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The Whitechapel murders of 1888 attributed to Jack the Ripper were, like many of the crimes of multiple-victim killers, well-publicised, bizarre and dramatic (Lunde & Sigal, 1990). Although in the public mind at the time the murders of at least seven women in and around the Whitechapel district of London's East End were believed to have been carried out by Jack the Ripper. However, according to police and forensic evidence his victims, all prostitutes, numbered only five, beginning with Mary Ann Nichols, found murdered on 31 August 1888, and ending with Mary Jane Kelly, whose mutilated body was discovered on 9 November 1888.

Since its inception (Hounsfield, 1973), computerised tomography (CT) has become an invaluable diagnostic and research tool, particularly in clinical neurology and neurosurgery. Clinically, CT has proved useful in differentiating between ‘functional’ and ‘organic’ psychiatric disorders where it is particularly helpful in the diagnosis of potentially treatable organic disorders. For example, Owens et al (1980) found clinically unsuspected intracranial pathology in 12 of 136 chronic schizophrenic patients examined by CT and Roberts & Lishman (1984) found diagnosis, management, and/or prognosis were influenced in approximately 12% of cases referred by psychiatrists for CT imagining.

BackgroundStudies in schizophrenia suggest that a longer initial period of untreated illness is associated with a poorer clinical outcome.AimsTo determine whether, in first-episode schizophrenia, a longer duration of untreated psychosis (DUP) or of untreated illness (DUI) (DUP plus any prodrome) is associated with clinical variables that could mediate a poor prognosis.MethodClinical, social, neuropsychological and oculomotor function data on 53 patients with first-episode schizophrenia were related to the DUP and DUI.ResultsComparing short and long DUP groups split around the median showed no statistically significant differences (except age); patients in the latter group tended to perform worse on an executive attentional set-shifting task, and were more likely to be unemployed, and living alone or homeless.ConclusionsThere was little evidence of any association between either DUP or DUI and progressive deterioration in the schizophrenic illness or the development of resistance to initial drug treatment. Social variables that augur a poor prognosis may be associated with delayed presentation of schizophrenia to psychiatric services.

As currently defined, attention-deficit/hyperactivity disorder (ADHD) encompasses a broad constellation of behavioural and learning problems and its definition and diagnosis remain controversial. The aetiology of ADHD is acknowledged to be both complex and multifactorial. The proposal considered here is that at least some features of ADHD may reflect an underlying abnormality of fatty acid metabolism. Clinical and biochemical evidence is discussed which suggests that a functional deficiency of certain long-chain polyunsaturated fatty acids could contribute to many of the features associated with this condition. The implications in terms of fatty acid treatment proposals are also discussed; such a form of treatment is relatively safe compared to existing pharmacological interventions, although further studies are still needed in order to evaluate its potential efficacy in the management of ADHD symptoms.

The administration of the omega-3 fatty acid eicosapentaenoic acid (EPA) to a drug-naive patient with schizophrenia, untreated with conventional antipsychotic medication, led to a dramatic and sustained clinical improvement in both positive and negative symptoms. This was accompanied by a correction in erythrocyte membranes of abnormalities in both n -3 and n -6 highly unsaturated fatty acids (HUFAs). Therefore EPA is able to reverse the phospholipid abnormalities previously described in schizophrenia. This reversal is associated with, and is likely to be the cause of, the clinical improvement. In particular, EPA appears to have reversed the depletion of not only n -3 HUFAs, but also of membrane arachidonic acid, possibly via inhibition of HUFA-specific phospholipase A 2 , an enzyme which removes HUFAs from the S N 2 position of membrane phospholipids, or by activation of a fatty acid coenzyme A ligase. Correction by EPA of abnormalities in both enzyme systems is not ruled out.

In the west London prospective study of first episode schizophrenia, the prevalence and nature of abnormal involuntary movements were examined in 27 patients who had never received antipsychotic drugs and 36 who had been treated with such medication. Motor disturbance was assessed with rating scales designed to cover the full range of spontaneous and drug induced movement disorder. Only one person in the drug naïve group showed evidence of parkinsonism, a finding which contrasts with recent reports suggesting that spontaneous extrapyramidal signs may not be uncommon in such patients. However, according to ratings on the modified Rogers scale, 11% of the drug naïve group exhibited orofacial dyskinesia, 4% trunk and limb dyskinesia, 7% postural abnormalities, and 4% increased muscle tone. The respective figures in the closely matched medicated group were not significantly different except for increased muscle tone, which was significantly more common (25%). The proportion of drug naïve patients fulfilling criteria for tardive dyskinesia on the abnormal involuntary movements scale ranged from 4% to 11% depending on the criterion threshold score used. These findings are in accord with the notion that abnormal involuntary movements, particularly orofacial dyskinesia, represent a neuromotor component of schizophrenia.

