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Catatonia is a common neuropsychiatric syndrome. There is a life-threatening subtype of this disease known as malignant catatonia. One of the hypotheses regarding the pathogenesis is an imbalance of multiple neurotransmitters (gaba, glutamate and dopamine). The first step in treatment is to administer benzodiazepines; if the response is insufficient, the treatment can be replaced by electroconvulsive therapy (ect). So far, there is no consensus with regard to the tertiary treatment step. On the basis of a case report we describe the beneficial effects of administering an nmda receptor antagonist, amantadine, as the tertiary step for treating a patient with treatment-resistant malignant catatonia.

Both Parkinson's disease and its treatment can be associated with psychiatric symptoms. We illustrate this link by focusing on a patient suffering from Parkinson's who received not only deep brain stimulation but also excessive amounts of dopaminergic drugs, a combination that resulted in hypomania which is also known as dopamine dysregulation syndrome. We discuss the symptoms, possible aetiological pathways and the implications for clinical practice.

In the first half of the 20th century, during the Spanish flu pandemic, more than half a million people died from a mysterious disease sleeping sickness which was named 'encephalitis lethargica'. Despite extensive research, the cause of the disease has not yet been established. In the Netherlands many doctors published cases in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine), also when chronic forms of the disease arose. An attempt to treat patients suffering from the chronic disease with levodopa initially had spectacular results but eventually lead to a new disappointment as a result of severe side effects. The experiment was stopped prematurely. Encephalitis lethargica is still being sporadically diagnosed in the 21st century. Recent research suggests that an autoimmune response targeted at the basal ganglia, possibly caused by a streptococcal infection, plays a role in the aetiology of the disease.

Problems in the Netherlands with respect to the reimbursement of memantine have led the patient organization 'Alzheimer Nederland' to establish an emergency fund. Several trials have documented the limited, but consistent beneficial effects of memantine in severely demented patients. It is not clear which subgroup of patients might benefit the most. The drug seems to have dopamimetic and antidepressant effects which might explain its overall effect. The publicity surrounding memantine contributes to an atmosphere in which patients and care providers have to explain why they are not yet using 'anti-dementia drugs'. This should be avoided. Patients can expect to gain more benefit from ongoing, thorough and independent investigations than from hastily established emergency funds to finance the use of a drug with a limited and poorly defined efficacy.

A 71-year-old single male who was being treated for Parkinson's disease with levodopa, had several episodes of hypersexual behaviour. Home care was terminated for this reason. Family members in particular had problems with his behaviour. It transpired that he was taking more levodopa than prescribed. After explaining the side-effect to the patient and after a special medication box was purchased which could be filled by the family, the patient's hypersexuality disappeared without deterioration of Parkinson's disease. Hypersexuality is a known, though not frequently recognised side-effect of dopaminergic anti-Parkinson therapy, especially levodopa. This side-effect is not life-threatening, but can have an enormous impact on the quality of life of the patient, his or her partner and environment. The mechanism is probably related to the pharmacological action of dopamine.

To determine the predictive value of the subcutaneous apomorphine test for the effect of dopaminergic drugs in the treatment of Parkinson's disease.Retrospective and literature study.University Hospital Leiden, the Netherlands.All articles regarding apomorphine administration in Parkinson's disease were reviewed. The data were compared with the results of apomorphine tests performed between October 1990 and September 1992 in the Leiden University Hospital.The positive predictive value for good clinical efficacy of dopaminergic medication was 85%, lower than the results from the literature (96%). The negative predictive value was 58% (in the literature 75%), with a sensitivity of 73% and a specificity of 73%.These predictive values are poor and practical problems with the test are substantial. Little indication remains for the application of the apomorphine challenge test.