity, and an increasing openness to adopting a male identity. Despite surgical interventions, her testosterone levels initially remained elevated and later surged, leading to a diagnosis of Munchausen’s Syndrome (Factitious Disorder).

Results: Munchausen’s Syndrome/Factitious Disorder: Munchausen’s syndrome involves intentional fabrication or induction of illness without external rewards, distinguishing it from malingering. Features include inconsistencies in patient history, overdramatic presentations, and willingness to undergo invasive procedures. While Ms R’s case lacked some typical features, her persistence in seeking medical attention and willingness to undergo surgical procedures supported the diagnosis.

Gender Incongruence: ICD–11 defines Gender Incongruence as persistent mismatch between experienced gender and assigned sex, often prompting medical interventions. In Pakistan, gender incongruence is stigmatized, compounded by legal prohibitions against homosexuality. Ms R’s case highlights the cultural and psychological conflicts arising from these societal pressures.

Psychodynamic Considerations: Ms R’s actions may have stemmed from a desire for attention and care amidst her challenging personal circumstances. The endocrinology team’s thorough investigation reflects the cultural emphasis on finding biological causes, but the eventual diagnosis strained the doctor–patient relationship, underscoring the complexities of treating such cases in resource-limited settings.

Conclusion: This case underscores the complex interplay of gender incongruence and factitious disorder within a restrictive socio-religious context. It highlights the importance of culturally sensitive, multidisciplinary care, the need for further research on gender identity in conservative settings, and deeper exploration of the psycho-dynamic relationships between patients and healthcare providers.

Aims: Safe and effective prescribing in people living with dementia (PLWD) is particularly challenging due to the increased risk of adverse events, polypharmacy and potentially inappropriate medications. Cognitive impairment and reliance on caregivers to report symptoms can further complicate the assessment of drug benefits. This case study demonstrates how novel contactless monitoring could address these challenges by enabling remote evaluation of drug effects in PLWD.

Methods: We present the case of a 77-year-old gentleman with late onset Alzheimer’s disease enrolled on the CR&T MINDER cohort study and continuously monitored using the Withing’s Sleep Analyzer. He visited his GP with complaints of insomnia and was subsequently prescribed 15 mg of mirtazapine. He reported immediate beneficial effects, although noted that the drug made him drowsy. We evaluated his sleep by comparing baseline sleep metrics (a 2-week average 1 month before drug administration) with average sleep metrics 2 weeks after starting mirtazapine. Statistical analysis was performed using a paired t-test and a rolling average to assess trends over time.

Results: Calculated rolling average showed reductions in time spent awake overnight and in light sleep, while deep sleep and total sleep time increased. These trends were confirmed by period comparisons. Baseline deep sleep duration (M = 1.19 hrs, SD = 1.02 hrs), and total sleep time (M = 7.16 hrs, SD = 1.03 hrs) significantly increased 2 weeks post mirtazapine (deep sleep: M = 2.63 hrs, SD = 1.03 hrs); total sleep time: M = 7.87 hrs, SD = 0.47 hrs), t(13) = −3.639, p = 0.003, and t(13) = −2.256, p = 0.042. There was also a significant reduction in time spent awake during the night from baseline (M = 1.17 hrs, SD = 0.51 hrs) to 2 weeks post mirtazapine (M = 0.65 hrs, SD = 0.43 hrs), t(13) = 2.616, p = 0.0214.

Conclusion: This case study shows that contactless remote monitoring could be used objectively to evaluate the effects of mirtazapine on sleep in PLWD. Our results demonstrate that improvements in sleep detected by monitoring align with the participants’ reported benefits. These findings suggests continuous remote monitoring could provide valuable, timely insights into drug effects in PLWD, improving clinical decision-making and personalising care.

Aims: An increasing number of patients with Autism Spectrum Disorder (ASD) and Intellectual Disability (ID) are being admitted to general psychiatric wards and managed by general psychiatrists. This case report describes a crisis admission and reviews the models of care, interventions, and outcomes delivered by a non-specialist multidisciplinary team (MDT) following the closure of a specialist ID unit.

Methods: X is a 30-year-old female with ASD and Moderate ID, presenting with complex self-harming behaviours (self-punching, head-banging), psychogenic polydipsia, self-neglect, and risks to others (aggression, property damage). She required 2:1 staffing observations. After the closure of the specialist ID ward, X was transferred to Cygnet Churchill Hospital in January 2024, initially for community discharge, but an unforeseen admission necessitated continued complex care.

Results: An interdisciplinary intervention programme including carer-informed change in antipsychotic medication and Clinical Genetics history review. Psychological interventions targeted three areas: patient-centred care, MDT-centred care, and personalized risk assessment. Patient-centred interventions involved exploring emotions and dysregulation management, with X identifying strategies to manage emotional regulation and self-expression. MDT interventions included rapid PBS training to upskill non-specialist staff in managing ID and ASD, alongside discontinuing communication aids. A personalized START risk assessment, integrating five case-specific items, enhanced X’s understanding of her behaviours.

