Background

Electroconvulsive Therapy (ECT) is among the most effective treatments for severe and life-threatening psychiatric illness, yet its use in medically complex patients demands refined clinical judgment.

With rising multimorbidity and increasing prevalence of implanted medical devices, clinicians are more frequently required to balance urgency against evolving physical risk.

This presentation introduces the concept of the therapeutic pause; not as delay, but as an active, patient-centered safety strategy, demonstrating how structured reflection and multidisciplinary collaboration can transform high-risk uncertainty into safe, timely intervention.

The aim is to highlight how deliberate pauses at critical decision points can improve both clinical outcomes and patient safety.

Case Reports

Two urgent liaison psychiatry referrals for ECT are presented.

Case 1 involved a 72-year-old man with schizophrenia and mild learning disability, admitted with catatonia, severe self-neglect, and nutritional failure requiring nasogastric feeding. He had a proximal deep vein thrombosis (DVT) diagnosed three weeks earlier and hyperkalaemia, raising concern about embolic risk and physiological stress during ECT.

Case 2 involved a 62-year-old woman with psychotic depression and catatonia, who had an implanted spinal cord stimulator (SCS) for chronic pain, creating potential risks of electrical interference and device damage.

In both cases, ECT urgency was balanced against medical risk using targeted investigations, literature review, consultation with the ECT Accreditation Service (ECTAS) Knowledge Hub, and early multidisciplinary input.

In Case 1, repeat Doppler imaging confirmed resolution of the proximal DVT and electrolyte abnormalities were corrected, allowing ECT to commence three days later. By the third and fourth treatments, the patient showed striking recovery: spontaneous speech, independent mobility, recognition of staff, and restoration of oral intake, facilitating discharge after completing the course.

For Case 2, collaboration with pain specialists and device manufacturers enabled safe deactivation, monitored ECT delivery, and post-treatment device integrity checks, followed by clear improvement in psychomotor function, affect, and nutritional status.

These cases demonstrate that ECT risk is rarely absolute; it is dynamic and often modifiable. In both cases, pausing prevented both premature exposure to harm and unnecessary therapeutic delay.

Pausing before ECT is not clinical indecision; it is clinical leadership. Individualized assessment, proactive multidisciplinary collaboration, and informed use of national guidance allow clinicians to navigate the interface between psychiatric urgency and physical vulnerability.

As ECT increasingly serves patients with complex comorbidity, reflective practice must replace routine automation. Thoughtful pauses protect patients, strengthen decision-making, and ultimately enable ECT to deliver its life-saving potential.

In complex ECT, the safest action may begin with a pause.

Attention Deficit Hyperactivity Disorder (ADHD) and Conduct Disorder (CD) are diagnoses that are frequently comorbid; the DSM-5-TR notes that 25% of patients with ADHD combined type present with CD. CD is characterized by persistent dissocial, aggressive, and defiant behaviors that defy age appropriate expectations. NICE guidelines and literature suggest that psychostimulants, specifically Methylphenidate, are indicated in cases where ADHD and CD arecomorbid.

This is the case of a 15-year-old male adoptee referred to Tier 3 CAMHS for severe aggression, impulsivity, and domestic violence. The patient exhibited coercive control toward his mother, physical violence involving weapons, and property damage, necessitating police involvement and risking family placement breakdown.

Following a failure of psychosocial interventions, the patient underwent a Qb Test and Conners 4 assessments and review by a consultant psychiatrist confirming ADHD and Conduct Disorder Diagnosis. Methylphenidate (Concerta XL) was initiated and titrated to 36mg daily.

Outcomes were significant. Within one month, antisocial behaviors reduced markedly. At seven months, domestic violence had ceased, and social care involvement ended. The patient successfully completed his GCSEs. Repeat testing on medication showed normalisation of scores: Qb Test activity dropped to the 23rd percentile and impulsivity to the 21st percentile. on repeat parent-rated Conners 4 scores for Conduct Disorder dropped to zero.

This case highlights the importance of identifying and treating underlying ADHD in adolescents presenting with severe conduct issues. Higher doses of Methylphenidate are often cited as beneficial for CD symptom reduction, this patient achieved remission of aggression at 36mg/day. The case shows that delaying ADHD diagnosis in favor of solely managing behavioral conduct symptoms can risk education and family stability. Treating the ADHD effectively mitigated the emotional dysregulation and violence, and reduced the negative impact on this patient during a crucial period of his life as he was completing high school.

This case highlights the importance of considering comorbid ADHD and Conduct disorder in patients presenting with impulsive behaviours and aggression as their primary presenting complaints. As appropriate management with Methylphenidate could have a significant therapeutic effect on these patients and their antisocial behaviours.

Compulsive skin-picking is a recognised complication of cocaine misuse, frequently driven by formication and somatic delusional beliefs of infestation.¹² Repetitive excoriation may result in significant tissue damage, impaired wound healing, and long-term disfigurement, particularly when combined with psychiatric comorbidity, poor insight, and psychosocial adversity. This case highlights the interaction between trauma-related psychopathology, cocaine-induced perceptual disturbance, and severe self-inflicted facial injury.

LA, a 60-year-old woman from Brazil who moved to the UK over 20 years ago, presented with a history of trauma-related psychiatric symptoms and recurrent cocaine misuse. She had developed progressive self-inflicted injury to the nasal cleft and upper lip, particularly during periods of cocaine use. The formication and infestation beliefs also lead to compulsive aggressive cleaning of the philtrum and nasal region, including the use of sharp implements and a toothbrush, resulting in extensive soft-tissue damage and chronic non-healing wounds.

