Integral to Bleuler's concept of schizophrenia, anomalous beliefs regarding the self are crucial to maladaptive social functioning. In schizophrenia, a predisposition to unusual bodily experiences, coupled with reduced awareness and increased social isolation, leads to hallucinations and delusions. Proprioceptive hallucinations, a subset of bodily hallucinations, present a challenging diagnosis due to their subjective nature, often resembling genuine bodily perceptions. We present the case of a 42-year-old man with untreated psychotic illness, manifesting perceptual abnormalities in the modality of proprioception.

Mr. X was referred to Early Intervention in Psychosis (EIP), believing that all his joints were dislocated despite a normal neurological examination, Magnetic Resonance Imaging (MRI), and blood tests. Pertinently, childhood adversities and a seven-year history of prodromal and schizophrenia symptoms, chronic marijuana usage, potentially triggered by separating from his ex-partner, were present. At assessment, Mr. X recalled a delusional memory from age 5, seemingly heralding the onset of his illness. He displayed thought disorder, poor sleep and lacked insight. Olanzapine titrated to 15mg omni nocte (ON) improved sleep, but insight remained poor.

This case of rare proprioceptive hallucinations presenting in middle-age underscores the impact of positive schizophrenia symptoms on social impairment, suggesting a link between unusual bodily experiences and social isolation. Proprioception, encompassing joint perceptions, muscle force, and effort, contributes to body image by combining with exteroception. Interactions with others, influenced by our bodily sense, are crucial for adaptive social functioning. The social deafferentation hypothesis posits that loneliness in schizophrenia may heighten susceptibility to bodily aberrations. The psychological formulation and the chronic use of marijuana on Mr. X's psychopathology, although not thoroughly explored, cannot be overstated.

Proprioception, vital for body image and social interactions, contributes to maladaptive functioning. The potent link between positive schizophrenia symptoms and social impairment needs exploring.

There has been criticism surrounding the lack of clarity regarding treatments offered within forensic inpatient units for people with learning disability and co-existing mental health problems. The Ten-Point Treatment Programme is a framework for treatments within such settings. It incorporates the four stages of assessment and motivational work, foundation and offence-specific treatments, consolidation and relapse prevention and finally discharge management. Although evidence based and evaluated in outcome studies, explaining its content to those with learning disability can be problematic. Communication difficulties affect the way information is comprehended and interpreted from both a linguistic and pragmatic perspective in this group. The provision of Easy Read information can address this difficulty.

Our aim was to co-produce, with experts by experience, an easy read version of the Ten Point Treatment Programme; and to evaluate this resource.

This was a quality improvement project within an in-patient medium secure unit in England. The co-production of the easy read version was led by two speech and language therapists, two psychiatrists, one Education Manager and two experts by experience. The latter advised on content, wording, format and font. Content was adapted in line with standard easy read requirements and guidelines. Following a focus group meetings, a provisional easy read version was approved and introduced in the service. This service innovation was evaluated through semi-structured interviews with six experts by experience and ten multidisciplinary team members who had used the resource. Responses were transcribed and subjected to thematic analysis.

The three main themes covered in the evaluation responses related to accessibility, appearance and usefulness. The sub-themes under accessibility were the simplicity of vocabulary and short sentence length. Regarding appearance, the key sub-themes were about the effective use of colour, the inclusion of relevant and meaningful images, and the balance between words and pictures. On usefulness, the main sub-theme was about understanding the treatment pathway better and hence feeling motivated to engage. This was reflected by the staff group as well. There were some comments on accessibility that were less positive, including service user indications that the number and complexity of words were still high.

The co-produced easy read version of the Ten-point treatment programme has been received positively by service users and staff. For both groups, it brings clarity about the treatment pathway and its stages. It is incorporated into the admission pack for new admissions and features in new staff induction programmes.

The primary aim was to establish the preferences of the majority of core trainees regarding online, in-person, or hybrid teaching in order to assess if the online format created during the COVID 19 Pandemic should be maintained.

Secondary aims were:

• • To collect feedback regarding the barriers to in-person teaching.

