872 HASSANYEH ET AL prednisolone was discontinued. Re-prescribing her MCCAWLEY, A. (1965) Cortisone habituation - a clinical note. prednisolone, at a relatively small dose of 3—4mg New England Journal of Medicine, 273, 976. a day, restored her to good mental and cognitive MINDEN,S. L., ORAv, J. & SCHILDKRAUT,J.J. (1988) Hypomanic reactions to AC'FH and prednisone treatment for multiple functioning. A synacthen test revealed partial sup sclerosis. Neurology, 33, 1631—1634. pression of her adrenal cortex. In view of a normal RUTGERS, A. W. F., LINKS, 1. P., COULTRE, R. L., et a! (1988) ESR and dramatic response to a small dose of Behavioural disturbances after effective ACTH - treatment of the dancing eyes syndrome. Developmental Medicine and Child prednisolone, cerebral vasculitis is unlikely. Neurology,30,408-409. This case illustrates the need to consider possible Woutowrrz, 0. M. & RAPAPORT, M. (1989) Long-lasting behavioural adrenocortical deficiency as a cause of psychiatric changes following prednisone withdrawal. Journal of the disorder or cognitive impairment in patients in whom American Medical Association, 261, 1731-1732. long-term corticosteroids have been discontinued. Such a deficiency state may persist for a considerable period of time after discontinuation. •¿F.Hassanyeh, MBBS, FRCPsych, Consultant Psy chiatrist, Department of , Royal Victoria References Infirmary, Newcast!e upon Tyne NEJ 4LP; R. B. BOSTONCOLLABORATIVEDRUGSURVEILLANCEPROGRAMME(1972) Murray, MBChB, Genera! Practitioner, Raby Cross Acute adversereactions to prednisone in relation to dosage. Medical Centre, Newcastle upon Tyne NE6 2FF; H. Clinical Pharmacology and Therapeutics, 22, 155-158. Rodgers, MBChB,MRCP, Medica! Registrar, Royal GLYNNE-JONES, R., VERNON, C. & BELL, G. (1986) Is steroid Victoria Infirmary, Newcastle upon Tyne psychosispreventableby divided doses?Lancet, ii, 1404. GREvES,J. A. (1984) Rapid onset steroid with very low dosageof predmsolone.Lancet, i, 1119—1120. •¿Correspondence

Amnesia in Relation to Fugue States —¿Distinguishinga Neurological from a Psychogenic Basis

NARiNDER KAPUR

A case of transient is described in which a patient wanders over some considerable distance, patientreportedmemorylossforfivedays,duringwhich often reports loss of personal identity and may he hadwanderedextensively.Analysisshowedthat he present himself to organisations such as the police did not have selective amnesiafor the publicevents rather than turn up in clinical settings. Since a fugue which had occurredduringthe five days for which he state can also be characteristic of some patients with professedmemoryloss.Thisfindingwas incompatible with our case having a neurologically based global temporal lobe epilepsy (Mayeux et a!, 1979), it is disorder during the fugue state. These findings clearly important to document those features which offer support for a distinction between personal and may help distinguish psychogenic and neurological public episodic memory. aetiologies, especially since psychiatric conditions British Journal of Psychiatry (1991), 159, 872—877 such as anxiety and may be accompanied by patchy cognitive impairment. Transient amnesic states can present in a variety of In contrast to clinical reports of psychogenic forms, ranging from transient global amnesia to memory loss, there have been few experimental conditions such as transient . studies on cognitive aspects of such a memory While the former condition has been well docu disorder. One exception to this is the case report by mented, our clinical and theoretical understanding Schacter eta! (1982). When admitted to hospital, he of the latter condition remains relatively limited. could not remember his name, his address or any Withintheclassofconditionsknownaspsychogenic other information about himself or his past (although amnesia, those which present with a fugue state there is no evidence of any prolonged fugue state represent a fairly distinct subset. In this state, the preceding this sudden memory loss). His retrograde PSYCHOGENIC AMNESIA 873 amnesia lasted for four days, ending fairly suddenly et al's patient, i.e. normal performance for famous while he was watching a funeral scene on television. faces in the presence of marked loss of memory for He subsequently had almost complete shrinkage of personal past events, we designed a memory task to his , and his only memory loss see if an analogous pattern of memory loss would was for the 12-hour period preceding his hospital be found in a patient with a more typical fugue state. admission when he had become aware of a loss of We were able