Functional neuroimaging is playing an increasing role in psychiatry and has moved from academic isolation into clinical practice. This review examines the basis for the use of Single Photon Emission Computed Tomography, the most widely available functional modality, in the two important areas of dementia and parkinsonism. Its contribution to the diagnosis and management of patients is discussed and its likely impact in clinical trials indicated. As functional imaging moves closer to those most able to utilise its power its impact in these and other areas of psychiatry and neurology will increase further.

Objectives: The manner in which psychiatrists dress and how they address their patients and in turn are addressed, may impact upon the therapeutic relationship. We undertook a survey to assess patients' preferences regarding doctors' dress and forms of address.

Method: Patients attending four psychiatric clinics were asked to complete a questionnaire asking them to rate photographs of doctors dressed in varying levels of formality, presented in random order.

Results: One hundred and forty-five patients agreed to take part. Patients had a strong preference for their consultants to wear suits but were more ambivalent about NCHDs' attire. When asked to rate the photographs in terms of competence and ease in forming a trusting relationship, suits scored the highest ratings. When asked to rate for friendliness, smart attire scored slightly higher than suits. Of the patients 50% said that they wished to be called by their first name and 50% said that they did not have a preference. Very few patients preferred to be addressed by title but 95% said that they tended to call their doctor by title. Of the respondents 70% preferred to be called patients rather than clients or service users.

Conclusions: The patients in this survey preferred their doctors to dress formally and were comfortable with an asymmetrical form of address.

Objectives: To evaluate the clinical utility and validity of the Health of the Nation Outcome Scales (HoNOS) in an Irish catchment area psychiatric service.

Method: One hundred consecutive outpatients were assessed using the HoNO S and Global Assessment of Functioning (GAF) scales.

Results: It was feasible to administer HoNOS in day-to-day clinical practice. There was a statistically significant correlation between the HoNO S and GAF scores. Attenders at the outpatient department had significantly lower HoNOS scores compared to individuals assessed on domiciliary visits or at the day hospital. Individuals with schizophrenia had significantly higher HoNO S scores compared to affective disordered patients. However, this difference was confined to the Social subscale of HoNOS.

Conclusions: Although these findings indicate that HoNOS has significant convergent and criterion validity as a measure of psychiatric morbidity, its widespread use in day-to-day clinical practice may be premature.

Objectives: This study was designed to explore the social correlates of the country suicide rate in Ireland.

Method: Suicide rates for Irish counties were calculated for the period 1978-1984, a seven year period centred around the 1981 Census.

Results: The county suicide rates were positively associated with death rates and the percentage of elderly population and negatively with change in population, the birth rate and the percentage of the population under the age of 15.

Conclusions: There is good evidence to suggest that the official suicide rate in Ireland has been underestimated in the past. This underestimation may not have been uniform across all of the counties.

Objectives: Nalbuphine (Nubain) is a synthetic opioid analgesic with agonist-antagonist properties. This study describes a characteristic patient profile, pattern of use and treatment outcome for a series of nalbuphine dependent subjects.

Method: Retrospective systematic case-note review of uniformly collected clinical data on 11 cases of nalbuphine dependence presenting to a substance misuse service.

Results: There were nine males and two females with a mean age of 31 years of whom nine were currently employed. At presentation the mean duration of nalbuphine use was three years, the average daily dosage was 60mg (range lOmg-lOOmg) and all subjects reported injecting between two and eight times daily (mean five times daily). All subjects met opioid dependence criteria (ICD-10). Drug-related problems were multiple and varied while forensic history was uncommon. Exposure to nalbuphine occurred exclusively within the gymnasium environment and was used by bodybuilders to enhance weight training and bodybuilding. Eight subjects admitted previous anabolic steroid use, and seven current cocaine use. Eleven subjects represented 14 separate treatment episodes of which 11 treatment episodes involved the use of methadone substitution therapy. The mean stabilisation dose of methadone was 29mg (range 15mg-40mg) and in eight episodes (73%) patients were successfully retained in treatment to completion of detoxification.

