Factitious post-traumatic stress disorder, a variant of the psychological Munchausen syndrome, was first recognised in Vietnam war veterans but has not been described since. The case is described of a young man who claimed to have been involved in a fishingdisaster, feigning the symptoms to post-traumatic stress disorder to gain admission to hospital This appears to be a novel presentation of a Munchausen variant which has not been describedin connection with peace time disasters. It would appear that the psychopathology of factitious disorder, like that of other phenomena, such as delusions, is keeping pace with the views ofsocietyand current media concerns. This issue is discussed in the context of a review of recently reported variants of this interesting clinical syndrome.

Objectives: General practitioners were surveyed by questionnaire for their opinions on their needs and usage of a new child psychiatric service in the Midwestern Health Board.

Methods: The questionnaire was returned by 72% of GPs. Their practices included inner city, new towns, country town, and rural communities.

Results: It was found that 160 children were awaiting referral to the new service of which the most prominent presenting problems were hyperactivity, learning difficulties, enuresis, poor parenting skills, dysfunctional families, anorexia/eating disorders and psychosomatic problems. Primary school children required more frequent referral than secondary school children. GPs appreciated telephone access to the psychiatrist and for the service to be available for emergencies. A few GPs requested discussion meetings following referral. Most GPs were satisfied with any member of the multi-disciplinary child psychiatric team assessing the children.

Conclusions: This study was a useful method of assessing the numbers and nature of problems which might present to a new child psychiatric service in order that staff and treatment programmes could be organised. Results suggest that further research is necessary.

Objective: To quantify the perceived discrepancies between the medication that GPs believed their patients were taking and that which was recorded on admission to acute psychiatric wards.

Methods: A prospective survey of 107 consecutive admissions to a Swansea psychiatric hospital was carried out.

Results: In 62% of patients studied, there was at least one discrepancy each and in 33%, the discrepancies were considered potentially clinically significant.

Conclusions: The study showed a significant number of potentially serious discrepancies in medication at the GP-Hospital interface and highlighted the need for improved communication between GPs and their psychiatric colleagues. The possible reasons for the discrepancies and the implications for communication between primary and secondary care for psychiatric patients are explored.

Death faces us all. Preoccupation with it however is commonly regarded as morbid. As a way of dying, suicide is seen as being abnormal. This is certainly so in a statistical sense. In 1993, there were 31,896 deaths in the Republic of Ireland of which officially 357 were suicides. This means that approximately one in a hundred deaths today are self-inflicted. The proportion of suicide deaths to other deaths varies across age groups, however. Generally speaking among the young, suicide is a more common cause of death because other types of death are less common. In the past the official Irish suicide figures may have under-estimated the true picture. Recent research however has shown that the official Irish suicide statistics are likely not to underestimate the true rate and are also more likely to be reliable than are the equivalent statistics from England and Wales.

The word ‘abnormal’, however, in medicine is also used in a nonstatistical sense to imply deviation from the ideal or desirable. If we say someone is abnormal, we imply that he is either mentally ill or suffering from a defect or blemish of personality. Most people assume that those who intentionally end their lives are abnormal in this latter medical sense, immediately prior to death. The opposite holds in murder. Society assumes the perpetrator is not mentally ill unless evidence is brought forward to the contrary. Not all believe this, however, and some actively canvass the viewpoint that suicide, in certain circumstances, is to be encouraged.

Suicide pacts are rare in clinical psychiatric practice and usually one or more of the parties die. Here we present a case report where both parties survived. We point out similarities and differences between this pact and others described in the literature.

This paper summarises the work of Michael Balint, offers a revisionist view of his work, and argues that the new term heartsink is an indication that the problems Balint addressed need to be re-examined.

The richness of Michael Balint's life was documented by Hopkins. The variety of his professional experiences meant that he was able to create a fertile atmosphere in which GPs felt free to express feelings about themselves and their patients. The Balint movement was based upon the talents of an exceptional man.

Early psychodynamic formulations of obsessive compulsive disorder (OCD)suggest that its aetiology lies in repressed sexual impulses. Despite this, sexual aberration has rarely been reported in conjunction with OCD or arising following treatment. This paper describes two case histories of patients with severe, chronic OCD whose sexually deviant behaviour increased following successful behavioural psychotherapy. Classical Freudian, behavioural cognitive and neuropsychological models for this finding are discussed.

The Mayan people of Mexico have a radically different concept of illness than that of western countries. In the absence of any formal psychiatric service in their area, the people continue to rely on the interventions of the traditional healers, which include the use of herbal medicines, prayers and magico-religious rituals. A case history of a Mayan patient with a chronic psychotic illness is described, which illustrates the gulf in concepts of mental illness that exists between Western and folk cultures. These cultural differences may have a profound impact on the application of modern psychiatric interventions in developing countries.

