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.

Through widespread enquiry, the population of adults with Down's syndrome (aged over 18 years) in Leicestershire was estimated at 376. For 315 of these (83.8%), the immediate carer was invited to complete the Adaptive Behavior Scale (ABS). Completed ABS assessments were obtained on 81.9% of the adult population with Down's syndrome in the county. Additional information concerning residential history was obtained. When the sample was divided into five cohorts on the basis of age when the ABS assessment took place, an exponential decline in ability was observed. Deterioration in most domains of the ABS achieved statistical significance in the cohort aged 50–59, and in all domains in those aged 60 and over. The deterioration in global skills in older cohorts was attributed to ageing (and thereby probably Alzheimer's disease). Institutional placement was associated with low scores in younger groups only.

The mean annual rates of hospital admission for deliberate self-poisoning were calculated for Caucasian and Asian 12–15–year-olds between 1982 and 1990 as 2.31 and 2.47 per 1000 respectively. There was an excess of girls in each group.

Sex offenders suffering from psychotic illness formed an important small group of a regional secure unit's patients. Ten of the 11 such offenders had a diagnosis of schizophrenia. There was a complex relationship between their mental illness and offending.

It is important to know how people with a schizophrenic disorder experience their cognitive vulnerability and how that experience affects their daily lives. Rehabilitation, as we understand it, has the aim of stimulating patients to make the best use of their residual capacities, especially in dealing with social complexity. Unfortunately, the rehabilitation approach in psychiatry still lacks a firm scientific basis. Strong links need to be developed between the practice of rehabilitation and theories of basic cognitive and behavioural dysfunction in schizophrenic patients (Watts & Bennett, 1983). It is a prerequisite that the subjective experiences of patients are included in this endeavour: schizophrenia is an ‘I am’ illness (Estroff, 1989).

Patients with an ICD–9 diagnosis of psychotic disorder were assessed for DSM–III–R schizophrenia. Rates of schizophrenia were found to be higher in males (39.8 per 100 000) than females (22.4 per 100 000). The DSM–III–R Incidence supports recent studies which suggest a decrease in rates of schizophrenia across time, and also suggests that men suffer from both more schizophrenia and a more severe form of the disease.

We present a case of acute dystonia in an adolescent, with features that fit the description of the Pisa syndrome. The symptoms developed postoperatively, in a non-psychiatric setting, following administration of antiemetic medication, and the phenomenon was misdiagnosed as a conversion disorder. This case reinforces previous reports cautioning against misinterpretation of dystonic reactions as functional disorders, especially in children and adolescents.

Separate episodes of both catatonia and the so-called ‘neuroleptic malignant syndrome’ (NMS) occurred within the same patient. The only evidence for NMS in this case was prior administration of a neuroleptic and the presence of generalised muscular rigidity. It is suggested that it is misleading to view these conditions as separate diagnostic entities and that NMS is probably more correctly incorporated into the catatonic disorders.

Ten patients with multiple sclerosis (MS) and psychosis were assessed using the Present State Examination, and matched retrospectively with respect to age, disability, duration of symptoms, and disease type with 10 MS patients without psychosis. Both groups underwent MRI of the brain. There was a trend for the psychotic group to have a higher total lesion score, particularly around the periventricular areas. This reached statistical significance in the areas around the temporal horn. In all cases, neurological symptoms preceded the onset of psychosis. The psychotic group also had a later age of onset of psychosis than psychotic patients without brain disease. These results point to an aetiological association between the pathological process of MS and psychosis.

A case of senile dementia that initially presented with complex visual hallucinations in the absence of clinical cognitive impairment or other psychopathology is described. Dementia must be added to the differential diagnosis of isolated visual hallucinations in the elderly.

One purpose of cognitive-behaviour therapy is to provide patients with a ‘psychological model’ of their illness; this would enable them to become aware of, and thereby gain insight into the ways that the symptoms and behavioural deviances they exhibit, and the circumstances of the onset of illness are actually related to their previous experience and social learning (for overview see Hawton et al, 1989). This concept provides a basis for gaining greater insight into special therapeutic interventions, and should help patients to develop their own lifetime methods of coping with problems.

