A pilot study of the effects of early intervention by a multidisciplinary community team in patients presenting as psychiatric emergencies to an inner London teaching hospital (St. Mary's) is described. Of 22 consecutive emergency referrals, 20 agreed to be formally assessed, 18 were successfully engaged and 16 had assessments of symptoms and social functioning assessed over a four week period. There was significant improvement in clinical symptoms but no important changes in social functioning. The discordance between improvement in social function and symptoms was unexpected and may reflect the unusual social circumstances of life in metropolitan London or be a consequence of the high proportion (55%) of patients seen with personality disorders.

The earliest signs and symptoms of manic relapse in eight bipolar patients after lithium discontinuation were changes in talkativeness, motor performance, self-confidence and sleep pattern; only two patients reported a change in mood. These changes were initially subtle and did not occur in patients who stayed well after stopping lithium. The lack of affective symptoms might result in clinicians ascribing the changes to the removal of the sedative and cognitive slowing properties of lithium, rather than signs of an impending relapse; similar changes may well occur in patients whose relapse is not associated with lithium discontinuation. Prompt early treatment with lithium (and additional thioridazine in some cases) resulted in only two patients requiring readmission, both for ten days. It is concluded that such symptoms may indicate an impending relapse and prompt treatment is recommended.

Sixty seven opiate dependent addicts receiving methadone maintenance completed the Beck Depression Inventory. A high level of depressive symptoms was found. Eighteen (27%) scored in the moderately depressed range while thirty eight (56%) scored in the severely depressed range. There was no statistically significant association between either sex or HIV status and level of symptom reporting. The clinical implications of depressive symptoms in opiate addicts are discussed.

In Ireland, the demographic pressure of greater numbers of elderly people surviving longer with an attendant increase in the prevalence of dementia and depression compounded by the running down of old mental hospitals and the closure of smaller general hospitals has provoked debate on the need for Old Age Psychiatry (Psychogeriatric) Services.

The first Old Age Psychiatry service in the Republic of Ireland started in North Dublin in January 1989. Detailed information on all referrals (173) assessed in the first six months of operation was collected and is presented. The findings are discussed in the context of the stated government policy of caring for the elderly within the community setting.

Wilson's Disease (Hepatolenticular degeneration) is an uncommon disorder of copper metabolism, characterised by excessive copper deposition in the liver, brain and eyes. Psychiatric symptoms were prominent in eight of the twelve patients originally described by Wilson some 88 years ago. Since then a wide range of psychiatric presentations have been documented including behavioural disturbances, affective psychoses, schizophrenia-like psychoses, intellectual deterioration and dementia. Here we describe a patient who presented with a psychiatric disturbance, was treated with neuroleptic medication and subsequently developed Neuroleptic Malignant Syndrome (NMS).

Some problems related to the formal diagnosis of Post-Traumatic Stress Disorder (PTSD) and the social implications of the concepts incorporated in the diagnosis are addressed. Increasing worldwide evidence of the circumstances likely to produce a PTSD and of patients of all ages and races satisfying the criteria for the diagnosis suggests a problem of epidemic proportions requiring intensive study.

The case of an ex-pugilist who developed a reversible Parkinsonian syndrome in response to ethanol intoxication, is described. The relationship between ethanol abuse and altered function in the nigro-striatal system is examined, and the relationship to boxing encephalopathy is reviewed. The patient described was the third neurological casualty in a family of boxing brothers, and suggestions are made regarding the potential dangers of this sport. The syndrome of alcohol induced Parkinsonism in an ex-pugilist has not previously been described in the literature.

The author proposes that the propensity to develop obsessional modes of reaction is virtually ubiquitous and, for most people, highly adaptive. As for other parameters of functioning (e.g. blood pressure, blood glucose etc.) there is a range of “obsessionality” which is essential for survival. From the standpoint of the clinician the following questions need to be addressed: (1) Is there a pattern of developmental experiences which can be correlated with the emergence of obsessional phenomena? (2) Are there defineable life circumstances which can be related both to the failure to develop appropriate levels of obsessionality and to the development of a level of obsessionality which is maladaptive? (3) How to distinguish the obsessional character from the individual suffering from an obsessional neurosis? and (4) What therapeutic interventions are likely to be effective in the managment of the obsessional individual?

In the avian cerebrum and in the spinal cord, sympathetic ganglia, hypothalamico pre-optic area and cerebral cortex of the rat sexually dimorphic' nuclei are clearly recognisable. Similar differences have been described in the human brain. Morphometric analysis has shown a sexually dimorphic nucleus in the pre-optic area. There is continuing controversy over differences in the size and shape of the corpus callosum, but there is accumulating evidence of cerebral asymmetry with more focal representation of language and praxic functions in the left cerebral hemisphere in females. The various sensory modalitites also show gender differences. The significance of these secondary sexual variations in brain structure resides in the developmental and behavioural characteristics of the underlying neural circuits.

We present a case showing inducement of acute dystonia by clomipramine therapy and discuss the possible explanations. We could find no previous reports of this phenomenon.

