Drunk and incapable in charge of psyche

I have never been drunk. This may seem like a boast but it reflects an inner fear. When I was an undergraduate our class did an experiment in pharmacology in which the participants had to perform simple calculations while breathing increasing concentrations of nitrous oxide. As predicted, with more nitrous oxide depressing the nervous system the performance gradually approached total incompetence, but not before I had experienced a great personal feeling of panic at my faculties slowly disintegrating, accompanied by experiences that were probably hypnogogic hallucinations in which our Lancastrian teacher's voice stridently rose in volume and his normally humorous comments were perceived as a personal threat rattling every part of my crumbling psyche. ‘So this is what it is to be drunk and incapable’, I thought, ‘a temporary descent into incoherent madness’, and so ended any flirtations with substance misuse for good. This issue suggests my reaction was probably a prudent one. It gives a possible explanation of the curious experiences I had at the time (Hoffmann et al, pp. ) as well as some of the dangers. Gupta & Warner's prediction (pp. ) of increasing alcohol-related dementia does not seem unduly alarmist on the basis of the data available, and our increasing awareness of the more subtle forms of cognitive impairment shows that these are constant companions in many illnesses. Dickinson (pp. ) shows clearly that our ability to code is a core feature in many psychoses but general cognitive impairment is also common and seems to be a stable marker ^{Reference Goswami, Sharma, Khastigir, Ferrier, Young, Gallagher, Thompson and Moore1} even when patients are apparently well.

The possibility that temporary or longer-term disruption to our cognitive function may make us more liable to schizophrenia and dementia is not an idle hypothesis. Cannabis not only appears to be a clear risk factor for psychosis ^{Reference Moore, Zammit, Lingford-Hughes, Barnes, Jones, Burke and Lewis2} but also brings forward its presentation in those who are susceptible ^{Reference Barnes, Mutsatsa, Hutton, Watt and Joyce3} and the review by Zammit et al (pp. ) shows that it clearly provokes more frequent relapse, although the authors are careful not to conclude that it makes the cognitive and clinical outcome worse as the evidence is not yet available. We also need more information on cognitive functioning in outcome studies in other countries, where schizophrenia appears to respond better to treatment and have a better outcome in general; ^{Reference Crumlish, Samalani, Sefasi, Kinsella, O'Callaghan and Chilale4,Reference Isaac, Chand and Murthy5} is this related to cognitive performance? Morgan et al (pp. ), in their elegant paper, look at the problem from the other side, from the population that is already cognitively disabled through intellectual impairment, and by so doing give a much better appreciation of the extent of Kraepelin's Pfropfschizophrenie. ^{Reference Doody, Johnstone, Sanderson, Owens and Muir6} Their prevalence figures of schizophrenia of up to 5% in those with intellectual disability is higher than other studies but the methodology is rigorous and the results convincing. So it appears that we should be paying more attention to improving the mentalising and cognitive performances in our patients with schizophrenia ^{Reference Wykes, Reeder, Landau, Everitt, Knapp, Patel and Romeo7,Reference Sprong, Schothorst, Vos, Hox and Van Engeland8} but if we are to do this successfully, we must follow the advice of Goss et al (pp. ) and improve our patient involvement skills, perhaps adding ‘thinking better’ to the ones of treatment satisfaction and need for care that patients commonly convey. ^{Reference McCabe, Saidi and Priebe9}

It still does not quite explain why my pharmacology teacher's comments about my poor mathematical and spelling performance in the nitrous oxide experiment were perceived as so psychotically threatening. ‘Ee,’ he said, ‘can't yer spell now? Yer've got to spell right if yer going to be a proper doctor, ‘cos if yer spell “tinnitus” and “formication” wrong yer'll get into reel trouble’. Why did this scare me so? Am I still at high risk for psychosis? ^{Reference Valmaggia, Freeman, Green, Garety, Swapp, Antley, Prescott, Fowler, Kuipers, Bebbington, Slater, Broome and McGuire10}

Andrej Marušič

The British Journal of Psychiatry is not normally celebrated for its international outlook, but in the past ten years it has turned its face outward at least a little way. It is sad for me to report that the person who played a major part in initiating this change, Professor Andrej Marušič, is no longer with us. He died in June this year at the early age of 43 and his loss will be felt tremendously by those who had the benefit of encountering his quicksilver intellect, personal charm and immense energy. He was invited by Greg Wilkinson, former Editor of the Journal, to edit a new section, ‘Psychiatry Around the World’, published during 2003 and 2004. He was a key figure in suicide studies, particularly in an international context, and will be missed in this growing area of research and as a major force in Slovenian psychiatry. Our tribute to Andrej is only one of many ^{Reference Dernovek, Tavèar and Kozel11} but it is important to us and in mourning his loss we need to trumpet the many achievements of his tragically short life.