A case of musical hallucinosis is presented, which failed to respond to neuroleptics but responded to carbamazepine. Parallels with the Charles Bonnet syndrome are discussed.

Multiple personality disorder (MPD) is being diagnosed with increasing frequency, especially in North America. However, soaring estimates of its current prevalence are accompanied by considerable controversy and heated debate. The author presents a number of grounds on which it seems reasonable to base a sceptical view of the validity of this disorder as a naturally occurring diagnostic entity.

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.

Objective: The objective of this study was to analyse general practice referrals to psychiatric out-patient clinics and their relation to practice and patient variables.

Method: Retrospective analysis of new episode attendances at out-patient services over a three year period was undertaken. Referring practices were examined for referral rates, single or group practice and the presence of Vocational/Psychiatric training within the practice.

Results: Referral rates were similar to national rates, but were lower than other jurisdictions. There was a tendency for group practices to have lower referral rates.

Conclusions: There was considerable difference between practices in referral rates. These differences were significantly related to GP vocational training.

A case of delusional disorder in a patient with the demyelinating disease tropical spastic paraparesis is presented. Only one similar case has previously been described. The implications are discussed.

Objective: To examine the service utilisation of a newly opened psychiatric day centre. We wished to determine if different diagnostic groups had different perspectives of the day centre, and to see if the drop-out rate differed among clients with neurotic or psychotic disorders.

Method: Demographic and diagnostic data was gathered for all clients referred in the first year of operation of the day centre. Those who defaulted from attendance were visited at home and asked to detail reasons for non-attendance. Those who continued to attend 16 months after the centre opened completed a satisfaction survey.

Results: The drop-out rate was high for both clients with neurotic and psychotic disorders. Clients who continued to attend were very positive about the day centre. Both client groups saw the benefits of attendance in social rather than therapeutic terms.

Conclusions: Consumer opinion may have a valuable part to play in overall measure,measurement of service quality, particularly if it includes the opinion of those who no longer use that service.

The treatment of psychosis in patients with Parkinson's disease (PD) is one of the most difficult problems in clinical psychiatry. Clozapine's low propensity to induce extrapyramidal side effects makes it an attractive treatment for psychotic patients with PD. A number of published uncontrolled studies suggest that low-dose clozapine is effective in these patients. However, the dose range, side effect profiles and length of treatment have varied in these reports. In this article, the authors review the literature and report on the effects of clozapine in a patient with Parkinson's disease and psychosis. Clozapine (50mg per day) resulted in a complete resolution of psychosis, improvement of motor function, reduction of “off” time and a major improvement in levodopa-induced dystonic dyskinesias. The only adverse effect was mild sedation during the first two weeks of clozapine treatment. The lack of acute blockade of striatal D2 receptors by clozapine and the failure of chronic clozapine treatment to suppress striatal dopamine release may account for its beneficial effect in Parkinson's disease. Additionally, an ameliorating effect of clozapine on parkinsonism might be due to its action on serotonergic systems leading to release of striatal dopamine.

Two separate cases are reported in which a woman believed that her pet dog had been replaced by an identical double. The psychodynamic issues which these reports raise are discussed. In the Capgras delusion the double is usually a key figure in the life of the patient. These reports highlight the fact that this key figure may be a domestic animal.

Objective: An audit of referrals to a child psychiatry clinic is described. The process of asking families to confirm appointments and offering appointments to other families if no confirmation is received was analysed.

Method: Referral information on those refusing appointments offered, whether by declining the offer or by default, was compared with that of families attending first appointments.

Results: Longer waiting times and referral for treatment as opposed to assessment or advice were associated with higher likelihood of appointment refusal

Conclusion: The referral process resulted in a reduction in wasted professional time.

14 patients are described sharing a remarkably similar presentation with chronic perineal and lower abdominal dysaethesias. The abnormal sensations of movements are described. Investigations revealed evidence of central nervous system damage, in particular multi-infarct disease.

Two cases of psychiatric disorder temporally related to the abuse of hallucinogenic amphetamines 3, 4 methylenedi-oxymethamphetamine (MDMA), methylenedioxyamphetamine (MDA) and methylenedioxyethylamphetamine (MDEA) are described, suggesting that a variety of psychiatric morbidity may be precipitated by abuse of these drugs, including paranoid psychosis, mixed affective psychosis and symptoms of obsessive compulsive disorder.

Acute Intermittent Porphyria (AIP) is often accompanied by psychiatric disturbance. Despite routine use of opiate analgesia in the treatment of the acute illness, only one case of dependence is described in the literature. We report a further case where dependence on morphine complicated the assessment and management of a woman with AIP who had been admitted to psychiatric hospital following the death of her child. Clinical implications are discussed.

The clinical and pathological features are described in a case of prolonged dementia in a 59 year old man with familial dementia and extrapyramidal disorder. Postmortem examination showed severe fronto-temporal and basal ganglia atrophy, with many “ballooned neurons” in the residual cortex most likely representing Pick's disease. The differential diagnosis is discussed and aspects of this rare condition are reviewed.

Objective: To examine the evidence concerning the psychological consequences of abortion, the risk of suicide in pregnancy and the psychological consequences for the mother and the child in cases of refused abortion. Method: An extensive literature search was undertaken and key relevant papers were examined and analysed. Results: Legal abortion has become more widely available throughout the western world and the actual reported incidence of cases of refused abortion is low. The majority of studies indicate that the psychological consequences of abortion itself are in the main mild and transient but there is evidence that women who have strong religious or cultural attitudes negative to abortion do experience high levels of psychological stress following abortion. The risk of suicide is low in pregnancy and suicide is a rare outcome of refused abortion. There is evidence of psychological and social difficulties experienced by mothers of unwanted pregnancies forced to proceed to term and by many offspring of such unwanted pregnancies. Conclusions: Definitive conclusions are difficult to draw from the published studies of refused abortion and many studies are over thirty years old.

The traitement moral, or so-called moral treatment, of insanity was instituted in Paris in 1794 by Philippe Pinel (1745-1826), and the fetters were removed from patients in May-June 1797 by Jean-Baptiste Pussin (1745-1811), lay governor of the insane at the Hospice de Bicetre, and by Pinel and Pussin at the Salpetriere in 1800; the chains were replaced by straitjackets or in some cases removed completely. His contemporaries looked upon Pinel as physician, but it is as a revolutionary psychiatrist that he is revered today.

Reports from the United States have linked fluoxetine with suicidality. As a result, litigation is pending, and the matter has recieved much media attention. There is no acceptable evidence to support the hypothesis that fluoxetine promotes suicide.

We describe an adolescent boy who presented with physical symptoms, for which no organic cause could be found. He proved a challenge to medical management and we highlight the reluctance to consider making a diagnosis of conversion disorder. Significant medical contact since infancy, a history of sexual abuse, and current stressors are considered as having contributed to his presentation. We discuss general issues in the management of conversion disorder and consider the risks of neglecting this diagnosis as technological advances are made and sophisticated investigations are relied upon.