A significant component of psychiatric practice relates to the management of patients with behavioural disturbance whose aetiology lies in the subtle alteration of brain biochemistry. The major handicap in assessing such patients, both from a clinical and a research point of view has been a lack of suitably sophisticated technology for studying brain function. Despite significant improvements in imaging technique and the development of positron emission tomography we are still lacking tools which assess brain receptor functioning. The neuroendocrine axis provides us with the means of assessing specific neurotransmitters in a safe and relatively inexpensive way. Such an approach is now widely used in research and has considerable potential within a clinical setting.

The fact that classic monoamine neurotransmitters are implicated both in affective disorders and schizophrenia and at the same time control hypothalmic-anterior pituitary function provides the basis for many psychoneuroendocrine investigations. The stimulation of certain central neurotransmitter systems results in the elevation of anterior pituitary hormones. If a pharmacologically selective drug is used, the rise in the anterior pituitary hormone gives some index of the integrity of the neurotransmitter pathway and the sensitivity of its receptor system. This approach is heavily dependent on the development of selective drugs for challenging specific receptor systems. As there are a myriad of potential confounding variables it is essential that there be rigorous control over such factors as gender, age, psychotropic drug exposure, weight loss etc.

The release of growth hormone (GH) from the anterior pituitary is under the control of 2 peptides, namely growth hormone releasing hormone (GHRH) and somatostatin (SS). Noradrenaline acting via the GHRH containing neurones stimulates the release of GH (1,2). We now know that the stimulated release of GH through this mechanism is significantly blunted in patients with major depression (3,4,5). When sone suppression and noradrenergic mediated GH release are both investigated in depressed patients, those subjects who show dexamethasone non-suppression are more likely to demonstrate blunted GH release than those with normal dexamethasone responses (5).

Acetylcholine (ACh) stimulates growth hormone release via the SS method (6). It is now clear that depressed patients show enhanced release when their cholinergic system is challenged with pyridostigmine (7). Overall therefore, depressed patients seem to have a downregulation or under activity of their NA receptors and an up-regulation or over-activity of their ACh receptors.

GH release is also under GABAergic control. In a study of patients with major depression baclofen the GABA-B agonist was used to induce GH release. Baclofen (20 mg) significantly elevated GH levels in all healthy subjects but a blunting of response was seen in those patients with major depressive illness. The finding indicates diminished responsivity of the GABA-B receptor system in depression (7a).

The release of prolactin from the anterior pituitary is under the inhibitory control of dopamine (DA) which acts directly on the lactotrophs of the pituitary. The release of prolactin is stimulated by serotonin (8,9). There is now unequivocal evidence to indicate that 5-HT mediated prolactin release is blunted in major depression (10,11). Such blunting has been demonstrated with a wide variety of probe drugs including 1-tryptophan and fenfluramine. The abnormality is however not entirely specific to depression as patients with obsessive compulsive disorder and sociopathic personality disorder also demonstrate such blunting even in the absence of mood disturbance (12,13).

The first evidence to emerge that central DA receptors might in some way control GH release was demonstrated by the administration of 1-dopa which led to an increase in GH levels (14). GH responses to the DA agonist apomorphine have been reported to be greater in patients with first rank symptoms of schizophrenia, but to be blunted in those patients with significant egative symptoms such as emotional flattening and social withdrawal (15,16).

The very complex neurotransmitter control of such hormones as GH and prolactin provides a window to the biology of neuro-behavioural disturbance. As a tool psychoneuroendocrinology is of relevance not just to the researcher but to the practicing psychiatrist as well.

Objective: The aim of this study was to examine the working of the 1945 Irish Mental Treatment Act in relation to compulsory admission and detention and to establish issues that will need to be addressed in imminent new legislation. Method: A 3 year retrospective study was carried out on all compulsory admissions to the Cavan/Monaghan Psychiatric Service using case note material. The circumstances surrounding application for compulsory admission in one year of the study period were further investigated by delivery of a schedule to Relative-Applicants. Results: The study revealed rates of compulsory admission equivalent to other Irish regions but much higher than neighbouring jurisdictions. There was no evidence of deliberate abuse of the act. Indications emerged of excessive and inappropriate recourse to certification by some relatives and General Practitioners. Excessive length of detained stay and lack of specific procedures for informing patients of their rights were evident. Conclusions: A new Mental Treatment Act will need to place much greater emphasis on patients' civil rights while facilitating access to treatment.

