bluuebunny/crossref_metadata_2025_split huggingface dataset:
Emotional Lability Secondary to Androgen Deprivation Therapy for Prostate Cancer: A Case Report
Authors: Keenan Mary , Rafiq Atiqa 
Published: July 2023

AimsProstate cancer accounts for more than a quarter (27%) of male cancer cases, making it the most common form of cancer in UK males. Androgen deprivation therapy (ADT) is the mainstay of treatment for prostate cancer. Its aim is to reduce the level of androgens which stimulate cancer cell growth, in turn reducing prostate cancer symptom burden over longer periods. Although the clinical benefits of androgen deprivation therapy have been well documented, the physical, and in particular psychological, side effects of this treatment are lesser reported and can be debilitating.MethodsWe present the case of an 84 year old male referred to Old Age Psychiatry outpatients for a one year history of low mood and tearfulness with no response to two antidepressant trials. The patient was receiving six-monthly injections of Decapeptyl (Triptorelin), a hormone therapy for prostate cancer. The patient's main presenting complaint was of bouts of tearfulness that were difficult to control and often mood incongruent. He reported low energy and reduced motivation; however other biological depressive symptoms were not endorsed.ResultsDepression and marked emotional lability have been reported by men who receive ADT for prostate cancer. This can be a cause of confusion or shame for patients, subsequently impacting interpersonal relationships and social functioning. Other side effects of ADT can lead to further negative psychological effects, including weight gain, gynaecomastia and genital shrinkage. It is possible that the side effects of this treatment are poorly recognized by clinicians initiating and managing it.ConclusionIn conclusion, patients commencing ADT should be informed of the possibility of psychological side effects and encouraged to report any symptoms that arise. It is important for urologists, psychiatrists and GPs to be mindful of the possible link between this treatment and new onset mood and emotional symptoms in patients.
A Young Girl in Distress
Authors: Khan Rummana 
Published: July 2023

AimsThe purpose of sharing this case is to bring attention to the complexities in implementing legal framework for children and adolescents as well as the serious shortages of in-patient adolescent psychiatric beds, which can adversely affect the mental health of young people.MethodsA young girl with a diagnosis of Depressive Disorder and Disordered Eating was treated by community mental health team for two years. She took an overdose and was admitted to a private NHS funded in-patient adolescent psychiatric unit, where she was placed on Section 2 of Mental Health Act. After two months she was transferred to an out of area psychiatric bed. While on home leave she took another overdose and needed admission in High Dependency Unit. When medically fit she was moved back to psychiatric unit. After two months she was moved to a local in-patient unit. Due to dietary restriction she was commenced on nasogastric feed. At that point the local psychiatric unit could not provide the support she needed and she was transferred to another in-patient adolescent unit in the region. After being an in-patient for 18 months when her condition improved a discharge planning meeting took place. She was still on nasogastric feed and sometimes had to be restrained. The local and regional in-patient and crisis consultants suggested that she should be discharged under Community Treatment Order. The community consultant took legal advice. The legal advice was that the provision of nasogastric feeding in the community without young person's consent would be likely to be unlawful and a violation of her Article 3 rights under the European Convention of Human Rights. Such restraint would be likely to amount to an unlawful deprivation of liberty and a breach of her Article 5 rights under the European Convention of Human Rights.ResultsIt is deeply concerning that she had to be moved between four in-patient units during one episode of in-patient admission due to lack of appropriate bed availability. Due to her age and complexities in the case, legal advice had to be taken because the consultants involved failed to agree on the appropriate application of legal framework.ConclusionThis case clearly highlights the need to address the issue of adolescent in-patient psychiatric bed shortages as well as the importance of educational programmes aimed at improving the knowledge and skills of professionals on the application of legal framework in children and adolescents.
A Case of Urticaria One Month After Initiating Fluoxetine
Authors: Muzenda Muredzwa Adelina , Grimwade Lucy 
Published: July 2023