The Vona du Toit Model of Creative Ability (VDTMoCA) was applied to create an individualized intervention plan promoting choice, including an interest checklist, healthier eating options, choice cards, and reformatted social stories tailored to X’s preferences. These strategies developed X’s Occupational identity and supported emotional regulation.

The comparison of pre- and post-admission Global Assessment of Progress (GAP) Scores showed a 44.7% improvement, with the highest gains in complex challenges (50%), Daily Living Skills Observation Scale (41.7%), Family Caregiver Support Program (64.2%), and Daily Risk Assessment (DRA). There was a significant reduction in self-harm (81.25%) and physical aggression (28.13%), but an increase in restraint (52.4%), verbal aggression (350%), property damage (183.3%), and absconding (33.3%). No changes were observed in rapid tranquillization or medication adherence. Discarding communication mats and Makaton led to notable improvements, with X independently chairing her ward rounds for the past four months, demonstrating progress in self-advocacy.

Conclusion: This case highlights the importance of regular reviews of long-stay patient interventions and demonstrates that general adult psychiatrists, when supported by interdisciplinary teams, can achieve significant improvements in managing complex cases, leading to better outcomes for individuals with ASD and ID.

Aims: Background: Depersonalization-derealization disorder (DPDR), classified under ICD–11 code 6B66, involves persistent or recurrent experiences of depersonalization, derealization, or both. Depersonalization refers to a sense of detachment from one’s thoughts, emotions, or body, whereas derealization involves perceiving the external world as unreal or distorted. These symptoms cause significant distress or impairment, are not attributable to other mental disorders, substance use, or medical conditions, and occur while reality testing remains intact.

Methods: Case Report.

An 18-year-old female A-level student presented with a two-year history of frequent episodes in which her surroundings, including people and familiar environments, felt unreal. These episodes varied in duration and were highly distressing, particularly during emotional extremes such as heightened happiness or stress. Symptoms were most pronounced in the evenings or when she was unoccupied, leading to emotional breakdowns. Despite these experiences, she remained aware of her own reality, with disturbances centred on external perceptions.

Her symptoms began following a nine-month psychiatric hospitalization. Prior to admission, she experienced unexplained gastrointestinal symptoms, and in the absence of an identifiable physical cause, she was diagnosed with conversion disorder. The hospitalization was distressing due to frequent invasive procedures, a perceived sense of blame for her condition, and feelings of entrapment. She subsequently developed post-traumatic stress disorder (PTSD), characterized by flashbacks, nightmares, and avoidance of medical settings. However, DPDR symptoms persisted outside of PTSD-related re-experiencing episodes, causing ongoing distress and impairment.

Results: Discussion: This case highlights the complex interplay between DPDR and PTSD, particularly following medical trauma. While dissociative symptoms frequently occur in PTSD, ICD–11 differentiates DPDR as a distinct disorder when symptoms persist beyond re-experiencing episodes. In this case, the patient’s prolonged hospitalization, combined with perceived invalidation and invasive interventions, likely contributed to the development of DPDR as a maladaptive dissociative response.

The exacerbation of symptoms during emotional extremes aligns with research indicating that dissociation may function as an affect regulation mechanism. Trauma-related dissociation has been linked to disruptions in emotional processing, potentially interfering with adaptive coping strategies. This underscores the importance of targeted psychological interventions to reduce distress and improve functional outcomes.

Conclusion: A trauma-informed, multidisciplinary approach is essential in managing this patient’s complex presentation. Psychological interventions such as EMDR or trauma-focused CBT should be integrated with ongoing medical care to address both dissociative symptoms and physical health concerns. Collaborative management between psychiatric and medical teams will be crucial in promoting long-term recovery, enhancing her psychological resilience, and improving overall quality of life.

Aims: Internally displaced persons (IDPs) in Nigeria experience numerous challenges, including psychological distress resulting from displacement and trauma. In October 2024, a cohort of volunteer mental health professionals based in the United Kingdom provided sessions of mental health support via virtual means to displaced women in Abuja, Nigeria. This intervention utilised telemedicine to address barriers to access and adhered to the principles of Psychological First Aid (PFA).

Methods: The initiative required significant pre-event coordination. Mental health professionals from local and international backgrounds were recruited to volunteer, and a structured counselling protocol was developed. Zoom conferencing was utilised to conduct the sessions, with efforts made to incorporate trauma-informed approaches. Despite thorough planning, technical difficulties arose, including unreliable Wi-Fi connections that intermittently disrupted sessions. Power outages were also problematic, necessitating the use of generators at the Nigerian location to maintain a supportive environment. During the sessions, participants disclosed accounts of hardship and trauma. Volunteers emphasised active listening, empathy, and cultural sensitivity to establish trust and provide meaningful support.

