Australian & New Zealand Journal of Psychiatry

Since psychosis occasionally leads to behaviour requiring constraint, psychiatrists are involved in decisions which may lead to loss of liberty. In some places and at some times psychiatrists and their predecessors have made those decisions unrestrained. This essay considers how we have used that power in the past, indicates some of the abuses extant now, recognises that there is no satisfying solution to the problems which exist and argues for the consistency of the legal system with all its limitations rather than the uncertain and unrestrained judgment of individual psychiatrists.

The question of whether sex offenders should be punished or treated is currently receiving serious attention from health, welfare and correctional authorities. Considerable enthusiasm is being expressed for the apparent advantages of treatment. It has been argued that treatment of offenders is more likely than punishment to reduce further offending and is consequently better for the community and more cost effective. This review looks at some of these issues, especially as they affect young sex offenders.

When deciding which treatments are of benefit, results from placebo-controlled trials are conventionally preferred above all others, and treatments not supported by such trials are viewed sceptically. In this paper it is argued that while randomised controlled trials are desirable they are not always informative. Other, less robust, research designs can be acceptable when they provide independent evidence that their results are not invalidated by remission, regression to the mean, or placebo effect, particularly if they provide post-treatment follow-up assessments. Even when there are difficulties with a research design one can reasonably conclude that the treatment was responsible for the improvement provided a standard treatment was delivered, patient compliance was good, and a dose-response relationship was identified.

The GHQ-28 was validated against the short PSE in a New Zealand community study of female psychiatric morbidity. The GHQ-28 total scores were significantly correlated with the PSE scores. Higher coefficients were obtained using the scoring method of Good child and Duncan-Jones than with the standard scoring method. In this data set, the 3/4 cutoff had the best sensitivity and specificity. The correlations of the GHQ-28 subscales with ICD diagnostic classes and ad hoc PSE sub-scores were also statistically significant. Because the distribution of the GHQ-28 scores is positively skewed, non-parametric statistics may be preferable to the traditional Pearson's correlation coefficient. Overall, the results from this study confirm the GHQ-28 to be a valid and practical screen for presence or absence of psychiatric disorder in New Zealand women.

A brief historical introduction to developmental psychology puts twentieth century views into perspective. The ideas of continuity, critical periods and predictability are examined. The case for a developmental perspective of human development is argued, and the tenets underlying such a model are suggested. The utility of the study of human development is discussed.

The self's contrary needs for separateness and for belonging are introduced as a significant polarity in the developmental process, and one which narcissistic persons have failed to resolve in a particular way resulting in a sense of self-distinction but with increasing alienation. Clinical material and material from literature are used to demonstrate this, as well as to raise the possibility that transformations of narcissism sometimes can occur quite quickly. The theoretical implications of this possibility are considered and Jungian ideas put forward as a possible explanation. Finally, brief consideration is given to the practical consequences for therapy that could follow if this understanding has some validity.

School refusal is a complex phenomenon that has been subject to definitional and diagnostic confusion. The aetiology of school refusal remains incompletely understood; heterogeneity rather than homogeneity prevails. In the behaviour management of school refusal, the clinician may plan either a gradual or rapid school return. Although a graduated return to school may be necessary in certain cases, secondary complications are minimized by an immediate return to school. Both graduated and rapid treatment require a flexible and integrative approach drawing on classical, operant and vicarious conditioning principles. Little research has been conducted on the effectiveness of the behavioural management of school refusal, as well as psychological adjustment to school.

This paper examines the suicide trends in Australia from a sociological perspective using a selected number of sociological variables. Our aim is not to minimize the importance of psychogenic factors in suicide but to highlight its sociological aspects. The analysis of suicide trends shows that the overall suicide rate in Australia has remained fairly stable over the past one hundred years. This outward stability, however, camouflages some important internal changes in the suicide trends in Australian society. The paper examines some of these trends and provides a profile of some of the possible sociological factors which appear to have influenced the suicide rates of men and women in Australian society between 1880 and 1985.

The use of seclusion within a psychiatric intensive care unit in a South Australian metropolitan mental hospital was documented over a ten week period. The seclusion rate within the unit was 32% of all admissions and 34% of new admissions. The overall seclusion rate for the hospital was 5.4% of all admissions and 6.3% of new admissions, somewhat higher than in the United Kingdom but considerably lower than in the Eastern United States. A comparison was then made between consecutive new admissions (30 secluded and 30 non-secluded) to this unit and to a similar unit without a seclusion room in the other mental hospital in the State. Although seclusion offered no clear advantages in terms of duration of admission, levels of medication or relapse rates, it appeared to reduce the level of dangerousness in the unit, thereby enhancing staff morale. The overall mean daily total of neuroleptic medication was about 1,200 mg chlorpromazine equivalent, somewhat less than in comparable units in the United States and Europe.

