The neuropsychiatric effects of corticosteroids are well described in the literature but relatively little is known specifically about their effects among older people. As the population ages, and increasing numbers of older people receive assertive medical treatment for physical conditions, more patients are likely to present to psychiatric services suffering from adverse neuropsychiatric effects associated with corticosteroid use. A review of the effects of corticosteroids among older people was carried out through Medline and PubMed searches and a review of article references. Very little has been specifically written about steroid use and the effects on older people. This paper briefly outlines the current level of knowledge of neuropsychiatric effects of steroids, and relates this to general treatment considerations for older subjects. Recommendations for further research and early identification of complications are made.

Objectives: To examine baseline testing and ongoing monitoring of cardiovascular and other risk factors in individuals prescribed atypical antipsychotic medications.

Methods: We derived a list of baseline and ongoing monitoring tests from the literature (Weight, BMI, blood pressure, U&E, LFTs, glucose, HbA1C, FBC, TFTs, prolactin, lipids & ECG) and then reviewed a random sample of 80 records of patients prescribed atypical antipsychotics and currently attending an Irish public catchment area service, for evidence of testing.

Results: Levels of testing for baseline tests ranged from 45% for blood pressure to 0% for BMI. Levels of ongoing monitoring tests ranged from 42.5% for U&E to 0% for BMI. Patients admitted to hospital were much more likely to have had testing.

Conclusions: The need for baseline and ongoing monitoring of certain tests in patients prescribed atypical antipsychotics is increasingly accepted. Levels of such testing are currently quite low and need to increase.

Objectives: To assess school refusal (school phobia) outcome in adult life.

Method: A 10 year follow-up used questionnaires completed by the target group of young adults and their parents and telephone interviews with their parents. Comparison groups were used.

Results: Psychiatric disorder was present in 30 % and caseness in a further 20%.

Conclusions: There is a need to identify interventions with long lasting effectiveness in this childhood disorder.

Objectives: This study was carried out to determine the prescribing of psychotropic medication of non-consultant hospital doctors in the management of delirium and to compare this with best practice guidelines.

Method: A structured questionnaire was forwarded to all non-consultant hospital doctors (n = 95) working at St Vincent's University Hospital and data was collected over a six month period. The questionnaire addressed type, dose and route of psychotropic medication use in delirium as well as adjunctive measures used to manage delirium.

Results: There was a 55% response rate (n = 52). Haloperidol and lorazepam were the two most frequently prescribed psychotropic agents used and over one third of respondents (n = 20) reported the use of risperidone. There was wide variation in doses used and a substantial proportion of NCHDs used higher than recommended starting doses for elderly patients with delirium. In addition, the intramuscular route was reported as the commonest route of administration with a majority of respondents reporting infrequent intravenous route of administration.

Conclusions: The drug choice reported by respondents followed best practice guidelines. However, the wide variation in drug doses used and frequency of parenteral route of administration (particularly intramuscular) indicate the need for increasing awareness of best practice international guidelines. Guidance and clarification regarding the use of atypical antipsychotic medication is required following concerns about their use in dementia.

This report describes a case of folie à famille in which an African man (Mr X), his wife and three daughters travelled around the world as Mr X transmitted his persecutory delusions to his family members. Mr X who had previously had two brief admissions in the UK and in Ireland, received an adequate trial of antipsychotic treatment in his third admission with us in Dublin. During informal contact with his daughter B, it became apparent that the whole family shared his delusions. On her advice, the other family members voluntarily consented for assessment and psychological interventions, they were interviewed separately. All the family members recovered following separation and psychological interventions without antipsychotic treatment. This case illustrates folie imposée, one of the four subgroups summarised by Gralnick1 from the 20th century literature. This family undertook an extreme measure of travelling around the world because of their induced delusions.