to assess the basis of his memory loss identity. by means of a specially designed public events Schacter et al administered both tests of past amnesia test in which we assessed the patient's ‘¿semantic'memory (identification of famous faces) recognition memory for 20 real or fictitious recent and a test of ‘¿episodic'memory(recall of any past events, some of which had occurred during the personal event in response to a cue word provided critical five-day period of the patient's fugue. If his by the examiner). These tests were carried out during memory loss had a neurological basis, the patient and after the period of amnesia. During both time should show impaired identification of the critical periods, the patient performed well when asked to events. However, if the global memory loss was identify famous faces. However, in the case of the psychogenic in nature, his performance on these autobiographical cued recall task, when assessed critical items should not be selectively impaired. during the amnesic episode he tended to only recall events from the previous few days; after his amnesia Case report had cleared, he retrieved much older episodes, usually ones which had occurred years earlier. Thus, AB, a 33-year-oldright-handedpsychologygraduate who the clinical symptom of an inability to recall personal worked as a computer consultant (born in 1956), first events or information from his past found a close presented to a hospital casualty department on a Saturday parallel in his performance on the cued recall task. in 1989 complaining that he had suffered a severe headache while driving his car the previous Monday, and that his next Schacter et a! pointed to the lack of temporal memory was of waking up in his car on Saturday morning gradient in the functional retrograde amnesia of their at 5.00 a.m. At this time, apart from a stiff neck, there were patient; they contrasted this with the temporal no other signs, and he was admitted to the medical wards. gradient which is usually observed in retrograde On further examination, he described the onset of his amnesia based on cerebral pathology. They also headache as sudden, bilateral frontal and then radiating observed that in their patient ‘¿islands'of intact totheleftsideandtotheocciput.Hereportedhavingsome memory in the period of retrograde amnesia were nausea, but no vomiting. He indicated that his headache those which had a strong positive affective com had persisted since that time, but had become less severe. ponent, rather than those which were related to any To detailed questioning several days after admission, he reported an almost complete memory loss from the time particular temporal sequence. Two points of note of the headache to the point when he awoke in his parked about this patient are —¿thepresence of some long car near the hospital five days later. The two exceptions standing right temporal lobe pathology following a to this were a brief memory of driving later on Monday head injury which the patient suffered in childhood, into the lay-by of a town about 40 miles from the hospital, and the fact that his complaints of back pains getting out of the car and walking for a short distance, and appeared to be genuine, since after his amnesia had then driving off again. He also had a brief memory for a cleared he underwent back surgery to repair a short period late on Friday night, driving on a road leading spinal abnormality which was found on physical to the hospital. His memory was normal for events examination. This highlights the interaction which preceding this five-day period. From indirect evidence (car mileage, cheque book stubs, receipts, etc.) it appeared that may often be present between psychogenic and he had travelledadistanceofaround 1800 milesduring physical factors in patients who present with non the period, and stayed in hotel accommodation for part neurological forms of memory loss. of the time. It also appears that during this time he looked In the present study, we were able to examine a after his needs and his personal hygiene. He did not admit patient who presented with some of the features at any time to having lost his personal identity, nor did he of a fugue state, but who did not show other at any stageapproach bodiessuch as the policeor the distinctive features —¿suchas loss of personal identity Samaritans. When he was visited by his relatives in hospital, or prolonged period of retrograde amnesia. He also there was no evidence of failure to recognise them. showed low-average cognitive scores which could On physical examination, there were no neurological signs. Past medical history was unremarkable (four weeks conceivably have been associated with a mild neuro previously he had a minor riding accident in which he fell logical condition. We therefore sought to design a off his horse, injuring his head and shoulders, but not definitive memory test which would establish the suffering any concussion). A computerised tomography presence or absence of organic amnesia. In view of (CT) scan was carried out, with 4 mm cuts in the area of the pattern of memory loss shown by Schacter the temporal lobes, but this failed to detect any abnormality. 874 KAPUR

