A short paper of this title reported a study by Ansseau et al (1991). The present authors were invited to comment upon the study.

A new phenomenon, found only in Gilles de la Tourette (GTS) patients, and which we have called ‘mental play’, is described. It was compared with the phenomenon of counting, which occurred in both GTS and obsessive-compulsive patients. In the GTS patients both mental play and counting were best characterised as playful impulsions. In contrast to the GTS patients, the counting of the obsessive-compulsive patients was in line with their obsessive-compulsive behaviour. These findings suggest that repetitive symptoms in GTS patients, even when they share superficial similarities with obsessive-compulsive symptoms, should not be diagnosed automatically as obsessive-compulsive.

An exposure treatment for patients suffering from post-traumatic stress disorder (PTSD) is described. Image habituation training (IHT) involves the patient in generating verbal descriptions of the traumatic event and recording these onto an audiotape. After the initial training session with the therapist, homework sessions of self-directed exposure in which the patient visualised the described event in response to listening to the audiotape were carried out. Of ten consecutive patients who received this treatment, six improved considerably after ten homework sessions, two showed moderate improvements, and two showed minimal improvement on a range of outcome measures. There were significant decreases in anxiety between and within homework sessions, suggesting that habituation did occur and was responsible for improvement. Treatment gains were maintained at six-month follow-up.

Previous studies have suggested that on the Auditory Comprehension Test, a significant proportion of schizophrenics demonstrate a binaural comprehension deficit. To test whether wearing an earplug in their more poorly performing ear would be beneficial, we studied 34 in-patient schizophrenics and noted a binaural deficit in 12 (35%). Of these, eight patients subsequently wore an earplug in each ear for at least one week. We found no effect of the earplug on psychopathology.

A questionnaire comprising 30 open-ended questions was sent to 450 people with chronic hallucinations of hearing voices who had responded to a request on television. Of the 254 replies, 186 could be used for analysis. It was doubtful whether 13 of these respondents were experiencing true hallucinations. Of the remaining 173 subjects, 115 reported an inability to cope with the voices. Ninety-seven respondents were in psychiatric care, and copers were significantly less often in psychiatric care (24%) than non-copers (49%). Four coping strategies were apparent: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.

Autism is currently detected only at about three years of age. This study aimed to establish if detection of autism was possible at 18 months of age. We screened 41 18–month-old toddlers who were at high genetic risk for developing autism, and 50 randomly selected 18–month-olds, using a new instrument, the CHAT, administered by GPs or health visitors. More than 80% of the randomly selected 18–month-old toddlers passed on all items, and none failed on more than one of pretend play, protodeclarative pointing, joint-attention, social interest, and social play. Four children in the high-risk group failed on two or more of these five key types of behaviour. At follow-up at 30 months of age, the 87 children who had passed four or more of these key types of behaviour at 18 months of age had continued to develop normally. The four toddlers who had failed on two or more of these key types of behaviour at 18 months received a diagnosis of autism by 30 months.

Research in the field of interpersonal behaviour is widely recognised as an important key to understanding the nature of mental illness. In schizophrenic patients especially, deviant social interaction has been proved to be associated with pathological behaviour (see Bellack et al, 1989). Numerous studies have revealed that affective attitudes expressed towards the patient by a relative during hospital admission for an episode of schizophrenia (high expressed emotion (EE)) are predictive of the short-term course of the disorder (Leff & Vaughn, 1985; Jenkins et al, 1986; Nuechterlein et al, 1986; Mintz et al, 1987).

In contrast to the West, bulimic disorders are rarer than anorexia nervosa in Hong Kong. Four female normal-weight bulimic patients with mostly typical clinical features and conspicuous morbidity are reported. The case histories support the hypothesis that binge-eating is used to regulate unpleasant affect.

Two cohorts of anorexia nervosa patients were followed up for a mean of 20 years. All except 4% of each cohort was traced. The crude mortalities were: St George's, 4%; Aberdeen, 13%. The SMRs were: St George's, 136; Aberdeen, 471. If the untraced were assumed to be dead, crude mortalities were 7.6% and 15.9% respectively, and SMRs were 276 and 592 respectively. Causes of death were complications of the illness and suicide. Medical treatment may reduce early mortality, while comprehensive medical and psychotherapeutic treatment may reduce late mortality.