LA intermittently denied ongoing infestation beliefs but the picking behaviours continued, particularly during periods of medication non-adherence and substance use. Collateral history confirmed continued delusional beliefs. She was treated with Fluoxetine 60mg OM and Olanzapine 5mg ON. Dermatological assessment reported pyoderma-like ulceration, exacerbated by repeated trauma and cocaine adulterants. Despite periods of partial healing, recurrent excoriation prevented sustained recovery leading to consideration of future reconstructive surgery.

Management was complicated by inconsistent engagement, housing instability, and fluctuating insight. Escalation to depot antipsychotic therapy was considered due to ongoing self-injury and poor adherence. Psychological assessment identified significant functional impairment, compulsive behaviour, and substance misuse disorder, with reliance on family members for daily support.

Chronic intranasal cocaine use causes nasal and dermatological tissue damage through intense vasoconstriction, leading to ischaemia, ulceration, and tissue necrosis.³ Over time, this may progress to nasal septal perforation, collapse of nasal structures, and destruction of midline facial anatomy, including the philtrum and upper lip.

This pattern of injury is described as cocaine-induced midline destructive lesions (CIMDL), resulting from repeated vascular insult and progressive breakdown of nasal mucosa, cartilage, and surrounding soft tissues.4 Adulterants such as levamisole further contribute to vasculitic and necrotising skin lesions.5 Cocaine is also associated with formication, which can drive compulsive scratching and excoriation, particularly in individuals with underlying psychotic or somatic delusional beliefs.¹

Cocaine-associated skin-picking can result in severe and enduring facial injury when driven by somatic delusional beliefs and substance-induced perceptual disturbances. This case underscores the importance of coordinated psychiatric, psychological, substance misuse, and physical healthcare interventions to prevent further harm.

Tardive Dyskinesia (TD) is a movement disorder that typically occurs in individuals with longstanding use of dopamine receptor blocking agents; this typically includes second generation anti-psychotics, but can also include anti-emetic/anti-vertigo drugs and even other drugs. The onset of TD is often insidious with the first symptoms presenting over days to weeks and usually even months, prior to development into a full syndrome. It can only occur 3 months after the exposure to such agents for those under the age of 60 and 1 month of exposure for those aged above 60.

We present the case of a 66-year-old gentleman with a severe intellectual disability and a history of challenging behaviour. He has been previously under the care of his community learning disability service for a previous history of challenging behaviour but was re-referred on this occasion with the concerns about strange behaviour.

Staff noted and reported a intermittent abnormalities in movement and this gentleman’s case was referred to Psychiatry for follow up. These abnormalities also included difficulties in swallowing food. As part of the psychiatric evaluation the physical health of the gentleman was reviewed and the nature of the intermittent abnormalities in movement prompted a referral to the local Neurology department in order to evaluate whether there may be a form of epilepsy that this gentleman was suffering from. This gentleman was diagnosed with Tardive Dyskinesia after extensive ruling out of potential physical and mental health concerns. His treatment of Tetrabenazine was initiated and has since been tapered up to a total daily dose of 125mg per day. His symptoms have improved and with the aid of his local speech and language therapy team and dietetics team, he is able to safely eat food.

This case highlights the complexities of Tardive Dyskinesia and how these symptoms can be easily overlooked in someone with an intellectual disability. It also underscores the importance of proactive monitoring as well as regular medication review. This case further highlights the importance of a multidisciplinary approach towards the care of individuals with intellectual disabilities.

This case further highlights the need for structures screening for Tardive Dyskinesia in the ID population; particularly those receiving long-term antipsychotics. This case further lends weight to the regular use of movement assessments and reinforces the need for continued deprescribing where clinically appropriate.

REM sleep behaviour disorder (RBD) is characterised by loss of physiological REM atonia, resulting in dream-enactment behaviours that may be violent and pose significant risk to patients and bed partners. RBD may be idiopathic, secondary to neurological disease, or medication-induced. Medications, including antidepressants and sedative-hypnotics, have been implicated in precipitating or unmasking RBD, particularly in individuals with underlying neuropsychiatric vulnerability and structural brain injury.

A 60-year-old man who was diagnosed with PTSD following a severe physical assault 30 years ago. He also sustained a scalp laceration, severe bruising to his body, hearing impairment, memory problems, and anxiety problems. Documentation of prior neurological and neuroimaging follow-up was unavailable.

He presented with a six-year history of progressively worsening sleep-related behaviours. These included snoring, talking, shouting, odd sounds, nightmares, increased restlessness, abnormal nocturnal movements, falls from bed when startled, and a recent episode of violent behaviour during sleep resulting in injury to his partner. He had a longstanding psychotropic polypharmacy, including paroxetine, carbamazepine, risperidone, and zopiclone. Collateral history highlighted worsening impairment of his memory and concentration levels, and recent changes in his personality.

Physical examination revealed an abnormal gait, positive Romberg’s test and tremors of his upper limb, with involuntary tic-like movements and repetitive blinking. Cognitive assessment revealed significant deficits in memory, recall, attention and language. Due to a childhood history of petite mal epilepsy, an electroencephalogram was done and it showed no epileptiform discharges. Neuroimaging identified chronic gliotic change and encephalomalacia in the left frontal lobe, consistent with previous injury. Previous oximetry and multi-channel sleep studies excluded sleep apnoea.