AimsAccording to NICE guidelines, fluoxetine is a first-line antidepressant for the management of depression in children and adolescents. There has been little discussion on urticaria occurring after 4 weeks on fluoxetine. Urticaria is defined as an itchy skin lesion "with localised oedema and is surrounded by redness which is also known as a wheal and flare phenomenon". In most urticarial scenarios, the trigger which is usually an allergen leads to an increase in levels of histamine among other chemicals into the skin.MethodsWe present the case of a 16-year-old young person with no previous history of skin conditions, who developed urticaria 4 weeks after starting fluoxetine for depressive disorder. No other trigger could be identified. On discontinuing fluoxetine, the rash gradually declined over time and completely resolved ten days later. On further enquiry, the patient reported eating at least one chocolate bar a day. He did admit to receiving a large amount of chocolate just before the rash began and hence was possibly eating more than his usual amount at the time. Furthermore, the rash occurred at the point when steady-state levels of fluoxetine were believed to have just been reached.ResultsAdverse effects of medication have always been a challenging part of managing patients. Although rash that develops acutely after starting fluoxetine has been published so far, literature on rash that develops after 4 weeks on treatment is limited. Cederberg et al (2004) and Gahir (2021) described the association of SSRIs (fluoxetine and sertraline) and chocolate (which contains serotonin) leading to an itchy hive-like rash. In these cases, discontinuation of the SSRI and use of antihistamine led to a resolution of symptoms.We report a case who developed urticaria 30 days on fluoxetine without any other identifiable triggers. Aspects of this case to support a possible rash caused by chocolate-fluoxetine interaction include the rash occurring when the patient was consuming chocolate (quantities possibly increased immediately prior to the onset of rash), rash occurring when steady-state levels of fluoxetine had just been reached, no other identifiable trigger to explain the rash in the history and the slow resolution of the rash which can be explained by the long half-life of fluoxetine.ConclusionThis report highlights the importance of being mindful of this rare dermatological side effect of fluoxetine despite it occurring weeks after initiation. Patients should also be made aware of this possible side effect and its association with consuming chocolate.
Rapid Cycling Bipolar Affective Disorder After COVID-19 Infection Accompanied With Neurological Symptoms
Authors: Raoof Abdul , Aboelenien Shaimaa , Elagawany Adel , Nurlu Derya 
Published: July 2023

AimsThis case highlights an atypical presentation of a patient with known history of Bipolar Affective Disorder who experienced rapid mood changes and atypical neurological symptoms after he was tested positive for COVID-19.MethodsHere we present a 63 years old male patient who was an inpatient in low secure forensic unit and has a history of Bipolar Affective Disorder. Patient reported that he started to experience COVID-19 symptoms and was tested positive on 12th April 2020. It was observed that patient experienced low mood, flat effect, anhedonia and decreased appetite for more than a month after he was tested positive. According to his medical records, he experienced significant mood changes suggesting major depression and manic/hypomanic episodes, 4 times to be specific, over 6 months period after having diagnosed with COVID-19 which is correlated with diagnostic guidelines for Rapid cycling Bipolar Disorder. Patient was observed to experience 1 major depressive episode over period of 6 months before his COVID-19 diagnosis. He also reported experiencing neurological symptoms such as tremor, numbness and unsteadiness on one leg. Although it was found that his lithium level was above therapeutic range at the beginning of these symptoms, even after successful reduction of Lithium dose, patient continued to experience these symptoms for another month. There were no gross abnormalities in physical examination and his blood results were not significant. In addition to Electroencephalogram (EEG); Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) were conducted and the results were all insignificant. During this time, he was fairly compliant with his medications. Additionally, his mood was stabilised only partially with the medications he was taking. He did not have any other major environmental, psychological or physical changes that might explain his rapid mood cycling.ResultsAuthors considered various different causes for this patient's fluctuating mood. One confounding factor that was considered was blood lithium levels. However, that was proven to be irrelevant since patient continued to experience mood changes and neurological symptoms with therapeutic lithium levels. Also no other organic reasons were found that could explain his neurological symptoms.ConclusionAlthough, authors consider that longer observation period and other confounding factors could affect findings, they cannot confidently reject the impact of COVID-19 infection on patients with enduring mental illness and recommend further research which could lead to more comprehensive guidelines
Psychosis Prompts Detection of Early Stage Angioimmunoblastic T-Cell Lymphoma
Authors: Ong Li Anne , Mok Tabitha 
Published: July 2023

