Objectives: To validate the hospital anxiety and depression scale (HAD) in an outpatient alcohol treatment centre.

Methods: Forty three patients referred to an alcohol outpatient treatment centre completed the HAD which was validated against the external criteria of the Montgomery-Asberg Depression Rating Scale and the Clinical Anxiety Scale.

Results: The HAD performed well operating at a cut-off of 7/8 for the depression scale and for the anxiety scale of the HAD the optimal cut-off value was 10/11.

Conclusion: The HAD is acceptable to patients and its use in alcohol treatment clinics is recommended as a screening instrument for anxiety and depression which can easily be administered by non-psychiatrists.

Objective: The aim of this study was to investigate the characteristics of patients whose identities are unknown at presentation to psychiatric services.

Method: We retrospectively reviewed 12 years of presentations to an emergency psychiatric unit and identified 37 anonymous presentations in that period. Cases were assessed with regard to demographic data, legal status, reasons for presentation, putative diagnosis at presentation, eventual documented (ICD-9) diagnosis, previous history, duration of anonymity, method of identification and re-occurrence.

Results: 0.6% of all patients who presented during the study period were unidentified for at least 24 hours. Patients were young (mean age 33.6 years). Over half were of foreign nationality (53%). The majority were suffering from major psychotic illnesses (86%). When compared with all admissions during the study period, schizophrenia and drug-induced psychoses were significantly more common in the group unidentified at presentation. Malingering, organic psychiatric disorders and dissociative states were not commonly encountered underlying diagnoses. All of our patients were subsequently identified. Successful identification methods included self admission, careful examination of personal belongings, careful history taking, liaison with police and recognition by staff. Patients frequently had a previous psychiatric history (91%). Recurrence was uncommon.

Conclusion: The anonymous presentation represents a unique challenge to the investigative skills of the psychiatrist. The application of basic strategies enables the successful identification of the majority of cases.

Objective: To ascertain the outcome of depression and factors associated with outcome over a minimum followup period of 12 months in patients referred to an Old Age Psychiatry Service.

Method: A retrospective study was performed. All depressed patients assessed by the service between January 1989 and December 1990 were followed up. This included patients seen on domiciliary and consultationliaison visits. Follow up data included information on physical, psychological, cognitive and social parameters using standardised scales where appropriate. Outcome of depression was assessed using a six point scale to enable comparison with other studies.

Results: 86 patients with a primary diagnosis of depression were seen in 1989 and 1990. At follow up, 37% were dead. 50% of patients alive at follow up were well and 7% were demented. Patients seen on domiciliary visits had the best outcome, and those with physical illness or cognitive impairment at presentation the worst outcome.

Conclusion: The association between physical status and outcome highlights the need for close monitoring of both physical and mental status of depressed elderly patients.

Various problems can occur when embarking upon training in psychodynamic psychotherapy for the first time. If the difficulties experienced by trainees are not given serious attention by supervisors, trainees may give up at an early stage. This paper looks at the subjective difficulties experienced by three junior trainees in psychiatry in adjusting to such training, and includes comments in reply from one of the organisers of the course which the trainees attended. It is essential for supervisors to address trainees concerns openly, in order to avoid a further decline in the use of this important part of the “therapeutic armamentarium”.

This report describes the case of a 62 year old man with late onset bipolar affective disorder whose mood swings were associated with episodes of thrombocytopenia. The inter-relationships between affective symptoms, the immune system and the hypothalamic pituitary axis are discussed.

Objective: The groupwork programme in this study sought to engage HIV positive drug misusers within a prison setting in order to introduce ideas and information, and by so doing promote desired behavioural changes in terms of risk behaviour and drug addiction. Such an effort was also seen as a strategy to help prisoners cope with imprisonment and to prepare them for the demands that they might face following release.

Method: Various methods of giving information and discussion were employed in order to influence members' views and behaviour. The interactions between group members were recorded using a modified version of Bale's Interaction Process Analysis Instrument during each session. In this way it was possible to analyse individual member's functioning as well as that of the whole group over the duration of the programme.

Results: While significant changes in members' views and behaviour could not be proven, an analysis of the group's communication, control, evaluation and decision making profiles reflected effort and engagement in tackling the subject inputs. Analysis of individual member's contributions was, however, open to more speculative interpretation.

Conclusion: The positive response from group members, combined with an analysis of the results suggests that the approach adopted in the programme was an encouraging step in devising an acceptable and relevant educational and treatment strategy in dealing with this usually reluctant client group, many of whom are unresponsive to traditional treatment methods.

Eleven case histories, including diagnoses and outcome, are presented of patients who made, or were the subject of, allegations of sexual abuse, but where these allegations were subsequently withdrawn or disproved. How such situations come about is discussed, with special reference to the false memory syndrome, a term made popular by recent media coverage. Given the complexity of this ‘syndrome’, an argument is put forward that diagnostic guidelines be established so that direct studies of its natural history and treatments may be undertaken.

A case of acromegaly presenting as psychotic depression is described. The relationship between psychiatric symptoms and acromegaly is reviewed and the importance of considering an organic diagnosis in a psychiatric syndrome arising de novo in later life is highlighted.

A patient with severe long-standing panic disorder who made a full recovery whilst pregnant, only to relapse during the postpartum period, is presented. Sex steroids may have a role in the aetiology and management of panic disorder. This is potentially an important area which requires further research.