Zopiclone and paroxetine were gradually discontinued, and sertraline and melatonin were initiated. Risk management involved separate sleeping arrangements. Subsequently, violent sleep-related behaviours resolved. The patient was referred to Memory Services for further neurocognitive assessment.

The combination of violent dream-enactment behaviours, associated injury to a bed partner, absence of epileptiform activity, structural frontal lobe injury and improvement following gradual withdrawal of long-term paroxetine and zopiclone supported a diagnosis of likely medication-induced RBD in the context of TBI.

This case illustrates the risks of diagnostic overshadowing in patients with established psychiatric diagnoses and highlights the importance of considering organic and iatrogenic causes when new behavioural disturbance emerges, such as violent sleep-related behaviours. This case highlights the importance of awareness of the long-term neuropsychiatric sequelae of TBI and regular medication review and rationalisation to minimise iatrogenic harm

Sodium Valproate is widely used in the treatment of epilepsy and is also commonly prescribed for psychiatric disorders, particularly Bipolar Disorder. Enuresis associated with sodium valproate has been reported in paediatric populations with epilepsy, and in a case report involving a paediatric patient with Bipolar Disorder. However, data in the adult psychiatric population remains limited.

This is a case report of a 20 year old gentleman diagnosed with Unspecified nonorganic psychosis. He had a four month psychiatric admission with first episode psychosis, which included 2 months in Psychiatric Intensive Care Unit (PICU). He was initially started on Olanzapine, which was titrated up to 20mg per day, however there was no response. Due to significant aggression, Sodium Valproate was introduced and increased up to 2500mg nocte. Due to lack of response with Olanzapine, antipsychotic medication was initially changed to Haloperidol during which he developed oculogyric crises which necessitated dose reduction. Due to persisting psychotic symptoms, it was changed to Zuclopenthixol. At discharge, he was on Zuclopenthixol depot 350mg every two weeks, Sodium Valproate 2500mg nocte and Procyclidine 5mg three times a day.

During follow up in the community by the Early Intervention Service, he was noted to have extrapyramidal side effects due to which the dose of Zuclopenthixol was reduced and Procyclidine was increased. He also reported nocturnal enuresis every night. There were no other urinary symptoms, and he had not had urinary incontinence or enuresis in the past. Initially, the dose of Sodium Valproate was split to 1000mg in the morning and 1500mg at night with a view to reduce nocturnal sedation, however the symptom persisted. The dose of Sodium Valproate was then reduced to 1000mg twice a day after which nocturnal enuresis resolved completely. During subsequent follow-ups, the dose of Sodium Valproate was reduced further, with a plan to gradually reduce and stop it in the long term. He remained free of psychotic symptoms during the period of follow up, without recurrence of enuresis.

The onset on nocturnal enuresis following initiation of Sodium Valproate, and resolution following dose reduction suggests a possible association between the two. This is in accordance with previous reports indicating enuresis as a dose related side effect of Sodium Valproate.

Nocturnal enuresis is a potentially under recognised side effect of Sodium Valproate. Clinicians should screen for this adverse effect as it may significantly impact quality of life and treatment adherence.

Postpartum psychosis is an acute and severe psychiatric illness, often characterised as a ’psychiatric emergency’ lacking distinct classification in the DSM-5. This leads to poor understanding of the condition and ambiguous management protocols. 1-2 per 1000 females are affected and this change in maternal behaviour can be characterised by affective mood symptoms but may also present with catatonic features. This case study highlights the challenge of recognising and initiating urgent management in the setting of postpartum psychosis.

Female admitted at 14 days postpartum under detention following significant concerns regarding non-communication, markedly reduced oral intake, poor sleep and rapidly deteriorating mental state. The patient suffered a similar episode after her first child. She initially displayed heightened anxiety and elated behaviour followed by mutism and flat affect. She was treated for endometritis due to elevated inflammatory markers and treated for a lower limb deep vein thrombosis. Treatment was then commenced for postpartum psychosis presenting with catatonia with lorazepam, olanzapine and mirtazapine, titrated up to effect.

This case study highlighted the effectiveness of a ’lorazepam challenge’ with marked improvements in mental state seen within 48 hours and discharge home soon after. The importance of antenatal screening for high-risk patients is evident here, with emphasis on a previous episode of postpartum psychosis being the strongest predictor of recurrence in subsequent pregnancies (50% recurrence risk), which went undetected due to a language barrier. Also highlighted was the need to rule out organic causes initially in the workup for a diagnosis of postpartum psychosis.

Postpartum psychosis is a condition requiring urgent attention and intervention with need for a multi-disciplinary team-based approach. Mother and Baby Units are vital in the setting of a postpartum psychosis in order to maintain the maternal-infant bond. Ongoing follow-up with the perinatal mental health team is vital in order to support the patient and family, to offer counselling and to provide information regarding recurrence risks. This case study is evidence of the need for more distinct classification and national guidelines to ensure accurate treatment is initiated in a timely manner.

This report details the forensic admission of Ms X, a woman in her 40s, following an index offence of Grievous Bodily Harm (GBH) driven by fixed persecutory beliefs. It underscores the clinical challenge of identifying Autism Spectrum Disorder (ASD) when masked by “social camouflaging” or obscured by somatic comorbidities. Historically, Ms X’s difficulties were attributed to Chronic Fatigue Syndrome and depression. At the same time, her forensic presentation was initially diagnosed as “Delusional Disorder,” illustrating the risks of diagnostic overshadowing in forensic risk assessment.

