A case of mania subsequent to head injury is presented. The literature reporting cases of mania after head injury is reviewed. It is suggested that the concept of Secondary Mania be broadened to include cases occurring after head injury. It is also suggested that a true bipolar illness can be secondary.

The case notes of all non-psychogeriatric patients attending the Psychiatric Day Hospital at the University Hospital of South Manchester during one week in October 1982 were reviewed. Clinical, demographic, social and occupational data were gathered for all patients, and their attendance at the day hospital monitored for the year following the census period. No significant differences between patients could be found on any of the factors that it was predicted would distinguish short from long-stay patients. The best predictor of length of day hospital attendance in the current admission was the total quantity of previous hospital treatment whether as an in-patient or a day-patient. It is concluded that in the day hospital studied all patients had similar characteristics, and the majority could be seen as ‘new long-stay’ patients. The implications of this finding are discussed.

As a treatment for tardive dyskinesia, sodium valproate was tested in a double-blind placebo-controlled parallel group trial, with 6-week base-line observation period followed by 6 weeks of treatment. Sodium valproate was not found to be an effective treatment for either tardive dyskinesia or drug-induced Parkinsonism, and did not affect mental state or behaviour.

Secondary mania has been described in association with a variety of physical conditions. While there have been a number of reports of mania occurring in individuals with intracranial cerebral lesions, there have been few reporting its occurrence in association with non-penetrating cerebral trauma. Two further cases of mania following non-penetrating head injury and the efficacy of ECT in its management are reported, and a brief review of the literature relating to the subject is given.

Kennedy (1946) stated that “A compensation neurosis is a state of mind, born out of fear, kept alive by avarice, stimulated by lawyersand curedby a verdict”. This theme, supported by Miller's influential paper in 1961, has ensured that genera tions of patients havebeenregardedwith suspicion if they daredto presentwith psychologicalsymptoms following an accident. The view remained un challenged for over a decade and is still often presentedto, and acceptedby, our Courts, despite the fact that Miller reached his conclusions after examiningpatientwsho presentefdorlegarleports in whose casesit was not surprising that he found a relationship betweencompensation and psycho logical sequelae The psychological effects of proceeding litigation on the victim of an accident remain a matter of current debate. McKinley et al (1983), reported differences betweenthose patients suffering a severeblunt headinjury claimingcompen sation and those not claiming compensation. The reports givenby relativesof changesin both patients werevery similar. However, reports given by patients themselves differed with claimants reporting slightly more symptoms than non-claimants. In a study by Whitein 1981, the author followed up 163 victims of accidents admitted to the Birmingham Accident Hospital (76 burns and 87 general accidents). One year after their accident, psychological sequelaewere found in approximately two-thirds of the group, one third being moderately-to-severely psychologically affected. There was no statistical difference between those victims in whom the accident had given rise to litigation and in whom the case was still proceeding and those victims where compensation was not an issue.

Forty patients with mild or moderate mental handicap were assessed by two psychiatrists using the scale devised by Mann et al, 1981 which describes abnormalities of personality. Analysis by weighted Kappa showed excellent agreement for some items (introversion, hysterical explosive, sociopathic, anankastic and affective). This questionnaire may be useful in the evaluation of personality in the mentally handicapped.

A study of the case notes of 52 patients with a diagnosis of hysterical personality disorder showed that 27 had no recorded features of that condition, but were frequently described as aggressive, uncooperative, or attention-seeking. Although 60% were recorded as depressed, only 17% received antidepressant treatment. In an experimental study, the core traits of the disorder were found to have a low inter-rater reliability. Two patients, who had received hospital diagnoses of hysterical personality disorder, were shown to display behaviour that caused psychiatrists to make a diagnosis on wholly inadequate information.

Of 30 agoraphobic married women undertaking home-based behaviour therapy, 15 each had a female friend as co-therapist and 15 had their own husband as co-therapist. At 12 months follow-up, women spent a mean of approximately 40 minutes a day more outside the home alone than at baseline. Women assisted by female friends made somewhat more behavioural gains than those assisted by husbands. Women in both groups whose husbands had been more depressed 2 months after the beginning of therapy did less well at 6 months. Husbands who become more depressed may retard their wives' progress in therapy, but the effect was small, and was outweighed by other considerations.

Oxygen saturation was measured during anaesthesia and electroconvulsive therapy (ECT) using ear oximetry. Significant hypoxia occurred during some treatments; desaturation related to the number of ventilations performed after muscle relaxation and prior to the shock. Desaturation did not correlate significantly with seizure duration. These findings highlight the need for adequate oxygenation during ECT.

The term ‘depression’ is now used to cover a wider range of emotional disturbances than was the case when psychiatrists confined their attention to patients referred to psychiatric hospitals. There is considerable confusion about the variety of meanings and the loose terminology leads to claims and counter-claims about aetiology and treatment. The current classificatory systems and the variety of rating scales do not clarify issues concerning appropriate management. The guidelines for a clearer definition of a biogenic form of the concept of depression, which is likely to respond to antidepressant drug therapy, would be of considerable value to psychiatrists, non-psychiatric physicians and others who try to treat or help people in states of disordered emotion. Such guidelines are proposed.

