Aims: Parkinson’s disease (PD) is mainly a movement disorder, although 30% of PD patients may also suffer from psychosis, which may impair quality of life. PD psychosis (PDPsy) may result following approximately 10 years of treatment using dopaminergic agonists. PDPsy is characterized by recurrent and continuous hallucinations and delusions lasting for at least 1 month.

Methods: A 59-year-old female was admitted under Section 2 of the Mental Health Act (MHA) due to concerns raised by the police and her family regarding her mental health. The police were particularly alarmed after she repeatedly contacted them, expressing paranoid delusions. Her confusion and memory issues further contributed to the concerns leading to her admission. She was under the Early Intervention Psychosis team at the time of admission but her engagement with them was very erratic. She was started on quetiapine 50 mg ON but was non-compliant. She was diagnosis with PD 12 years prior to admission, and was still under the neurology team, and being regularly reviewed. The medication prescribed for PD were Sinemet 12.5/25 2 tabs QDS and ropinirole 8 mg BD.

Upon admission, the patient reported feeling monitored via 16 satellites connected to her television, broadcasting signals worldwide. She denied calling the police and instead suggested that her phone had been hacked. The police reported that she alleged that she had been sexually assaulted by her ex-partner or individuals organized by him while being drugged, though she had no memory of these events when questioned. She believed she was being followed, a notion she first experienced on a train to Cornwall a year prior. She also alleged that her ex-partner frequently entered her home at night to steal from her. She, also, exhibited delusional beliefs regarding her YouTube presence, asserting that her ex-partner manipulated satellites to influence her views online. Risk factors identified included medication non-compliance, poor insight, risk of falls due to Parkinson’s disease, potential financial exploitation due to engagement with strangers on social media, and vulnerability.

Results: The differential diagnosis considered for this patient:

Delusional Disorder.

Late-Onset Psychosis.

Parkinson’s Disease Psychosis.

Alzheimer’s Disease with Psychosis.

Brief Reactive Psychosis.

A literature search showed that management of PDPsy involves a balance between reducing PD medication and introducing an antipsychotic for symptom management.

Conclusion: This case highlights the diagnostic challenges of psychosis in Parkinson’s disease and underscores the importance of a multidisciplinary approach in managing psychiatric symptoms in neurodegenerative conditions.

Aims: This case highlights the cognitive functions of the cerebellum which is often forgotten about.

Methods: An 80-year-old lady with a previous mental health diagnosis of Bipolar Affective disorder (BIPAD). She presented to the general hospital in July 2024 with a sudden onset of confusion and aggressive behaviour. She was referred to the Psychiatric Liaison Service (PLS). On assessments, she presented with no clear mood or psychotic disorder suggestive of relapse in her BIPAD. She scored 8 out 30 on the Mini-Addenbrooke’s Cognitive Examination (M-ACE) – losing marks on attention, memory – registration/recall, verbal fluency and the clock drawing test showed neglect. She lacked insight into her presentation and thus was in hospital under Deprivation of Liberty Safeguards (DoLS). Collateral history from her son corroborated that this was not a relapse in BIPAD. He enquired about an MRI head which revealed a small old infarct in the left cerebellar hemisphere.

Results: Cerebellar cognitive affective syndrome (CCAS; Schmahmann’s syndrome) would explain the timeline of symptoms, assessment findings and collateral history. CCAS is characterized by deficits in executive function, linguistic processing, spatial cognition, and affect regulation. Neuropsychiatric features include impairments in attentional control, emotional control, psychosis spectrum disorders and social skill set. The deficits suggest a disruption of the cerebellar modulation of neural circuits that link frontal, parietal, temporal, and limbic cortices with the cerebellum which is known as Cerebellum-Cerebrum cortex loop. Movement, co-ordination, and cognition are intricately connected within the brain, however the role of the cerebellum in cognition has often been ignored.

Conclusion: Clinicians tend to focus on the motor-coordination functions of the hindbrain, and this case report highlights cognitive functions of the hindbrain that are often forgotten. CCAS may be underdiagnosed due to the lack of awareness of the intricate connections between the hindbrain and forebrain through the cerebellum-cerebrum cortex loop, responsible for cognitive function within the hindbrain. This can lead to inappropriate treatment plans being devised for patients, and subsequent negative impact on management outcomes and even quality of life.

Aims: More than 200,000 clients are referred to memory assessment annually in the United Kingdom. Alzheimer’s disease and vascular brain injury are found to be the main causes for the memory impairment among these clients. However, a minority of clients present with memory impairment due to metabolic causes.

Methods: Mr M, a 65-year-old Caucasian male was referred to memory assessment service due to memory problems for 7 months duration. He had evidence of amnesia, aphasia and apraxia. His executive functions, recognition, personality were intact. He scored 91/100 in Addenbrooke’s cognitive examination. M also struggled with balance and tremors of his limbs.

He was diagnosed with liver impairment secondary to metabolic syndrome, type II diabetes, hypertension, long-standing cervical pain and heart block. He reported to sleep more than usual and was suffering from frequent episodes of constipation which was exacerbated by morphine. His partner reported that his cognitive symptoms coincides with constipation.

M was on treatment for mixed anxiety and depressive disorder with sertraline for 4 years. He was euthymic at presentation.

His laboratory work showed mild anaemia and low platelets. He was known to have a platelet disorder as well. Most recent HbA1c was raised but other basic blood investigations were largely within normal ranges.