• • To collect feedback regarding the course content.

• • To alter the way the course is presented (if required) and to incorporate the feedback regarding the course content into the course.

• • To re-audit to see if the intervention was successful.

• • Surveymonkey was used to generate an online survey with 5 questions.

• • There were a mix of quantitative and qualitative questions.

• • Responses were collected between 26th September 2022 and 10th October 2022 and results were presented at the Tutors Committee Meeting and Junior Doctors Forum.

• • Changes were implemented in the curriculum:

  1. 1. Introduced specific neuroscience teaching.

  2. 2. Small exam specific study groups were encouraged.

  3. 3. It was decided that teaching would remain hybrid as per the majority preference and to allow equal access to teaching for all trainees (as per the GMC guidance).

Sept – Oct 2022

• • There were 20 responses overall.

• • 50% (n = 10) preferred online teaching; 45% (n = 9) preferred hybrid; 5% (n = 1) preferred in-person.

• • The most common barriers to in-person teaching were the difficulty in finding parking (70%, n = 14), and being unable to leave work on time due to clinical responsibilities (50%, n = 10).

• • The most common preferred frequency of in-person attendance for the hybrid model was monthly (45%, n = 9).

• • Topics requested to be covered (free-form question) included psychopharmacology, CAMHS, perinatal, geriatric, neuroanatomy and neuroscience.

Nov 2023

• • There were 22 responses overall, including new trainees that had not done the survey last year.

• • 50% (n = 11) preferred online teaching, 41% (n = 9) preferred in-person; 9% (n = 2) preferred in-person.

• • The most common barriers were the same: difficulty finding parking (64%, n = 14) and clinical responsibilities (55%, n = 12).

• • It was commented that neuroscience related teaching had improved.

There was a clear preference in both surveys amongst trainees for either online or hybrid teaching formats. Hence a decision was made to continue the current format of flexible teaching.

This project aimed to create and deliver a simulation-based course to improve trainees’ knowledge, practical skills and confidence as well as leadership and multidisciplinary-team working. We evaluated the effectiveness of this training and simulation as a learning experience. Simulation in psychiatry is a relatively new field compared with other specialities. Literature shows that experiential learning in psychiatry is effective for developing clinical and communication skills for doctors, and confidence in leadership. It is vital we work towards the National Health Service Long Term Plan for improving mental health care for those with serious mental illness which includes better training for doctors. This course was designed to enhance the ELFT training programme focusing on applications of theoretical knowledge.

A simulation-based course was delivered to core trainees and general practitioner trainees at induction to psychiatry. This was based on the Royal College of Psychiatrists curriculum and input from our People Participation team to ensure authenticity of scenarios. We surveyed trainees to inform the development of our pilot in February 2022 and subsequently developed two half-day courses facilitated in August 2022 following feedback. The scenarios we created were: risk assessment, section 5(2) Mental Health Act (MHA) assessment, managing agitation and violence, escalating concerns to a senior, section 136 MHA assessment, seclusion review, discussion with medical registrar for physical health concerns, collateral history and information-giving in child psychiatry. We used a structured debrief model (what went well, what could you have done differently, what was the ‘golden moment'?) and provided relevant teaching. Service users joined the debrief to share their perspectives and lived experiences. We collected and analysed quantitative and qualitative feedback.

Ten trainees attended the pilot course, followed by eleven on day 1 and nine on day 2 in August 2022. Results from questionnaires revealed post-course, 100% of participants felt more confident in their psychiatric skills and found this experience to be valuable for clinical practice. 100% would recommend this simulation to others. Qualitative data showed participants thought scenarios were realistic, the environment was supportive and feedback was comprehensive. They also appreciated the service user involvement.

Trainees reported simulation provided a safe and engaging environment to learn practical skills which better prepared them for work. This course is now embedded into the ELFT induction programme and enables doctors to develop their confidence and have a better understanding of service user perspectives. Future development of this course will involve allied health professionals.

To implement a digital handover system within Oxleas inpatient sites to improve the visibility of tasks both completed and pending, to reduce the number of tasks missed and to provide a clear audit trail relating to tasks handed over.