Conclusions: Dependence on nalbuphine, an agonist-antagonist opioid previously believed to have low abuse potential, does occur and may be particularly associated with bodybuilders who use its analgesic properties to facilitate pain free training. Its use appears linked not only with other performance enhancing drugs (viz. anabolic steroids) but may also be associated with other psychoactive drugs such as cocaine. Methadone substitution therapy appears to be a viable treatment option.

Objectives: Psychological coronary-proncncss is most probably one of the first recognised risk factors for coronary heart disease (CHD). The mechanisms by which psychological risk factors might exert their influence on the cardiovascular system arc less clear than those for the more standard biological risk factors. The aim of this review was to classify all possible mechanisms of potentiation of CHD by psychological factors.

Method: A MEDLINE search was conducted by selecting literature on both standard biological risk factors (eg. dyslipidaemia, hypertension, smoking) and psychological risk factors (eg. personality traits, behavioural characteristics, coping with stress) for CHD.

Results: It was suggested that six biological mechanisms could mediate psychological influences specifically for CHD, of course, together with the seventh mechanism of general alterations in health-related behaviours. These are: increased oxygen demand of the heart muscle, decreased blood supply to the heart muscle, increased concentration of blood, enhanced blood clotting, increase in cholesterol and other plasma lipids, disturbances of blood sugar level, and alterations in health-related behaviours.

Conclusions: If more studies of CHD were conducted with both physical and psychological risk factors simultaneously, it would be possible to investigate which of the above suggested mechanisms are important, which could in turn substantially improve both primary and secondary preventive measures.

Objectives: To review the most recent information on completed suicide for the general adult psychiatrist.

Methods: Literature review.

Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.

Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.

Major advances have been made in ADHD over the years, both in terms of diagnostic validity, different subtypes, comorbidities and treatment options. A comprehensive assessment needs to include medical, developmental and educational history using multiple sources of information and across different settings. In certain cases, additional investigations and neuropsychological testing may need to complement basic physical and neurological examination. The focus of treatment must include not only the core ADHD symptoms but also additional comorbid problems, family and peer relationships, and academic achievement. Treatment should therefore be multi-modal with simultaneous medication, behavioural and educational management. Both diagnosis and treatment response needs to be reviewed regularly to ensure optimal response with minimal adverse side effects.

The increased awareness of ADHD by both clinicians and other professionals has resulted in a huge increase of referrals for assessment, diagnosis and treatment. In particular, families are becoming increasingly knowledgeable about the disorder and are rightly requesting adequate assessment and treatment of their children. It is therefore essential that all clinicians are equally knowledgeable about the advances in this area and offer a service to families which represents good clinical practice. This article reviews what constitutes good clinical practice in ADHD.

Schizotypal personality disorder is the DSM equivalent of the ICD category schizotypal disorder. It may be seen as part of the schizophrenia spectrum of disorders. Patients with schizotypal personality disorder (SPD) share many features with schizophrenic patients. These include symptoms of social isolation and cognitive impairment. They also share imaging and biochemical evidence of brain dysfunction, and genetic similarities. SPD patients, however, for some reason do not become chronically psychotic. The study of schizotypal patients is of great importance in attempting to clarify the genetic and biological basis of the schizophrenia spectrum. It is also important in helping to delineate the differences between schizophrenic and schizotypal patients, and to distinguish those factors that protect the schizotypal patient from becoming floridly psychotic. In this article we present recent findings regarding the biological basis of schizotypal personality disorder. We illustrate the contribution of these findings to our understanding of risk and protective factors in the schizophrenia spectrum.

Stammering (or stuttering) may be defined as an impairment of continuous utterance. Developmental stammering, regardless of country or language, affects one per cent of adult populations. Exacerbation by the stress of adult conversation or public speaking contrasts sharply with normal flow during singing, acting or conversation with children. Alterations in regional cerebral blood flow suggest that there are underlying differences in sensorimotor function in developmental stammerers whose symptoms commonly appear during the period of intensive language acquisition around the third and fourth year. Emotional tensions may exacerbate the disturbance, but equally psychological growth is adversely affected by the handicap. Abnormal motor control is confirmed by the exaggerated activity in the right hemisphere. The normal sequence of articulatory programming and motor preparation for single word reading is reversed. Absence of activation over the left auditory cortex supports the notion of impaired or diminished auditory feedback in the self-monitoring of speech seen in normal brains. Subcortical abnormalities are a feature of both developmental and acquired stammering.