Ms X presented with persistent beliefs that an online group had compromised her devices and that neighbours were surreptitiously filming her. These beliefs culminated in her confronting neighbours while armed. On admission, her presentation diverged from primary psychosis; she exhibited limited conversational reciprocity, sensory hypersensitivities (noise and olfaction), and a narrow, obsessive preoccupation with cyber-security. A retrospective developmental history revealed core ASD traits missed due to female-typical compensation strategies, including long-standing social aversion and ritualistic behaviours. This led to a formal diagnosis of ASD, replacing the previous diagnosis of primary Delusional Disorder.

The clinical formulation reframed Ms X’s “delusions” as intense manifestations of autistic cognitive style. Her beliefs were formed through a concrete, literal interpretation of ambiguous stimuli; for example, interpreting the online phrase “I see you” as evidence of physical surveillance. Her inherent cognitive rigidity rendered these beliefs resistant to challenge. Furthermore, deficits in Theory of Mind caused her to misattribute neutral or ordinary environmental actions as intentional threats. Consequently, the index offence was formulated as a reactive defence rooted in neurodevelopmental rigidity and emotional dysregulation, rather than a psychotic break.

This case highlights the imperative for forensic practitioners to screen for masked ASD in women, particularly when intense somatic or mood symptoms are present. Understanding ASD-related rigidity is crucial for accurate risk formulation and legal mitigation. Management must shift from traditional antipsychotic protocols toward integrated, specialised psycho-social interventions–such as Neurodevelopmental Outreach Services–focused on building ASD-specific insight and adaptive coping mechanisms.

Superficial siderosis of the central nervous system is a rare progressive disorder caused by chronic deposition of haemosiderin in the superficial layers of the brain and spinal cord, often following recurrent subarachnoid bleeding. The cerebellum and hindbrain structures are particularly vulnerable to iron-related toxicity. Although classically characterised by ataxia, dysarthria, and gait disturbance, cognitive impairment is increasingly recognised as part of its presentation. This overlap can obscure diagnosis, especially when patients first present to memory services with primarily cognitive complaints.

A 75-year-old woman was referred to the memory clinic with a one-year history of worsening forgetfulness, difficulty recalling recent events, and episodes of disorientation. Her family reported rapid decline in her functional abilities, and she had become dependent on her son for daily organisation. She appeared anxious during cognitive testing and showed impaired short-term memory, word-finding difficulty, and repetitive speech, although reading and writing remained intact.

Initially, her presentation resembled a primary cognitive disorder. However, neurological examination revealed significant abnormalities, including difficulty following complex commands, tongue and limb apraxia, bilateral dysdiadochokinesia, and impaired tandem walking. Although there were no cranial nerve deficits or nystagmus, prominent cerebellar signs prompted neuroimaging. MRI demonstrated severe superficial siderosis symmetrically affecting the infratentorial region with lesser supratentorial involvement.

Her cognitive and neurological function deteriorated despite anti-dementia medication. A neurology opinion was sought, and she required multidisciplinary involvement, including speech and language therapy for dysphagia and fallsprevention support. As the condition progressed, she developed leftsided weakness, an upgoing plantar response, and reduced ankle reflexes. Chelation therapy with deferiprone was considered but not pursued due to advanced cognitive impairment, marked ataxia, and limited potential for benefit.

This case highlights an important diagnostic challenge for memoryassessment clinicians: superficial siderosis can initially present as a cognitive disorder, even though the underlying pathology is neurological. Without thorough neurological examination, such cases may be misdiagnosed as dementia, particularly when dysarthria and inconsistent cognitive testing obscure the picture. Dysarthria limits verbal responses, reduces the validity of cognitive scores, and can exaggerate perceived deficits. The patient’s apraxia, coordination abnormalities, and gait disturbance indicated a broader process inconsistent with typical neurodegenerative dementia. Early recognition is essential, not because curative therapy exists, but to guide appropriate imaging, avoid unnecessary treatments, initiate timely multidisciplinary care, and prepare families for progressive decline.

Cognitiveled presentations of superficial siderosis are uncommon but clinically important. This case highlights the value of thorough neurological assessment in memory services, particularly when cognitive symptoms present with atypical neurological features.

Stalking is an under-recognised occupational hazard within mental health services and disproportionately affects women clinicians. Boundary violations by current or former patients can pose risks to clinician safety, disrupt professional identity, and generate significant emotional distress. Experiences of stalking are often under-reported, and clinicians may feel uncertain about how best to seek support.

This case study reflects on the professional, organisational and emotional learning arising from a single experience of stalking encountered by a female psychiatrist during her Core Psychiatry training in Yorkshire, UK. The hypothesis underpinning this work is that, for this clinician, early institutional support, clear boundary-setting and access to protected reflective spaces mitigated psychological harm and supported resilience.

The case involved escalating stalking behaviour from a former patient, targeted towards a female Core Psychiatry trainee. This progressed from letters and unsolicited gifts to persistent social media contact, culminating in messages containing threats of harm and suicide. As a result, the clinician experienced fear, hypervigilance and moral tension between compassion for a mentally unwell patient and the need to preserve personal safety. The experience was explored using a narrative-reflective approach and supported through clinical and educational supervision, Balint group discussion, police involvement, advice from specialist stalking services, and implementation of digital-safety measures.