An electroencephalogram (EEG) examination was also personalities from the 1960sto the 1980swere dead or alive, normal. Cerebrospinal fluid (CSF) was examined to exclude he correctly recognised almost all of the items (44/46). He the possibility of a subarachnoid haemorrhage, but no was also able to name four of the past five leaders of the abnormality was found. Routine biochemical investigations Labour Party, and four of the last five presidents of the did not reveal the presence of any other pathology. United States of America. AS deniedanyrecentorpastepisodesofdepressionor other psychiatric illness, although when seenin the casualty department he did admit to some ‘¿nervousproblems' in Experimental investigation his teens. He did not offer any current memory or other A recognition memory test was designed to assess AB's cognitivesymptoms.Ondirectquestioning,hedid think memory for public events which had taken place over the his word-finding ability was a little impaired, but this past six months (this was administered 11 days after his symptom was not corroborated by his fiancée.Headmitted presentation to hospital). Twenty items were drawn up, ten his job was stressful, but did not consider that recent of which were fictitious news events, but which had some levels of work or domestic were unusually high. A degree of credibility and were similar in content to real discussion with his fiancée,however, brought to light a events (e.g. a bomb explosion in the American consulate rather turbulent family background. AB was born as the in Hamburgkilled35 people,manyof themwomenand result of an extra-marital affair. His mother's husband children) and ten of which related to real events —¿fourof brought up AB, but it was only when he was around 17 these had taken place during the critical five-day period of years of age that he became aware that his real father was AB's fugue state, four had occurred in the precedingsix elsewhere. At the age of 23 years, he spent a year away from months, and two had happened in the week after the end home trying to find him, and eventually succeeded in this. of his fugue state. Care was taken, especially for the four In the meantime, his step-father had died, and his mother critical events, to choose items which related to a single, fairly had remarried.Her newhusband,a nativeof Hungary,left dramatic event, and one which would be unlikely to have her after a few years, and she held AB largely responsible been repeated in the news over the following weeks (an for this, since AB had given him the fare to travel to example of a critical event was the following item —¿Two Hungary for a holiday, only to find that he did not return. robbers were shot dead, and a third seriously injured, when In the few weeks before the transient amnesic episode, AB's police gave chase after an attempted hold-up of a Post mother had been putting considerable pressure on AB so that Office van in Harrow, Middlesex). AB was presented with hecouldpersuadeherhusbandtocomebackfrom Hungary. the list of events on a sheet of paper, the items being randomly ordered. He was given the following instructions: Neuropsychologlcai investigations “¿Someofthe events written down here have actually taken place in the past six months, while others have been made A range of neuropsychologicaltasks were administered up and never took place at all. Can you put a tick to the approximately 4—7daysafter his presentation to hospital. ones which you think actually took place.