His magnetic resonance imaging scan showed Symmetrical T1 high signal in bilateral globus pallidus on sagittal T1 weighted images. It was concluded that appearances could be due to manganese deposition consistent with history of hepatic dysfunction.

Small vessel ischaemic changes were seen in bilateral supratentorial white matter.

His electro encephalogram was in keeping with diffuse cerebral dysfunction.

Neurology multi-disciplinary meeting has concluded that the clinical presentation is one of a hepatic encephalopathy.

Results: Human physiological functions require many essential elements and manganese is identified as an essential element. Accumulation of manganese in excessive amounts in brain due to various metabolic derangements can causes central nervous system dysfunction known as Manganism. Manganism is an extrapyramidal disorder characterized by motor disturbances associated with neuropsychiatric and cognitive disabilities similar to Parkinsonism.

Manganese is cleared from the body by the liver. Chronic liver impairment hinders the clearing process causing accumulation of manganese in blood and brain. M was suffering from chronic liver impairment which was the most likely cause for manganese deposition in his brain.

Conclusion: It was concluded that M’s cognitive impairment was due to hepatic encephalopathy and Manganism. Clinicians need to be aware of Manganism while assessing the patients with chronic liver impairment and neurocognitive dysfunction.

Aims: Levetiracetam is a broad spectrum antiepileptic used in a variety of seizure disorders in both adults and children. Although a popular antiseizure medication, levetiracetam’s association with new onset behavioural disturbance such as agitation, hostility, psychosis and mood symptoms has been widely reported in scientific literature. Seizure disorders themselves can present with psychiatric manifestations. We are reporting a case of an adolescent male where the interphase of physical and mental health came into play.

Methods: A 13-year-old male presented to A&E brought by his family following a referral from the epilepsy clinic due to two weeks history of bizarre behaviours including abnormal gait, tapping on the shoulders of his family members, talking to himself and generally being more irritable. From history, we noted he had been diagnosed with epilepsy (unspecified) for two years and recently his seizure activities increased in frequency, which prompted his neurologist to increase his antiseizure medication (levetiracetam from 1250 mg twice a day to 1500 mg twice a day) two weeks prior to his presentation, which coincided with the onset of his symptoms.

He reported experiencing intrusive and unpleasant thoughts about the safety of his family, experiencing multiple times of the day and to reduce the anxiety he was tapping on their shoulder, and checking the locks of the door and windows of the house, the thoughts and rituals corresponded to obsession and compulsion. He also reported thought broadcasting – people are able to know what he was thinking, and abnormal perception of hearing his own thoughts spoken aloud – appeared to be Gedankenlautwerden.

In the emergency department he underwent extensive blood (including auto-antibodies associated with first episode of psychosis) and radiological investigations to rule out acute neurological causes. The investigations did not yield any positive results, his levetiracetam level was also within therapeutic range.

The description of his seizures indicated that he experiences gustatory and olfactory auras with focal to generalised seizures followed by postictal transient paresis of the left arm, which has been consistent over the course of the two years he had the seizure.

Results: Diagnostic formulation was the acute onset obsessive-compulsive and psychotic symptoms are likely the direct result of the increase in the dose of levetiracetam which had a temporal relationship, differentials included psychiatric symptoms associated with epilepsy: we queried temporal lobe, and a functional psychotic illness. We advised for a medication review, and his levetiracetam was reduced to a prior dose and lamotrigine was added on by the epilepsy clinic.

Conclusion: Two months after the presentation we received a letter from his paediatrician mentioning his psychiatric symptoms have improved and the add-on medication managed to control his seizure.

Aims: This case study explores the psychiatric and physical health complexities in a 28-year-old female service user with Autism Spectrum Disorder (ASD) and Intellectual Disability, focusing on the interplay between neuropsychiatric diagnoses, hormonal treatments, and significant mental health deterioration. It also examines the impact of hormonal changes on mood and behaviour, highlighting potential misdiagnosis of emotional instability versus neurodevelopmental conditions. The service user has a history of polycystic ovary syndrome (PCOS), irritable bowel syndrome, and Benign Rolandic Epilepsy (seizure-free since age 13). She has engaged with mental health services since adolescence, carrying multiple diagnoses including generalized anxiety disorder, post-traumatic stress disorder and emotionally unstable personality disorder (EUPD). Her mental health worsened suddenly and significantly following a switch from an oral progesterone contraceptive to the Depo-Provera injection, prompting inpatient psychiatric care.

Methods: A thorough medical and psychiatric evaluation was conducted during the nine-month inpatient admission. This included a mental state examination, routine blood tests, CT head imaging, and extensive collateral history collection. Medication adjustments were made including trials of SNRI and SSRI medication, and multidisciplinary therapeutic interventions were provided. Her Depo-Provera was not re-administered. Her PCOS diagnosis was confirmed and she was started on metformin. A diagnosis of ASD was implemented seven months into the admission and her EUPD diagnosis removed. Her depressive and anxious symptoms were noted to be cyclical, worsening before her menstruation. Following MDT review, she was started on an oral contraceptive with good evidence in pre-menstrual syndrome and PCOS (estradiol with nomegestrol)

Results: The service user presented with severe depression, anxiety, and active suicidal ideation, including multiple attempts to leave the ward to act on her plans. Initial physical and neurological workups were unremarkable. The pre-admission switch to Depo-Provera was identified as a likely contributing factor to her deterioration, as no other psychosocial triggers were found. She was subsequently detained under the Mental Health Act due to ongoing suicidality. Despite intensive psychiatric and therapeutic interventions, her mood remained persistently low – however after initiating an appropriate contraceptive, her symptoms showed some stabilization. Her risk of self-harm persisted.