Junior doctors providing on-call cover to acute sites across all 3 boroughs served by Oxleas were invited to complete a questionnaire relating to the efficacy of handover. With this data & information gathered through discussions with the trust's informatics team, a digital handover system, based in Microsoft Teams, was developed. This was piloted and refined through 6 PDSA cycles from September 2022 – August 2023 before being implemented across all Oxleas acute sites from August 2023. Further questionnaires were completed 1 month & 6 months after its roll out to assess the impact of the change.

Doctors were asked to complete a questionnaire at 3 time points: pre-intervention (T0, 20 respondents), 1-month post-intervention (T1, 13 respondents), and 6-months post-intervention (T2, 12 respondents).

• • At T0, 92.3% of respondents reported tasks created by the on-call team had been missed due to staff not being aware, this reduced to 11.1% at T1, and 28.6% at T2.

• • At T0, 23.1% of respondents agree/strongly agree that it is easy to view tasks that have been done on their ward out-of-hours.

• • By comparison, at T1 69.2% reported the digital handover system has made it easier to view what had been done on a ward out-of-hours, rising to 83.3% at T2.

• • At T1, 76.9% reported the digital handover system has made it easier to view tasks when on-call, rising to 83.3% at T2.

• • At T0, 30% agree/strongly agree that the outgoing on-call doctor leaves a written record of tasks completed and outstanding. This rose to 69.3% at T1, and 41.7% at T2.

There is strong evidence that effective handover is a key aspect of clinical care, and failure of this is a preventable cause of patient harm. The initial questionnaire highlighted issues with the efficacy and safety of the handover process within acute sites at Oxleas, which the digital system sought to address. After implementation of the digital system, the findings demonstrated improvements in the handover process, with visibility increasing for tasks both completed & in progress, and fewer reports of tasks being missed by the ward-based doctors, which was maintained over the 6-month follow up period.

A large body of evidence suggests that experiences of, and access to mental healthcare in England varies according to ethnicity. Inequitable use of restrictive interventions is of particular concern, including within perinatal services: a national-level study of inpatients on Mother and Baby Units (MBU) in 2017 found that 28% of white patients were detained under the mental health act (MHA), compared with 61.5% of Black African, and 66 – 77% of Asian mothers. We carried out an audit with the aim of examining detention rates, length of stay, and time to first section 17 leave on an MBU in South Manchester according to ethnicity and English language ability, to compare with national averages.

We identified all patients discharged from Andersen Ward (an MBU) between March 2022 and March 2023. Using electronic medical records we extracted information on: ethnicity, language spoken (English vs other), mental health act status (detained under Section 2/3 vs informal), duration of admission, date of detention, date of first Section 17 leave. We calculated the percentage of patients who were detained according to ethnicity (White British, Mixed/other, Asian, Black), and the odds of detention according to ethnicity. Statistical significance was assessed using chi-squared testing. We also compared average length of stay and time to first section 17 leave by ethnicity.

74 patients had been discharged from the MBU within the audit period. 88% of Black inpatients were admitted under the Mental Health act, compared with 72.7% of Asian mothers, 33.3% of Mixed ethnicity or other ethnicities and 28.3% of white mothers. Differences in detention rates according to ethnicity were statistically significant. Of 11 mothers documented as having a language other than English as their primary language, all had been detained. Length of admission and days to first section 17 leave were not significantly different between ethnicities.

Many factors may contribute to the observed higher detention rates among non-White patients: language barriers and a lack of intercultural competence could lead to risk-averse decision-making during MHA assessments, and different help-seeking patterns might mean White mothers seek help earlier, or for less severe mental health problems. Recommendations include expanding access to high-quality interpreters; investigating factors underlying MHA decision-making through qualitative research; and improving cultural competence among section 12 approved clinicians by incorporating feedback from ethnic minority patients into training and refresher courses.