With advancements in medical science over past decades, our aging population has increased substantially. Census studies in 2001 showed that 429,100 of the population of the Republic of Ireland were aged 65yrs and older, making up 11.2% of the overall population. While the overall population of the Republic is expected to remain stable over the next ten years, the demographic projections for the elderly population is for significant growth: numbers of over 65yrs are expected to increase by nearly 108,000 people between 1996 - 2011, comprising over 14.1% of the overall population. In particular, our communities will contain a much higher proportion of octogenarians and nonagenarians: at present 21% of our over 65's are 80 yrs or older; by 2011, it is projected that this number will increase to 25%. In tandem, the prevalence of dementia will increase.

In 2000, it was estimated that 31,000 people suffered with dementia in the Republic of Ireland, and this figure is expected to increase by 5000 cases per year between 2001-2011. The ultimate outcome of this demographic shift, will be higher demands on medical services for older people, especially geriatric medicine and old age psychiatry. This paper will focus on two particular aspects of management which will increasingly impact on the work of old age psychiatrists – medicolegal issues and management issues in dementia.

Autistic spectrum disorders (ASD), are a group of disorders characterised by qualitative abnormalities in social and emotional behaviour and are associated with restricted, stereotyped and repetitive interests and activities. There has been considerable understanding of ASD in recent years. This educational review paper focuses on four areas of interest and relevance to trainees preparing for the membership examination of the Royal College of Psychiatrists (MRCPsych): (a) diagnosing ASD; (b) epidemiology of ASD; (c) aetiology, including genetic, cognitive and neurochemical/neuropathological theories in ASD; and (d) treatment of ASD. Relevant papers are discussed and recommendations for further reading are provided.

Objectives: To examine potential reasons for poor attendance at the lecture programme and exploring possible alternatives to existing course structures.

Method: A postal questionnaire was circulated to all basic specialist trainees and consultants in the Irish Psychiatric training committee Eastern Region

Results: Response rates were 73 % and 44 % for consultants and trainees respectively. Respondents expressed concern about the content, relevance and structure of the current lecture programme.

Conclusion: Change is required to the current lecture programme which should give due consideration to the opinions of trainees and consultants. A number of suggestions are made based on the study findings.

The association between intellectual disability and offending is complex. Recent evidence would suggest that the received wisdom of intellectually disabled persons being more prone to offending is either incorrect or only tells part of the story. Those within the ‘borderline’ intellectual disability range may be more prone to committing sexual and criminal damage offences but those with an IQ less than 50 rarely offend.

The offender with intellectual disability shares characteristics with his counterpart from the general population. As with the general population as a whole, offending in this group is often unreported and its recognition is complicated by issues of competence. The lack of validated forensic assessment schedules for this population poses a further challenge. Some general approaches to assessment in this population are discussed. This case report illustrates the difficulties of assessing and managing offending behaviour in an individual with moderate intellectual disability. The challenge of treating offenders with an intellectual disability is immense and requires specialist expertise. Managing such cases in a generic setting is inappropriate and the need for a forensic learning disability service in Ireland is highlighted.

There have been considerable advances in the understanding of schizophrenia in recent years. This educational review paper focuses on three areas of interest and relevance to trainees preparing for the membership examination of the Royal College of Psychiatrists (MRCPsych): (a) recent advances in the genetics of schizophrenia; (b) advances in cognitive behavioural therapy in schizophrenia; and (c) advances in early intervention strategies for schizophrenia. Relevant papers and systematic reviews are discussed, and recommendations for further reading are provided.

Body dysmorphic disorder (BDD, previously called dysmorphophobia) is an excessive preoccupation with trivial or non-existent physical abnormalities, perceived to be deformities. BDD causes significant distress or functional impairment and is both time-consuming and difficult to control. Feelings of low self-esteem, shame, embarrassment and unworthiness are common, as is fear of rejection. This report presents a case of BDD in a young male who sought surgery abroad in an effort to ameliorate his perceived deformity. His suicidal ideation, low mood and anxiety symptoms responded well to venlafaxine, olanzapine and cognitive behavioural therapy; however his overvalued ideas with regard to his physical appearance were slow to improve.