Conclusion: This case highlights the potential influence of hormonal changes on psychiatric symptoms in women with complex neurodevelopmental disorders such as ASD. It also raises important considerations about the potential misdiagnosis of personality disorders in neurodivergent individuals and the need for careful management of hormonal treatments in this population. Further research into the hormonal impact on mood disorders in neurodivergent patients is warranted.

Aims: Attention Deficit Hyperactivity Disorder (ADHD) has a well-established link with substance misuse, with growing evidence that individuals with ADHD are at higher risk of developing addictive behaviours including substance use disorders.

The Club Drug Clinic is a specialised addiction service providing support for individuals experiencing problems related to the use of club drugs. During assessments and reviews, patients presenting with symptoms suggestive of ADHD are formally assessed. Those who are diagnosed with ADHD are then commenced on appropriate treatment.

Methods: 15 out of 98 patients (15%) under the service since July 2023 were diagnosed with ADHD by the Club Drug Clinic, all of whom were subsequently commenced on atomoxetine.

Data was collected from patient notes including: age, gender, sexuality and information about their substance misuse. The doses of atomoxetine prescribed as well as side-effects and perceived benefits was also recorded. Information around co-morbid mental illness was also analysed.

Results: 87% of patients in this series were male with the majority of patients reporting their sexuality as either homosexual or bisexual which is reflective of the population group served generally by the Club Drug Clinic. The age range of the patients was 24–58 with an average age of 40.

Crystal Methamphetamine was the most frequently used illicit drug with 70% of those diagnosed with ADHD using Crystal Meth in an either a harmful or dependent manner. 60% of those with ADHD were using GHB often in conjunction with Crystal Meth. 50% of those identified in this study were using ketamine.

47% of patients commenced on atomoxetine reported side-effects and 33% of patients commenced on atomoxetine stopped due to side-effects or a lack of perceived benefit.

Depression was the most common co-morbidity in those diagnosed with ADHD seen in 20% of this cohort. Other co-morbidities include: anxiety disorder, borderline personality disorder, bipolar affective disorder and interestingly gaming disorder.

Conclusion: This series reflects the strong association between ADHD and addiction particularly within the Club Drug Clinic population. Implications include routine screening for ADHD in Club Drug users to help identify cases early and potentially reduce long-term substance misuse. It also highlights the importance of integrated mental health services given the high rates of co-morbidity in patients suffering from addiction.

Aims: Very late onset schizophrenia-like psychosis (VLOSLP) can be defined as individuals presenting with symptoms of psychosis after the age of 60 that cannot be attributed to an “affective disorder or focal or progressive structural brain abnormality”. Despite being described by an international group consensus in 1998, this diagnosis is not included in ICD–11 or DSM–5 manuals.

Methods: A 79-year-old female presented with a 3-month history of auditory hallucinations, involving 10 voices talking in the 2nd and 3rd person and providing commands. The patient also described visual, tactile and olfactory hallucinations.

The patient did not have any previous psychiatric history. Significant past medical history included previous surgical removal of right-sided acoustic neuroma resulting in facial nerve palsy.

On assessment, there was right-sided facial paralysis, deafness and slurred speech. The patient was calm and well kempt. Speech and mood were normal. There was no formal thought disorder and the patient was not responding to unseen stimuli. They were orientated to time, person and place. The patient displayed insight into their mental state.

CT head showed mild small vessel disease. The patient scored 79/100 (attention 17/18, memory 16/26, fluency 8/14, language 23/26, visuospatial 15/16) on the Addenbrooke’s cognitive examination, whilst psychotic and without hearing aids in situ.

The patient was started on aripiprazole, titrated to a dose of 20 mg. Fewer voices were heard and became incredibly faint, with there being some days where she was unable to hear them. The patient had not been experiencing hallucinations at 3 months post-discharge.

Results: There have been some case reports of acoustic neuromas presenting with psychiatric symptoms such as hallucinations and persecutory delusions and emerging post resection.

Individuals with hearing impairment are significantly more likely to develop psychosis. Hearing impairment is a modifiable risk factor for developing dementia and individuals with VLOSLP display an increased risk of developing dementia. It has been postulated whether VLOSLP could be a prodrome for dementia. The mainstay of treatment for VLOSLP involves low dose atypical antipsychotics.

Conclusion: We describe a case of VLOSLP in a patient 40 years post acoustic neuroma removal. There needs to be further work to investigate neuropsychiatric presentations post acoustic neuroma removal. There is increasing evidence to suggest an association between hearing impairment and development of psychosis and dementia. Any hearing impairment should be treated promptly. Patients with VLOSLP should be monitored for the development of dementia given it could be a prodrome for dementia.

Aims: Clozapine is recommended for treatment-resistant schizophrenia after two other antipsychotics have failed. We discuss a case of clozapine toxicity on therapeutic dose and its complications due to multifactorial causes.

