We report the case of a 48 year old woman who presents with a 25 year history of somatisation disorder. She has ten volumes of notes from four hospitals in one city which together weigh almost 10kg. She has been under the care of ten hospital specialities, had eleven operations, with 77 admissions and a total of 856 days in hospital over a period of twenty-five years. No physical diagnoses can satisfactorily explain her presentations which have been accurately costed to a total of over £250,000 as a conservative estimate.

Somatisation disorder is a chronic illness with financial, medical and personal costs. We report in detail recurrent dangers and pitfalls which arose during her hospital contact. By undertaking a case note review, contacting all the physicians involved and writing a “Key” summary letter outlining the contribution of psychological factors to her problems, her annual health care costs were reduced from a total of over £10,000 a year to a little over £2,000 after psychiatric intervention and the appointment of one physician to take overall charge of her case. Implications for service provision are discussed.

Objectives: Patients with schizophrenia are known to be at higher risk than the general population of cardiovascular disease. Clozapine has been associated in the literature with high levels of cardiovascular risk factors such as weight gain, diabetes, hyperlipidaemia and hypertension. We set out to determine the prevalence of these risk factors in a population of Irish psychiatric patients.

Method: In February 2006 we measured body mass index, fasting blood glucose, haemoglobin A1c (HbA1c), lipid levels, mean blood pressure and smoking rates among all outpatients prescribed clozapine attending an urban, community based mental health service.

Results: There were 50 outpatients (33 male; 17 female) on clozapine and they had been taking it for a mean of 5.4 years (mean daily dose 428.8mg). The mean body mass index was 28.3. Patients had gained a mean of 8kg since commencing clozapine. One patient had been diagnosed with diabetes. Of the other 49 none met diagnostic criteria for diabetes. The mean fasting blood glucose was 5.5mmol/l and the mean HbA1c was 5.7%. One patient was on treatment for hyperlipidaemia. The mean fasting cholesterol among the other 49 patients was 5.4mmol/l, while the mean fasting triglycerides was 2.1 mmol/l. Thirty (61.2%) had a fasting cholesterol greater than 5.0mmol/l, while 18 (36.7%) had triglycerides of greater than 2.0mmol/l. Three patients were on treatment for hypertension. Thirty-six of the 50 (72%) smoked (mean 13 cigarettes per day).

Conclusions: The prevalence of obesity, diabetes, hyperlipidaemia and hypertension in this population was high but lower than might have been expected from US studies. It is important that cardiovascular risk factors are closely monitored and actively addressed in this at risk population.

Objectives: Primary care teams have the potential to deliver much of the care currently provided by specialist services. The aim of this review was to determine from patients' clinical records and multidisciplinary team discussions, those that may be suitable for discharge back into primary care.

Methods: A retrospective review of the clinical notes of all patients attending a psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to determine the appropriateness of continuing to provide psychiatric services in a specialised psychiatric clinic rather than in a primary care setting, taking into account the patients demographic and clinical variables.

Results: It was recommended that 60% of all the patients needed to continue attending the local mental health service, 35.2% could be discharged back into primary care for continuing management whilst the remaining 4.8% could be managed jointly between primary care and the community mental health service. The bulk of the patients recommended for discharge into primary care had a diagnosis of anxiety disorder or depression and all of them had been stable on their treatment for more than six months.

Conclusion: Regular multidisciplinary team review has a potential to identify patients who could be discharged back into primary care.

Anorexia nervosa in males is relatively uncommon and therefore is difficult to research. Nevertheless, the study of such cases is important and may yield valuable clues to the aetiological mechanisms and expression of this disorder. This study compared the characteristics of 12 males with primary anorexia nervosa with 36 female anorectics. The pattern of the disorder was remarkably similar in both sexes. Our findings are discussed with relevance to the available literature on this topic.

We present a case of the Charles Bonnet syndrome the onset of which appears to have been associated with vascular pathology. The syndrome typically involves the appearance of mute, colourful and pleasing visual images with the retention of insight into their hallucinatory nature. However, the case progressed in a very atypical way and a system of paranoid delusions developed around the visual hallucinations. The syndrome is reviewed and the possible reasons for the atypical course discussed.

Objectives: People with schizophrenia are at increased risk of cardiovascular and endocrine disease. National guidelines recommend the physical health of people with schizophrenia be monitored by primary care, but little is known about whether such people attend primary care. We sought to examine the prevalence of cardiovascular and endocrine disease in a stable population with schizophrenia, and factors associated with attending primary care.

Method: A cross sectional survey of people with a diagnosis of schizophrenia/schizoaffective disorder was taken from a larger cohort participating in the Resource for Psychoses and Genomics in Ireland (RPGI) study. Participants were interviewed using standardised clinical assessments, and underwent anthropometric measurements, and further information was collected by medical record review and contacting the general practitioner (GP).

Results: Thirteen percent (n = 14) had established cardiovascular disease and 4.3% (n = 4) had type 2 diabetes. Risk factors for cardiovascular disease and type 2 diabetes were higher than the general population. Sixty-eight point five percent (n = 63) had attended their GP at least once in the previous year. Only 35% self reported a physical illness. Females (p = 0.03), those with both self-reported presence of physical illness (p = 0.007), and diagnosed physical illness (p = 0.001) were more likely to attend their GP. Other psychosocial, psychological and illness related variables did not predict attendance at primary care.