AimsAngioimmunoblastic T-cell lymphoma (AITL) is a rare (2%) and aggressive form of Non-Hodgkin lymphoma, with poor prognosis and median overall survival under 3 years. Most patients with AITL present at an advanced stage (3 or 4). Neuropsychiatric manifestations of lymphoma, though rare, have been reported as associated symptoms. We present a case of successfully treated Stage 2 AITL, whose rare presentation, of florid affective and atypical psychotic phenomena without neurological deficit, eluded clinical detection of AITL for months.MethodsA 58 year-old gentleman with a history of Major Depressive Disorder, presented to hospital with a second episode of generalised tonic clonic seizure, following 4 months of manic disorganised behaviour and multimodal hallucinations.Atypical psychotic features (preserved insight, multimodal hallucinations resistant to high dose anti-psychotics) and new systemic symptoms prompted suspicion of underlying organic pathology. CT Thorax Abdomen and Pelvis uncovered enlarged bilateral common iliac and external iliac lymph nodes, and small sub-centimetre retroperitoneal nodes. Eventually, Stage 2 Angioimmunoblastic T-cell lymphoma (Pattern 1 & 2), with concomitant psychosis with atypical features, was diagnosed.Olanzapine 10mg ON and 2.5mg OD PRN, Sodium Valproate EPILIM CHRONO 300mg BD and Diazepam 10mg ON were continued over 6 rounds of chemotherapy and autologous stem cell transplant. The patient remains in remission.ResultsNeuropsychiatric manifestations of lymphoma are rare and usually associated with Central Nervous system (CNS) lymphoma. Here, we observe Stage 2 AITL (without CNS involvement), can present with neuropsychiatric symptoms in the absence of neurological deficits.We found the combination of Olanzapine, Sodium Valproate and Diazepam to be effective in managing secondary neuropsychiatric symptoms.Limbic Encephalitis is an important consideration for similar cases despite this patient not meeting the qualifying criteria (unremarkable neuroimaging and EEG).This case highlights the importance of a thorough history, documenting and understanding the patient's psychopathology (both reported and observed), and differentiating atypical psychotic features which raise suspicions for underlying organic pathology.ConclusionThis case is an an eye-opener for psychiatric and non-psychiatric clinicians. It reminds us to remain vigilant in such florid psychiatric presentations and highlights the importance of thorough organic workup and psychiatric medications that may be used to successfully address psychosis secondary to lymphoma.We hope to contribute to the increasing awareness and broadening literature of psychiatric disturbance as initial manifestations of malignant illnesses, and the association between psychiatric manifestations and the rare form of lymphoma, AITL.
Atomoxetine as an Alternative Therapy for Adolescent Adhd With Comorbid Cerebral Palsy: A Case Report
Authors: Calilung Dominique , Yaman Busra 
Published: July 2023

AimsThe prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in children with Cerebral Palsy (CP) is 19%. Whilst there is evidence that methylphenidate is an efficacious first line therapy for patients with ADHD, there is a lack of literature describing atomoxetine use in ADHD with comorbid CP.MethodsHere we report the case of a 17-year old Caucasian female with ADHD and CP. The patient was referred to Child and Adolescent Mental Health Services (CAMHS) for ongoing anxiety following extensive orthopaedic surgery, which was managed with sertraline and concurrent Cognitive Behavioural Therapy.A CAMHS assessment led to her subsequent diagnosis of ADHD resulting in an initial treatment of low-dose methylphenidate (Ritalin). This was discontinued after four days due to progressive headache, tachycardia, and unilateral leg restlessness. The patient was hesitant to commence lisdexamfetamine, a second line stimulant medication, due to the possibility of similar adverse side effects.Atomoxetine (20mg/day) was commenced for a month then increased to 30mg/day. After five months, it was discontinued. The patient reported no significant improvements to attention or concentration, but reported a later onset of escalating anxiety prior to discontinuation. Consultation revealed that the patient's anxiety may be attributed to biopsychosocial factors unrelated to pharmacotherapy, but could not discount the possibility that this was a side effect of atomoxetine. Following the discontinuation of atomoxetine, the patient and her carer were amenable to trialling lisdexamfetamine.ResultsPrevious data have demonstrated that patients with CP have lower tolerance to particular pharmacological agents, therefore atomoxetine was started at a low dose (20mg/day) to permit a gradual titration up to the recommended therapeutic dose. Worsening anxiety whilst on atomoxetine (30mg/day) may be a result of one or a combination of the following: (1) long-term side effect, (2) subtherapeutic dose response, (3) identified precipitating and perpetuating psychosocial factors, particularly in the school setting.ConclusionThe case report demonstrated an acceptable safety profile for the use of atomoxetine in a young person with ADHD and comorbid CP. The expected therapeutic benefits of atomoxetine for ADHD may have been offset by extenuating biopsychosocial factors. Further research is needed to determine whether there exists a causal relationship between atomoxetine therapy and worsened anxiety within this patient group. Furthermore, this case highlights the importance of understanding the complexities of ADHD treatment in patients with confounding environmental factors and comorbid neurological disorders.
Improving the Admission Process to Inpatient Wards for Gender Diverse Service Users at Oxleas NHS Foundation Trust: Service Evaluation
Authors: Abdelsamie Ahmed , Pontes Diogo , Absi Musa , Aboelsoud Sarah 
Published: July 2023