Methods: 60 years Caucasian female, diagnosed with Paranoid Schizophrenia in the early 80s and on clozapine since 2000. Her mental health had been stable since and she was on 375 mg/day. There were some residual symptoms but otherwise functioning well with support. She was admitted to General Hospital with pneumonia, weight loss and altered bowel habits but nil sinister found. Her clozapine was missed for 72 hours and she developed rebound psychosis. Clozapine was re-titrated to 300 mg/day as her clozapine levels were 720 mcg/L before admission. She was discharged on the 300 mg/day however she was readmitted to General Hospital within a few months after sustaining a fracture of the femur and underwent surgery. Clozapine assays showed high levels of 1882 mcg/L with MR 2.68. She had ongoing symptoms suggestive of delirium. She was investigated for possible infections, drug interactions, and liver issues and initiated on lamotrigine for seizure prophylaxis. The clozapine dose was gradually reduced with regular monitoring of levels and side effects. She later developed stroke-like symptoms, with a normal CT scan. The clozapine dose was reduced to 100 mg/day as clozapine toxicity can mimic stroke/TIA. Repeat levels were 483 mcg/l. The patient’s mental and physical health remained stable after this.

Results: Clozapine is an effective antipsychotic agent with a dose range of 200 mg/day to 450 mg/day, the maximum licensed dose up to 900 mg/day. In clinical practice, the dose of clozapine is usually adjusted to provide plasma concentrations of 350–600 mcg/L. Acute infection can increase clozapine levels by reduced expression of CYP1A2 due to increased inflammatory cytokines and increase in a-1 acid glycoprotein. Acute infection and illness can lead to significantly increased clozapine levels and presumed toxicity, but symptoms of toxicity may be minimal or absent as the concentration of unbound drug is not increased. Certain drugs such as antibiotics and enzyme inducers can also affect levels.

Conclusion: Drug monitoring of clozapine is not a routine practice; certain clinical situations warrant multiple comorbidities, increasing age, polypharmacy, infections (pneumonia), and recent surgery, if poor (reduced) clozapine metabolism is suspected. Monitoring can help minimise the risk of toxicity. Patients should be evaluated for dose-related side effects such as constipation, seizures, cardiac arrhythmias and seizure prophylaxis should be considered if very high clozapine plasma levels.

Aims: Clozapine is the most effective treatment in patients with treatment resistant Schizophrenia as recommended by the National Institute of Health and Care Excellence (NICE). This case study aims to explore a patient’s journey in mental health services during the relapse of his mental illness and the significance of reconsidering clozapine in patients who responded well to the medicine before.

Methods: 35-year-old male diagnosed with Paranoid Schizophrenia admitted to the acute ward following relapse of his mental illness. He had many admissions under sections in the past and was tried on several antipsychotics. Historically he has shown non-compliance with his medications and poor engagement with the mental health services. In the current presentation, he was found to be floridly psychotic with paranoid and persecutory delusions. He mentioned that people were coming to his flat through the walls and injected him with drugs. He was prescribed clozapine in his last admission as he met the criteria for treatment resistant Schizophrenia. During his stay, we tried him on a combination of non-clozapine antipsychotics due to the history of poor drug compliance. Since he didn’t show any response after trying other antipsychotics for a longer period of time, the team decided to restart him with clozapine. Patient showed a good response following this.

Results: In the above case scenario, though the patient previously responded well to clozapine, the team was reluctant to restart clozapine because of the following reasons: history of poor drug concordance, sudden withdrawal of clozapine leads to various side effects like withdrawal associated psychosis and catatonia, cholinergic rebound and rarely it causes serotonergic symptoms. The pharmacological profile of clozapine is complex as it induces a range of neuronal changes at the receptors particularly when taken for a prolonged period of time. Evidence suggests that these neuronal changes are responsible for the occurrence of withdrawal symptoms on clozapine discontinuation.

Conclusion: Evidence suggests that one third of patients with schizophrenia are treatment resistant and clozapine is the treatment of choice for refractory psychosis. Although the literature says that sudden stoppage of clozapine is associated with an array of withdrawal symptoms, it is important to consider restarting the patient with clozapine, especially if they showed a good response in the past. This case study also highlights the good practice for communicating with patients about the significance of clozapine, its effect and withdrawal symptoms due to discontinuation which helps treatment adherence.

Aims: For patients prescribed methadone wishing to access buprenorphine ORT, the current practice is to reduce the methadone dose to 30/40 ml and cessation of methadone for 48 hrs prior to the switch. This exposes these patients to risk of psychological, physical distress or relapse into non-prescribed opiate use.

Using guidance published by the Canadian Journal of Addiction we adapted this to a local UK setting to evaluate its implementation into regular service provision.

We aim to demonstrate effective transition, in a series of patients prescribed methadone onto sl (sublingual) buprenorphine, without adverse effects/precipitated withdrawal or the requirement of methadone dose reduction nor 48 hour abstinence from methadone, in community-based settings.

Methods: We collected outcomes on 12 patients (dose range 26 ml – 90 ml of methadone daily), 12 of whom successfully transitioned from methadone to buprenorphine ORT via buprenorphine Microdosing Bridging Method.

We enquired and assessed for precipitated opiate withdrawal symptoms using a daily modified SOWS/COWS and psychological response throughout the transition period.

Patients were initiated onto buprenorphine initially using transdermal 20 mcg/24 hr buprenorphine patches over the first 48 hrs of treatment, after which urine was tested. Once the urine screen showed buprenorphine, oral initiation of sublingual buprenorphine began on Day 1 at 400 mcg daily and increased according to the following schedule:

Day 2: Usual dose methadone daily, buprenorphine 0.8 mg.

Day 3: Usual dose methadone daily, buprenorphine 1.2 mg.

Day 4: Usual dose methadone daily, buprenorphine 1.6 mg.

Day 5: Usual dose methadone daily, buprenorphine 2.0 mg.