The rate and degree of consanguinity in the parents of 143 schizophrenics who satisfied the DSM-III diagnostic criteria, was compared in the same number of controls matched for age, sex and socioeconomic class. A family history of disorders suggestive of schizophrenia in the offspring of consanguineous parents who were schizophrenic, was compared with the incidence of a similar history in the schizophrenic offspring of non-consanguineous parents. There was no statistically significant difference in the former, but there was in the latter. This finding supports the theory of a familial tendency towards schizophrenia and the possibility of recessive or a multigene pattern of inheritance.

Twenty non-alcoholic patients with DSM-III defined simple phobias for small animals received behavioural approach tests and exposure therapy while under the influence of a moderately intoxicating dose of ethanol or after placebo administration. Ethanol did not demonstrate any acute anti-anxiety effect, but retarded the rate of behavioural in vivo desensitisation, without changing the final treatment outcome. State-dependent effects of ethanol on anxiety were not demonstrated. This study supports prior research indicating no anti-anxiety or ‘tension-reducing’ effects of ethanol for simple phobias.

Kreitman (1979) reported that up to one-half of patients given out-patient appointments one week after an episode of deliberate self-harm (DSH) fail to attend, and gave a number of possible explanations for this. Firstly, parasuicide is often the result of a crisis which may have resolved (albeit temporarily) by the end of a further week. Secondly, someone in a state of heightened tension may find one week too long to wait, and may resort to other strategies to deal with his problems. Thirdly, many parasuicides may find a psychiatric label unacceptable in the context of their problems, and fourthly, an appoint ment made for a fixed day and a fixed hour may not fit the need for immediate action which the subjects subculture had inculcated in him as a habit pattern. Morgan et al (1976) reported that up to 40% of their DSH patients either did not attend any appointment or failed to complete their treatment. Two possible explanations for this were that they either felt that they did not need psychiatric treatment, or else believed that psychiatric treatment was not an answer to their problems. Kessel and Lee (1962), probably in line with much psychiatric practice, did not give a follow-up appointment to 40% of their self-poisoners; this was for two reasons. Firstly, these patients did not have a problem for which psychiatric treatment was appropriate and secondly, many of these patients had an entrenched personality disorder, which made it unlikely that psychiatric intervention would be beneficial.

A case of apparent ‘lethal catatonia’ in a 14-year-old girl is described; similarities with earlier descriptions are identified, although the precise cause of death in this case remains somewhat obscure.

A mentally handicapped man with Cotard's syndrome is described, and the usefulness of electroconvulsive therapy in his management discussed. Even the more uncommon psychiatric syndromes such as this can be found in people with lower intellectual functioning, with clinical features little modified.

For many hundreds of years the fresh leavesof the Khat shrub have been used for their stimulant properties. Several miffion people in East Africa Cathinone is considered the most active ingredient and has been recently isolated and synthesised (United Nations Document, 1975). The effects of cathinone closely resemble those of amphetamine (Halbach, 1972), to which it is chemically related. Regarding the beneficial effects of Khat, Carothers wrote in 1945: The chewing of this weed induces a happy and mellow friendliness and an increased intellectual vigour and acuity, thought tends to rise to a high plane, desire for war and women ceases, and conversation tends to concern itself with ‘the afairs of God’ and the accumulation of wealth by peaceful trade.

Hypercalcaemia, whether due to undiagnosed hyperparathyroidism or some other cause, can lead to clinical depression. The patient described here developed a severe depressive illness in the setting of hypervitaminosis D after 15 years of inappropriate therapy with calcium gluconate and strong calciferol. The importance of monitoring serum calcium levels in anyone on vitamin D therapy is stressed.

A case of anorexia nervosa associated with gastric rugal hyperplasia in a 36-year-old male is reported and some speculations are made about the relationship between these two conditions.

A study comparing the use of electrodermal response with the cuff technique and clinical judgment as monitors in electroconvulsive therapy is reported. A sensitivity of 90.5% and a specificity of 41.7% were found and it is, therefore, suggested that this method is not used routinely.

Skin conductance level (SCL) and skin conductance responses (SCR) to a random series of tones were measured in 25 drug-free schizophrenic patients, 15 male and 10 female, before and after standard chlorpromazine treatment. The DSM-III diagnostic criteria were used for selecting subjects. Psychopathology was measured with the Brief Psychiatric Rating Scale. After treatment, patients showed an improved psychopathology and decreased SCL. There was a transition of patients to lower response categories: the number of responders decreased twice and the number of non-responders increased three times. Responders exhibited significantly higher SCL than non-responders and fast habituators were between the two groups.