Missing data is a challenge that most researchers encounter. It is a concern that continues to be analyzed and addressed for solutions. Missing data occurs when there is no data stored for certain variables relating to participants. In health surveys, when participants answer in the form of “I don't know” or “I'd prefer not to answer”, these responses can, in many cases, be categorized as missing data responses from a participant in a specific category or question.

The eight-item Patient Health Questionnaire (PHQ-8) is an essential tool in healthcare and clinical settings to assess an individual's mental health, specifically related to symptoms of depression. The items are scored on a scale from 0 to 3 with the total score obtained by summing the scores for each item. Higher PHQ-8 scores indicate the presence of depressive symptoms.

We used empirical data from a previous study on depression symptoms in patients with coronary heart disease to study the effect of considering the answers “I do not know” and “I prefer not to answer” as missing values when estimating the percentage of depression using PHQ-8. Moreover, we studied the effect of the complete case analysis and multiple imputation on parameter estimates and confidence intervals. The outcome of this study aims to shed light on the development of missing data procedural knowledge and provide methodological support for public health decision-making when data with missing values are collected.

Furthermore, this study aims to prevent the exclusion of missing data rather than to generate data.

A simulation study with 1000 replicates was performed. Four common statistical machine learning methods for handling missing values were included in this study. These are K-Nearest Neighbor (KNN), K-Means, Classification and Regression Trees (CART), and Random Forest (RF) imputations. Five clusters were used for KNN and K-mean. Likewise, five multiple imputations were used for the CART and RF methods. The simulation was based on publicly available data with available PHQ-8 data for 1096 subjects. In the simulation study and for each replication, multivariate missing values were generated using the missing-at-random (MAR) assumption with 10%, 20%, 30%, 40%, and 50% proportions of missingness. The percent of depression was calculated using the PHQ-8 questionnaire and a comparison was made between estimated actual depression, complete-case analysis, KNN, Kmean, RF, and CART, respectively.

The Median age of the subjects was 69 (interquartile range: 61–67) and more males (72.9%) than females were included in the data. The estimated actual depression was 16.8, whereas the estimated percentage of depression varies between 6.9–13.5, 16.2–16.7, 16.3–16.7, 16.6–16.7 and 16.7–16.8 for the complete case, KNN, Kmean, RF and CART respectively.

The results of this simulation study show that missing PHQ-8 data are best handled by applying multiple imputations based on CART or RF. However, using K-Means or KNN leads to a good estimate of the true percentage of depression. Furthermore, the results of this simulation study show that complete-case analysis leads to biased estimates of the true percentage of depression. Nevertheless, further investigation is needed to address the problem of missing PHQ-8 data under the assumption of missing not at random.

This review delves into the understanding of depression within African communities, extending its scope to nations with significant African populations, aiming to enhance service provision for these patients. While focusing on cultural experiences of depression that transcend geographical boundaries, it builds upon existing literature predominantly centred on sub-Saharan African countries.

A comprehensive literature search was conducted across multiple databases, yielding 13 relevant articles after applying stringent criteria. Following Cochrane guidelines, search terms encompassed population (Africa, Africans, African communities), exposure (Depression, Depressive disorder, Dysphoria, Dysthymia, Low mood), and outcomes (Cultural expressions, Cultural variations, Somatization, Cultural framework, Cross-cultural research, Service provision).

Analysing selected articles through the CASP checklist, a narrative synthesis of qualitative studies over the past twelve years elucidated diverse perceptions and expressions of depression in African communities compared with Western contexts. Three major themes emerged: Expressions of depression (with subthemes: Attitudes towards depression), Perceptions of depression (including Stigmatization), and culturally acceptable forms of treatment (including Barriers towards treatment).

The review underscores the significance of integrating culturally acceptable treatment methods into psychological therapy for improved healthcare delivery. Collaboration between clinicians and patients is pivotal, with religious assistance emerging as a culturally acceptable treatment avenue. Establishing therapeutic alliances with religious communities could enhance treatment effectiveness. Further research is warranted to explore the impact of religious activity on depression symptoms and progression, as well as the influence of mental health providers' religious backgrounds on treatment dynamics. This holistic approach is crucial for addressing the unique cultural nuances surrounding depression in African communities and optimizing patient care.