Day 6: Usual dose methadone daily, buprenorphine 4 mg daily.

Day 7: Usual dose methadone daily, buprenorphine 6 mg daily.

Throughout this period, the patients’ methadone dose remained at their pre-transition dose. The last dose of methadone was administered when the patients were administered 6 mg sl buprenorphine daily on Day 6. The following day, patients were administered 8 mg sl buprenorphine with subsequent dose titration to achieve optimal daily dose.

Results: 12 patients achieved the transition from methadone to buprenorphine without experience of precipitated opiate withdrawal or adverse psychological effect.

Conclusion: Transition from methadone to sl buprenorphine without requiring prior dose cessation or reduction of methadone up to 90 ml daily is safe, effective and practical in a community-based and acute care setting. This provides methadone ORT patients the option of accessing buprenorphine ORT over a short period of time (10–14 days) without the experience of precipitated opiate withdrawal, and can be undertaken in a variety of community settings.

Aims: Temporal Lobe Epilepsy (TLE) is the most common symptomatic cause of partial epilepsy worldwide. It can present with vague symptoms including affective disturbances, personality changes, sensory disturbances, altered consciousness etc., which can confound diagnosis. Overt focal or tonic-clonic seizures are present in only 60% patients. It manifests with psychotic symptoms in around 5%. This case report describes how undiagnosed TLE with psychotic symptoms led to grave consequences.

Methods: We present a 52-year-old male who was found to have killed his father and was subsequently diagnosed with TLE. This diagnosis was later found to be directly implicated in the act. When arrested on suspicion of homicide he presented with several psychotic symptoms and severe agitation in custody. He was then detained under the Mental Health Act to a high secure psychiatric hospital. He had no formal psychiatric or medical diagnosis prior to his arrest but it was noted that he had presented on multiple occasions to secondary neurology and psychiatric services over the preceding 10 years with vague but consistent symptoms which were labelled as night terrors. These included clouding of consciousness, affective disturbance, night terrors, suicidal ideation, and isolated aggressive outbursts. Following his hospital admission, he was assessed by neurologists and was diagnosed of TLE after his EEG clearly demonstrated abnormalities in line with the diagnosis. The gentleman’s psychiatric symptoms resolved entirely when he was treated adequately for TLE with an anti-epileptic (lamotrigine). At trial, he was found not guilty of murder by reason of insanity and received a hospital order with restrictions.

Results: TLE is a treatable neurological disorder but is associated with a risk of heightened violence especially if misdiagnosed. In this patient, repeated opportunities were missed in diagnosing and treating TLE in a timely manner. Potential differentials that can confound TLE diagnosis include night terrors, functional psychosis, anxiety disorders, affective disorders, substance misuse etc.

Conclusion: TLE can have far-reaching and life-altering consequences. To obviate these, it is recommended that repeated presentations with unexplained neurological and psychiatric symptoms in outpatient or emergency settings should trigger robust assessments and multi-specialty liaison. It would be beneficial to develop a protocol to trigger a thorough evaluation of suspected TLE cases with a lower threshold to investigate them than what is currently practised. This could involve earlier and wider utilisation of electro-encephalogram (EEG) (ambulatory or residential).

Aims: New onset psychosis in the elderly is rare with lifetime prevalence rates of 0.3–1%. Schizophrenia occurs in 0.1–0.5% of the elderly, however more common causes of new onset psychosis include dementia, delirium, drug-induced psychosis, and primary psychiatric disorders, most commonly depression. More than 50% of patients with Alzheimer’s disease experience psychotic symptoms and 70% develop delusions, in particular, persecutory type. Visual hallucinations are the most common type of hallucination occurring in 80% of patients with Lewy Body dementia. Second person auditory hallucinations occur in schizophrenia-like psychosis, however musical hallucinations where one perceives music without an external source are rare.

Methods: An 84-year-old female patient with no psychiatric background reported a 2-month history of musical hallucinations, causing distress and poor sleep. Patient denied hearing voices and other modalities of hallucinations. The musical hallucinations were not lateralised to either ear or side of space but experienced as external. Delirium was ruled out and patient’s medications were screened for anticholinergics and sedative-hypnotics. Patient had good cognition and a CT head excluded organic causes. The patient appeared distracted by the musical hallucinations, however, was not agitated and her mood was euthymic with congruent affect. No evidence of mood disorders ruled out psychotic depression and other affective disorders with psychotic symptoms. No thought disorders or delusions were present. Antipsychotics quetiapine and amisulpride proved no benefit for the patient.

Results: The patient’s presentation showed no clear reversible pathology and was unresponsive to antipsychotics. Musical hallucinations was given as a diagnosis of exclusion.

A musical hallucination is a type of auditory hallucination involving the perception of music without an external source. Patients are usually female, over 60 and subdivided into those with hyperacusis, psychiatric disorders, focal brain lesions, epilepsy and intoxication. Our patient was female and over 60 with presbycusis.

Musical hallucinations are proposed to be due to abnormal autonomous activity in the auditory brain systems responsible for normal music imagery. Sensory auditory deprivation or acquired peripheral deafness leads to impoverished auditory input and spontaneous activity occurs within the network for the perception and imagery of music.

Conclusion: This case report describes a rare phenomenon of musical hallucinations in an elderly patient. It identifies important diagnoses to exclude including delirium, dementia and other organic causes. The patient was female, over 60 yrs and diagnosed with presbycusis, characteristic of patients with musical hallucinations. The patient showed no improvement with antipsychotics and so treatment consisted of psychoeducation.