Objective: To assess the effect of specific psychoeducational sources – support group meetings, lectures and literature – on bipolar disorder patients' knowledge and attitude to their illness. Methods: Eighty bipolar disorder patients attending for a lithium blood test were asked to complete a questionnaire detailing their demographic characteristics, duration of illness, knowledge of manic-depressive illness and their attitude towards their illness and what exposure they had had to relevant support group meetings, lectures and literature on bipolar disorder. Results: The 43 group attenders had a statistically significant higher mean score on the illness and lithium knowledge and the attitude to illness sections of the questionnaire than the 30 patients who did nto attend groups (P<0.001). A multiple regression analysis indicated that, in addition to group attendances, only reading literature contributed significantly to illness knowledge and attitude. Age, sex, duration of illness and socio-economic status did not contribute significantly to these outcome variables. Conclusions: Bipolar disorder patients who attended support group meetings and availed of relevant literature knew more about their illness and lithium therapy and expressed more positive and realistic views about their illness than those who only read literature and attended lectures.

Objective: This survey attempts to ascertain the attitude of the general public towards the mentally ill and former psychiatric patients in Ireland. Method: A random selection of 155 adults were interviewed using Likert-type scales (29 items). Results: Factor analysis revealed four main attitude dimensions: fear, lack of sympathy, personal rejection and perceived community rejection. Overall, respondents express a low level of fear and a high level of sympathy towards the mentally ill. Lack of sympathy correlated highly with older age group, lower educational level and lower socio-economic class of respondent. Respondents with higher self-reported knowledge about mental illness were less fearful and more sympathetic towards the mentally ill. Conclusions: The findings are encouraging to the development of community psychiatric services and support the usefulness of public education in the area of mental health.

Objective: To assess the extent of cognitive impairment in a group of female alcoholics and to examine if any relationship was present between the degree of cognitive impairment, and the duration of alcohol dependence, impairment of liver function or associated prescribed medication abuse. Method: The subjects were thirty consecutive women in a residential alcoholism treatment programme who were assessed two weeks after detoxification. The visual reproduction subtest of the Wechsler Memory Scale was used, together with four subtests of the Wechsler Adult Intelligence Scale: vocabulary, similarities, block design and object assembly. We examined the effect on these scales of prolonged alcohol abuse (>5 years), abnormal liver function tests and prescribed medication abuse. Results: The group showed a significant impairment on the subtests, similarities, block design and object assembly when compared with the general population mean for the WAIS-R. Analysis of sub-groups showed little statistically significantly greater impairment on cognitive testing then the remainder of the group. Conclusions: The pattern of cognitive dysfunction for the group indicated subjects had deficits in abstraction, visual spatial and visual motor reasoning similar to previous studies involving male alcoholics. The usefulness of the sub-group comparisons was limited by the small numbers involved and larger studies would help clarify the role of contributory factors in the development of cognitive dysfunction in alcoholic subjects.

Objective: To investigate factors influencing general practitioner referrals of children with psychiatric disorders to specialist services. Method: One hundred and sixty seven general practitioners were asked to complete a detailed questionnaire concerning their referral practices. Results: Emotional disorder, conduct disorder, drug abuse and habit disorder were the problems most likely to be referred to the child psychiatric clinic. Parental concern and the severity of the child's illness were considered to be more important than social circumstances in determining referral to specialist services. Conclusions: Many general practitioners indicated that they would have referred children with psychiatric disorders to specialist services other than child psychiatry. Proactive liaison work is needed to increase the awareness and confidence of general practitioners in child psychiatric services.