― His performance on a shortened form of the Wechsler Adult On this test,AB correctly recognisedallthetargetitems, IntelligenceScale—Revised(WAIS—R;Wechsler,1981)was including the four critical items relating to the five-day normal (verbal IQ = 91, performance IQ = 110, full-scale periodof memoryloss,anddid not makeany falsepositive IQ = 98).On anadult readingtest,hisscorewasratherlower errors,i.e. indicatethata fictitiouseventhadin factoccurred. than might be expected from his background (estimated pre He thus obtained the maximum score of 20/20. His morbid IQ = 104), but was not very different from the pro performance was higher than that of a matched group of rated WAIS—Rfull-scale IQ. While his IQ scores were nine neurological patients with an amnesic syndrome (mean also rather lower than might be expected from his back score= 11.8, range 8—17),and similar to that of a group ground,it shouldbe pointedout that onlythe moredifficult of five control subjects (mean score 18.2, range 16—20). WAIS-R subtests were administered (digit span, arithmetic, Long-term follow-up. Approximately a year after this similarities,picturearrangement,blockdesign,digitsymbol), study was carried out, AB went missing again. On this and that administrationofthebatteryin fullwouldprobably occasion, there was clearly a stressful event (losing his job) have yielded higher IQ scores. The lower verbal compared which had precipitated his walking out on his wife and with performance IQ scores may simply reflect his average family. He was eventually found in Gibraltar, and was verbal ability as indicated by his reading-derived IQ score. On persuaded to return home. Detailed investigations around a range of verbal and non-verbal recall(Coughlan & Hollows, this time revealed that several years previously (in 1986) 1985)and recognition memory tasks, he scored within normal he had in fact unexpectedlyleft his family and friends to limits, although there was a tendency for verbal memory spenda year in Geneva.This wasfor the apparentreason tasks to be performed less well than non-verbal memory of studying, although on further inquiry it becameclear tasks. There was no evidence of any nominal dysphasia on that before his trip to Geneva he had been under a picture naming task (22/30), and he also performed well considerable business pressure. on a verbal fluency task, naming 20 words beginning with the letter ‘¿s'in60 seconds. His performance on a modified card sorting test (Nelson, 1976) was unimpaired. Discussion On testsof remotememory, healsoperformedwell - on a test of famous personalities, the ‘¿dead-or-alive'test We were able to demonstrate that in our patient there (Kapur et a!, 1989), where he had to indicate which was selective preservation of during the PSYCHOGENIC AMNESIA 875 five-day period of the fugue —¿personalmemories at no stage did our patient report any loss of personal were completely lost, but by means of a specially identity. Whether our case differs qualitatively, or designed public events recognition memory task we only in severity, from that of Schacter et a!is an open showed that his memory was preserved for news issue —¿itis possible that if our patient showed a loss events occurring during the fugue period. This of past autobiographical events covering a much dissociation between memory for personal and longer time period, then he may have displayed public events is consistent with earlier clinical and features such as a loss of personal identity which were experimental observations relating to patients with present in the Schacter et a! patient. psychogenic amnesia, and provides a potential Our case study also has some implications for the diagnostic tool for the accurate assessment of distinction between episodic and semantic memory. patients presenting with sudden, prolonged periods A number of researchers, such as Tulving (1989), of memory loss. have argued for a distinction between memory for Our case is similar to the one reported by Schacter specific events (‘episodic' memory) and retrieval of et a! (1982) which was presented as support for a factual knowledge (‘semantic'memory).Tulving et a! broad distinction between ‘¿episodic'memoryand (1988) have described a patient with dense amnesia ‘¿semantic'memory.However, there are a number after a severe head injury who could retrieve past of critical differences, both at the clinical and the knowledge in the absence of any conscious awareness theoretical level, between this study and that of as to the circumstances in which the knowledge was Schacter et a!. Schacter et al's patient did not have acquired. Tulving (1989) has further proposed that a fugue state as such, and some features which he the awareness associated with these two types of displayed —¿lossof personal identity, extensive retro memory retrieval be referred to as ‘¿noeticawareness', grade amnesia, presentation to a non-clinical agency, in the case of retrieval of factual knowlege, and and presentation during rather than at the end of the ‘¿autonoeticawareness', in the case of recall of fugue state —¿werenot present in our patient. In personal