Reflection on this case identified learning points specific to the author’s experience. Early reporting reduced isolation and enabled coordinated risk management. Clear documentation supported organisational responses and escalation. Proactive digital-identity management increased perceived safety. Explicit acknowledgement of gendered vulnerability was validating and reduced self-blame. Supervision and Balint groups provided emotional containment and helped reframe vulnerability as professionalism rather than weakness. For this clinician, maintaining clear boundaries supported wellbeing without undermining compassionate patient care.

This reflective case highlights how stalking may affect clinician safety, professional identity and emotional wellbeing within psychiatric training. While experiences and responses will vary, this account suggests that organisational openness, supervisory support and access to reflective spaces were helpful in this instance. Sharing individual experiences may support awareness and encourage dialogue about clinician safety and boundary-violating behaviour within mental health services.

Pregnancy/Childbirth is a period of immense physical, emotional and social changes to women’s life due to drastic hormonal, body image changes. The immunological and circadian rhythm disturbances postpartum is compounded by potential obstetric complications.

Postpartum psychosis can arise in about 1-2/1000 live births, developing rapidly within weeks of delivery. Presentation is heterogeneous ranging from affective, psychotic and a mixture of symptoms. A smaller proportion of women can have Catatonia presenting with abnormal movements/behaviours.

A 26year old woman was brought to A/E, confused and disorientated 5weeks after her first childbirth. Pregnancy was uneventful until 40weeks when developed hypertension. She was induced at 41weeks/3days after passing meconium-stained liquor. Labour lasted 3nights with postpartum haemorrhage of 1600mls. She had mastitis and UTI postpartum.

She was admitted to a mother and Baby Unit due to her deteriorating mental state. She was noted to present as mute periodically, with labile mood and abnormal movements. Other features of her presentation included thought disorder, gross confusion, delusions of paranoia and misidentification.

She experienced distressing visual, tactile and auditory hallucinations. In addition to catatonic features of echolalia, abnormal movements like walking backwards, crawling or climbing, negativism and staring with periods of immobility.

She had no previous psychiatric or medical history. She had no family history of mental illness and the rest of her psychiatric history was unremarkable with a good social support.

She had extensive investigations including Haematological, CSF tests, brain and body scans, EEG to rule out Autoimmune encephalitis or other organic aetiology. Results were unremarkable. She was commenced on Olanzapine with poor response despite optimisation resulting in a switch to Risperidone. She was commenced on Intra-muscular (IM) Lorazepam and responded to daily doses at 5mg though improvements were not sustained. There was a poor response to oral and sublingual Lorazepam that was tried due to concerns about frequent IM treatments.

She was subsequently treated with Electroconvulsive therapy (ECT), which led to a dramatic and rapid response. By the second session, most of the catatonic and psychotic symptoms resolved. She was subsequently discharged after 8sessions of ECT, and was able to rebuild the bond with her baby and reconnect with her family.

Postpartum Psychosis is a psychiatric emergency with significant impairment in functioning and impact on parenting, with associated risks to self and the infant. Diagnosis and treatment must be timely. ECT remains an evidence-based treatment for rapid relief of symptoms of postpartum psychosis with Catatonia.

Ketamine misuse is an emerging public health concern, with increasing reports of severe physical and psychological complications. Chronic use is associated with hepatobiliary and urinary tract injury, often linked to ketamine’s metabolic pathways and toxicological effects (1-3). This report describes the complications and treatment outcomes of a young adult with severe ketamine dependence admitted to a specialist detoxification unit in South Wales.

A 25 year old British male with severe ketamine dependence (up to 8 g/day) presented with abdominal pain, urinary frequency, jaundice, and weight loss. Initial investigations revealed markedly deranged liver enzymes and raised creatinine. He was diagnosed with ketamine induced cholangiopathy (2) and cystitis, conditions well documented among chronic abusers (3). Despite initial improvement during detoxification, he relapsed shortly after discharge, escalating use to approximately 90 g and requiring ICU admission for ketamine overdose with emerging multiorgan failure. After medical stabilisation, he was readmitted for detoxification and demonstrated improved motivation and abstinence, with plans for residential rehabilitation.

Management followed general principles of substance-dependence treatment due to the absence of ketamine-specific guidelines (4). Oxazepam was used to manage withdrawal due to hepatic impairment, alongside analgesia for bladder pain. Mirtazapine was prescribed for mood symptoms, and the patient engaged in relapse-prevention therapy and occupational support.

Ketamine addiction has risen significantly across the UK, with documented multisystem toxicity including hepatobiliary injury, bile duct fibrosis, and cholangiopathy (1-3). Renal and lower urinary tract damage are similarly common in chronic users (3). This case demonstrates how rapid deterioration and multiorgan failure can occur following relapse, underscoring the need for sustained support after detoxification.

Ketamine abuse can cause severe and potentially irreversible liver and kidney damage. Relapse following detoxification carriesrisk of multiorgan failure. Sustained abstinence and structured follow-up are essential.

Body Integrity Dysphoria (BID) is a rare disorder characterised by a persistent sense of incongruence between bodily anatomy and experienced identity. ICD-11 situates BID within disorders of bodily experience, whereas DSM-5-TR lacks explicit diagnostic recognition, often leading to misclassification as body dysmorphic disorder, psychotic illness, or affective pathology. Extreme self-directed bodily modification remains exceptionally uncommon and poses profound diagnostic, ethical, and risk-assessment challenges.

