bluuebunny/crossref_metadata_2025_split huggingface dataset:
Case Study on an Ethical Dilemma
Authors: Akella Anusha , Moe Kyaw 
Published: June 2022

AimsMr AB is a 58-year-old male with diagnosis of Schizoid Personality disorder. An articulate and intelligent man, AB derived happiness and contentment from his work. Due to workplace conflicts, he was asked to resign several years ago and has not worked since. Mr AB then found a sense of purpose in life by looking after his elderly parents. His parents sadly died a few years ago and since then he has been living on his own. He has never married. AB has one brother who helps him with shopping and groceries. Prior to this admission, AB was admitted once a few years ago when he was diagnosed with Depressive Disorder.MethodsMr AB was admitted last year with profound self-neglect. He was detained under Section 2MHA as he wasn't eating and drinking and wasn't engaging with services. With the initial diagnosis being Recurrent Depressive Disorder, AB was commenced on treatment for the same and eventually received ECT, for which he had strongly opposed. Following 6 sessions of ECT, AB bargained with the team that he would start eating and drinking if ECT was stopped and did so as well. He then requested a transfer to a different ward and consultant, with whom he shared that he doesn't agree with our diagnosis of depression or Schizoid personality disorder. AB expressed that he doesn't find his life worth living and wants to be left alone. He strongly believed that his liberty to take decisions about his life is being unfairly taken away by the NHS and accused professionals of trying to protect themselves. No evidence of SMI found at this stage. Following several discussions, AB was discharged home. He however was readmitted within a couple of days’ time by his brother following disengagement, self-neglect and again, no evidence of SMI.ResultsA capacitous patient, in the absence of Serious Mental Illness puts forth an argument that purely because his way of living and his opinions on life and death differ from that of the society, doesn't mean that his rights over his life can be taken away from him. He, however, struggles to acknowledge that as fellow humans we are strongly inclined to intervene and try to stop anyone from taking their own life.ConclusionA Challenging case that raises several questions surrounding Medical Ethics. The team is now looking into guardianship to ensure welfare of the patient.
Key Learning Points from a Case of Cannabinoid Induced Catatonia
Authors: Benazaize Lydia , Mercadillo Nieves 
Published: June 2022

AimsCatatonia has an effective treatment: benzodiazepines. A first presentation of catatonia may present initially to an acute medical trust. It is important acute clinicians are familiar with its manifestations, medical differentials, and most importantly, understand the role of benzodiazepines in both the investigation and management of catatonia.MethodsHere we describe a case of catatonia in a nineteen-year-old male, who presented acutely to the accident and emergency department with odd behaviour following inhalation of the synthetic cannabinoid ‘spice’. Initially, he was found to be rigid, mute and doubly incontinent, but able to follow vague commands. He was admitted to the acute trust for twelve days in which he was worked-up as a case of drug induced psychosis. As he was not improving, he was then transferred to psychiatric inpatient services for further investigation and management.ResultsThe acute medical team did not recognise this as a presentation of catatonia and did not conduct a lorazepam challenge, as suggested by specialist services. A lorazepam challenge is helpful in both diagnosing and treating catatonia. In this case, we believe this may have been missed, due to a lack of knowledge and understanding of the condition. Medical mimics of psychosis, such as autoimmune encephalitis, may be life threatening, but have a good prognosis if treated early. Here, these were not considered, which may have led to disastrous consequences had they been present. This case shows an opportunity for education into the differentials and management of catatonia.ConclusionWe believe this case highlights a degree of poor understanding surrounding catatonia and its clinical work-up in the acute setting. There were missed opportunities to instigate treatment earlier and consider rarer alternative causes for the presentation. We hope this case will simplify diagnosis and management for acute clinicians, and highlight important medical mimics of catatonia. This case also shows the potential significant harms of synthetic cannabinoids such as ‘spice’ and highlights a need for further research and potential review for grading above Class B in the Misuse of Drugs act 1971.
Trauma-Informed Care on CAMHS ID Unit. Case Study of a Child with Neurodevelopmental Disorder and Self-Injurious Behaviour
Authors: Eggleston Evelina , Daoud Omaima 
Published: June 2022