Conclusion: While established patients attend their GP, they had significant unidentified risk factors for cardiovascular disease and type 2 diabetes. It is likely that non-attendees at secondary care would fare worse yet.

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) differ from almost every other psychiatric diagnosis in that they may only be diagnosed with reference to an aetiological event – an external traumatic stressor. ASD occurs immediately after the stressor and is comparatively short-lived, while PTSD is a prolonged abnormal response that may take months to develop. The types of stressor leading to ASD and PTSD are identical and were intended to be tightly defined, involving a perceived threat of death, serious injury or loss of physical integrity.

It is useful initially to distinguish ASD and PTSD from adjustment disorders, which are also diagnosed only after an observable life event. An adjustment disorder may be thought of as a gradual and prolonged response to stressful changes in a person's life. The range of stressors precipitating an adjustment disorder is potentially much broader than that precipitating ASD or PTSD, as a threat of death or injury is not needed.

Indeed, a ‘threat’ as such is not needed, as the event may be a loss. Events such as job loss or the breakup of a relationship may lead to an adjustment disorder, as well as threats such as accidents or assaults. The diagnostic criteria for adjustment disorder do not specify what the immediate response, if any, to the precipitating stressor must be.

Objectives: Rapid cycling mood disorder is an important clinical phenomenon. The concept of rapid cycling has evolved since it was first described in 1974. The purpose of this review is to summarise current diagnostic criteria, postulated risk factors and suggested management strategies.

Method: A Medline and Psych-Lit computerised literature search was supplemented by tracing back through the references from existing review work.

Results: Over 80 papers were identified which discussed diagnosis and management of rapid cycling.

Conclusions: DSM-IV provides a useful but narrow definition of rapid cycling. Standard treatment of affective disorder may exacerbate rapid cycling. If a rapid cycling course develops, discontinuation of antidepressants and use of mood stabilisers is recommended.

Clozapine is an atypical anti-psychotic medication that has proved useful in the management of both psychotic and mood disorders and that has been shown to decrease aggression and the risk of suicide, which suggests that clozapine may be useful in the management of severe borderline personality disorder. Here we present the case of a 36 year old female with severe borderline personality disorder with symptoms of psychosis, aggression and violence. We discuss how treatment with clozapine resulted in a marked clinical improvement in this patient.

Interest in the process of reminiscence has increased in recent years. This article reviews changing attitudes to reminiscence and the various theories as to its function. Some clinical applications are discussed, in particular its potential therapeutic value in dementia.

Objectives: In an earlier qualitative study we explored the attitudes of young men aged 15-19 (Group A) to mental health and, in particular, to engaging with the various mental health services available. We found that the participants perceived stigma in connection with mental ill health and they displayed particularly strong negative attitudes in relation to both doctors and medication. The investigation was then repeated with students who had been given a short (less than two-hour) programme called ‘Beat the Blues’ (BTB) about mental health (Group B) in order to assess the effect of that exposure by comparing the attitudes of the two groups of students. This present phase of the analysis is a quantitative examination of the written responses by both Groups A and B to an administered questionnaire.

Methods: A total of 42 young men took part in eight focus groups held in boys-only Dublin secondary schools, described in Burke et al. A questionnaire, administered to each participant, examined the students' attitudes to depression and mental illness. The results were analysed by computer using SPSS to search for any trends and any contrasts between groups A and B and among the different socio-economic groups (SEGs) within the sample.

Results: Almost no statistically significant differences were found between groups A and B. However, some differences were found among the SEGs. In particular, very significant differences (p < 0.01 in each case), were found in attitudes towards depression, with increasing support for statements such as “People with depression just need to snap out of it”, “Drinking alcohol can help cure depression” and “Depression is only an excuse for laziness” found among the lower SEGs. A very high percentage of students indicated their desire to talk to someone in times of personal stress; this was almost always their best friend or their mother. However, most students said they would be uncomfortable if a friend raised such a topic.

Conclusion: The main conclusion – that a single exposure to a positive programme about depression produces little or no effect – is hardly unexpected. Nonetheless, there are indications of a great willingness among older secondary students to learn about and discuss mental health issues. Furthermore, the highly negative attitudes among students from the lowest socio-economic group in this study would seem to indicate that the greatest need for education about mental health lies with working-class adolescents. Hence, it is recommended that a programme of multiple interventions be introduced into the senior cycle of secondary education.

This paper considers recent research on suicide risk assessment to support calls for a ‘rethink’ of our assessment of the patients in our care, along with the adoption of a more collaborative approach to care planning with service users who remain at risk of self-harm and in need of a plan for their safety.

This edition of Irish Journal of Psychological Medicine is a Special Themed Issue on Autism Spectrum Disorders (ASD). Mental health services are not currently meeting the needs of autistic people across the lifespan. We have limited evidence based treatments for core symptoms and comorbidities and there is lack of awareness and under-recognition of ASD, particularly in adults and certain groups of individuals. The key themes in this edition focus on challenges with recognition and diagnosis and address these from both clinical and research perspectives. Co-occurring conditions also feature, which are also under-recognised and can contribute to less optimal outcomes. New and existing research developments in stratification for clinical trials and neuroimaging are also discussed. We hope this Issue highlights relevant current issues in ASD, and provides insights which can help address the challenges in providing evidence based pathways to better meet the needs of autistic people into the future.