Aims1.To evaluate the knowledge and experience of staff members working in inpatient units at Oxleas NHS trust on the topic of healthcare of gender diverse service users.2.To improve the admission process for gender diverse service users by creating an admission checklist, increase awareness and provide training when possible.MethodsA questionnaire with 11 questions was sent to different staff member groups. The questions assessed their knowledge of the policies for gender diverse service users and their clinical experience in dealing with this group of service users when being admitted to inpatient wards.Results25 members of staff completed the questionnaire. Of those, 52% were not aware of the existence of a specific policy for admitting and treating gender diverse service users at Oxleas. From the respondents who knew about the policy, 60% did not know where to find it. 44% of all respondents do not ask service users for their preferred name, gender and pronouns when they are admitted to an inpatient ward. From those who ask service users, 45% do not document service users’ chosen name, pronouns and gender identity on RiO (the digital record system used at Oxleas). 68% of participants do not know how to change the demographics information on RiO for service users. When asked about the allocation criteria for inpatient beds, 24% replied that it should be done according to the service user's assigned gender at birth, while 8% responded that they should be allocated to any available bed. 40% of staff members reported that trans service users can not easily access daily personal products on the ward that are related to their trans-specific health needs. 72% of those who responded do not know what specific services or organisations to direct this group of service users to in case they need any further support. 56% of staff do not feel confident in dealing with trans specific needs and 88% have not received any training on the area from the Trust.ConclusionAlthough the Trust has created a specific policy for gender diverse service users, staff members’ knowledge of such policy is sub-optimal. Moreover, there is a lack of training available to staff on inpatient wards, which is reflected in their lack of confidence in working with this group and the lack of knowledge around external services to refer these service users to. In response to this, we have implemented some changes. Pronoun preference has been added to RiO and we have encouraged staff members to use it when completing demographics. An admission checklist specific to gender diverse service users was created and shared within the organisation. We scheduled teaching sessions on this topic, however, these did not go forward due to lack of attendance.
Awareness of Fitness to Drive Guidance Amongst Doctors in Black Country Healthcare NHS Foundation Trust : A Survey
Authors: Sundhar Reka Ajay , Chandra Pallavi , Fraser Alistair , Kar Nilamadhab 
Published: July 2023

AimsPsychiatric patients have a higher risk of road traffic accidents than others. The Driver and Vehicle Licensing Agency (DVLA) has provided guidance on different psychiatric conditions and medication that would impact driving. The General Medical Council and Royal College of Psychiatrists advice doctors to notify the DVLA when patients unfit to drive fail to inform the DVLA themselves. In this context, it was aimed to study the awareness of doctors regarding DVLA guidance and its use in their clinical practice.MethodsWe conducted a survey about doctors’ awareness of guidance on Fitness to Drive via an online questionnaire. Likert type scoring ranging from strongly agree to strongly disagree was used to assess the (i) awareness of DVLA guidance for psychiatric patients, (ii) confidence in advising patients, (iii) feeling it is a job requirement to advise patients on driving; and (iv) checking the driving status and if patients have informed DVLA where necessary. This included questions on years of experience in medicine, current grade and subspecialty of Psychiatry.ResultsThe sample consisted of 78 doctors, from various grades from Foundation Year 1 trainees to Consultants; working in different Subspecialties in Psychiatry. There were 36 trainees, 12 middle grades, 28 consultants and 2 ‘other’ doctors. The average year of experience of the responding doctors was 14.2±11.0 years with a range of 1-38 years.Majority (62.8%) of doctors responded that they are aware of the DVLA guidance for psychiatric patients; however 47.5% reported having confidence to advise patients on DVLA guidelines. Considerable proportions (79.5%) of doctors felt that as psychiatrists, it was their job to give advice on driving; but only 50% said they check the driving status and whether patients have informed the DVLA when necessary as part of routine practice.When using the Likert scale, comparing to other subspecialties, General Adult Psychiatrists responded that they check driving status less routinely (p<0.05), however there was no difference in other areas evaluated. Trainees’ responses indicated less awareness (p<0.001), confidence (p<0.001), and checking of driving related issues routinely in clinical practice (p<0.005).ConclusionThe survey results suggest variation in awareness of Fitness to drive guidance for psychiatric patients and their use in routine clinical practice amongst doctors. While trainees would need more information and training to increase their confidence, there is a need for all psychiatrists to use the guidelines in regular clinical practice.