Aims: We report on an Afghan refugee is in his 30s who presented to a Community Mental Health Recovery Service (CMHRS) with a two year history of visual and auditory disturbances and distressing persecutory beliefs revolving around 'Jinn'. This led to significant distress, a decline in functioning and shared experience with his wife also complaining of similar events.

Methods: Our patient’s symptoms commenced when he and his family moved into a new property and believed that his house was possessed by 'Jinn'. He had moved from Afghanistan to the UK as a refugee, speaking predominantly in Farsi and a practising Muslim. Examples of his experiences which he attributed to the ‘Jinn’ included; hearing noises in the house, seeing a broken cup and bathroom toiletries on the floor, and seeing a male figure during the night described as ‘frightening, headless and with claws’.

We conducted a thorough assessment and encompassed cultural and spiritual components of his health, liaising with their refugee support worker and involving our Trust multifaith team and a Farsi-speaking psychiatrist.

Affective conditions, Post Traumatic Stress Disorder and folie à deux were considered during the assessment period and felt that Adjustment Disorder reflected the current presentation. Precipitating factors included moving to UK, change in culture, and lack of local provisions to accommodate his faith such as no local access to a Mosque or Halal food shops.

Psychotropic medication was not indicated and the patient declined psychological therapy. Following movement of housing to an Afghan community, there were no further concerns expressed in relation to Jinn. The patient was subsequently discharged back to their GP.

Results: This case highlights the important influence religion and culture can have in symptom formation and how altered perceptions can be interpreted subjectively. The patient’s distress of migrating, separation from family and friends and change of cultural environment are likely to contribute to the patient’s experiences.

Symptoms of possession can overlap with mental illnesses and can be a socially accepted explanatory model of disease in non-Western cultures in expressing distress and conveying conditions including depression, bipolar disorder and anxiety along with stress and marital hardship.

Conclusion: Our patient’s diagnosis of Adjustment disorder highlights the importance of a holistic approach to psychiatric assessment. A better understanding of symptom formation within trans-cultural psychiatry could minimise the risks of subsequent misdiagnosis and inappropriate medication prescription. Correct formulation means we can support patients in accessing appropriate religious and spiritual resources and care where appropriate.

Aims: Avoidant Restrictive Intake Disorder (ARFID) is characterised by insufficient intake, for reasons unrelated to body image concerns, but is strongly associated with autism spectrum disorder (ASD). It causes weight loss, nutritional deficiencies and physical health consequences, which can be fatal, as seen in the tragic 2021 case of Alfie Nicholls. Despite ARFID’s impact, there are no national guidelines and treatment recommendations are limited, advising psychological interventions and nutritional counselling.

Methods: A male in his thirties with ASD and restricted eating, resulting in multiple admissions for malnutrition, including to intensive care, was readmitted with electrolyte disturbance and dehydration. Numerous psychiatric assessments concluded his restrictive eating to be ASD-associated ARFID. Despite psychological and nutritional support throughout his life, he was unable to maintain a healthy BMI and developed chronic malnutrition. Similarly, during this admission after four months of dietetic input, nasogastric feeding, which he found difficult to tolerate, and psychological intervention, he lost weight, causing recurrent infections, persistent anaemia and perforated gallbladder secondary to gallstones. Long-term enteral feeding (LEF) had not previously been explored, so there were multi-disciplinary team discussions, deciding a percutaneous endoscopic gastrostomy (PEG) would be in his best interests. This enabled him to reach a safe weight for discharge, continue to gain weight, improve his general health and minimise readmission risk.

Results: Decision-making is challenging due to a lack of research on ARFID management and the role of LEF. The treatments currently recommended are sometimes inappropriate in concurrent ASD, due to restricted thinking and social interaction difficulties, as demonstrated here. There is hesitance to start LEF in psychiatric diagnoses, like ARFID, as the underlying issue is not tackled. However, ASD, a lifelong developmental disability, is often driving ARFID, so psychological interventions alone may be ineffective. This particularly applies to adults with ARFID as psychological interventions were found to be less effective than in children/adolescents. Therefore, in severe malnutrition despite intervention, LEF benefits likely outweigh the risks. Psychological support should continue whilst LEF improves nutrition, offering possible earlier discharge to an environment more conducive to improving oral intake and general mental health.

Conclusion: ASD-associated ARFID requires a different therapeutic approach to ARFID alone. Although the initial priority should be meeting nutritional requirements orally, LEF should be considered in severe individual cases to improve quality of life, reduce admissions and reduce mortality, but further research is required to improve outcomes.

Aims: Long-acting buprenorphine has been explored in context of its use in opioid dependence, however its potential for managing self-harm behaviour is limited. Self-harming behaviour often signals extreme emotional distress. This case report brings an insight into the effectiveness of injectable buprenorphine in a person with extreme self-harm behaviour.

Methods: Miss SD, 30-year-old single, unemployed woman, with history of emotional abuse, sexually abused by father from the age 6–8 and mother having difficulties with alcohol abuse. She has been involved with Psychiatric services from the age of 13 and had several Psychiatric hospital admissions, transfer to low secure Forensic unit and step down to supported accommodation. Having difficulties with self-harming behaviours, suicidal thoughts or attempts and aggression towards staff. Self-harm behaviour included cutting, overdoses, ligatures; to an extent she needed multiple surgical interventions for cutting, inserting glass and glueing the genitalia multiple times, along with glueing nose and lips.