Two semi-automated methods for quantification of ventricular volume change from baseline and follow-up magnetic resonance imaging scans have been developed. Technique 1 employs direct segmentation of the ventricles from both the scans using thresholding and contour extraction. Technique 2 operates on difference images produced by voxel based intensity subtraction of the baseline from the registered follow-up images. Here, all voxels with intensities above a noise threshold and in a restricted area are monitored to compute volumetric changes. In phantom measurements the first technique was accurate to 0.0046%, the second to 0.167% of the phantom volume. Results from normal volunteers was that the average ventricular volume changed by 1.52% and 1.54% for images acquired within 9 months using techniques 1 and 2, respectively. With schizophrenic patients mean change of 10.78% and 9.43% were found employing the first and second procedures, respectively. All measurements agreed with a radiologist's visual grading of the changes. Robust, objective, fast, easy-to-use, and fairly accurate procedures have been developed and validated to quantify volumetric changes.

Family studies have shown that abnormalities of smooth pursuit eye movement are increased in the adult relatives of schizophrenic probands as well as in the probands themselves. More recently, an inability of schizophrenic subjects to inhibit reflexive saccades reliably has been shown. This study aimed to test the hypothesis that the latter dysfunction is part of the extended schizophrenia phenotype.With the use of infrared oculography, measurements of reflexive saccades and antisaccades were undertaken in 29 probands with schizophrenia, 50 of their nonpsychotic first-degree relatives, and 38 unrelated healthy volunteers.Probands, relatives, and healthy subjects showed no overall differences in the generation of reflexive saccades. However, in the antisaccade task, probands showed more saccadic distractibility when they were required to inhibit reflexive saccades. Analysis of corrective saccades showed that this was not due to failed comprehension or motivation. Relatives of the probands with high saccadic distractibility showed a higher distractibility rate than relatives of the probands with normal distractibility. Across all subjects, females showed a higher rate of distractibility errors than males.The ability to suppress reflexive saccades is an objective neurocognitive measure that is impaired in schizophrenic patients and in a proportion of their biological relatives. This antisaccade abnormality may be a vulnerability marker in a subset of schizophrenic patients and their families.

OBJECTIVES (1) A biochemical investigation of the motor cortex in patients with incomplete spinal cord injury and normal control subjects using proton magnetic resonance spectroscopy (MRS). (2) To relate any altered biochemistry with the physiological changes in corticospinal function seen after spinal cord injury. METHODS a group of six patients with incomplete spinal cord injury who showed good recovery of motor function were selected. The patients were compared with five healthy control subjects. Electromyographic (EMG) responses of thenar muscles to transcranial magnetic stimulation (TMS) of the motor cortex showed that inhibition of cortical output was weaker in the patients than the controls. Proton MRS data were collected from a plane at the level of the centrum semiovale. Two 4.5 cm3 voxels in the motor cortex and a third voxel in the ipsilateral occipital cortex were examined in the patients and control subjects. RESULTS The mean level of N- acetylaspartate (NAA), expressed relative to the creatine (Cr) peak (NAA/Cr), was significantly increased in the motor cortex of the patients compared with their ipsilateral occipital cortex or either cortical area in the controls. No differences between patients and controls were seen for any of the other metabolite peaks (choline (Cho), glutamate/glutamine (Glx) or the aspartate component of NAA (AspNAA)) relative to Cr. Choline relative to Cr (Cho/Cr) was higher in the motor cortex of the control subjects than in their ipsilateral occipital cortex. This difference was not present in the patients. CONCLUSIONS Raised NAA/Cr in the motor cortex of the patients probably results from increased NAA rather than a decrease in the more stable Cr. The possible relevance of a raised NAA/Cr ratio is discussed, particularly with regard to the changed corticospinal physiology and the functional recovery seen in the patients.