Results: Collaboration played a pivotal role in the success of this initiative, showcasing its critical contribution to the field of mental health care. The collaboration between local and international mental health professionals underscored the strength of teamwork. Each volunteer’s dedication, despite the challenges, contributed to the overall impact of the project. The shared responsibility among the team fostered a supportive network that bolstered resilience against challenges, which is key in mental health-care provision. Feedback from participants and volunteers reflected the success of the initiative, with attendees expressing gratitude and an openness to future mental health interventions.

Conclusion: This initiative demonstrated the power of perseverance, creativity, and collaborative efforts in delivering psychosocial support to underserved populations. By adopting a flexible approach and prioritising the needs of the participants, the event successfully bridged gaps in care and provided a platform for displaced women to be heard and supported. Future initiatives can build upon these findings, enhancing technological resilience and refining to ensure greater reach to those most in need.

Aims: Bipolar Affective Disorder (BAD) is known to present with manic or hypomanic episodes, along with depressive episodes occurring at different times. Considerable within-normal-range mood variations between episodes are expected. In some cases, mania or hypomania can be induced by medications. While well-established medications such as corticosteroids and levodopa are known to induce mania, a careful examination of possible triggers for manic switches is essential to ensure individualized patient care.

Methods: This 34-year-old Caucasian female patient presented with depressive disorder. She has a history of multiple depressive episodes. She had been on sertraline for seven months for her most recent depressive episode. However, due to excessive sweating as a reported side effect, her medication was switched to fluoxetine at 20 mg daily, which was subsequently increased to 40 mg after three weeks. On the fifth day after the dose increase, she presented with hypomanic symptoms, changing her diagnosis to Bipolar Affective Disorder (BAD), current episode hypomania. Fluoxetine was identified as the causative agent for this switch. However, at the patient’s request, fluoxetine was continued with antipsychotic and/or mood stabilizer cover, as the patient retained the capacity to make decisions regarding her medical management. The patient was otherwise fit and well, with no recent drug or alcohol involvement. She was prescribed lorazepam 0.5 mg PRN QDS, zopiclone 7.5 mg PRN nightly, and risperidone 1 mg BD in addition to fluoxetine 40 mg daily. Due to drowsiness associated with risperidone, she was commenced on lithium PR titration. Two weeks later, her subsequent symptoms were consistent with mixed affective states. The fluoxetine was discontinued with the patient’s consent. Lurasidone 37 mg was initiated alongside lithium (Priadel XL) 600 mg. Four days after the medication change, the patient reported feeling sedated and experiencing low energy levels. After this review, her lithium dose was increased to 800 mg. Eight days after initiating lurasidone, the patient called the clinic with marked irritability. She reported having high energy levels and feeling very well. The review revealed another hypomanic switch with marked rapid speech and reduced need for sleep. The symptoms of hypomania have resolved following discontinuation of lurasidone.

Results: This case report highlights the possible hypomanic switch associated with the use of lurasidone. With several new drugs approved for mental illnesses including BAD, it is crucial to monitor their side-effect profiles to ensure safer and more effective management.

Conclusion: There are several potential confounders identified in this case.

Aims: Aphonia, defined as partial or complete loss of voice, can have multifactorial origin, ranging from organic to functional aetiology. This paper aims to describe an unusual presentation of aphonia on the background of psychotic symptoms and catatonia.

Methods: Mr KC, a 23-year-old mechanic presented to an outpatient ENT (Otorhinolaryngology) clinic at a tertiary care hospital in North India. As per available information, KC was asymptomatic until 1 month ago. Over the next week, the family members observed KC to be withdrawn, quieter than usual and skipped work. He would reluctantly accept food and eat less than usual. Family members consulted general practitioners who advised multivitamins and supportive measures, with no improvements in KC’s symptoms.

In the week preceding hospital visit, family members got concerned as KC would spend an entire day without speaking. He would occasionally nod yes/no or utter 1–2 words at his own will. He clenched his jaws when family attempted to feed him. Family googled KC’s symptoms and guided by the suggestions over the internet, they decided to visit the ENT clinic for further evaluation.

Upon presentation to the clinic, KC appeared dishevelled and had clearly lost weight, with his clothes hanging loosely. He refused cooperation for the oral and laryngoscopic examination. Neurological examination revealed increased rigidity in both limbs following which a psychiatry referral was done and a provisional diagnosis of catatonia was established.

After a lorazepam challenge, the rigidity reduced, and KC became more compliant, accepting small amounts of food. The laryngoscopy was performed when KC was cooperative, revealing no structural abnormalities or any pathological finding. His speech returned, and he expressed fear, saying, “I can hear people plotting against me”. With a diagnosis of psychosis, oral risperidone 4 mg per day (divided dose) was started. Routine blood tests revealed nutritional deficiencies likely due to prolonged food refusal. Two weeks into the treatment, KC resumed normal interaction, and his speech was fully restored.