Lofepramine at the upper limit of its therapeutic range (210mg/day), was associated with the development of sinus tachycardia with atrial ectopic beats and progression of right bundle branch block to trifascicular block in an 82 year old man with a history of heart disease. As with any antidepressant administered in a high therapeutic dose, caution and regular electrocardiographic monitoring of elderly patients with heart disease receiving lofepramine is recommended.

The incidence, characteristics and patterns of female homicide are reviewed, with special reference to England and Wales. The male:female ratio for homicide offences (7.6) is similar to the ratio for other offences of violence. However, murder is almost exclusively committed by men, and in the 1980's the annual average of female murder convictions was only 6.5 per annum. By contrast, females relatively more often commit homicide offences related to mental disorder (diminished responsibility manslaughter and infanticide). Women have a better chance of acquittal of murder and are more likely to be dealt with by a Probation Order than imprisonment. About 80% of the victims of female homicide are family members; 40-45% kill their children and about one-third kill their spouse or lover. The patterns of female filicide and parricide are reviewed. Further research is required into patterns of spouse-murder.

In the present work the author presents a literature update regarding the pharmacotherapeutic management of rapid cycling affective disorder. This phenomenon is characterized, according to Dunner and Fieve (1974), by the presence of at least four affective episodes per year. After a consideration of the clinical features of the disorder, which are in many respects similar to those of the ‘classic’ bipolar disorder, the author describes the different therapeutic strategies available to the psychiatrist. Withdrawal of antidepressant therapy and administration of lithium salts are likely to constitute the best initial approach. In case of treatment non-responsiveness, it is possible to consider the use of different drugs; for example, carbamazepine, sodium valproate, clorgyline, thyroid hormone. To date, the therapeutic management of rapid cyclers remains extremely difficult. Further studies, especially addressed to the aetiopathogenetic aspects of the disorder, are required.

Two cases of fathers who committed suicide following the revelation that they had sexually abused their own or other children, are described. The importance of being alert to the possibility of suicide and suicidal acts by family members following a disclosure, is emphasised. Improved liaison and co-ordination between agencies working with these families may enable vulnerable cases to be more readily identified and consequently offered appropriate support and treatment.

The revelation that the father in a family has sexually abused his own or other children often precipitates a crisis within the family. The distress suffered by the children themselves and by their mothers is well documented. (Browne and Finkelhor, Hildebrand and Forbes). Goodwin reported suicide attempts in 11 of 201 families, in which sexual abuse had been confirmed. Eight of the attempts were made by daughter-victims. In three of the five cases of mothers who attempted suicide, the abuse was intrafamilial. The impact on father perpetrators, previously a less well researched field, has been receiving more attention of late. Maisch, in a sample of 63 fathers convicted of incest reported that two fathers subsequently committed suicide. Wild has reported on six cases of suicide and three of attempted suicide by perpetrators following disclosure of child sexual abuse. The Cleveland Inquiry Report mentions one father, charged with several sex offences, who committed suicide while awaiting trial. A recent letter to The Guardian newspaper (18th February 1989) by 11 local paediatricians in that area suggests that there are now two such cases of suicide committed by alleged perpetrators.

Levels of immunoglobulins were measured in 32 schizophrenic patients with tardive dyskinesia and 34 schizophrenic patients without tardive dyskinesia. The duration of neuroleptic treatment in years was similar in the two groups. The serum immunoglobulin concentrations (mg%) were found to be significantly different in the two groups; IGA and IGM levels were higher in patients with tardive dyskinesia. The present results may be explained on the basis of dysfunction of the immunological system in tardive dyskinesia.

The Psychoanalytic Deficiency Theory of the Schizophrenias postulates that the symptomatology results from psychical dissolution. Its claim for credibility rests on the range of the clinical observations which it embraces – from the prodromal symptoms to the variety of courses which the schizophrenias follow. The fate of the prodromal symptoms, often indistinguishable from neurotic manifestations, suggest that dissolution and not mental conflict is responsible. The deficiency theory acknowledges the part played by phantasy and conflict in creating the content of delusions. Their form can only be determined by psychical dissolution. The therapeutic approach based on the deficiency theory is to strengthen the residues of the patient's healthy mental life within the context of the psychiatrist-patient and nurse-patient relationship in order to encourage insight into the falsifications and misinterpretations of reality which have contributed to the symptoms.

A service based on the principle that the comprehensive mental health needs of a community can be more efficiently met by supporting the existing primary care services has been developed in the North Aylesbury Vale, Buckinghamshire, England. The Buckingham Project is a home-based mental health service and caters for a rapidly expanding rural community of approximately thirty five thousand people between the ages of 16 and 65 years. Professional support is provided to the services and care already provided by primary health care teams, social agencies and above all, by families. Specially trained nurses work as specialists within the primary care teams in the area. Initial consultation is provided on the day of referral, often in the patient's home. Cost effective management approaches are employed throughout. The emphasis is on early detection of major mental illness and immediate intensive treatment using cognitive/behavioural treatment methods, and targeted low dose medication where necessary. The approach differs from the traditional hospital-based specialist services.