episodes from the past. It would appear that addition, he did have some chronic cerebral pathology while such a framework may help to account for dating from an early head injury, and his initial many forms of neurological memory loss, in the case somatic symptoms (severe back pain) appeared to of the psychogenic amnesia displayed by our patient, be genuine. At the cognitive level, Schacter et a! were a modification may be needed in order to explain able to demonstrate a dissociation between memory his pattern of memory performance. for famous faces and their patient's failure to recall Our patient could recall factual events which personally experienced events from his past, and they had occurred during the fugue period but had no considered this in terms of intact semantic memory memory for the personally experienced episodes and impaired episodic memory systems. which occurred at the same time. In the light of this Our patient also performed well on tests dealing dissociation, it may perhaps be more appropriate to with past famous personalities (the dead-or-alive test, entertain a distinction between two types of episodic generating names of past presidents/politicians). memory - one which relates to personally experienced However, his normal performance on the specially events (‘personal'episodicmemory), and a different designed public events amnesia test was not readily type of episodic memory which concerns non predictable from his other test scores. The events personal events (‘public' episodic memory). We which he correctly identified were presumably ones would propose that the distinction between these two which he personally experienced by watching/hearing types of memory can best be considered in terms of news bulletins or reading the newspaper. As such, whether someone else, at the same time but in a they would therefore appear to form a part of his different place, could have learned the information episodic memory system. It is possible, therefore, in question —¿ifso, this item would then be stored that one needs to allow for at least two distinct in ‘¿public'episodic memory. In the case of our episodic memory systems —¿onedealing with events patient, his personal episodic memory for the fugue in which the individual takes a direct part, and period was lost but his public episodic memory another system concerned with events observed/heard remained intact. The reverse form of dissociation has second-hand by the individual. Schacter et a! been reported in a patient with focal left temporal hypothesised that “¿accesstospecific autobiographical lobe pathology (De Renzi et a!, 1987), although in episodes depends upon the activation of the higher this patient the impairment in public episodic order classes or categories of personally relevant memory was part of a more general semantic knowledge― such as knowledge of one's own name. memory disorder. At the level of the type of fugue state found in our It may be useful to summarise the distinctive patient, this hypothesis cannot be supported since features of our patient's memory loss compared with 876 KAPUR those found in other transient amnesic states such The patient's report of a severe, sudden headache as transient global amnesia and transient epileptic initially suggested to clinicians that our patient may amnesia (e.g. Kapur, 1990). The duration of the have incurred a subarachnoid haemorrhage. Although memory loss was much longer than that described transient global amnesia may occur as a rare in most reported instances of transient global accompaniment of subarachnoid haemorrhage, it amnesia and instances of transient epileptic amnesia. does not have clinical features such as the prolonged The absence of any confusional state, either witnessed fugue state shown by our patient (Sandyk, 1984). Any or at time of clinical presentation, and of any speculations, therefore, in respect of a neurological definitive period of pre-ictal amnesia is also a feature disease must relate to the unlikely scenario of a which sets it apart from transient global amnesia. coexistent neurological and psychiatric condition Although we were unable to obtain any first-hand rather than a single, primary neurological one. accounts of his behaviour during the fugue state, it In conclusion, we have shown that in a patient would seem that there was no clinically obvious presenting with a prolonged period of transient global memory loss during this state, since this would memory loss, his amnesia for autobiographical events presumably have been picked up at some of the during that period can be dissociated