Limited data suggest that negative mood symptoms in the menopause transition may be associated with a higher prevalence of alcohol misuse and other risk-taking behaviours in menopausal women. Excessive alcohol consumption can exacerbate menopausal symptoms, reduce quality of life and is associated with chronic morbidity that overlaps with the consequences of long-term oestrogen deficiency (such as osteoporosis and cardiovascular disease). The aim of this survey was to explore the impact of mental ill-health on alcohol consumption and gambling habits in menopausal women.

We constructed an anonymous survey consisting of multiple-choice and free-text questions. The survey was distributed online via social media channels on the 22 August 2023 and was open for 6 weeks. All perimenopausal and menopausal women were invited to participate. Responses were collected using the Qualtrics survey platform and analysed in Excel for descriptive statistics.

1,178 responses were submitted. One in three women reported drinking more alcohol during the perimenopause/menopause; 15% of women drink more than the recommended maximum of 14 units per week, and 24% (286) are spending up to £50 per week on alcohol. 70% (332) cited anxiety, stress, and/or depression as the reason for their increased alcohol consumption, whilst 29% (135) said they drank to alleviate menopause symptoms. Further, 5% (54) of respondents admitted gambling more since the onset of perimenopause/menopause; 43% (27) said it was due to anxiety, stress, and/or depression, whilst 13% (9) said they do so to help manage their menopause symptoms.

This anonymous, cross-sectional survey found evidence of an association between menopause and addiction. Increased awareness of this association should facilitate earlier recognition and more timely access to support and effective treatment for addiction, including hormone replacement therapy to treat menopausal symptoms that may underlie and/or exacerbate unhealthy lifestyle behaviours.

Self-harm affects around 20% of all young people in the UK. Treatment options for self-harm remain limited and those available are either non-specific or long and costly and may not suit all young people. There is an urgent need to develop new scalable interventions to address this gap.

Imaginator is a novel imagery-based intervention targeting self-harm initially developed for 16–25-year-olds. It is a blended digital intervention delivering Functional Imagery Training (FIT) via therapist sessions and a smartphone app. In this study we piloted a new version of Imaginator extended to adolescents from age 12 after co-producing a new app with a diverse group of young people experts-by-experience.

We aimed to assess feasibility of delivering Imaginator in Children and Adolescent Mental Health Services (CAMHS) and adult secondary mental health services and gather young people's feedback on the intervention

Participants were recruited from West London NHS Trust Tier 2 CAMHS and adult Mental health Integrated Network Teams (MINT) teams. They underwent a baseline screening and were allocated to a therapist for three face-to-face FIT sessions in which the app was introduced followed by five phone support sessions. Outcome assessments were conducted after completing therapy, approximately 3-months post-baseline, including questionnaire measures and a qualitative feedback interview.

Qualitative data were analysed using a co-produced thematic analysis method with lived experience co-researchers.

Thirty-four participants were referred (31 female, 2 male, 1 transgender; mean age = 18.4), of which 30 met inclusion criteria and completed screening. Out of 25 who started therapy 16 completed the intervention. Only 15 completed the quantitative outcome assessment, and 10 the interviews. There was an overall reduction in number of self-harm episodes over 3-months from pre- to post-intervention

Five main themes were identified: Imaginator therapy impact, mental imagery acceptability and efficacy, usefulness and usability of the app, integration of the app in therapy and need for improvements. Young people found Imaginator helpful at improving their mental health, in particular the use of mental imagery techniques. The app was overall well received but improvements were suggested.

Our study suggests that Imaginator can be extended to adolescents, is acceptable and has potential as a brief intervention reducing self-harm in young people under mental health services. A future RCT is needed to robustly test the intervention efficacy, after considering issues around high attrition in outcome measures.

This audit reviewed the use of Treatment Escalation Plans (TEPs) on the Borders Specialist Dementia Unit (BSDU). We aimed to use data on completion rates and quality to adapt the TEP form to both improve practice and develop a more specialised form for use in inpatient old age psychiatry.