AimsCrystal House is a specialist CAMHS ID inpatient 5-bedded unit based in the Kingswood Centre, North West London - for children aged between 13 and 18 years with primary diagnosis of Intellectual Disabilities with or without additional concerns that warrant admission to hospital for purpose of assessment and management. Reporting this case, we wanted to highlight complexities of management of children presenting with neurodevelopmental conditions and history of trauma.MethodsThis is a case of a fourteen-year-old girl with established diagnoses of Moderate Intellectual Disability, Childhood Autism, Foetal Alcohol Syndrome and childhood trauma. She was admitted to our CAMHS ID Assessment and Treatment Unit with a nine- year history of self-injurious behaviour, suicidal ideation and voice-hearing experiences – after failed treatment in the community and in-patient treatment (including under restrictions of long-term segregation) on generic CAMHS unit. Her current treatment includes a person-centred Trauma- Informed Positive Behaviour Support Plan; individual and family therapy psychology sessions based on the principles of trauma-informed care and consultation with staff on trauma-informed care. She also undertook ADHD assessment, and we are in the process of optimising ADHD medication.ResultsTrauma-Informed Positive Behaviour Support Plan was a new concept for the team. Therefore, this was supported by training and consultations with staff. The latter was introduced to create a psychologically oriented environment using trauma-informed care principals and helping the team understand what trauma means and how it affects the individual. ADHD assessment confirmed the diagnosis of ADHD which was followed by optimising ADHD medication.ConclusionSystemic and a person-centred approach is used for this child with concerning presentation and history of neurodevelopmental disorder and childhood trauma.
Surviving Fifty Years With Shrapnel Within the Brain
Authors: Inam Muhammad Sayed 
Published: June 2022

AimsTraumatic brain injury during the war by shrapnel or bullet is lethal and life-threatening. The mortality rate from traumatic brain injury is more than 90%. Mrs. N (70) of Bangladesh is an exceptional and one of the luckiest women of the world. She is a war victim and has been living with shrapnel within her brain for the last 50 years.MethodsAccording to the patient attendant, half a century ago, during the Liberation War of Bangladesh, one shell accidentally exploded in their backyard. Unfortunately, a few pieces of shrapnel penetrated her arm, leg and right side of the head. She lost her consciousness and immediately treated at war hospital as per level best. She forgets details of her treatment and has no treatment records. Last 50 years, she has been surviving with movement difficulties, weaknesses of the upper and lower limbs and occasional convulsions. Her sufferings have intensified day by day. Last few years she has been experiencing headaches, dizziness, vomiting and forgetfulness. Two months back, she drank some insecticide mistakenly. She also suffering insomnia and she often cried out from deep sleep. She complains about hearing unknown voices. The voices were talking about her. She also started to suspect her family members. She claims that her family members were conspiring to kill her. She has history of convulsions three times in the last 50 years, which were generalized and tonic clonic in nature. She didn't take any medication for convulsion. As her suspicion, irrelevant talk and oddity in behavior worsened, her family members took her to me for treatment. Considering her past traumatic brain injury, an X-ray skull was advised. Surprisingly, it showed a metallic foreign body (shrapnel) within her skull. Furthermore, a CT scan of the brain was done, and it showed there was an irregular bony gap at right parietal area, a shrapnel at right frontal area with extensive encephalomalacic Porencephaly communicating with lateral ventricle. Her thyroid and liver function are normal. She is non-diabetic, non-hypertensive. She was advised to take risperidone 2 mg daily at night. With this low dose antipsychotic medication her psychosis controlled.ResultsSurviving with shrapnel within the brain followed by traumatic brain injury is very much rare. Shrapnel gradually damages the brain parenchyma and creates a large porencephaly.ConclusionTraumatic brain injury by bullet or shrapnel is always fatal. It is very much rare in medical to survive fifty years with shrapnel within the brain after shrapnel injury.
Who Let the Dogs Out? a Case of Delirium Induced by Lyme Borreliosis in a Patient With a Severe Intellectual Development Disorder
Authors: Pinto Joana Marques , Andrade José Diogo , Andrade Joana , Martins Vera 
Published: June 2022

AimsLyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixode. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves regardless of antibiotic treatment. It may result in a range of clinical manifestations involving different organ systems, and can lead to persistent sequelae in a subset of cases.MethodsWe describe a case of a 47-year-old male, with severe intellectual development disorder (IDD), who presented with behavioural changes, aggressiveness, psychomotor agitation and confusion. 15 days prior to admission in the psychiatry ward he had recurred several times to the emergency department with similar clinical presentation, and had been discharged following adjustments to his medication. After showing no improvement and no response to treatment he was admitted. He then presented fever and laboratory study (LS) revealed increased inflammatory markers. His family also informed he came from a rural area and had contact with wild dogs. No tick bite or erythema was identified during physical examination. Nevertheless a serologic study for Borrelia burgdorferi was performed and turned out positive. An antibiotic regimen was administered and and the patient's symptoms fully remitted 48 hours after treatment was initiated.ResultsBorreliosis usually presents erythema at the site of the tick bite which could have already resolved when the patient was examined. It was first assumed that the clinical manifestations were part of his psychiatric condition. An infectious etiology was presumed after the onset of fever and increased inflammatory markers were identified. Given the patient's context, Borrelia in particular was considered a likely hypothesis. This case illustrates the difficulties of differential diagnosis inherent to patients with IDD, both because of the pathology itself, which can mask such clinical manifestations as delirium, and of the stigma associated with mental health patients, which frequently cuts the diagnostic work-up of organic causes short.ConclusionThis case highlights the clinical challenge patients with IDD represent. Differential diagnosis can be elusive, especially in the context of infectious diseases like borrelia, as they can present with unspecific clinical manifestations in this subgroup of patients, and hence why a complete and thorough clinical evaluation is essential. This case also illustrates that mental health patients suffer from stigma: Being branded a “psychiatric patient” created a 16-day delay between onset of symptoms and appropriate treatment initiation- antibiotics.
Chronic Misuse of Paracetamol in OCD Without Hepatic Injury: A Case Report and Literature Review
Authors: Mohamed Ashma , Wacker Alexa , Schmidt Martin 
Published: June 2022

AimsParacetamol is a commonly used antipyretic and analgesic over the counter medication. In acute or chronic overuse it is associated with dose-dependent hepatic injury. There is a narrow therapeutic margin and that consistent use of as little as 7.5 g/day may be hazardous. Unintentional overdose with paracetamol is the most common cause of acute liver failure in the United Kingdom Here we present an unusual case of a 60-year-old lady with a reported chronic history of self-medicating with an above daily recommended dose of paracetamol without evidence of hepatic injury.MethodsA 60-year-old Caucasian lady known to psychiatric services for 20 years with Recurrent Depressive disorder, Obsessive Compulsive Disorder (OCD), Dependent Personality Disorder with Borderline personality traits. She reported consuming 32 tablets of paracetamol (16gm per day) every day for the past 11 years. She experienced obsessions of fear that if she did not take a particular number of paracetamols in a day then her friends will come to harm and her anxiety was relieved by the compulsion of consuming supratherapeutic doses of paracetamol. There was no evidence of misuse of any other medications other than paracetamol. Her blood investigations revealed liver function tests within normal limits and ultrasound of the liver was unremarkable.ResultsA literature search of “paracetamol or acetaminophen” and “no liver or hepatic” and “damage or injury” found only one case report. The case reported that studies of paracetamol metabolism were performed in a 58-year-old female with rheumatoid arthritis who had consumed 15–20 g paracetamol daily for 5 years without developing liver damage and data were compared with results in seven normal volunteers. The report concluded that a combination of slow paracetamol absorption, enhanced detoxication of paracetamol (by sulphation) and reduced metabolism to potentially cytotoxic metabolites may have reduced the risk of liver damage in this patient.ConclusionIn OCD, misusing medications can be an uncommon presentation of compulsive acts to relieve anxiety. The diagnostic dilemma of factitious illness is probable, however supratherapeutic use of paracetamol without physical harm is rare but possible.
Beyond “Evidence-Based Medicine” in “Detained Patients"
Authors: Shaddel Farshad 
Published: June 2022