A case of traumatic encephalopathy from persistent and long-standing self-inflicted punches to the head is described in a patient with obsessive compulsive disorder. This rare complication is best seen as a mild form of ‘punch drunk syndrome’ in the light of the clinical, neuropsychological and radiological findings.

In Bipolar affective disorder, the importance of genetic factors is well established through family, twin and adoption studies. However the exact mode of inheritance is not yet known. Genetic studies using DNA linkage have been attempted to identify susceptibility genes. Linkage studies of chromosome 11 and X chromosome have proved to be inconclusive. Recent studies have focused on chromosome 18 and 21, although confirmatory findings are awaited. As such, determining which part of the genome needs to be studied remains a problem. One way of overcoming this is to look for ‘candidate’ genes, ie. genes for which a priori evidence exists that a susceptibility gene may be located nearby.

Such strategies have been used for example, trying to identify genes of interest by looking at association between chromosomal aberrations and bipolar affective disorder, and the study of co-segregation of certain diseases with affective disorder. More studies are needed to provide regions of interest. I would like to report three cases of bipolar affective disorder with a rare autoimmune disorder, cryptogenic fibrosing alveolitis.

A 24 year old man with established Gilles de la Tourette Syndrome (GTS)and schizophrenia of recent onset is described. Other comorbid reports of schizophrenia and GTS are reviewed showing this association to be rare, with only nine previous reported cases. GTS and schizophrenia have many phenomenological similarities and a link has been considered between the two disorders but never clearly established. Reasons for the lack of an association where one might be expected are considered. Possibilities include under reporting or misdiagnosis of GTS or the possible masking of psychotic symptoms by treatment of the GTS.

The international pilot study of schizophrenia (IPSS) was the first major study to show that the use of standardised assessment and classification instruments allows the reliable comparison of data on the prevalence, psychopathology and prognosis of major psychiatric illness between different cultures. Important questions about the methodology used in cross-cultural research remain to be answered, however These include the inherently ‘Eurocentric’ nature of much of western psychiatric terminology and the absence of directly comparable concepts and language to describe emotional and psychological distress between western and non-western cultures. These difficulties especially arise in relation to illness where organic factors appear to contribute little to aetiology, such as the neurotic and Axis II disorders, and need to be overcome before useful crosscultural research into these disorders can be accomplished.

Therapeutic drug monitoring of tricyclic antidepressants is a controversial issue. A case is reported in which a patient with recurrent depression developed asymptomatic tricyclic toxicity while on trimipramine, a tricyclic antidepressant, and diltiazem, a calcium channel blocker. A metabolic interaction involving cytochrome P450 3A (CYP3A) is postulated. It is suggested that routine therapeutic drug monitoring of tricyclic levels should be an essential part of the management of depression.

Thomas Willis [1621-1675] was not the first to describe the circle of vessels at the base of the brain that bears his name, but it was he who first recognised its functional significance in maintaining cerebral perfusion even after one of its feeding vessels was completely closed. Although Willis made many astute, original clinical observations (concerning myasthenia gravis, paracusis, restless legs syndrome and diabetes mellitus) his reputation suffered because he was an inveterate theorist in an age that frowned on hypotheses. Nonetheless he is now recognised as one of the earliest neuropsychiatrists who attempted to understand and explain mental illness, as he encountered it in his daily practice, in terms of brain dysfunction more than 300 years ago.

Historically Western medicine has been divided into two main schools that were based on the ancient Greek tradition. These are the Hygeian school, based on the views of Hippocrates (born 460 BC), and the Asclepian school which is named after the Greek god of medicine but probably based on the physician Asclepius who was said to have performed miracles!

In brief, the Hygeian school of medicine views health as a natural state of the body. The body is believed to be endowed with inherent healing powers which, if one lives in harmony with these powers, maintains health and helps to restore it should it become impaired. Disease is seen as a manifestation of a weakness of the inherent healing powers of the body and the function of the physician is to help the patients to live within the natural law (vis medicatrix naturae) and to remove impediments to those mechanisms that maintain and restore health.

The second school that has profoundly influenced the development of modern medicine is the Asclepian school which arose in about 1200 BC around the teaching of Asclepius. This school focuses on diseases, their causes and cures. Each disease is considered to be the effect of, or response to, a specific cause that primarily affects a specific organ system. For every disease it is postulated that there is a specific drug or procedure which can alleviate the symptoms or cure the disease. Thus, the successful physician is the one who can make the correct diagnosis and prescribe the correct therapy.