We describe a 71-year-old retired engineer with a lifelong pattern of non-psychotic, non-suicidal self-amputation. He had previously undergone medically indicated above-knee amputation due to osteomyelitis and deliberate mid-forearm self-amputation with an axe in midlife, preceded by longstanding discomfort with the limb and followed by subjective relief and euphoria. Approximately five years later, he developed persistent thoughts of genital amputation. These thoughts persisted for 15 years, were internally compelling but not delusional, and were unaccompanied by concerns regarding genital appearance or function, hallucinations, or depressive syndrome (PHQ-9=0; GAD-7=3). He repeatedly sought psychiatric and primary care support, expressing difficulty understanding his experiences and enquiring whether surgical intervention could be medically justified to minimise harm. He received antidepressant medication and psychological therapy.

Despite chronic ideation and a previous history of self-amputation, repeated clinical risk assessments concluded that imminent self-harm was unlikely, largely due to the absence of suicidality, affective instability, or behavioural escalation. Following his mother’s death, he executed a meticulously planned penile self-amputation after informing emergency services. Post-operatively, he reported relief and pride, without regret or depressive symptoms.

Phenomenologically, this presentation aligns more closely with BID than with body dysmorphic disorder or affective illness. Unlike body dysmorphic disorder, distress was not rooted in perceived defect or appearance but in a fundamental disturbance of bodily identity. Unlike suicidal self-harm, the act was purposeful, planned, and directed toward identity resolution rather than death. This case exposes limitations in contemporary risk frameworks, which prioritise acute, dynamic indicators of risk while undervaluing the clinical significance of chronic, identity-driven ideation. The persistence of symptoms was interpreted as stability rather than progressive consolidation of intent.

This case underscores the need for phenomenologically informed, longitudinal approaches to psychiatric risk assessment and greater conceptual clarity regarding BID within diagnostic systems. Disorders of bodily identity can culminate in irreversible outcomes that evade conventional predictive models, highlighting the necessity of rethinking how risk, chronicity, and identity-related psychopathology are conceptualised in psychiatry.

Delusional parasitosis is defined by a persistent belief of infestation despite absence of objective evidence and is classified as a somatic delusional disorder in ICD-11 and DSM-5-TR. It often arises where plausible environmental exposure interacts with affective vulnerability and pre-existing anxiety traits, blurring the line between obsessional preoccupation and psychotic conviction. Such cases provide insight into how real-world threats can crystallise into enduring delusional beliefs, exposing the limitations of rigid diagnostic categories.

Mrs X, a 65-year-old woman with a history of obsessive–compulsive disorder, agoraphobia, and depression, was referred for psychiatric assessment because of persistent concerns that insects inhabited her skin, clothing, and living environment. Her symptoms began following a suspected flea exposure while living in Cornwall, which she experienced as highly distressing. Despite relocation, repeated cleaning and environmental interventions, and multiple medical reviews showing no evidence of infestation, her conviction persisted.

She described ongoing sensations of particles entering her skin, ears, and face, with burning and itching, worsened at night. These experiences became central to daily life. She discarded most personal belongings, slept on inflatable mattresses, engaged in repetitive washing and decontamination rituals, and spent hours documenting “evidence” through photographs, videos, and microscopic examination. Progressive social withdrawal, disrupted sleep, reduced appetite, and secondary low mood developed as her preoccupation intensified.

Examination revealed only healing excoriations and minor skin dryness without objective signs of infestation or systemic illness. Mental state assessment showed anxiety, labile affect, circumstantial speech, and fixed somatic beliefs with limited insight. There were no hallucinations or formal thought disorder, and she denied suicidal ideation. While relapse of obsessive–compulsive disorder or severe health anxiety was considered, the persistence and rigidity of her beliefs supported a diagnosis of delusional disorder, somatic type.

This case illustrates how a plausible environmental event may catalyse the consolidation of somatic delusion, marking a transition from threat-based anxiety and obsessional monitoring to psychotic-level conviction. It highlights the phenomenological continuity between obsession and delusion and exposes the limitations of rigid diagnostic boundaries when symptoms evolve across domains. Clinically, the case underscores the profound functional impairment associated with somatic delusions and the therapeutic challenges posed by limited insight and partial engagement with treatment.

This presentation emphasises the need for integrative formulations that account for environmental triggers, affective vulnerability, and evolving belief structures. It supports a dimensional understanding of psychopathology and the value of multidisciplinary approaches in assessing and managing complex somatic delusional states.

Challenging behaviours in individuals with intellectual disability and autism spectrum disorder are complex, multifactorial phenomena that often result in significant distress for patients, families, and caregivers. They are associated with poor quality of life, increased use of mental health services, and heightened risk of trauma for carers. Pharmacological management has traditionally favoured antipsychotics, with limited evidence supporting the use of antidepressants.

We report the case of a 26-year-old woman with moderate learning disability and autism spectrum disorder who exhibited severe challenging behaviours, including self-harm, aggression and property damage. These behaviours persisted despite trials of benzodiazepines, analgesia, and multidisciplinary behavioural interventions. Antipsychotics were avoided due to comorbid pituitary tumour.

Following a clinical review that identified anxiety as a perpetuating factor, trazodone was introduced and titrated to 50 mg three times daily.

Initiation of trazodone has resulted in marked reduction in the frequency and severity of challenging behaviours, improved identification of triggers, and enhanced engagement in structured ward activities. Residual incidents are shorter, less severe, and easily redirected, with fewer requiring physical intervention. The patient demonstrated improved participation in therapeutic activities, and staff reported greater confidence in managing residual behaviours.