Over the course her diagnoses included EUPD, PTSD, Depressive disorder, transient Psychotic episodes, alcohol dependence and polysubstance misuse.

Due to escalating behaviour she was trialled on injectable buprenorphine as off-licence use for self-harming behaviour. We have compared the data of 2 years on injectable buprenorphine to history prior to that.

Initiation on buprenorphine treatment had a dramatic improvement in Miss SD given the number of incidents of both alcohol use and self-harm.

Results: Buprenorphine treatment had a greater reduction in self-harming behaviour in Miss SD. There have been only 1–2 episodes of self-harm per year since she started on buprenorphine i.e, in last 2 years, when compared with the several episodes a week. In addition the number of hospital admissions reduced to 2 brief admissions, compared with several admissions including long stay in Low Secure Unit.

Recurrent self-harm can have an endogenous opioid response, and in the long term the pattern is similar to addiction.

Buprenorphine is a partial μ-opioid receptor agonist and a potent kappa antagonist, and treatment with long-acting opioid antagonist could block the reward of enhanced endogenous opioids caused by self-harming behaviours and subsequently lead to their extinction.

Conclusion: A retrospective case study of Miss SD since the initiation of buprenorphine suggests this may be an alternative therapeutic option to treat people with significant Self-harming behaviour with functional impairment. In addition it is much safer as it causes less respiratory depression than other opioids.

The evidence is promising, however more research is needed to review the effectiveness, establish efficacy, and safety.

Aims: This project investigates whether mother and baby music sessions in the inpatient perinatal mental health setting can effectively reduce maternal anxiety, improve mood, and strengthen the mother–baby bond. It aims to review existing literature and reflect on the practical implementation of a pilot music group within a mother and baby unit (MBU).

MBUs are specialist inpatient wards which keep mothers united with their babies during treatment to maintain the mother–baby bond. Therapeutic activities vary across units, but music groups have been explored as a potential intervention to improve maternal mental health and bonding.

Methods: A literature review was conducted, identifying 8 relevant studies. The pilot music group, based on supporting literature, consisted of 6 weekly hour-long sessions, involving singing nursery rhymes and improvisation. Participants included 15 mothers with various mental health conditions. Reflections from the author/session lead and staff present were recorded to evaluate the intervention.

Results: Literature showed improvements to maternal anxiety and maternal mood after attending singing groups however the populations studied in most papers did not reflect those with more severe mental health conditions and few showed statistical significance. Bonding improvements were consistently noted across studies, often assessed through qualitative feedback or bonding scales. The pilot sessions were well-received, with mothers reporting relaxation and enjoyment. However, practical challenges emerged, not alluded to in previous literature, including cultural relevance of songs, emotional triggers, and varying levels of engagement amongst mothers with differing mental health conditions.

Conclusion: Music groups show promise as a therapeutic intervention for enhancing maternal mental health and bonding, reflected in those who attended the pilot music group. Quantitative research on its benefit in more unwell mothers admitted for treatment is still required. Challenges such as emotional triggers and the inclusion of diverse patient populations were identified in this pilot and efforts should be made to mitigate this in further interventions of a similar nature. Future research should focus on mothers with severe illness, particularly those admitted to MBUs, and explore the long-term impact of music groups as a routine intervention to support maternal–infant bonding during treatment.

Aims: Epilepsy can present with a wide range of neuropsychiatric manifestations. A seizure episode may take the form of motor convulsions, complex abnormal behaviours or unusual subjective experiences.

Seizures originating in different anatomical locations take characteristic forms, however, there is considerable overlap in the presentation.

Frontal lobe seizures are characterised by motor phenomena which may include complex posturing and behavioural automatism which tend to begin and end abruptly.

This condition is of particular importance to psychiatrists, due to the bizarre nature of automatic behaviour. They may be mistaken as dissociative phenomena or psychotic disorders.

Methods: A 55-year-old female who was previously well, presented to the psychiatric service following episodic disorganised behaviour for two weeks duration. For example, she had cooked rice three times per meal without an apparent reason. Also, she had started collecting a large number of vegetables repeatedly in a shopping centre without a clear purpose. At that time her husband had to forcefully stop her. When inquired later she was unable to recall these events. Family members also noticed that the patient is having episodic repetitive facial movements without losing consciousness.

General physical and neurological examination was normal. Her EEG showed right frontal sharp waves which progress into generalised spikes, suggestive of frontal lobe epilepsy with secondary generalisation. The contrast CT brain was normal. Haematological tests including random blood sugar, serum electrolytes, full blood count, serum calcium levels and the ECG were normal. Intravenous phenytoin sodium was given to control repetitive seizures at the onset.

Subsequently, oral sodium valproate was commenced. She responded well, and symptoms disappeared within a couple of days.

Results: Epilepsy presenting as behavioural and psychiatric manifestations is common but can be easily overlooked. Frontal lobe epilepsy with common aetiology like post traumatic, tumours and genetic causes can have complex seizure semiology.

Overall frontal lobe seizures tend to begin and end abruptly, are brief and frequent. They show a tendency to occur at night and in clusters. Motor phenomena which may include complex posturing and behavioural automatism are usually the most conspicuous feature.

This patient had several bizarre behaviours which could be complex behavioural automatism. The bizarre nature of automatism means that they can often be mistaken for non-epileptic dissociative seizures as well as another psychiatric diagnosis like mania or psychosis.

Conclusion: Our patient highlights the unusual way of presentation of frontal lobe seizures. Clinicians need to be aware of this presentation to minimise possible misdiagnosis and mismanagement.

