“I have three specific aims: firstly, to review some of the concepts supporting contemporary American (USA) Psychiatry; secondly, to explain the origins, strengths and frailties of these particular foundations; and thirdly, to provide examples of activity in the Department of Psychiatry at Johns Hopkins School of Medicine that intends to both revise and restructure these foundations in ways that enhance teaching, practice, and research.”

A cocaine-abusing patient was treated with phenelzine and tranylcypromine, under supervision, as deterrent drugs; other medical and psychological treatments had fated. When he eventually risked using cocaine there was no hypertensive reaction. Nevertheless, the deterrent effect seemed helpful in breaking his pattern of cocaine use, as confirmed by hair analysis for cocaine.

The handedness in three randomly sampled groups of people with learning disabilities consisting of patients with Down's syndrome, epilepsy, and autism were studied using a validated instrument. All subjects were controlled for neurological and other medical disorders. A statistically significant increase in left-handedness and ambiguous handedness compared with the general population was found in all groups. There was no significant difference in the rate of left-handedness between the three groups.

Current theories suggest that there is a relatively frequent association of self-mutilative behaviour with eating disorders, particularly with the modern binge-purge syndrome, bulimia nervosa. In order to consider this association on a historical dimension. 25 bulimic cases, reported from the late 17th to the late 19th century, were investigated. These were found to include four examples of self-mutilative behaviour, in three males and one female: these cases are described and discussed. The historical evidence lends some support for the suggested connection between eating pathology and self-mutilation.

A 42-year-old mentally handicapped woman presented with symptoms of affective disorder which resolved completely on excision of a colloid cyst of the third ventricle.

A patient with chronic refractory hysterical aphonia was treated by prokalesis (challenge) and hypnosis within a psychotherapeutic relationship. A temporary remission was achieved but this was followed by subsequent relapse. This report Mustrates the therapeutic effectiveness of prokaletic techniques. It also emphasises that these potent interventions are unlikely to achieve abiding change unless they are applied within the context of a longer-term relationship with a clinical team.

Disorders of the thyroid gland are associated with disorders of mood (Thomas et al, 1970; Van Uitert & Russakoff, 1979; Folks, 1984; Young, 1984; Jadresic, 1990). Both hypothyroid and hyperthyroid states can be associated with depression, which is sometimes accompanied by psychotic features such as delusions and hallucinations (Wilson & Jefferson, 1986). Similarly, primary affective disorders can be accompanied by changes in thyroid function, with low thyroid-stimulating hormone (TSH) levels and elevated thyroxine (T4) (Kirkegaard & Faber, 1980), and in major depressive illness there is often a blunted TSH response to thyrotrophin releasing hormone (TRH) (Prange et al, 1972; Loosen, 1987).

We report on a family with co-occurrence of affective disorder and Hailey-Hailey disease in two brothers and the mother. The putative chromosomal locus of Hailey-Hailey disease, which is a rare dominantly inherited dermatosis, may be a promising candidate region for genetic studies in affective disorder.

British Journal of Psychiatry (1993), 163, 109–110

Hyponatraemia and persistent urinary excretion of sodium are associated with imipramine, used to treat an elderly woman with depressive illness, which resolved on withdrawal of the drug.

A first episode of mania is described in a previously healthy man who was partially sleep deprived for four nights. The sleep deprivation preceded the psychosis. During the psychotic episode he believed that he was the Messiah. This case is discussed in the light of reports exploring the relationship between psychosis and sleep deprivation.

In an attempt to address the low compliance with offers of treatment shown by patients after episodes of non-fatal deliberate self-harm (DSH), patients who had harmed themselves for the first time were offered rapid, easy access to on-call trainee psychiatrists in the event of further difficulties, and they were encouraged to seek help at an early stage should such problems arise. The follow-up data obtained after one year showed a significant reduction of actual or seriously threatened DSH in the experimental group, who also made considerably less demands on medical and psychiatric services, when compared with controls.

British Journal of Psychiatry (1993), 163, 111–112

A 43-year-old man presented with an 18-month history of acute-onset cyclical behavioural change affecting mood, appetite, sleep, and energy levels. This had followed an initial episode of transient drowsiness which lasted 24 hours. On examination, there was soma evidence of visual memory and frontal lobe deficits. A brain CT scan showed bilateral thalamic infarcts and a brain SPECT scan showed bilateral hypoperfusion of the frontal lobes. To our knowledge, this is the first reported case of thalamic infarction associated with acute-onset cyclical affective psychosis with clinical and neurophysiological features of frontal lobe syndrome. The case also highlights the possible role of thalamofrontal circuits in the pathogenesis of the Kleine-Levin syndrome.

British Journal of Psychiatry (1993), 163, 113–115

Prader-Willi syndrome (PWS) is associated with an insatiable appetite and (often) other maladaptive behaviours (self-injury, sleep disorders, insistence on routines, and temper tantrums). Psychoses are not a recognised feature. Most affected people have a chromosome 15 abnormality (deletion, disomy, structural rearrangement, etc.). Three people with PWS who developed psychotic disorders in early adult life are described. The nature of the psychoses and the significance of the association are discussed.