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Abstract Munchausen syndrome is a rare psychiatric disorder in which patients inflict on themselves an illness or injury for the primary purpose of assuming the sick role. Because these patients can present with many different complaints and clinical symptoms, diagnosis is often made at a later stage of hospitalisation. In contrast we report a case of a 40-year old woman very easy to diagnose with Munchausen syndrome. This trained nurse presented at our emergency department (ED) complaining of abdominal pain. Interviewed by the medical trainee, she immediately confessed having put a knitting needle into her urethra four days earlier. She was not able to remove it anymore because it was beyond her reach. Abdominal X-ray confirmed the presence of the needle and a median laparotomy was performed to remove it. The diagnosis of Munchausen syndrome seemed immediately obvious in this case.

An increase of psychopathology such as post-traumatic stress disorder (PTSD) is described in patients affected with COVID-19 that stayed at an intensive care unit (ICU). However, data on follow-up and on impact of contextual factors are limited. In a single-center, observational study, PTSD symptomatology was prevalent among 38% of participants (n=8), persisting in clinical PTSD in 2 participants after one year. In patients with initial PTSD symptoms, scores on depression, anxiety and insomnia scales were significantly higher. A higher mental burden due to avoidance of contact and a reduced quality of life was also retained in patients with PTSD symptoms.

We present a case of a patient with severe treatment resistant depression who relapsed while being treated with vagus nerve stimulation. We describe that he was safely treated with unilateral ECT concomitantly with the VNS.

Despite adherence to treatment guidelines, some patients are resistant to several psychopharmacological interventions. Guidelines to overcome treatment resistance are scarce and new treatment modalities are needed. When confronted with psychopharmacological failure, repetitive transcranial magnetic stimulation (rTMS) therapy can be considered. In these case series a combative high frequency (HF)-rTMS protocol with frequent stimulations at suprathreshold intensity was applied for treatment-resistant depression (TRD), schizoaffective- and bipolar I disorder, mixed episode. Besides effectiveness, tolerability was closely monitored. All three patients, suffering from different psychiatric conditions were experiencing limited to excellent clinical improvement without serious side effect or adverse events. These very preliminary results suggest, along with research using comparable intensive stimulation parameters for treatment-resistant depression, that 'aggressively' targeting the left DLPFC is well tolerated and safe. Our clinical results suggest a possible beneficial treatment strategy of HF-rTMS protocols following unsuccessful. Larger sham-controlled studies are needed to substantiate our results.

We aimed to Examine the safety and effectiveness of HF-rTMS in a treatment-refractory bipolar I patient in a mixed affective episode. Our case illustrates that "combative" HF-rTMS therapy could be a safe and valid treatment alternative for refractory bipolar I patients in mixed episode, not successfully treated with ECT.