A significant component of psychiatric practice relates to the management of patients with behavioural disturbance whose aetiology lies in the subtle alteration of brain biochemistry. The major handicap in assessing such patients, both from a clinical and a research point of view has been a lack of suitably sophisticated technology for studying brain function. Despite significant improvements in imaging technique and the development of positron emission tomography we are still lacking tools which assess brain receptor functioning. The neuroendocrine axis provides us with the means of assessing specific neurotransmitters in a safe and relatively inexpensive way. Such an approach is now widely used in research and has considerable potential within a clinical setting.

The fact that classic monoamine neurotransmitters are implicated both in affective disorders and schizophrenia and at the same time control hypothalmic-anterior pituitary function provides the basis for many psychoneuroendocrine investigations. The stimulation of certain central neurotransmitter systems results in the elevation of anterior pituitary hormones. If a pharmacologically selective drug is used, the rise in the anterior pituitary hormone gives some index of the integrity of the neurotransmitter pathway and the sensitivity of its receptor system. This approach is heavily dependent on the development of selective drugs for challenging specific receptor systems. As there are a myriad of potential confounding variables it is essential that there be rigorous control over such factors as gender, age, psychotropic drug exposure, weight loss etc.

The release of growth hormone (GH) from the anterior pituitary is under the control of 2 peptides, namely growth hormone releasing hormone (GHRH) and somatostatin (SS). Noradrenaline acting via the GHRH containing neurones stimulates the release of GH (1,2). We now know that the stimulated release of GH through this mechanism is significantly blunted in patients with major depression (3,4,5). When sone suppression and noradrenergic mediated GH release are both investigated in depressed patients, those subjects who show dexamethasone non-suppression are more likely to demonstrate blunted GH release than those with normal dexamethasone responses (5).

Acetylcholine (ACh) stimulates growth hormone release via the SS method (6). It is now clear that depressed patients show enhanced release when their cholinergic system is challenged with pyridostigmine (7). Overall therefore, depressed patients seem to have a downregulation or under activity of their NA receptors and an up-regulation or over-activity of their ACh receptors.

GH release is also under GABAergic control. In a study of patients with major depression baclofen the GABA-B agonist was used to induce GH release. Baclofen (20 mg) significantly elevated GH levels in all healthy subjects but a blunting of response was seen in those patients with major depressive illness. The finding indicates diminished responsivity of the GABA-B receptor system in depression (7a).

The release of prolactin from the anterior pituitary is under the inhibitory control of dopamine (DA) which acts directly on the lactotrophs of the pituitary. The release of prolactin is stimulated by serotonin (8,9). There is now unequivocal evidence to indicate that 5-HT mediated prolactin release is blunted in major depression (10,11). Such blunting has been demonstrated with a wide variety of probe drugs including 1-tryptophan and fenfluramine. The abnormality is however not entirely specific to depression as patients with obsessive compulsive disorder and sociopathic personality disorder also demonstrate such blunting even in the absence of mood disturbance (12,13).

The first evidence to emerge that central DA receptors might in some way control GH release was demonstrated by the administration of 1-dopa which led to an increase in GH levels (14). GH responses to the DA agonist apomorphine have been reported to be greater in patients with first rank symptoms of schizophrenia, but to be blunted in those patients with significant egative symptoms such as emotional flattening and social withdrawal (15,16).

The very complex neurotransmitter control of such hormones as GH and prolactin provides a window to the biology of neuro-behavioural disturbance. As a tool psychoneuroendocrinology is of relevance not just to the researcher but to the practicing psychiatrist as well.

Objective: To assess the extent of cognitive impairment in a group of female alcoholics and to examine if any relationship was present between the degree of cognitive impairment, and the duration of alcohol dependence, impairment of liver function or associated prescribed medication abuse. Method: The subjects were thirty consecutive women in a residential alcoholism treatment programme who were assessed two weeks after detoxification. The visual reproduction subtest of the Wechsler Memory Scale was used, together with four subtests of the Wechsler Adult Intelligence Scale: vocabulary, similarities, block design and object assembly. We examined the effect on these scales of prolonged alcohol abuse (>5 years), abnormal liver function tests and prescribed medication abuse. Results: The group showed a significant impairment on the subtests, similarities, block design and object assembly when compared with the general population mean for the WAIS-R. Analysis of sub-groups showed little statistically significantly greater impairment on cognitive testing then the remainder of the group. Conclusions: The pattern of cognitive dysfunction for the group indicated subjects had deficits in abstraction, visual spatial and visual motor reasoning similar to previous studies involving male alcoholics. The usefulness of the sub-group comparisons was limited by the small numbers involved and larger studies would help clarify the role of contributory factors in the development of cognitive dysfunction in alcoholic subjects.