Background. Previous studies of oculomotor dysfunction in schizophrenia have tended to concentrate on abnormalities of smooth pursuit eye tracking in chronic medicated patients. We report the results of a study of smooth pursuit, reflexive and antisaccade performance in drug naive and antipsychotic treated first-episode schizophrenic patients.Methods. Smooth pursuit and saccadic eye movements were recorded in 36 first-episode schizophrenic patients and 36 controls matched for age and estimated IQ. The schizophrenic patients were divided into drug-naive (N=17) and antipsychotic treated groups (N=19).Results. Smooth pursuit velocity gain was significantly lower than controls only in the drug-naive patients. The treated patients did not differ significantly from either the controls or the untreated group. In an antisaccade paradigm both treated and drug-naive schizophrenic patients demonstrated an increased number of errors, but only drug-naive patients also demonstrated an increased latency in initiating correct antisaccades.Conclusions. These impairments are unlikely to be due to a generalized deficit in oculomotor function in the schizophrenic groups, as there were no differences between the groups in saccadic metrics on a reflexive saccade task. The results show that both smooth pursuit and saccadic abnormalities are present at the onset of schizophrenia and are integral to the disorder.

BACKGROUND: We tested the hypothesis that schizophrenia is primarily a frontostriatal disorder by examining executive function in first-episode patients. Previous studies have shown either equal decrements in many cognitive domains or specific deficits in memory. Such studies have grouped test results or have used few executive measures, thus, possibly losing information. We, therefore, measured a range of executive ability with tests known to be sensitive to frontal lobe function. \ud METHODS: Thirty first-episode schizophrenic patients and 30 normal volunteers, matched for age and NART IQ, were tested on computerized test of planning, spatial working memory and attentional set shifting from the Cambridge Automated Neuropsychological Test Battery. Computerized and traditional tests of memory were also administered for comparison. RESULTS: Patients were worse on all tests but the profile was non-uniform. A componential analysis indicated that the patients were characterized by a poor ability to think ahead and organize responses but an intact ability to switch attention and inhibit prepotent responses. Patients also demonstrated poor memory, especially for free recall of a story and associate learning of unrelated word pairs. \ud CONCLUSIONS: In contradistinction to previous studies, schizophrenic patients do have profound executive impairments at the beginning of the illness. However, these concern planning and strategy use rather than attentional set shifting, which is generally unimpaired. Previous findings in more chronic patients, of severe attentional set shifting impairment, suggest that executive cognitive deficits are progressive during the course of schizophrenia. The finding of severe mnemonic impairment at first episode suggests that cognitive deficits are not restricted to one cognitive domain.

AIM: To conduct the first systematic test of the hypothesis that modulation of cardiac vagal tone is impaired in Lyme disease. METHODS: The response of cardiac vagal tone to respiratory modulation was measured in 18 serologically positive Lyme disease patients and in 18 controls. RESULTS: The two groups were matched in respect of age, sex, body mass, mean arterial blood pressure, mean resting heart rate and mean resting cardiac vagal tone. The mean maximum cardiac vagal tone during deep breathing in the Lyme disease patients [11.2 (standard error 1.3)] was lower than in the matched controls [16.5 (standard error 1.7); P = 0.02]. CONCLUSION: Respiratory modulation of cardiac vagal tone is impaired in Lyme disease, which suggests that Lyme disease may directly affect the vagus nerve or the brainstem.

Cellular origins of methylarginines are not precisely known but the presence of free methyl and dimethylarginines in the brain were reported. We have investigated the circulating concentrations of asymmetrical dimethylarginine NG,NG-dimethylarginine (ADMA), NG,NG-dimethylarginine (SDMA), nitrate and nitrite levels in drug naive first episode schizophrenic patients and matched control subjects. Three of those patients were treated with neurolepties for 3 months. Plasma ADMA levels increased significantly but nitrate levels were significantly low compared to control subjects. Drug treatment apparently lowered ADMA levels and increased nitrate levels in plasma. Methylation of arginine to methylarginines may have an important role in regulating signal transduction through the nitric oxide system in the brain, and suggest novel therapeutic targets.

Introduction Inpatient facilities for people with LD are highly specialised services that are a valuable, but expensive, component of mental health services. Although there are no national data describing these services, commissioners need good quality data to inform their contracting and pricing strategies for LD psychiatric inpatient care. To help fill this information gap, we carried out a review to explore the general characteristic of inpatients population, duration of admission and delays in discharge in the inpatient LD unit. Aims To analyse admission trends including the reasons for delayed discharges to a LD unit from 2008 to 2011. Method A retrospective review of the case records of all inpatient admissions to the LD Unit (Seacole) between 2008-2011. Results There were 41 admissions made to the service in the time period from 2008 to 2011. More male patients (76%) were admitted compared to females (24%) (p=0.073). Male patients (55%) were more likely than female patients (20%) to be admitted from a residential home (p = 0.075).There was no statistically significant difference between the male and female sexes regarding diagnosis of challenging behaviour or psychotic or affective disorder. 59% of discharges in 2008–2011 were delayed. The main reason for the delayed discharge was social and was significantly more likely to result from difficulty in finding appropriate placement (p=0.008). Conclusions Social problems were the main cause of delayed discharges. Early identification of social issues, better utilization of community resources and robust discharge planning should be done to avoid delay in discharge.