Aims: Prosopometamorphopsia is an extremely rare phenomenon where the individual perceives facial distortions in self or others. “Demon face syndrome” and “Alice in Wonderland syndrome” are some lay terms coined to describe this condition.

Methods: We report a case of a male in his thirties, married, and a father of one, who presented to the psychiatry unit perceiving distorted facial features of self (autoprosopometamorphopsia) for eight years with exacerbation since last year. He alluded to his reflection in the mirror as the face of a demon. This resulted in significant social avoidance and rumination of other people’s perceptions of his appearance. At the time of presentation, he was having a severe depressive episode with significant occupational and functional decline and was consuming excessive alcohol as a maladaptive coping strategy.

When the symptom first appeared eight years ago while working in the military, he perceived similar distortions in a co-officer’s face in addition to his face, which culminated in him resigning from the forces due to the distress. He did not seek medical treatment, and symptoms went into spontaneous remission after a few months. He was satisfactorily functioning until a year ago.

Apart from prosopometamorphopsia, he did not have any other psychotic symptoms or symptoms suggestive of manic episodes. He was diagnosed with anti-NMDA encephalitis one year ago and had suffered seizures. He reportedly lost the neuroimaging and treatment records related to this episode.

Results: The patient was initially diagnosed of Body Dysmorphic Disorder (BDD) and had been treated with adequate trials of antidepressants with very poor response. Due to the severity of depression, functional decline and previous poor response to antidepressants, he was treated with electroconvulsive therapy (ECT) during his current admission. During the one-month post-discharge evaluation, he showed satisfactory improvement and was continued on imipramine 150 mg and olanzapine 20 mg in the night. He was also on topiramate 50 mg nocte from the neurology clinic.

Conclusion: Existing literature reveals that prosopometamorphopsia has an organic basis with malfunctioning brain facial recognition systems playing a critical role in its manifestation. In this patient, a history of NMDA encephalitis suggests neuropsychiatric aetiology. Lack of response to conventional treatment for BDD and good response to ECT indicates that this condition is a different entity warranting tailored treatment.

Aims: With this systematic review, an attempt will be made to systematically compare the efficacy and side effects of Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) in Chronic Pain Conditions in terms of functional improvement and quality of life with placebo.

Methods: The relevant studies were included after conducting a literature search in OVID, PubMed/MEDLINE, EMBASE/SIGLE, CINAHL, and Web of Science. Randomized controlled trials that compared SNRIs in chronic pain were included in the review. In the assessment of study quality, the Cochrane Risk-of-Bias tool was used. A number of data extractors and analysts were used in the study so as to reduce possible bias in the study results.

Results: Duloxetine appeared to be the SNRI with the best therapeutic efficacy profile across different chronic pain types and aetiologies such as osteoarthritis, fibromyalgia, and chronic low back pain. It showed reasonable effectiveness in alleviating pain magnitude and enhancing motor activity. The results were consistent between standard and higher doses of single administration 60 mg. Duloxetine demonstrated a significant reduction in pain when compared with placebo. An improvement in functional status and quality of life measured through self-reported scales was also noted. This trend was more pronounced in the treatment of the patients on SNRI compared with those on placebo.

Conclusion: Duloxetine appears to be effective for chronic pain conditions and may help reduce pain intensity, increase functional status and improve the quality of life. Even though rigorous trials indicate that these drugs are superior to placebo after 8–16 weeks, long-term effect and safety profiles are not very clear, and more long-term studies are needed to understand the durability and application of the drugs in clinical practices. Further research should prospectively investigate the efficacy in long-term pain, different comorbid conditions, and include predictors of SNRI response.

Aims: This study through systematic review approaches and meta-analysis aimed to determine safe drug options for treating male sexual dysfunction due to erectile dysfunction by comparing sildenafil, tadalafil, vardenafil, mirodenafil, coenzyme Q and testosterone.

Methods: Systematic review methodology was used to retrieve data from complete database searches done in PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Randomized controlled trials research designs with adult male participants who presented with erectile dysfunction on sildenafil, tadalafil, vardenafil, mirodenafil, coenzyme Q and testosterone were included as part of the review. The Cochrane Risk of Bias version 2.0 was utilized by two independent reviewers for assessing bias risk and extracting data. Sensitivity analysis was used to reduce the risk of bias.

Results: Phosphodiesterase inhibitors type 5 (PDE 5) are the most effective medications for erectile dysfunction (ED). Participants on sildenafil had effective erections between 77–84% at doses of 50–100 mg and tadalafil emerged as the “Weekend pill” because of its 36-hour maximum effect duration of action. The concentration-focused activity along with higher potency values of vardenafil make it superior to other PDE5 inhibitors. The newly developed therapeutic medication mirodenafil exhibits better PDE5 selectivity than existing drugs within its operational mechanism. Minor variations were noted as a cohort of participants preferred tadalafil above sildenafil. Testosterone supplementation is beneficial for when monotherapy with a PDE5 inhibitor has not been effective.

Conclusion: Being the first-line treatment for erectile dysfunction, PDE5 inhibitors should be prescribed based on the distinctive pharmacological attributes they possess. Medical treatment selection methods must take into account both the need of patients as well as their preference. The recent introduction of mirodenafil medication has opened new possibilities in the medical treatment of ED. The effectiveness of ED treatment brings optimistic outcomes to the quality of life to hundreds of millions of men across the globe and further studies will drive medical progress to improved treatment modalities including stem cell therapy.