Objective: To assess the importance of psychotropic medications in Compulsive Water Drinking (CWD) among psychiatric inpatients. Method: The psychotropic medication regimes of 21 CWD inpatients (16 of whom had a diagnosis of schizophrenia) and 21 age and sex matched control inpatients were compared. The CWD group was selected on the basis of urine specific gravity testing amongst the non-geriatric rehabilitation population of a Canadian psychiatric hospital. Regular and prn medications were compared by type and dose. Results: Both groups had generally similar regular medication regimes. No significant differences were found for any of the more commonly prescribed medications. There was a nonsignificant tendency for more CWD subjects to be given prn psychotropics, likely a consequence rather than a cause of the polydipsia. Conclusion: No significant differences were found between the two groups. However, because of the large number of medications used and the relatively small number of subjects, the study has relatively low power. A larger study, combining the CWD inpatients of several hospitals, would be required to definitely rule out a role for psychotropics in the aetiology of CWD.

Objective: To study the relationship between epilepsy and aggression in a population of severely mentally handicapped people. Methods: Comparing epilepsy and aggression variables in people with epilepsy without aggression, people with aggression without epilepsy, and people with both. The epilepsy variables were: seizure frequency, classification, anticonvulsant drugs, therapeutic drug monitoring, and neuroleptic drugs. Aggression variables were: frequency, direction, type, and neuroleptic drugs. Results: Prevalence of aggressive behaviour was similar in people with and without epilepsy (36%). Partial seizures were less prevalent in people with epilepsy and aggression. People with epilepsy were more likely to manifest unprovoked aggression directed against property. Conclusion: Some episodes of aggressive behaviour in people with epilepsy may be ictal in origin.

Objective: To investigate the relationship between behavioural disturbance and psychiatric diagnosis in male mentally handicapped adults resident in a long stay unit. Method: The case notes of all 144 residents of St. Raphaels were reviewed. Diagnoses were classified according to the International Classification of Diseases Ninth Revision (ICD-9) and grouped into one of four categories Infantile Autism, Functional Psychoses, Personality/Behavioural Disorder and Emotional Disorders. Carers (Senior Nursing Staff) were interviewed using the Adaptive Behaviour Scale Part 2 (ABS Part 2) as a measure of behavioural disturbance in the preceding year for the 144 residents. Results: 56% of residents had significant psychiatric disorder. Those with a psychiatric diagnosis showed increased behavioural disturbance across a wide range of measures (p<0.001) with Hyperactivity, Self Abuse and Violence showing greatest discriminative power. However there was not a relationship between diagnostic category and pattern of scoring on the ABS Part 2. There was a significant relationship between Degree of Mental Handicap and Psychiatric Diagnostic Category (p<0.001). Neither psychiatric morbidity nor behavioural disturbance was associated with epilepsy, age or duration of stay. Conclusions: Mentally handicapped adults in residential care show high rates of psychiatric disturbance. Those with psychiatric diagnoses exhibit a wide range of disturbed behaviours but similar patterns of maladaptive behaviour occur across the spectrum of psychiatric disorders. These findings refer to a male residential population and cannot be generalised to all mentally handicapped.

A patient is presented who resorted to frequent hospitalisation to avoid economic hardships. Psychiatric assessment and admission relieved the medical unit but was achieved at the cost of a valuable psychiatric bed. The question is raised: Is psychiatric hospitalisation an answer?

A case of Asperger's syndrome is presented with evidence of left hemisphere and cerebellar abnormalities.