AimsTreatments without robust evidence are not recommended. However, some patients detained in secure hospitals might need novel approaches such as: off-license use of medication, use of psychological (rather than their biological) effects of drugs. In addition, some detained patients may request for unconventional treatments they believe in. In community and capacitous patients, the clinician's role is advisory and the burden is on the patient to make the final decision and access such treatments privately. However, in a detained patient (with or without capacity), it may fall on the Responsible Clinician (RC) to deny or facilitate access to such interventions. Currently, there is no guidance for such circumstances. We have presented three real cases followed by proposing a flowchart to guide RCs.MethodsCase 1 (2019–2020): X with mild Learning Disability (LD) and mixed personality disorder detained under Section 3 with no leave to community. X asked for Hypericum which has been helpful with her headaches in the past. X had capacity to make that decision.Case 2 (1996–97): Y with mild LD and aggressive behaviours responding instantly to any injection. Y lacked capacity so injections of distilled water was tried in his best interest, with equal positive effect. The question was about using distilled water as rapid tranquilisation with no side effects.Case 3 (2020–21): Z with a treatment-resistant psychosis who has been unwell for months and detained in four different PICUs. Z's father requested N Acetyl Cysteine which had historical calming and sedative effects for Z.ResultsThe main issue in case 1 is the conflict between the patient's Human Rights and RC's Duty of care. Here the patient could be potentially deprived of their right to make an ‘unwise decision’ should the RC bar her access to a treatment which lacks evidence but is privately available to public. This can be construed as an infringement of Article 8 of Human Rights.The issue in case 2 and 3 is rather different. Here the conflict is between the RC's duty of care to provide evidence-based treatments and the patient's “best interest” which seems to be an intervention without robust evidence.ConclusionWe have developed a flowchart to help RCs by navigating amongst several competing/ conflicting legal and ethical concepts such as: Patient's wish/Human rights, Patient's capacity, Bolam test, “Medical Treatment” Under Section 63, 62 or 58 of Mental Health Act 1983, Best interest, Second Opinion (SOAD) and advice from court.
The Impact of Stigma on Forensic Psychiatric Patients - a Case Report
Authors: Umakanthan Tharshni 
Published: June 2022

AimsThe Royal College of Psychiatrists’ Fair Deal (RCPsych 2008) highlighted the far-reaching impact of stigma and discrimination on the lives of people with mental illness. The pervading nature of stigma has been acknowledged in recent national and international mental health policies (WHO). The World Health Organisation reiterates people affected by mental illness should not suffer social exclusion and marginalisation due to stigma.MethodsA sixty-year-old gentleman presented to the Emergency Department following self-inflicted stabbing to the neck resulting in pharyngeal tear and surgical repair. Previous psychiatric history included inpatient admission on Section 2 following a major depressive episode. On this admission, inpatient psychiatric review elicited three months of psychotropic medication non-adherence due to difficulties the patient had encountered in acquiring repeat medications from his GP. He had relapsed into alcohol misuse as a coping mechanism culminating in a suicide attempt at home with a knife. Upon recommencing of sertraline and risperidone during admission, he was assessed as euthymic with low risk to self. The patient had been previously abstinent from alcohol and described religion as a protective factor. Prior to discharge, the patient's GP stated he must present to the surgery in person with a form of identification. This is despite CQC guidance stipulating practices should not refuse patients registration if proof of identity cannot be produced.ResultsThis case illustrates the socioeconomic factors increasing likelihood of suicide including forensic history, low financial status, unstable housing and lack of social support. Substance dependence is a risk factor that can be reduced by supporting patients in accessing specialist misuse input from inpatient and community teams. The patient reported fear of stigmatisation and criminalisation which led to the avoidance of seeking treatment, deterioration in mental health and severe clinical consequences. It is imperative marginalised patients with mental illness can access quality health care and this starts with GP registration.ConclusionForensic mental health patients experience multiple stigmas impacting on well-being including social, institutional and media stigmatisation and high levels of internalised stigma. The Time to Change campaign focused on changing attitudes and behaviour however evaluation illustrated difficulties in tackling this issue. Healthcare professionals should be mindful to avoid stigmatising language and actions to ensure fairness in care. There is a need for the medical profession to continue striving for a tangible shift in attitudes. Advocating for those with mental illness can enhance quality of life for vulnerable patient groups.
Ataque De Nervios: A Case Report
Authors: Ustun Sitki 
Published: June 2022