Disordered associative processes have long been regarded as central to the psychological description of psychotic states such as acute schizophrenia. Previous work is briefly summarised concerning the idea that hyperactive associative processes of thought underlie many of the symptoms of psychosis. The idea is developed further, with respect to several features of the psychotic state. Schneiderian symptoms are seenas a consequence of hyperactive associations of thought, combined with perceptual hypersensitivity characteristic of many psychotic individuals. Anxiety in psychotic states is seen as arising from the great ambiguity of mental images when associations are loosened. A vicious circle between high anxiety and hyperactive associations is postulated. The slow and variable response to neuroleptic treatment is seen as being determined in part by the dynamics of change of the memories acquired during a period of hyperactive associations.

This essay has dealt exclusively with the positive (productive) symptoms of psychosis, and their treatment. It has briefly traced the origin of the idea that hyperactive associations of thought (i.e. of inductive inference) play an important part in the psychology of acute psychosis. Further it has attempted to show that this idea can be extended to give an account of Schneiderian symptoms, the high anxiety levels commonly found in acute psychosis, as well as the great variability in the rate and extent of response to drug treatment. The negative symptoms of schizophrenia are not included in the discussion. Some of these symptoms are not responsive to neuroleptic drugs. This leads one to suspect that other pathological processes in addition to those discussed above may be involved in the genesis of the negative symptoms.

Recent years have witnessed an increasing demand for cosmetic or reconstructive facial surgery. This paper addresses the pre-operative psychiatric assessment of the patient requesting facial surgery. Most patients adjust well to surgery and appreciate and accept the outcome. The psychiatrist who helps to screen difficult cases needs specific skills and must understand the body image issues involved. The psychiatrist needs to evaluate the patient's motivations, expectations and understanding of the risks and implications of surgery. Potential problem patients are described, including the minimal defect patient, the patient with secondary gain from the deformity, the older patient, the patient in crisis, the polysurgical patient, the paranoid patient, the schizophrenic patient, and the male patient. Guidelines for evaluating the patient need to be applied flexibly. The psychiatrist must communicate with the surgeon to appreciate clearly the concerns the surgeon has about each patient.

We describe the three stages of our attempt to predict parenting problems and child abuse antenatally. In the first stage, we made an intuitive check list of ten items from 173 risk factors drawn from the literature. The check list was useful in predicting who would relinquish care or have majorparenting difficulty in two different samples drawn four years apart and before and after some major sociocultural changes in New Zealand. In the second stage we used statistical techniques rather than intuition to maximise the predictive ability of the checklist and produced a new one of 9 items. In the third stage we validated the new list in a random sample of pregnant mothers. It was effective in predicting parenting difficulty In the 2 years after childbirth. We recommend it for routine use in a New Zealand setting. We do not know how useful the checklist will be in other cultural settings.

Sixty-nine female patients, mean age 27.5 years (range 20-40), with a past or current history of anorexia nervosa (DSM Ill-R) had spinal trabecular bone density assessed by single energy quantitative CT scan. Current exercise and dietary calcium levels were assessed by detailed questionnaires and categorized. A semi-structured interview was used to record weight, menstruation, exercise and dietary calcium intake histories from early adolescence. Serum sex hormones and total calcium assays were measured. Bone density was significantly lower in the patients compared to 31 controls. Bone density was significantly positively correlated with body mass index, and negatively correlated with illness duration and duration of amenorrhoea. Exercise levels, dietary calcium intake and taking an oestrogen pill did not correlate significantly with bone density. Recovered patients did not have osteopaenia but they had shorter illness histories than non-recovered patients. Management to minimise bone loss should focus on weight gain and resumption of normal menstruation.

We compared serum cortisol, ACTH and plasma P-endorphin in 21 Post-Traumatic Stress Disorder patients and 20 controls. Although we found no important disturbance in diurnal rhythms, the PTSD patients had significantly higher A.M. serum cortisols compared with controls. Both A.M. and P.M. plasma P-endorphins in PTSD patients were significantly lower compared with controls. These data suggest that plasma P-endorphin may be a marker for PTSD and that chronic endogenous opioid depletion may play a role in the pathogenesis and perpetuation of this disorder.

Alcohol-related problems made up 17.6% of the case load of psychiatric emergencies in an Indian general hospital. The police brought three-quarters of them, 45% for quarrels, street-fights and under influence of alcohol and 20% for minor offences like abusing in public. A psychiatric illness was definitely present in 40% of the cases. Only 10% of the patients with alcohol-related problems were referred for outpatient treatment, Eighty-five percent were not given any follow-up advice because the patients said they needed no help.

This is a personal account of trying to live and cope with obsessive compulsive disorder (OCD) written primarily by a sufferer attending the Victorian OCD Support Group. It outlines some of the suffering and distress of having the disorder, some of the efforts and techniques used in trying to understand and cope with the disorder, the fortitude and endurance required, the difficulty in seeking and accepting treatment and some of the sufferer's hopes for a better future.