Woodbury (1918) described the manifestations of Graves' disease as fatigue, irritability, intolerance to heat, fine tremor, restlessness, insomnia, excitability, labile emotional disposition, nervousness, weight loss, palpitations, doubts, and fears. Similarly, Sachar (1975) included nervousness (manifested as apprehension, restlessness, and inability to concentrate), marked emotional lability, and hyperkinesis as the most common presenting symptoms. That fatigue, irritability, emotional instability, and excitability are all common features of the hyperthyroid state, as are episodes of severe and often disabling anxiety, is therefore, accepted. On the other hand, no clear picture exists concerning any fixed constellation of psychotic symptoms or progression of psychiatric disease. The psychiatric presentations vary from a delirious state to periods of hyperexcitability simulating mania that alternate with periods of exhaustion and depression. Greer & Parsons (1968) reported that some patients do. however, develop a clear schizophrenia-like picture, closely associated with the course of hyperthyroidism, with prominent paranoid symptoms and no pre-morbid history of psychosis.

Depression is common in Huntington's disease. It is customary to treat such patients with tricyclic antidepressants, although there is disagreement about their effectiveness. The use of monomine oxidase inhibitors for depression in HD has not previously been reported; three cases are described here. MAOIs appear to be of value in the management of depression in HD.

The response of patients with major depressive illness to citalopram of amitriptyline was compared in a double-blind multi-centre trial. No differences in efficacy were observed, but citalopram had less hypnotic effect and a remarkably lower profile of side-effects.

A doctor is trained, perhaps over-trained, to try to limit his diagnosis to a single disease process or entity. This may lead on occasion to a somewhat blinkered approach to the management of patients. The following case illustrates multiple and concomitant pathology in a single individual.

I first came across this particular book during my training at Boston City Hospital in 1970. It was by that time 12 years old. Skinnerian operant conditioning was the rage in the psychological and psychiatric circles; reciprocal inhibition seemed at the time to be considered passe. The psychoanalysts had already discounted any suggestion that the only effect of insight-oriented therapy was to provide a therapeutic setting in which reciprocal inhibition took place. Behaviour therapists were busy working out complex positive and negative reinforcement schedules for illnesses as diverse as schizophrenia and alcoholism. Dr Laing put in an appearance in Boston at that particular time, extolling the virtues of the existential benefits of madness. But, I imagine that in its day, this book was highly controversial, since it challenges the central premise of psychoanalysis-that the essence of psychotherapy is uncovering and expression of the repressed.

A young male castrated himself in response to the biblical passage, Matthew 19:12. Although extremely rare, autocastration usually occurs in men with chronic paranoid schizophrenia, with a long history of delusions of sexual guilt which can only be relieved by castration. Management of these patients is long-term, involving both pharmacotherapy and individual and family therapy.

This is the first reported case of anorexia nervosa in association with Klinefelter's syndrome. Although the patient was initially diagnosed as suffering from ‘atypical’ anorexia nervosa, Klinefelter's syndrome was cytogenetically proven and other organic pathology ruled out.