Objectives: To evaluate the self-rated or subjective quality of life of individuals with schizophrenia in residential care settings.

Method: Forty individuals who fulfilled DSM-IV criteria for schizophrenia were interviewed using the Lancashire Quality of Life Profile.

Results: Fifty-two per cent of the sample reported their global subjective quality of life to be satisfactory. Global subjective quality of life was rated lower than the majority of life domains evaluated. The areas of least satisfaction included finances and work. However, the majority of patients were satisfied with their living situation, safety, health, religion, leisure, social and family relations. There was some evidence of a quality of life gradient across these residential settings.

Conclusions: Although these patients were satisfied with the majority of life domains assessed, these data need to be interpreted cautiously given the limitations of the study design and the method used to evaluate quality of life.

Doctor Maurice O'Connor Drury worked for most of his life in Saint Patrick's Hospital, Dublin. While going about his routine clinical work at that hospital, Doctor Drury quietly maintained a close, lifelong friendship with the man regarded as perhaps the greatest philosopher of the 20th century, Ludwig Wittgenstein.

Few realised that before studying medicine at Trinity College, Dublin, ‘Con’ Drury had read philosophy at Cambridge, where he came into close contact with some of the great minds of philosophy this century; Bertrand Russell, George Moore and Gilbert Ryle.

Con Drury is importan t not just because of his own philosophical work but because, through his enduring friendship with the deeply troubled philosopher, he challenged the portraye d image of Wittgenstein as a ‘cantankerous, arrogant and tormented genius’.

Objectives: The aims of this study were to identify the social and clinical needs of patients attending an inner city psychiatric service, to examine the relationship between need and various demographic and social parameters, and to demonstrate the usefulness of the Camberwell Assessment of Need (CAN) in an Irish population.

Methods: A random sample of patients was selected from a census of patients attending the Mater Hospital (Dublin) sector psychiatric service on March 1, 1997 for inclusion in the study. Needs were assessed using the Camberwell Assessment of Need.

Results: Fifty-seven patients agreed to participate in the study. The mean number of needs identified by patients was 2.14 (+/− 2.09) and by staff 1.92 (+/−1.18). There was a high level of correlation between staff and patients. The areas where patients most frequently expressed a need were ‘psychological distress’, ‘company’, ‘physical health’, ‘information’ and ‘looking after the home’. Eighteen patients (32%) identified needs that were not being met.

Conclusions: This study confirms the usefulness of the Camberwell Assessment of Need in the identification of clinical and social needs in psychiatric populations and demonstrates its usefulness in an Irish population.

A patient presenting with co-existent Capgras and deClerambault's syndromes, with a history of morbid jealousy is described. This combination of syndromes has not previously been described. The relevant literature to this case is reviewed, in relation to the onset of these syndromes, aetiology and treatment. Abnormalities in pathways involving recognition of familiar faces have been implicated in a number of similar cases.

A case of suicidal behaviour precipitated by sleep paralysis is described. The condition and related phenomena are briefly considered.

Objectives: The aim of this study was to examine the prevalence of, and factors associated with violence in a drug treatment centre.

Method: This study is a retrospective audit of all incident forms completed at an urban drug treatment centre between December 1991 and July 1996 with reference to case notes for additional clinical information on individuals involved in violent incidents.

Participants included all patients attending the centre in the aforementioned time period who were involved in violent incidents. Information was obtained about the prevalence and severity of violent incidents and patient details including main drug of abuse, route of use, reason for attendance, comorbid axis 1 diagnosis, history of previous incidents and HIV status at the time of the incident.

Results: One per cent of all patients were involved in violent incidents. Less than one quarter of incidents involved serious injury or assault. Most perpetrators were male intravenous heroin users on a methadone maintenance programme. Nurses and doctors were most frequently the victims of incidents. Ten per cent of patients had a history of previous incidents and almost half the perpetrators were HIV positive. A comorbid axis 1 diagnosis was found in 9% of perpetrators (n = 6), mainly alcohol dependence syndrome.