AimsAtaque de nervios is a culture-bound syndrome among individuals of Latin descent.The case study presents an ataque de nervios case triggered by unique stressors in a transgender female of Mexican origin. This case also highlights the critical features of ataque de nervios, and discusses the challenges in diagnosis, classification and management.Methods47-year-old transgender (male to female) woman was admitted to an acute female inpatient unit following a presentation of erratic behaviour and a collapse episode under mental health act. During her observation and assessment period, multiple ataque episodes were observed with characteristic features triggered by gender phobic comments. After ruling out the organic causes and ruling out other differentials, she was diagnosed with ataque de nervios. She completed her treatment and continues to remain on remission.ResultsThe case presents a rather recognized presentation of ataque de nervios, however, the unique triggers rooted from her gender identity are more relevant to the current 21st century social context which is also an important ongoing discussion topic in psychiatry. The themes are also good presentation of the evolving psychosocial context of the specialty.ConclusionFurther study is needed to examine the relationship between ataque de nervios and gender identity, as well as the relationship to cultural, demographic, environmental, and personality factors.
Behavioural Changes in a Patient With Schizoaffective Disorder
Authors: Varughese Anto 
Published: June 2022

Background:A 46-year-old man has a diagnosis of schizoaffective disorder complained of intermittent abdominal pain for many years. Due to this, he had been reviewed by the GP and he was prescribed medication to help with his intermittent abdominal pain.Case Report:Over the years the abdominal pain gradually worsened. He also has communication issues due to language barriers and was unsettled for most of his assessment.His past medical history includes a duodenal ulcer, infected swollen legs and recurrent urinary tract infections.He continued to have pyrexia despite being on regular paracetamol. Following his second episode of pyrexia, he was referred to the hospital for further investigation.This was found to be acute acalculus cholecystitis, with possible cholecystocolic fistula and pneumonia. He was managed conservatively with intravenous antibiotics and is awaiting cholecystectomy.Discussion:Behavioural change in people with mental illness need not necessarily be linked to their mental state as it can very well be the atypical manifestation of physical illnesses- some of which could be fatal. Prompt recognition and referral to acute medical or surgical services is essential. Staff need training in bias, diagnostic overshadowing and atypical presentations in those with mental illness which will help reduce rates of avoidable morbidity and premature mortality.In any case physical illnesses may not present typically. Acalculous cholecystitis is a rare type of gall bladder inflammation and the cause in Mr X's case is not clear. At times of COVID-19, with the anxieties around exposure to hospitals and infections, it is important to be aware of this and ensure that people with worrying physical symptoms are promptly referred whether or not it is considered to be related to COVID-19.ConclusionDue to the pandemic, we were cautious on the ward and community about COVID-19 and preventing catching and spreading the infection. During all this, patients change of behaviour shouldn't be alluded to deterioration of mental health and mental health professionals should also consider ruling out physical causes for the change of presentation.