Twenty-three adolescents with DSM–III major depressive disorder (endogenous subtype) and 23 normal controls were studied polysomnographically (PSG). The depressed group showed significantly shortened REM latencies (P=0.005) and longer sleep latencies (P=0.04). No other PSG measures differentiated the two groups. The implications of these findings for adolescent depression are discussed.

A 50-year-old man presented with hyperosmolar nonketotic diabetic coma associated with the neuroleptic malignant syndrome (NMS) after intramuscular treatment with haloperidol. It is suggested that NMS may occur as a complication of uncontrolled diabetes mellitus with dehydration. Conversely, NMS might precipitate diabetic coma in patients with previously well controlled blood glucose.

A double-blind clinical trial of clomipramine versus phenelzine was carried out on 30 patients suffering from DSM–III obsessive–compulsive disorder. The study period was 12 weeks, and the maximum doses used (from the fifth week on) were 225 mg/day for clomipramine (14 patients) and 75 mg/day for phenelzine (12 patients); four patients dropped out. Obsessive symptoms improved significantly in both drug groups, but there was no significant difference between groups. Depressive symptoms improved before obsessive ones.

The total number of adults with Down's syndrome living in Leicestershire, ascertained by widespread enquiry, was found to be 378. Of these, 371 were matched with adults with mental handicap due to other pathologies, on the basis of age, sex, and type of residence. Those with Down's syndrome were found to have a different spectrum of mental disorders from those without the syndrome. In particular, Down's syndrome patients were more likely to have been diagnosed as having depression and dementia; the controls were more likely to have been diagnosed as suffering from conduct disorder, personality disorder, or schizophrenia/paranoid state. The same proportion of each group had been given a diagnosis of autism.

An auto-antibody screen for SLE, which included anti-nuclear antibodies, was performed on 296 patients admitted to acute psychiatric and psychogeriatric wards. Three cases (1% of those screened) of previously undiagnosed SLE were found, and one patient was found to have autoimmune chronic active hepatitis. An auto-antibody screen may be a useful investigation in psychiatric practice.

Using a structured instrument, 325 elderly patients admitted to a general hospital for an acute medical problem were evaluated daily in order to detect symptoms of delirium. Patients were scored for ‘hyperactive’ or ‘hypoactive’ symptoms, and then the 125 patients with DSM–III delirium were rated as ‘hyperactive type’ (15%), ‘hypoactive type’ (19%), ‘mixed type’ (52%), or ‘neither’ (14%). There were no statistically significant differences between the groups with respect to age, sex, place of residence, or presence of dementia. These definitions of subtypes should be studied further.

The association of a recurrent psychosis in the premenstrual period with an increased blink rate is reported. This case adds to evidence supporting a hormonal hypothesis of certain psychotic disorders.

The case of a female patient showing aggressive, compulsive, destructive behaviour, ritualistic faecal smearing, and hyperactivity is presented. The behaviour is long standing, therapy-resistant, and its aetiology is unknown, although it is seemingly associated with chromosomal abnormalities secondary to abnormal plasma factors.

The analysis of schizophrenic persons' attempts at coping with their disease has developed into a fertile research area over the last few years. Results are expected that may lead to a better understanding of specific psychopathological phenomena, and hopes are raised for improvements in specific therapeutic programmes (cf. Böker & Brenner, 1983; Wiedl & Schöttner, 1989a). Previous studies have shown that schizophrenics use many different strategies to cope with their disease. Sometimes conflicting results deal with the frequency of specific ways of coping, their orientation to specific symptoms or strains, their relationship to the course of the disease and the nosological classification of the patients, and finally, with their suitability or usefulness (cf. Wiedl & Schöttner, 1989b). Altogether, these investigations have contributed to correcting the image of the schizophrenic as a person who is passive and helpless against his/her illness, and have expanded the scope of knowledge in psychiatry and clinical psychology (cf. Strauss, 1989a,b).

Clozapine, an ‘atypical’ antipsychotic drug, rarely induces allergic complications, which usually present as cutaneous reactions. We report the case of a 69-year-old woman, suffering from chronic schizophrenia, who developed an allergic asthmatic reaction following clozapine therapy. Intensive-care treatment was necessary. The reaction could be repeated by further exposure to the drug. Skin tests for hypersensitivity were negative.

Following a road-traffic accident, an 18–year-old man developed episodic dyscontrol which brought him into conflict with the law. Two years after the accident, treatment with carbamazepine was initiated and further aggressive outbursts subsided. The efficacy and mode of action of carbamazepine is discussed and the literature reviewed.