The mortality experiences of a hospitalized mentally handicapped population between 1981 and 1990 (inclusive) were examined. A continued trend for increasing longevity in both males and females was found, with mean ages at death now approaching those in the general population. The commonest cause of death was non-tubercular respiratory infection, from which patients were particularly at risk during the months of December to February (inclusive). Patients diagnosed as suffering from psychoses other than schizophrenia and mood disorder had an increased mortality and should be thoroughly investigated for the presence of organic pathology. Epilepsy and Down's syndrome were associated with increased risk of earlier death, although in the case of Down's syndrome there has been a marked increase in longevity.

Section 5(2) of the Mental Health Act 1983 (England and Wales) is a commonly used short term power of detention often implemented by junior medical staff, which has no statutory right of appeal. There is little published analysis of its use in clinical practice. A detailed case note study of its use in a psychiatric service with a large catchment area is presented. Fifty-seven per cent of the patients detained under s.5(2) were female. Affective psychosis was over-represented in detained females, while schizophrenia and paranoid states were over-represented in males. Eight per cent of s.5(2) detentions were initiated via the nurses' holding power, s.5(4). None of these patients were subsequently regraded to s.2 or 3, which may be accounted for by the finding that personality disorder and alcohol dependence were more commonly diagnosed in this subgroup. Of s.5(2) detainees, none of those with a non-psychotic disorder were regraded to s.2 or 3. Three patients had not accepted in-patient admission prior to implementation of s.5(2). Moreover, 38 per cent of all s.5(2) detentions took place within 24 hours of admission. Patients with a psychotic disorder were more likely to be detained within 24 hours of admission. Doubts regarding the validity of consent to voluntary admission in these patients are raised.

A hypothetical model is proposed that connects the risk of relapse in schizophrenia and expressed emotion in relatives with genetic factors in the individual, familial schizophrenia, severity of illness, family psychopathology, age of onset of the illness, and length of family exposure to a psychotic relative.

A man suffering from persecutory delusions attempted to commit suicide by holding the head of a three-inch masonry nail against a wall and head-butting its point until he had driven it fully into his forehead.

Background The aim of this study was to determine whether there is published evidence for increased oxidative stress in neuropsychiatric disorders. Methods A PubMed search was carried out using the MeSH search term 'oxidative stress' in conjunction with each of the DSM-IV-TR diagnostic categories of the American Psychiatric Association in order to identify potential studies. Results There was published evidence of increased oxidative stress in the following DSM-IV-TR diagnostic categories: mental retardation; autistic disorder; Rett's disorder; attention-deficit hyperactivity disorder; delirium; dementia; amnestic disorders; alcohol-related disorders; amphetamine (or amphetamine-like)-related disorders; hallucinogen-related disorders; nicotine-related disorders; opioid-related disorders; schizophrenia and other psychotic disorders; mood disorders; anxiety disorders; sexual dysfunctions; eating disorders; and sleep disorders. Conclusion Most psychiatric disorders are associated with increased oxidative stress. Patients suffering from that subgroup of these psychiatric disorders in which there is increased lipid peroxidation might therefore benefit from fatty acid supplementation (preferably with the inclusion of an antioxidant-rich diet) while patients suffering from all these psychiatric disorders might benefit from a change to a whole-food plant-based diet devoid of refined carbohydrate products.

BK Puri,’ AJ Richardson,’ JM Allsop,’ CJ Higgins,3 CM Calvin3 N Saeed4 ‘MRI Unit, MRC Clinical Sciences Centre, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 OHS, *University Department of Physiology, Parks Road, Oxford OX1 3PT, ‘Charing Cross Campus, Imperial College School of Medicine, London W6 SRP, 4Picker Research Group, MRI Unit, Hammersmith Hospital, Du Cane Road, London W12 OHS

The Mental Health Commissioners recommend that whenever possible two doctors should be involved in the decision to admit a patient to hospital under the Mental Health Act (1983). That is, Sections 2 and 3 of the Act should always be used in preference to Section 4, where only one doctor is required. It further recommends that the use of Section 4 should be confined to emergencies when it is only possible to secure the attendance of one doctor.