TEPs improve clinical decision-making in frail and elderly patient populations, and are commonly used on medical wards. However, these forms are primarily orientated towards acute medical environments and may not be appropriate for use in psychiatric inpatient settings, despite the clear benefits they could provide in this patient group.

This retrospective audit reviewed completion rates and quality of completed TEP forms for 10 BSDU inpatients in December 2023. Data was gathered by reviewing TEPs and using a data collection form to collate information on completion rates and quality of information provided. Both the TEP form and the ReSPECT form were used to review what information would be relevant to include when completing TEP forms for new admissions to BSDU.

Some sections of TEP forms were consistently well-completed – typically those that were quick to complete e.g. tick boxes. However, limitations of the existing TEP form reduced these sections’ usefulness in practice. Most significantly, the form does not indicate whether “ward level care” refers to care on the old age psychiatry ward, or transfer to a medical ward. The “Additional Information” section, which could be used to clarify the patient's ceiling of care and transfer status, was only completed in 40% of cases, despite being particularly relevant to the BSDU patient population. In addition, this audit highlighted that there is no process for reviewing TEPs to ensure they remain appropriate for the patient, which is particularly relevant for old age psychiatry inpatient populations due to their advancing frailty and quickly changing clinical picture.

This audit showed that the current TEP form is not ideally suited to old age psychiatry settings. However, this could be improved with simple adaptations such as distinguishing between psychiatric ward care and medical ward care, and adding a review date to ensure these forms are regularly updated in light of the advancing frailty of old age psychiatry inpatient populations. I would also recommend implementing an initial review of TEP forms shortly after patients are admitted, to ensure the information contained on them is accurate and that they are countersigned by the responsible consultant.

Overactive negative memories are thought to contribute to the core symptoms of psychiatric conditions such as anxiety disorders or post-traumatic stress disorder (PTSD). For talking therapies, such as exposure therapy, there are high rates of relapse demonstrating the necessity for innovative new treatments. It is thought that enhancing the ability to extinguish fear responses to the reactivation of these memories in patients with pharmacological adjunct treatments will enhance the efficacy of interventions.

N-methyl D-aspartate receptors (NMDARs) regulate the process of memory formation and consolidation. It is hypothesised that increasing the function of NMDARs would augment the consolidation of safety learning, during treatment sessions. NMDARs require the co-agonists glycine or d-serine to function. Bitopertin, a GlyT-1 inhibitor, increases the availability of glycine. Bitopertin has been studied in the context of schizophrenia, and therefore has been demonstrated to be safe for use in humans. In this preclinical study, we aim to determine if bitopertin can enhance safety learning, so-called extinction, in rodent models.

24 Lister Hooded rats (male, n = 12) will undergo aversive Pavlovian conditioning to form an associative memory. Rats will then be administered with saline or bitopertin systemically, prior to a session to extinguish fear responses. The strength of the extinction of responses will be measured the following day with a rapid re-acquisition test.

This study is being carried out as part of an intercalated master's degree, so the final results will be available in spring 2024. Given pilot data, it is expected that we will observe that the rats administered with bitopertin exhibit lower levels of fear responses on the rapid reacquisition test than the rats administered with saline. We do not predict any sex difference in responses. This would demonstrate bitopertin has the potential to enhance and safety memory consolidation in rats.

This is an exciting area of research for which results could provide a break-through in improving talking therapies and adjunct treatments offered to patients with anxiety disorders. Negative results would be informative as this allows neurobiologists to refine the search for a pharmacological agent which could be used as a cognitive enhancer in this manner.

Caregivers of autistic children may experience greater stress and reduced mental well-being compared with caregivers of typically developing children or children with other neurodevelopmental conditions. Less is known about earlier child and family predictors of later caregiver stress, as most studies have been cross-sectional. This study aimed to examine how caregiver (coping strategies and appraisal of their child's autism) and child factors (behavioural difficulties and adaptive functioning) were related to mental health and quality of life in caregivers of 2–7-year-old autistic children over 4–6 years.