Fifty years ago, on July 13, 1955, Professor John Dunne delivered his presidential address to the annual meeting of the Royal Medico-Psychological Association in Dublin, focussing on the contributions of ‘the physical sciences to psychological medicine.’ In his address, Professor Dunne discussed (a) the principle of conditioning, and the work of Hans Selye, especially in relation to ‘General Adaptation Syndrome’ and the role of stress in producing psychosomatic symptoms; (b) cybernetics and the generation of partial models of cerebral functioning, such as Grey Walter's Conditioned Reflex Analogue and the Electronic Delayed Storage Automatic Computer of Cambridge and (c) the development of integrated, holistic models of cerebral functioning, that took account of advances in both physical medicine and psychoanalytic thought. Professor Dunne placed particular emphasis on the importance of basic scientific research and the development of broadly based models of psychiatric care, both of which were to play critical roles in the development of more scientifically-based, bio-psycho-social models of service provision in the decades to follow.

‘Handedness’ as an expression of cerebral lateralisation is valuable in analysis of hemispheric asymmetries, carrying implications for implementation (as well as interpretation) of complex cognitive functions. In recent decades it has become possible to categorise handedness in a reproducible manner and, independently, to estimate accurately the degree of language lateralisation of the brain. These advances have re-focussed attention on cerebral organisation and hemispheric asymmetries, and there is now considerable interest in the neuropsychology of left-handedness. Because of procedural and ethical constraints there are relatively few large scale studies on language dominance, whereas handedness has been studied extensively in recent decades. Language is represented in the left hemisphere in all but 1% of right-handers, and in 60% of left-handers; in 15% of right-handers speech representation was bilateral.

Precise determination of handedness or lateralisation does not appear to have been assessed in major studies of electroconvulsive therapy (ECT). Results in 29 reports, when the electrodes were placed over either the non-dominant or both hemispheres, were tabulated and briefly discussed by d'Elia and Raotma, but the criterion of lateral dominance assignment was not clearly specified; the unilateral and bilateral placements were equally efficacious in their antidepressant effect. d'Elia, who introduced unilateral therapy in 1970, accepted the assumption that the left hemisphere was ‘dominant’, but later workers were more circumspect.

Clozapine is associated with a risk of myocarditis and cardiomyopathy. The exact mechanisms still remains unclear although there have been a range of proposals ranging from hypersensitivity reactions, toxic effects of the drug to vitamin deficiency. We present three cases where there were minor deviations of heart function or structure prior to the onset of clozapine treatment. One case developed a mild rise in troponin-1 levels within one month of clozapine treatment. We also review the current literature on the link between clozapine, myocarditis and cardiomyopathy and suggest clinical guidelines for monitoring patients for cardiac symptoms prior to commencing and while on clozapine treatment.

We report a case of erotomania with onset coinciding with a cerebrovascular accident in a 65-year-old woman. She believed Dick Haymes, a famous singer and actor who died in 1980 was in love with her, visited her and wanted to have sex with her. It is argued that the erotomania stemmed from an interaction between the frontotemporal impairment due to the cerebrovascular accident and personality factors.

A 19 year old girl developed an immediate psychotic reaction following IV clarithromycin (Klacid). She responded to atypical antipsychotics but needed psychiatric hospitalisation. She recovered after a year and is now symptom free without any medication. This is a rare side-effect but needs to be recognised.

London born James Henry Pullen (1836–1915) was admitted to Essex Hall in Colchester, an institution catering for learning disability, at the age of 13. Here his artistic talent was spotted before he moved two years later to Earlswood Asylum for Idiots, where he was apprenticed to woodworking. Such was his manual skill he was eventually employed making furniture for the asylum. His artistic propensity was similarly encouraged and although he never mastered coherent speech he has left a pictorial autobiography of some distinction. At observation he underwent detailed examination by Frederich Sano (1871–1946), particular attention being paid to tokens of arrested development. The clinical and pathological evidence of a pervasive developmental disorder points to a retrospective diagnosis of autism.