Fifteen consecutive cases of moderate and severe depression were treated with moclobemide in recommended dosage and followed for six months. Eleven developed excitatory side effects including agitation, insomnia, restlessness and aggressivity; five patients reported unreality experiences. Subject to confirmation, these findings, together with indications of similar side effects in published studies and in non fatal overdose, raise the possibility that the potential of moclobemide to cause excitation in depressed patients refractory to other treatments may have been hitherto underestimated.

Neuroleptic Malignant Syndrome (NMS) is a rare but potentially fatal reaction to neuroleptic medication. Both the incidence and aetiology of the NMS are matters of considerable controversy. We present a clustering of cases of NMS in a distinct geographical area in South Wales. Five cases were reported in an eight month period in 1990 and more recently, a second cluster of three cases occurred in a three week period in November, 1991. We discuss some of the possible explanations for this apparent “epidemic” of cases in South Wales.

Clozapine was substituted for standard antipsychotic drugs in the treatment of 24 chronic schizophrenic inpatients and the response assessed after a mean of ten months. The majority (71%) improved (33.3% markedly), on their previous level of functioning. The response was better in those under 40 years of age, but neither duration of illness nor previous neuroleptic dose appeared to predict response to clozapine. The drug was ultimately discontinued in five (21%) patients – in three because of non-response and intolerance of sedation and in two because of neutropenia.

A case of inappropriate ADH secretion, water intoxication, convulsion and unconsciousness occurring during abrupt withdrawal of benzodiazepines due to the patient under reporting her consumption is described.

The case of a lady who developed a major depressive illness with secondary pathological gambling is described. The gambling was manifest by uncontrolled purchasing of lottery tickets. The inter-relationship between affective disorder and pathological gambling and the effect, if any, of lotteries on pathological gambling is discussed.

Three cases of schizophrenia (DSM-III-R) (l), whilst responding to treatment, exhibit a group of symptoms which had the essential features of “flashbacks”, as described in relation to psychedelic drugs, though there was no evidence of psychedelic drug misuse. Symptoms were characterised by memory flashes of the original psychotic experience, followed immediately by very brief re-experiencing of earlier symptoms, including visual perceptual changes in clear consciousness and full insight. Symptoms were less clear, less severe, but more distressing, than the original episodes. Symptoms were triggered by stress/anxiety, and relieved by an anxiolytic. The association of flashbacks with schizophrenia is discussed.

A case of Koro or the Genital Retraction Syndrome in a young man where the symptom of Koro was secondary to a Major Depressive Disorder is reported here. This is the first such case to be reported from Ireland.

Modern methods of investigation in conscious subjects have shown that in normal brain, language is catered for by several essential areas localised in the frontal and temperoparietal cortex and by widely dispersed neurones that serve subsidiary, specialised linguistic functions. These sensory specific, phonological, articulatory and semantic ‘modules’ are activated in parallel. A relatively limited amount of language heard during the sensitive period, when one or other cerebral hemisphere usually becomes dominant for language, is all that is required for any normal child to develop fluency. The specific details of the code, or ‘set’, developed are dependent on the language of the child's environment; they are culturally acquired, but the propensity for language is inborn. During this sensitive period, two languages may be as easily accommodated as one. In stark contrast to the acquisition of natural bilingualism, after about the age of 10 years, any new language is acquired with difficulty for it must be translated into the individual's established language or languages. If a nation is to become bilingual, full advantage of the evanescent sensitive period must be taken by regularly exposing the pre-school child, rather than the older child undergoing formal education, to two languages.

Objective: The authors were aware of a high level of aggression in their centre and felt that a systematic review of incidents of aggression could be of benefit to both staff and residents. Method: A retrospective review of all incidents over a one year period was performed. Data involving the resident and the incident itself were analysed. An ICD 9 psychiatric diagnosis was attributed to each resident where possible. Results: The results show a large number of incidents, mostly of a minor nature. In almost half the incidents the nurse was the victim. There was a lower number of incidents in January and February. Forty one of the 45 residents involved in incidents had a psychiatric diagnosis. Conclusion: There is a general trend for moving from residential settings to the community. Our results suggest that as time goes on our centre will contain more residents with a psychiatric diagnosis who have a potential for aggression. We suggest ways of coping with this aggression and produce an incident form for recording aggressive incidents.