Australian & New Zealand Journal of Psychiatry

Phenomenology is a word much abused in psychiatry. It has come to mean the objective description of the symptoms and signs of psychiatric illness, a synonym for clinical psychopathology as opposed to that other psychopathology which derives from psychoanalytic theory. Thus it is sometimes stated that the phenomenology of a condition is remarkably consistent although its psychopathology is varied. In truth, phenomenology is a technical term in psychiatry with a specific meaning quite distinct from and in a way opposite to that of objective psychopathology. The inappropriate use of the word is unfortunate not only for semantic reasons but also because there is a real danger that the concept to which it refers will be forgotten.

Professor Andrews has long been an ornament to our profession. Amongst his many achievements has been the construction of an abattoir for the processing of sacred cows. Since so much psychiatric theory has been manufactured by the accumulation of positive associations, rather than by the refutation of testable hypotheses and their replacement by better ones, there was a great need for such a facility. Already the manure produced by the cows and their spouses, if not less in quantity, is of a better quality and packaged more attractively. True it is that occasionally Professor Andrews has been discovered leading useful, profane cows to the slaughter, but this is as nothing beside his tours de force.

The prevention of mental disorders has been neglected but the public health burden now is too high for this to continue. Nearly one half of all mental and neurological disorders are amenable to primary prevention. Effective measures could be applied even in countries with few resources. By and large these measures all rely on available knowledge and commonly involve sectors other than health. This paper calls attention to the opportunities that offer but that have been so far largely unheeded.

Over recent years, clinical psychological services have diversified within the health sector, leading to a breakdown in the traditional nexus between clinical psychology and psychiatry, and to the emergence of the interdisciplinary field of behavioural medicine. From their earlier limited role as providers of psychometric assessments in educational and psychiatric hospital settings, clinical psychologists now provide a wide range of therapeutic services and research skills to general hospitals, universities, community health centres, and the private sector. This evolving trend has significant implications for the future structure and direction of clinical practices in clinical psychology, psychiatry and medicine.

Levels of anxiety and depression were assessed for 207 HIV seropositive homosexual/bisexual men (AIDS = 34, ARC = 72, asymptomatic HIV infection = 101), and 36 seronegative controls. Lymphocyte subset enumeration, history of opportunistic infections, and occurrence of HIV-related symptoms were recorded at the time of assessment. No differences between groups were found on age, educational level, state/trait anxiety or depression scores. Neither the number of symptoms reported, their duration, severity, frequency of occurrence, nor the proportion of patients who reported a specific symptom was different between the three HIV seropositive groups. Severity of anxiety and depression was related to the magnitude of symptomatology, but not associated with either degree of immunodeficiency, number of opportunistic infections or diagnostic group. Principal component analysis extracted five symptom factors (cognitive, affective, psychosocial, neurological and physical), none of which predicted state anxiety scores. However, affective and psychosocial symptom factors predicted trait anxiety and depression scores. The results indicate that ratings of anxiety and depression are independent of stage of HIV infection, may be in part mediated by constitutional and physical symptoms of HIV disease, but are primarily associated with the presence of psychological and psychosocial symptoms.

Four hundred and twenty-five nurses working in a 420 bed metropolitan psychiatric hospital were asked to complete a questionnaire about their experience of physical assault by patients and their attitude toward the problem. 61% returned the questionnaire. The overall mean annual rate of assault per nurse was 2.0, with student psychiatric nurses (mean 6.7) significantly more at risk than any other group. Nurses working in the psychogeriatric area reported more than double the rate of assaults reported by nurses working in rehabilitation services. 60% of respondents were female; there were very few sex differences in attitudes to assault. Overall, nurses reported a high tolerance for assault, although they recognised it as an experience that was often very traumatic psychologically. Views about managing assaultiveness differed widely, and this lack of consensus probably hinders the development of optimal strategies to deal with what is a major problem in many psychiatric units.

Dose-effect studies have found that 600 mg/day of chlorpromazine (or its equivalent) is generally sufficient to treat acute psychosis. This paper reports on the doses of antipsychotic medication prescribed for inpatients in a Schizophrenia Unit at an Australian state hospital. Fifty five percent of patients received daily doses equivalent to more than 600 mg of chlorpromazine and 26% received daily doses equivalent to more than 1500 mg of chlorpromazine. Low potency drugs were prescribed in lower doses than high potency drugs. Patients prescribed depot medication tended to receive higher doses of medication than those prescribed oral medication only.

Sixty-six alcoholic men who had been abstinent from alcohol for at least four weeks were assessed clinically and then investigated in terms of Thyroid-Stimulating Hormone (TSH) and prolactin responses to a Thyrotropin-Releasing Hormone (TRH) challenge. Consistent with other studies, a third of the subjects had a blunted TSH response to TRH. This blunted response was not associated with a family history of alcoholism, or current depressive symptoms, past history of depression or family history of depression. However, subjects with a blunted TSH response were more likely to have had an earlier onset of alcoholism and to have had shorter alcoholic remissions in the past.

Sleep apnoea (OSA), a common sleep disorder, is well recognised as a cause of morbidity including psychiatric disorders. There is increasing recognition of the link between OSA and depression. Sleep changes are intrinsic to depressive disorders, most notably disturbances of REM sleep; OSA causes predominantly REM sleep disturbances. The neuro-vegetative features of depression are similar or identical to the symptoms of OSA — an issue which has not achieved wide clinical recognition. A growing number of studies confirm the statistical link between the two conditions. The implications are twofold: OSA needs to be excluded in cases of chronic or resistant depression and treatment of OSA will make it easier to treat the primary depressive disorder. A new method of treatment for OSA, the Sullivan continuous positive airway pump (CPAP), raises the theoretical possibility of treating depression by this means as well.