Methods: At Time 1 (T1), 119 caregivers completed the Coping Health Inventory for Parents (CHIP), Family Impact of Childhood Disability (FICD), Centre for Epidemiology Studies Depression Scale (CES-D), Autism Treatment Evaluation Checklist (ATEC), and Scales of Independent Behavior-Revised (SIB-R). Of those, 50 completed the same measures 4–6 years later (Time 2-T2). Demographic data at T1 and the World Health Organization Quality of Life (WHOQOL) questionnaire at T2 were also collected. The relative contributions of T1 caregiver and child factors in predicting T2 caregiver self-reported depression and quality of life were analysed with multiple regressions.

Caregivers’ depressive symptoms remained generally stable across 4–6 years (30% at T1 and 38% at T2 scoring at or above the CES-D cut-off), and earlier caregiver depression predicted later caregiver depression. At T2, child adaptive functioning significantly improved compared with T1, while mean child behavioural difficulties (e.g., behaviours disruptive to others, damaging to property, socially offensive or inappropriate) remained generally stable. Caregiver appraisal of the impact of child's autism on the family also did not change much over time, but higher T1 negative caregiver appraisals of their child's diagnosis predicted poorer later social quality of life on the WHOQOL. There were mixed findings regarding the helpfulness of coping patterns assessed by the CHIP, with our findings suggesting that family integration and optimism could be helpful in improving caregiver mental well-being.

Modifiable predictors of longer-term caregiver adaptation indicate that in addition to providing early supports for children's adaptive functioning and social communication, caregivers’ appraisals of autism, caregiver and family coping strategies, and earlier caregiver depressive symptoms also need to be targeted.

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening idiosyncratic reaction to medications, specifically dopamine receptor antagonists. We report a case of a patient who initially developed extrapyramidal side effects (EPSE) and subsequently developed NMS after being treated with flupentixol depot.

A 64-year-old woman with an underlying recurrent depressive disorder with psychotic symptoms presented to a psychiatric hospital in June 2023. She exhibited self-neglect, low mood, paranoid delusions, and non-concordance to oral psychiatric medications.

In the first week, she declined all oral medications and was subsequently started on flupentixol decanoate (Depixol) depot injection at 40 mg once every 2 weeks. While showing good improvements in her mental state, she began complaining of akathisia and dystonia since July 2023, consistent with extrapyramidal side effects secondary to flupentixol.

The symptoms improved by lowering flupentixol to 30 mg every 2 weeks and adding procyclidine 5 mg twice daily and propranolol 20 mg three times daily.

In early September 2023, she experienced severe restlessness, stiffness, muscle weakness and felt hot and clammy over 36 hours. Physical observations showed fever, tachycardia, and hypertension. Examination revealed diaphoresis, rigidity in both upper and lower limbs, lower limb weakness, and normal reflexes. Blood tests indicated acute kidney injury (AKI) stage 1, deranged liver function tests, and a creatinine kinase (CK) level of 9405.

She was promptly admitted to the medical hospital for NMS and received extensive intravenous fluid rehydration along with oral Dantrolene. She made a complete recovery, and Depixol was discontinued. Two weeks later, she was started on quetiapine and gradually titrated to 50 mg once daily.

EPSE and NMS are associated with dopamine receptor blockade and commonly occur during the initiation or dosage increment of neuroleptic medications.

NMS is rare but life-threatening, presenting with manifestations of muscle rigidity, pyrexia, altered mental status, sympathetic nervous system lability and elevated CK.

In our case, our patient, who recently started taking neuroleptic medication, experienced EPSE and later deteriorated acutely, raising a high suspicion of NMS. It is essential to consider other possible diagnoses, including serotonin syndrome, malignant hyperthermia, malignant catatonia and electrolyte disturbances.

The commonly used diagnostic criteria include Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and Levenson's criteria but diagnosis of NMS remains clinical.

The crucial step after identifying NMS is to immediately stop the neuroleptic agent, followed by supportive medical treatment.

Early recognition and prompt treatment of NMS in our patient led to a full recovery.