This case highlights the potential role of trazodone, an antidepressant, in managing challenging behaviours in individuals with intellectual disability and autism spectrum disorder. It underscores the importance of individualized treatment approaches and contributes to the limited evidence base supporting alternative psychotropic strategies beyond antipsychotics. Further studies are needed to assess antidepressant efficacy in managing challenging behaviours.

Background

Women admitted to Psychiatric Intensive Care Units (PICU) frequently present with complex trauma histories, emotional dysregulation and heightened sensitivity to coercion, confinement and interpersonal authority. While restrictive boundaries may be required to maintain safety, poorly implemented or inflexible restrictions risk re-traumatisation, escalation of distress and disruption of therapeutic engagement. There is limited literature exploring how boundary implementation itself influences safety and engagement for women in PICU.

Aim

To explore how boundary-related clinical decisions influenced safety, emotional regulation and engagement in women admitted to PICU, and to identify gender-sensitive, trauma-informed approaches perceived by clinicians as helpful in practice.

Methods

A qualitative service evaluation using reflective thematic analysis was undertaken involving three anonymised female PICU admissions detained under the Mental Health Act. Cases were purposively selected to illustrate differing trajectories following boundary implementation: escalation, de-escalation and neutral outcomes. Data were derived from contemporaneous clinical documentation and multidisciplinary team reflections. The evaluation aimed to generate practice-based learning rather than generalisable outcomes.

Direct service-user interviews were not conducted to avoid placing additional demands on patients during acute admission. Findings reflect clinician interpretations of observed patterns of response to boundary setting.

Results

Three key patterns emerged:

Collaborative and relational boundary setting was associated with reduced agitation and improved engagement.

Blanket or rigid restrictions were more frequently linked with trauma re-experiencing, protest behaviours and escalation.

Necessary restrictive interventions, when poorly communicated, negatively affected dignity and delayed therapeutic re-engagement, even when clinically justified.

Gender-sensitive negotiation, preservation of autonomy where safe, and compassionate communication appeared clinically impactful.

Discussion

The findings suggest that in female PICU populations, how boundaries are enacted may be as influential as what restrictions are applied. Trauma-informed, collaborative approaches may mitigate escalation while maintaining safety. A reflective boundary-decision framework is proposed to support proportionality, transparency and restoration of autonomy.

Conclusion

Boundary implementation in female PICU settings has important implications for safety, emotional regulation and therapeutic alliance. Gender-sensitive, trauma-informed boundary practices may support safer care and improved engagement. Future work should incorporate co-produced evaluation and service-user perspectives to strengthen the evidence base.

Multiple sclerosis (MS) is the most common demyelinating neurological diseases worldwide. Around 2.3 million people globally and 100,000 people in the UK were living with MS. Psychotic presentation is rare, but it may affect 2-4% of the individuals with MS, which is more than in the general population (1%). The psychotic symptoms reported in multiple sclerosis included both affective and schizophrenia-like symptoms with a predominance of positive psychotic symptoms, most frequently persecutory delusions.

Case reports

Patient X is a 35-year-old female of Asian origin, with an established diagnosis of Multiple sclerosis, presented to the crisis team with thoughts to end her life as she firmly believed with impregnable conviction that her husband was unfaithful and was having an affair with the patient’s mother for the last 3 months. It impacted her sleep and overall quality of life as she used to keep up throughout the night to gather evidence of her husband’s infidelity. She was diagnosed with ‘Secondary psychotic syndrome, with delusions’ according to ICD 11. (6E61.1) The diagnosis of Multiple sclerosis was established around two years prior to her psychotic presentation which was treated with Natalizumab infusion. During the time of her presentation to our service, the symptoms related to MS was stable with no significant findings on neurological examination. X was commenced on a low dose of antipsychotic, initially Quetiapine (which she declined to take due to metabolic side effect) and then on Aripiprazole, 10 mg once daily. X showed considerable improvement within four weeks of initiation of the antipsychotic along with psychosocial support. She has been followed up by local neurology specialist teams actively and remained stable with respect to the demyelinating process secondary to MS on repeat MRI.

Discussion:

Psychotic symptoms may develop during the onset of MS or more frequently during illness as seen in this case. Regarding management, presence of Multiple sclerosis also makes the individual vulnerable to the side effects of antipsychotic drug like extrapyramidal side effects. Psychotic symptoms can be secondary to the demyelination process or results as a side effect of medication to treat MS like corticosteroids and beta- interferon.

Although, cognitive and affective symptoms like depression are very common in pertinent among patients with MS, psychotic symptoms among them are more than the general population. Considering these, it is important to explore the organic underpinning of patients presenting with psychosis.

Background-Functional Cognitive Disorder ( FCD) is an under-recognised condition which is different from dementia or Mild Cognitive Impairment. It causes problems with memory but unlike dementia, it is not a neuro-degenerative condition.

Case Report- 63 year old female presenting with cognitive problems, corroborated with a collateral history and scoring low 56/100 in Addenbrooke cognitive examination. Higher cortical functions processing, judgement, awareness of risks and orientation and functioning intact. CT scan was unremarkable and no structural changes related to dementia seen. The clinical presentation was incongruent with the low scores in the Addenbrooke. Patient recently diagnosed with functional neurological disorder as she had been presenting with tremors.

Discussion- Functional cognitive disorder (FCD) refers to complaints of persistent problematic cognitive difficulties, when accompanied by positive features termed ‘internal inconsistency’, and which are not better explained by another disorder e.g. a neurodegenerative disease process. Internal inconsistency is when a person may present with significantly impaired ability to perform tasks, particularly when the task is the focus of attention. Therefore, the individual components required to execute the task are intact, but there is difficulty engaging them at the appropriate intensity or duration on demand.