The concerns expressed by Dr. Trigwell and his colleagues are not new. They have been expressed by many critics of psychoanalysis and psychodynamic psychotherapy including within the past decade Frederick Crews and Robert Wilcocks. What gives them a particular relevance and urgency is the fact that they have been articulated by young psychiatrists in training, individuals exposed to the actual practical application of psychoanalytic theory as distinct from theoretical explorations of it. The depressing thing is the reaction of one of the course supervisors. It may well serve only to reinforce their critical view.

The criticisms can be summarised as follows. First, the theories of Freud and his successors were taught on this course at any rate as scientifically established facts rather than as theories or constructs concerning human behaviour, helpful insights in certain instances but not always relevant. These theories and related interpretations were formulated in a way that made it impossible to refute them. They tended to be used in a way that suggested that they explain everything from the most trivial and reflex of thoughts and responses to the most complex and profound.

These criticisms, it might be said, relate to the actual content of psychoanalysis and psychodynamic psychotherapy, to what is being taught. Raymond Tallis has put the same general criticism with somewhat more force, observing that the manner in which psychoanalytic conclusions are drawn from clinical case histories “is reminiscent of how a first year medical student or a hypochondriac, using a few observations to light a gunpowder trail of inference primed with his own preconceptions, might arrive at a wrong diagnosis”.

Objective: Irish psychiatrists may begin to spend, as their British have counterparts have, at least some of their time delivering a psychiatric service from primary care settings. It was therefore decided to review the origins and development of attitudes towards and outcome this practice in Britain.

Method: A literature search and review of relevant papers was undertaken.

Results: Collaboration between psychiatrists and general practitioners began to expand significantly in the 1970s and 1980s. Three main models are used, the shifted outpatient model, the selected consultation model and the liaison-attachment team model. The shifted out-patient model is liked by patients whose attendance rate is better at such clinics and in some areas this model has resulted in a fall in hospital admission rates. There is a paucity of papers examining outcome of the other models. Results of the one extensively studied team liaison approach reports higher treated prevalence rates and lower admission rates for those patients referred. There was no effect on detection of illness by GPs and the service was much more costly.

Conclusions: While some benefits may result from use of the shifted out-patient approach, they are not compelling enough to enable a firm recommendation for its widespread implementation to be made. The results to date suggest the team-liaison approach does not produce benefits sufficient to outweigh the increased cost. The selected consultation model may hold greater potential but needs to be more extensively researched. Finally the structure of general practice in Ireland, with so few GPs working in multiple partner practices makes it highly unlikely that the widespread introduction of collaboration will be feasible.

There is broad agreement in the literature that depression in the community dwelling elderly is under-diagnosed and under-treated by general practitioners. Somatisation, overlap with medical illness, bereavement and atypical presentations of depression in this age-group may contribute to the difficulties in diagnosis in primary car settings. Furthermore, the apparent reluctance of primary care physicians to treat depression in the elderly may reflect the mistaken notion that depression in this population is a benign condition, an understandable reaction to physical illness and as such untreatable. Fundamental changes in the patterns of collaboration between psychiatry and general practice will be necessary to overcome these barriers to the detection and treatment of depression in the community dwelling elderly.

We report on a patient with a rare type of dissociative disorder, dissociative psychosis (hysterical psychosis), in whom gustatory, olfactory, visual and auditory hallucinations occurred. Auditory and visual hallucinations have been described in previous cases of dissociative psychosis, and olfactory and gustatory hallucinations have been described associated with sexual assault but this case is unusual in that hallucinations occur in all modalities in one patient, as yet not described in the literature The basis of the dissociative disorder lay in a childhood sexual trauma and therefore the traditionally advocated treatment for such a case is the psychotherapeutic abreaction of these previous traumatising events. This approach caused worsening symptomatology and the patient experienced frequent lapses into dissociative psychosis. However, focused cognitive-analytic therapy concentrating on the patient's personal conflicts at the time of presentation resulted in a resolution of symptoms and a return to health.

Self-enucleation is a rare and disturbing form of self-mutilation. A case is reported in which a schizophrenic patient simultaneously attempted the three main forms of major self-mutilation, that is self-enucleation, amputation of the penis and of the right hand. The historical background, underlying psychiatric factors and possible complications are discussed.

Patients with frontal lobe meningioma may present to psychiatric services. Clinical diagnostic sensitivity, particularly in the absence of neurological signs, remains central to diagnosis.

Three cases of neuroleptic induced blepharospasm successfully treated by botulinum toxin type A are reported.

Two cases of school refusal are presented. From the experience of these two cases, and support from the literature, early assessment of parental control in cases of school refusal is advocated. When parental control, even with professional therapeutic support, is not sufficient to effect an early return to school, intervention in the wider systems which are organised around the problem is recommended.

In Ireland patients who are found unfit to plead are automatically detained in the Central Mental Hospital (CMH) at the pleasure of the court. The CMH is the only high security psychiatric hospital in the Republic of Ireland. There is no limit on the length of detention and no review system in place. We reviewed the case notes of all the prisoners admitted to the CMH since 1937 who were found unfit to plead. We identified 24 cases which included only one female. The mean age was 33.5 years. Nearly 25% had a criminal record and over 60% had a past psychiatric history. The primary diagnoses were schizophrenia (12), mental handicap (4), personality disorders (3), psychotic episode (2), dementia (2) and manic depression (1). The average length of stay in the CMH was 18 years. We review the situation in the UK and in the USA and we make recommendations about legislation.

A case of Munchausen syndrome associated with habitual voluntary false confessions is described. It is suggested that voluntary false confessions may be an overlooked feature ofMunchausen syndrome. Furthermore, it is suggested that this case raises the possibility that a yet unidentified variant of Munchausen syndrome may exist which substitutes prison for hospital.