The Problem

Over the last two decades increasing attention has been paid to the rights and safety of the subjects of clinical research. A key safeguard against any abuse has been the requirement to obtain the subject's informed, valid or true consent, which has been defined by the Medical Research Council as ‘consent freely given with proper understanding of the nature and consequences of what is proposed’ (M.R.C., 1962–3). However, it has been recognized by the M.R.C. that it may not be possible to obtain such consent from, among others, some subjects who are mentally ill. Whether or not a research project should be carried out on such subjects should depend, they say, on whether or not ‘there are reasonable grounds for believing that a particular new procedure will contribute to the benefit of that particular patient…’, and further, ‘when true consent cannot be obtained, procedures which are of no direct benefit and which might carry a risk of harm to the subject should not be undertaken’ (M.R.C., 1962–3).

On the basis of reports of reduced MAO activity in migraine and cluster headaches and on a report that lithium carbonate activates MAO, the authors administered lithium carbonate to two patients whose cluster headaches had brought them to the point of contemplating suicide. Both patients responded quite dramatically. Case 1 has now been virtually free of headaches for over two years and Case 2 has been in remission for over twelve months.

Transsexuals are defined as subjects who have a sustained feminine gender identity combined with a wish to alter their bodily appearance towards the feminine. The results of this study indicate that they can be differentiated into two clinically discrete groups.

In an investigation of 29 transsexuals who sought a change of sex operation it was found that those who had experienced fetishistic arousal were significantly more likely to be older, to have experienced heterosexual intercourse, to be married and to show penile responses to pictures of men and women indicative of a more heterosexual orientation. They had less experience of homosexual contact to orgasm as compared with transsexuals who had not experienced fetishistic arousal, but this difference was not statistically significant. Frequency of cross-dressing, strength of feminine gender identity and intensity of desire for a sex change operation did not discriminate the two groups. The fact that desire for a sex change operation may be associated with experience of fetishistic arousal could be one reason for the higher incidence of transsexualism in men than in women.

Two drug trials in schizoaffective patients are reported. Nineteen ‘schizomanic’ patients were treated for one month, on a double blind basis, with chlorpromazine or lithium and 41 ‘schizodepressive’ patients with amitriptyline, chlorpromazine or both.

In the schizodepressive patients there was a trend to a better response to chlorpromazine, but drug response generally was poor, only 20 per cent of patients recovering within the month. In the schizomanic patients lithium seemed as effective as chlorpromazine, which supports the view that these patients were suffering from a variant of mania.

Assessment of cognitive and behavioural disability on 100 elderly psychiatric admissions was carried out by means of the Clifton Assessment Schedule and the Shortened Stockton Geriatric Rating Scale. The results provided useful predictive indices, confirming the relationship between cognitive impairment and unfavourable outcome at two-year follow up.

Brain membranes from rat and human contain a single class of brain specific binding sites for pharmacologically and clinically active benzodiazepines. There is good correlation between the pharmacological effects of benzodiazepines and the affinity for the 3H-diazepam binding site.

Benzodiazepine binding sites are not present on glial cells. Selective neuronal degeneration experiments in rats indicate a neuronal localization. 3H-Flunitrazepam is a very suitable ligand for affinity binding and it binds to the same class of binding sites as 3H-diazepam.

Our results indicate that the in vitro3H-diazepam and 3H-flunitrazepam binding sites are the receptors which in vivo mediate various pharmacological and clinical effects of benzodiazepines.

Benzodiazepines bind with high affinity to a specific benzodiazepine receptor, which occurs exclusively in the central nervous system. The affinity of various benzodiazepines to the receptor closely parallels their pharmacological and therapeutic potency. Binding to the receptor is stereospecific. The receptor is mainly localized in the synaptic membrane fraction and has its highest density in cortical areas of the brain. In Huntington's chorea a decrease in benzodiazepine receptor binding is found in caudate nucleus and putamen, which, at least in putamen, is due to a loss of benzodiazepine receptors apparently located on GABA neurones, which degenerate in Huntington's chorea. The loss of benzodiazepine receptors might explain why the ameliorative effects of benzodiazepines in the early stages of the disease are not sustained in the later stages.

A therapeutic trial with chlorpromazine was conducted with a homogeneous (for age and sex) group of recently admitted schizophrenic patients. Extrapyramidal effects were measured through quantitative analysis of digital tremor, after four days of fixed-dose treatment. Assessment of treatment efficacy was based on Brief Psychiatric Rating Scale ratings, done at the end of four weeks' treatment. Those patients whose tremor was least affected by drug were most likely to benefit from the treatment. Implications of this negative correlation for our understanding of the neuroleptic hypothesis and the closely associated dopamine hypothesis of schizophrenia are discussed.

—Previous reports of sexual orientation and gender identity in subjects with XYY karyotype are reviewed. Two patients seeking a change of sex operation and found to have an XYY karyotype are described. It is argued that an XYY karyotype may predispose to a disturbed gender identity and possibly to the development of the transsexual syndrome.

A recurrent nightmare of 14 years' duration rapidly disappeared after it was rehearsed repeatedly in treatment. The nightmare was independent of co-existing compulsive rituals and sexual problems, but was related to co-existing depression.

The Delusions-Symptoms-States Inventory (DSSI) was administered to 33 chronic non-paranoid schizophrenic patients resident on long-stay wards. It was found that the vast majority of cases (81 per cent) produced symptom patterns conforming to the hierarchy of classes of personal illness model, but with a radically different distribution among the classes from that in acutely ill patients. Within the model a half of the patients were allotted to the two lowest classes—Class 0 (Symptom-free) and Class 1 (Dysthymic States). When each set of items was considered separately and independently of the model, it was found that a half of the group professed to have recently experienced delusions. Affective states and depressive symptoms were reported by over a third of the patients.

Psychotropic drugs are but one of our tools in treatment and when appreciating articles or books about these compounds, it is always stimulating to see that the author(s) know as much about people and the disorders they are treating as about the drugs which they are using. It is also helpful when the separation between symptomatic and curative treatment is made, and “comfort” and “cure” are distinguished. Papers which help doctors help patients rather than those of somewhat esoteric interest have more appeal, and I think we may ask: Does the author relate this to the work of the clinic and ways to assist the next patient?

Twenty-five schizophrenic patients with tardive dyskinesia were given 600 mgs sodium valproate daily with their neuroleptic medication. After one month there was no change in their signs, as judged by a panel of nine viewing films of them taken before and at the end of this treatment.

The term forensic psychiatry is used broadly here to describe the involvement of the psychiatrist at any stage—pre-trial, during the trial, or post-trial—of the legal process, whether this be criminal or civil. In its widest sense, it is also concerned with the procedures associated with the Mental Health Acts. The subject interdigitates closely with general and adolescent psychiatry, mental handicap, criminology, sociology, social work, psychology, legal studies, alcohol and drug dependence studies. Accordingly, reading in forensic psychiatry must necessarily carry the student into such related fields.