Results: The case highlights the collaborative approach of ENT and mental health professionals in prompt identification and treatment of aphonia. Unlike many patients who present to ENT clinics with aphonia due to stress-related causes, this case is unique because psychotic symptoms overlapped with the aphonic presentation.

Conclusion: This case emphasizes the importance of a multidisciplinary approach in the diagnosis and management of aphonia. It serves as a reminder to consider a broader differential diagnosis when encountering aphonia, particularly in patients with unusual behavioural changes or neurological signs.

Aims: Charles Bonnet syndrome (CBS) is a phenomenon characterized by complex visual hallucinations in visually challenged patients. CBS may go unrecognized and be misdiagnosed as early dementia or psychosis.

Methods: We present the case of an 83-year-old Caucasian gentleman ‘X’ who was referred to the older adult home treatment team.

X reported that his problems began when some men turned up at his door a few weeks earlier, regarding an application he had made to the council for solar panels. X suffered from a complex delusional framework, believing that these men have stayed around in his home and are living in his loft. He believed that there are microphones in his bedroom and that his conversations are being transmitted to malicious people who work for the council.

X reported distressing visual hallucinations of men in his kitchen threatening him with guns. Other hallucinations included his ex-partner engaging in sexual activities with the aforementioned men, which led him to believe that she has been forced into the sex trade. He reported seeing distorted faces in his bathroom mirror, bodies floating up against the ceiling, and children with metallic prostheses for limbs. X recently received a diagnosis of a mild cognitive impairment following a referral made by the GP to the memory clinic. Prior to this, he did not have a history of psychiatric or neurological illness.

Interestingly, X had previously undergone excision of his right eyeball for the treatment of cancer, and has a skin graft at the site. He has only partial vision in his remaining eye due to macular degeneration.

Results: Three criteria should be fulfilled to diagnose CBS; namely, visual loss, clearly formed recurrent visual hallucinations, and insight into the unreal nature of the hallucinations.

In our case study, X fulfilled the first 2 criteria, but was unable to appreciate that the images that he sees are not real. We surmise that X may initially have understood that his hallucinations are not real, but these hallucinations gradually became amalgamated with his delusional belief systems, leading to a loss of insight.

Conclusion: CBS should be considered as a diagnostic possibility in persons with visual impairment presenting with visual hallucinations, and differentiated from psychotic and neurological disorders such as dementia, delirium and late-onset psychosis.

Aims: Solute Carrier Family 6 member 1 (SLC6A1) genetic mutations are rare and mostly reported in the paediatric population. Few reports on adult cases have been mentioned in the literature. At present only pathological and likely pathological variants can confirm a diagnosis of SLC6A1-related neurodevelopmental disorder.

Methods: We report the clinical presentation of an adult male with a heterozygous variant of uncertain significance of the SLC6A1 gene. He presented with developmental delay initially and only in later years presented with other features in keeping with SLC6A1-related neurodevelopmental disorder. This includes moderate intellectual disability, epilepsy, autism, attention deficit disorder, behavioural difficulties including aggression. A further EEG at age 14 also showed focal and general abnormalities, however an MRI was normal. He was trialled on methylphenidate, lis-dexamphetamine and atomoxetine which were all unsuccessful. In 2024, genetic testing revealed a heterozygous variant of uncertain significance of the SLC6A1 gene.

Results: Our case adds further credence to the growing literature on SLC6A1 gene-related disorder and SLC6A1-related neurodevelopmental disorder. This individual illustrates the diverse clinical phenotype. Given the lack of published evidence, the result from genetic testing for this person was classified as a variant of uncertain significance.

Uniquely, this case report describes an adult who has been tested, as opposed to paediatric cases which comprise much of the literature in this area. The notable case described by Verhowen of a patient who presented with a late onset of seizures, similar symptoms, progression and prior failed trials of medication as the case presented here, also benefited from genetic testing in later life. In addition, this patient responded well to sodium valproate which is known to be beneficial in cases with SLC6A1. This is most likely related to the GABA mediation. The findings of this case demonstrate the SLC6A1 gene-related disorder provides a unifying explanation for this diverse clinical phenotype, previously thought to be a constellation of syndromes and co-morbid symptoms.

The individual in this case study failed to respond to three adequate trials of medication for ADHD, all which have a robust evidence base. This suggests a possible alternate pathway for the development of ADHD features in cases such as this, as the majority of individuals with moderate-severe ADHD symptoms achieve symptomatic relief with pharmacological intervention

Conclusion: This case highlights the relevance of genetic testing in adults and the reporting of variants of uncertain significance that could possibly lead to reclassification of a variant.