This paper reviews the literature on the assessment and management of suicide risk of psychiatric inpatients. Even though a large number of scales have been developed to assist the prediction of suicide for patients admitted for suicide ideas and attempts, none of them were designed to predict suicide in the short term. However the Modified Suicide Intent Scale and the Hopelessness Scale appear to have the potential to predict immediate suicide risk. Risk factors associated with specific psychiatric conditions were all derived retrospectively and their predictive validities have not been established by prospective studies. Important issues relating to the management of suicidal inpatients, such as staff-patient relationships, use of constant observation and medical-legal aspects are reviewed.

Three hundred and forty-two cases of suicide in Singapore (1986) were studied. The rates were highest among Indians males. Jumping from a height was the method used by 60% of the subjects, and the predominant associated factor as ascertained by the coroner was illness (51%), both physical and mental. About 40% had seen a doctor in the year prior to their death, and 20% had a history of a previous suicide attempt. The majority of cases killed themselves during the daylight hours.

Based upon standardised mortality figures, between 1973–1987, Australian male suicide rose by 39%, and New Zealand male suicide by 53%. In both countries there were even greater increases in male youth suicides (15–24 years), 66% and 127% respectively. The female suicide statistics were more varied with a fall of −24% in Australia, but an increase of 26% in New Zealand. In both countries however, female youth suicide, relative to their general rates, increased. A comparison of youth suicide in the western world demonstrated that Australia and New Zealand were unique as they were the only countries in which male and female youth suicide levels were higher than their average rates.

This article examines a recent decision of the English Court of Appeal. It concerned a psychiatrist who examined and reported on a convicted murderer in a secure hospital. The report was commissioned by the patient's solicitors as evidence in support of his release. The report was emphatically unfavourable and the doctor insisted that it be revealed to the hospital authorities. The solicitors refused and litigation ensued. The courts were forced to rule on the conflict between the patient's right to privacy and the public interest in revealing the report.

Forensic psychiatry operates at the interface of the Justice and Health systems and has been defined as: “That branch of psychiatry which requires special knowledge and training in the law as it relates to the mental state of the offender, or alleged offender” [1]. As a consequence of working in this area, psychiatrists are often called into court to give evidence as “expert witnesses”. This article examines some of the professional and legal issues involved in providing expert testimony. Secondly, it aims to outline some practical guidelines for giving evidence in the court-room. The predominant focus is on criminal, rather than civil, proceedings in which the forensic psychiatrist gives expert testimony; however much of the information is also relevant to other psychiatrists and psychologists undertaking this role in the legal arena.

A systematic review was carried out of all patients admitted to a specialised mother-baby unit who had significant phobic avoidance of their own infants. Demographic and diagnostic information on this group showed phobic avoidance to be common and associated with a range of psychiatric illnesses. There was a trend towards association with relatively prolonged admission. The relationship of such avoidance to attachment behaviour from mother to child is discussed. It is recommended that phobic symptoms warrant early recognition and treatment in their own right, simultaneously with treatment of the major illness.

This is a retrospective study of 134 cases of sexual abuse in Chinese children aged 16 years or under in Hong Kong. The data with respect to the victim's age, sex, severity and type (intra- or extrafamilial) of abuse, perpetrator's characteristics and family disturbances were analysed. The overall profile is similar to that reported in the West. The reasons for the apparently low prevalence, younger age of victim and low proportion of male victims are discussed.

Although the treatment of childhood anxiety disorders can be approached from numerous theoretical perspectives, the concentration of research has been on the efficacy of behaviour therapy. Behaviour therapy procedures are briefly described and evaluated, including systematic desensitisation, flooding, modelling, reinforcement and cognitive procedures. We also review research findings on pharmacotherapy, focusing on benzodiazepine and antidepressant usage. Finally, several conclusions are drawn concerning the scientific and clinical status of these treatment approaches for childhood anxiety disorders.

This study describes the different prevalences obtained when varying combinations of informants were used to identify emotional and behavioural disorders in a representative sample of 336 children living in two-parent families in the community of Adelaide, South Australia. When different informants were used to identify children with disorders, the estimated prevalences ranged from 3.3±1.6% to 17.9±4.1% for younger children, and 6.0±2.9% to 19.9±4.9% for older children. Results from the study highlight potential methodological problems which arise in epidemiological studies due to differences between reports from children, parents, and teachers describing childhood emotional and behavioural problems.

A 22 year old female-to-male half-Aboriginal transsexual had been exposed to gross neglect and violence, separation and inconsistent cultural supports during childhood. Her mother had also been convicted of homicide in a context of alcohol and violence. Transsexual identification, antisocial behaviours, self mutilation, substance abuse and unmet dependency needs were evident from childhood or early adolescence. The killing was a confrontational peer group stabbing in a brawl under influence of alcohol — the male mode of homicide. This is the first known case in world literature of a female-to-male transsexual guilty of homicide.

This report describes a patient with schizophrenia who developed episodes of ocular dystonia as a delayed side effect of neuroleptic medication. Each episode was preceded and accompanied by marked agitation, stereotypic behaviour and exacerbation of hallucinations. Both the psychotic and dystonic symptoms responded to anticholinergic medication. The theoretical and practical implications of this observation are discussed.

Two patients are reported, one with severe brain damage and epilepsy, and the other with limbic epilepsy, who were treated with unilateral microsurgical amygdalo-hippocampectomy for the control of rage and aggression. Both had significant improvement in their aggressiveness, and the second patient also improved in the frequency of his seizures and psychotic episodes. The significance of these observations for our understanding of the morphophysiological basis of rage and aggression is discussed.