Objective: The assessment of the personality status of Adolf Hitler using a structured interview schedule, the Personality Assessment Schedule, with two informants, one a psychiatrist with an interest in psychohistory and the other a historian with special knowledge of the Third Reich and Weimar Republic. Method: The Personality Assessment Schedule was given in two forms to the two informants at different times; on each occasion Hitler was assessed as he was in 1937. Results: There was considerable discrepancy between the ratings of the two informants, the historian recording less-personality disturbance in all areas of function, although correlations between the two sets of ratings were relatively high (R1 0.5-0.6), with rater bias accounting for the differences in severity. Both informants regarded Hitler as having a dissocial personality disorder (using the new ICD-10 criteria), but the psychiatrist's rating also scored the diagnosis of paranoid and histrionic personality disorders. Conclusions: Interview schedules which use informants to assess personality disorder can be of value in examining the personality status of historical figures.

Objective: The Objective of this study was to analyse the characteristics and disabilities of patients becoming new longstay in a Mental Health District, to describe their needs and define the implications for service development. Method: All patients entering into the new longstay category between January 1st 1981 and December 31st 1991 were analysed. New longstay patients were defined as those remaining continuously in hospital for one year or longer. An accumulated inpatient group, still resident in the hospital, was examined using the Community Placement Questionnaire (CPQ), a standardised questionnaire useful for estimating needs for care and accommodation. Results: The analysis revealed a globally disabled patient group, largely intractable to treatment, the majority of whom required care and supervision in the longterm. An estimate of new longstay bed requirements, based on a stay of 1-5 years, was 11.3 per 100,000 for those under 65. The assessment team categorised current inpatients into four groups with regard to placement recommendations. An analysis of the CPQ results supported these recommendations which were: Specialist Unit for chronically disturbed Geriatrics, Geriatric Unit, High Support Staffed Hostel and Medium Support Staffed Hostel. Conclusions: Despite current service practice and community provision new longstay patients continue to accumulate. Given further specialist alternative community structures, it is suggested that these patient's requirements can be met without the need for continued longstay mental hospital beds.

Objective: To assess the importance of psychotropic medications in Compulsive Water Drinking (CWD) among psychiatric inpatients. Method: The psychotropic medication regimes of 21 CWD inpatients (16 of whom had a diagnosis of schizophrenia) and 21 age and sex matched control inpatients were compared. The CWD group was selected on the basis of urine specific gravity testing amongst the non-geriatric rehabilitation population of a Canadian psychiatric hospital. Regular and prn medications were compared by type and dose. Results: Both groups had generally similar regular medication regimes. No significant differences were found for any of the more commonly prescribed medications. There was a nonsignificant tendency for more CWD subjects to be given prn psychotropics, likely a consequence rather than a cause of the polydipsia. Conclusion: No significant differences were found between the two groups. However, because of the large number of medications used and the relatively small number of subjects, the study has relatively low power. A larger study, combining the CWD inpatients of several hospitals, would be required to definitely rule out a role for psychotropics in the aetiology of CWD.

Objective: To assess the preparedness of psychiatric nurses to care for patients with Acquired Immune Deficiency Syndrome (AIDS). Method: Voluntary anonymous questionnaires were sent to psychiatric and general nurses in a district general teaching hospital. The behaviour, knowledge and attitudes towards AIDS of both groups were then compared with those of three experts specialising in the care of AIDS patients. Results: No inter group differences were found but a majority of nurses differed from the experts on two statements. Contrary to expert opinion nurses believed AIDS could be spread by needle stick injury and if given a choice they stated they would not volunteer to work on an AIDS ward. On controversial issues such as testing and where best to treat psychiatrically disturbed AIDS patients there was wide variation. Conclusion: While this study shows an improvement in health professionals knowledge, behaviour and attitudes towards AIDS, there remain underlying anxieties that need to be addressed with continuing education and training.

A case is presented of multiple tooth autoextraction performed by a 22 year old male known to be afflicted with the Gilles de la Tourette syndrome.

This unusual and rarely reported aspect of the syndrome caused initial diagnostic confusion and improved following psychiatric therapy.