Conclusion- Although uncommon, functional cognitive disorder should be considered as a differential diagnosis in people presenting with cognitive difficulties where the clinical picture does not fit the picture of a neuro-degenerative condition like dementia. A misdiagnosis as dementia will a profound impact on a person’s personal, social and occupational aspects of life. The right diagnosis can provide re-assurance to people and enable them to be sign-posted to the right support services. This can reduce distress, stop people from being sent for unnecessary investigations, being misdiagnosed as a dementia and enable them to access the appropriate help for their symptoms.

Oculogyric Crisis (OCG) is one of the few presentations within psychiatry considered an emergency due to the potential features which can make OCG life-threatening. OCG is poorly understood and can be difficult to recognise due to other features which may mask the classical presentation of a fixed upper gaze of the eyes with associated anxiety and hallucinations. This case study looks at how we have managed a patient within a low secure forensic service with this presentation.

Our male patient in their 30’s was admitted with a working diagnosis of treatment resistant schizophrenia. There were frequent episodes of this gentleman becoming acutely unwell with vivid hallucinations and aggression directed towards staff and other patients. Due to staffing concerns regarding autonomic function, the associated eye movements were missed and as such this was not recognised as OCG which is an acute dystonic reaction.

During these episodes, there were many times where our patient would appear in an immobile state, with an inability to speak or follow commands with marked feelings of reference and ideas of persecution. This would include refusals to take prescribed medication because of visual hallucinations of seeing his medication and food and drink being contaminated. Episodes of seclusion were due to aggression towards others he believed were after him. Frequent emergency department attendances were required due to autonomic and conscious level disturbance.

Our patient was admitted on a regular depot of zuclopenthixol which we gradually reduced to nothing following the recognition of OCG. We also supplemented this with procyclidine, which helped to reduce symptoms.

Following these changes, we initially noticed a marked improvement in our patient’s presentation as he was engaging well with the ward staff and other patients. There was no longer any requirement for frequent hospital visits and the absence of a movement disorder.

However, they appear to have escalated again following complete cessation of the depot. We need to understand if this is an exacerbation of OGC, which the literature does document when antipsychotic medication is withdrawn or an exacerbation of the schizophrenia due to reduction in antipsychotic medication, even though he remains on an oral atypical antipsychotic known to have minimal risk for side effects.

OCG is a rare but serious condition. However, if it is recognised early, an individualised approach based on the patient and clinical picture may improve long term outcomes whilst considering alternative diagnoses.

Acute behavioural disturbance in older adults frequently presents diagnostic challenges, particularly when symptoms arise in the context of polypharmacy, physical illness, and sleep disruption. Delirium is often the initial working diagnosis in such presentations; however, evolving clinical features may indicate an underlying primary psychiatric disorder. Distinguishing between delirium and late-onset affective illness is especially complex in older adults with pre-existing psychiatric vulnerability and medication exposure.

This case describes a 67-year-old woman with a background of recurrent depressive disorder, anxiety, and obsessive–compulsive disorder who presented with acute confusion, severe insomnia, behavioural disorganisation, and pressured speech following recent changes to her analgesic regimen, including the initiation of tramadol.

The initial presentation was characterised by fluctuating cognition, psychomotor agitation, disinhibition, and paranoid ideation. A provisional diagnosis of medication-induced delirium with hypomanic features was made. Tramadol was identified as a likely precipitating factor, given its opioid and serotonergic properties and the patient’s increased vulnerability as an older adult.

Management initially focused on withdrawal of potentially offending medications, optimisation of physical health, and symptomatic treatment with antipsychotic and benzodiazepine medications. Due to impaired insight, behavioural disturbance, and risk of self-neglect, the patient required detention under the Mental Health Act for assessment and treatment.

Over the course of admission, features typically associated with delirium improved, including confusion and disorientation. However, the patient continued to demonstrate sustained mood elevation, reduced need for sleep, increased goal-directed activity, pressured speech, and intrusive behaviour, with preserved cognition. These symptoms were non-fluctuating and persistent.

Collateral history obtained during admission revealed a possible family history of bipolar affective disorder. In light of the clinical course and longitudinal observation, the diagnosis was revised to a manic episode, likely precipitated by medication exposure and sleep deprivation.

This case illustrates the diagnostic complexity of acute mental state changes in older adults, particularly in the context of polypharmacy and pre-existing affective disorders. While delirium is a common and appropriate initial diagnosis in such presentations, persistence of non-fluctuating manic symptoms following resolution of cognitive disturbance should prompt reconsideration of the diagnosis.

Tramadol has recognised serotonergic and noradrenergic properties and has been associated with both delirium and affective destabilisation, particularly in vulnerable populations. Sleep deprivation may have further contributed to the precipitation of mania. The presence of preserved cognition, sustained mood elevation, and increased goal-directed activity distinguished the evolving presentation from delirium and supported the diagnosis of late-life mania.

This case highlights the importance of longitudinal assessment, collateral history, and diagnostic flexibility when managing behavioural disturbance in older adults.

This case underscores the need to consider late-life mania in the differential diagnosis of acute behavioural disturbance in older adults, particularly when symptoms persist beyond the resolution of delirium. Medication exposure, sleep disruption, and affective vulnerability are important contributing factors. Careful longitudinal observation and willingness to revise initial diagnoses are essential to ensuring accurate diagnosis and appropriate treatment in this population.