A patient with a 15-year history of psychiatric illness treated with neuroleptics presented with vomiting, thought alienation, auditory hallucinations and self-neglect. Dopaminergic supersensitivity was diagnosed and increased doses of neuroleptics caused cessation of vomiting. The patient is currently attempting discontinuation of neuroleptics.

Minaprine (200 mg daily, either once or divided b.d.) was compared with amitriptyline (25–50 mg t.d.s.) over six weeks in 144 patients with major depression. Significant reductions in HRSD scores at the end of six weeks' treatment were recorded with both dose regimes of minaprine and with amitriptyline, with no significant differences between them. There was a significantly greater incidence of drowsiness and dry mouth with amitriptyline than with minaprine.

A rare case of Charles Bonnet syndrome, which presented in a 38-year-old man, responded to carbamazepine.

Two cases of self-neglect in adult patients with no psychiatric diagnosis are reported. The presentation included domestic squalor and hoarding of rubbish, with the patients living alone and having a history of schizoid and paranoid personality traits. Both refused all recommended help. A move to more protected accommodation was the only practical measure that led to a degree of improvement.

A group of 25 patients (16 women, 9 men) attending an ENT department with globus sensation and 25 matched ENT controls were assessed using the Beck Depression Inventory and scales for daily stressful events (‘hassles’). Globus patients of both sexes were significantly more depressed than controls and had Beck scores suggestive of significant depression. Thirteen patients, but only two controls, had an independent life event within two months of disease onset, and patients had higher hassles scores than controls.

A 21–year-old woman suffering from bipolar affective disorder developed systemic lupus erythematosus (SLE) with characteristic laboratory findings, 18 months after starting carbamazepine maintenance treatment. SLE receded after withdrawal of carbamazepine and treatment with anti-inflammatory drugs. Although both the spontaneous occurrence of SLE and the psychosis as a sign of CNS involvement of SLE cannot be excluded, SLE could be considered as an adverse effect of carbamazepine.

The psychiatric community seems determined to ground its medical legitimacy on principles that confuse diagnoses with disease. If mental illnesses are diseases of the CNS, they are diseases of the brain, not the mind. If mental illnesses are the names of (mis)behaviour, they are forms of behaviour, not diseases. Psychiatric metaphors have the same role in medicine as religious metaphors have in theology. Religion is, among other things, the institutionalised denial of a finite life. Psychiatry is, among other things, the institutionalised denial of the tragic nature of life: individuals who want to reject the reality of free will and responsibility can medicalise life, and entrust its management to health professionals. Psychiatrists have succeeded in persuading the scientific community, the courts, the media, and the general public that the conditions they call mental disorders are diseases, that is, phenomena independent of motivation or will. The more firmly psychiatrically based ideas take hold of the collective American mind, the more foolishness and injustice they generate. Long ago, the law makers agreed to let psychiatrists literalise the metaphor of mental illnesses. Thus, the Americans With Disabilities Act (AWDA), scheduled to be fully implemented by July 1992, covers claustrophobia, personality problems, and mental retardation, though unlike DSM–III–R it excludes kleptomania, pyromania, compulsive gambling, and transvestism. The literal language of psychiatry allows motivated actions to be called ‘diseases'. Other examples of behaviour for which psychiatrists have disease names, and which AWDA implicitly accepts as genuine diseases, include dysmorphophobia, multiple personality disorder, frotteurism, hypoactive sexual desire disorder, and factitious disorder with physical symptoms. However, it remains an open question whether premenstrual syndrome will achieve similar recognition in DSM–IV. Diseases occur naturally, whereas diagnoses are artefacts; why do psychiatrists make diagnoses?

The discovery of neuroleptics some 40 years ago brought about a revolution in the treatment of schizophrenia. Until then, schizophrenic patients were primarily treated with various forms of coma and shock therapy, and many were permanently confined in psychiatric hospitals. With the availability of neuroleptic medication, however, hospital stays have become considerably shorter and many patients can be returned home for out-patient care. In addition, psychosocial therapy for schizophrenic psychoses could not have been effective without the protective effect of neuroleptics.

A 13-year-old girl was referred because of sexual identity problems. There was no mental illness or neurological abnormalities. As her twin sister had no sexual identity problems, it appears that transsexualism is not transmitted by a simple genetic mechanism.