from intact places where he stayed. This too is unlike what occurs memory for non-personal, public events processed in transient global amnesia, but it may occasionally by the patient during the same time period. This occur in patients with transient epileptic amnesia. selectivity of memory loss may prove to be a useful The normal performance of our patient on most diagnostic tool in distinguishing transient psychogenic cognitive tests given within a week of the end of amnesia from transient amnesia with a neurological the amnesic episode may occasionally be seen in basis, although in cases where there is no discrepancy corresponding patients with transient global amnesia, between memory for public and personal past events, although in general this is the exception rather than it should be borne in mind that this may sometimes the rule (Hodges & Ward, 1989). be for reasons other than a primary neurological Patients with transient epileptic amnesia tend to memory disturbance. Finally, in cases such as the one show signficant cognitive impairment as a fairly reported here, the possibility that the patient's consistent feature of their condition (Kapur, 1990) —¿pattern of memory disorder is simply due to feigning the lack of such impairment, together with the of his memory loss for the past should always be absence of any clinical or EEG evidence to suggest borne in mind (cf. Anderson et a!, 1959), in spite the presence of temporal lobe epilepsy, further of the fact that he did not show any evidence of distinguishes our case from those patients. The feigning on any of the formal memory tests. distinction between a psychogenic fugue state and one due to epilepsy is particularly apposite in Acknowledgements view of the occasional occurrence of so-called I am gratefulto ProfessorJ. Howell for the opportunity to examine ‘¿epilepticfugues'. Lishman (1987) and others have a patient under his care, and to Dr K. Kyriallis for his assistance. pointed to some of the possible distinguishing Dr B. Wilson kindly provided amnesic data relating to the features —¿inpsychogenic fugues, which are more real/fictitious News Events Test. likely to persist for relatively long periods (days or weeks) than epileptic fugues, the behaviour of the References patient during the fugue state will tend to have ANDERSON,E. W., TRETHOWAN,W. H. & KENNA,J. C. (1959) An been more purposeful and well-integrated, with experimental investigation of simulation and pseudo-. appropriate care and concern for personal appearance Ada PsychiatricaetNeurologicaScandinavica,suppl.132,1-42. and hygiene; consciousness will not be disturbed; COUGHLAN, A. K. & Hoiiows, S. (1985) The Adult Memory and and there will often be few if any accompanying Information ProcessingBattery.St James'sUniversityHospital, Leeds. physical or cognitive abnormalities. Where there is DE RENZI,E., Lioi-ri, M. & NICHELLI,P. (1987) Semantic amnesia additional clinical evidence of attacks resembling with preservation of autobiographical memory. A case report. temporal lobe epilepsy, as in the case reported by Cortex, 23, 575—597. Prchal & Smythies (1977), then this will obviously HoDGES, J. & WARD, C. (1989) Observations during transient global amnesia: a behavioural and neuropsychological study of make the diagnosis easier, although the possibility five cases. Brain, 112, 595—620. of a psychogenic fugue state in a patient with KAPUR, N. (1990) Transient epileptic amnesia: a clinically distinct confirmed temporal lobe epilepsy needs always to form of neurological memory disorder. In Transient Global be borne in mind. In the case of our patient, it Amnesia and Related Disorders (ed. H. J. Markowitsch). Stuttgart: Hans Huber. seemed that during the fugue period his behaviour YOUNG, A., BATEMAN,D. et al (1989) Focal retrograde was relatively ordered, with a maintenance of amnesia: a long term clinical and neuropsychological follow-up. personal hygiene. Cortex, 25, 387-402. PSYCHOGENIC AMNESIA 877

LISHMAN, A. W. (1987) Organic Psychiatry (2nd edn). Oxford: TULVING,E. (1989) Memory: performance, knowledge, and experi Blackwell Scientific Publications. ence.European Journal of Cognitive Psychology, 1, 3-26. MAYEUX, R., ALEXANDER, M. P., BENSON, D. F., et al (1979) SCHACTER, D. L., McLAcm.AN, D. R., et a! (1988) Priming Poriomania. Neurology, 29, 1616—1619. of semantic autobiographical knowledge: a case study of PRCHAL, V. & SMYTHIES,J. R. (1977) Temporal-lobe epilepsy retrograde amnesia. Brain and Cognition, 1, 3-20. presentingas a fugue state. Lancel, ii, 1034. WECHSLER,D. (1981) The Wechsler Adult Intelligence Scale —¿ SANDYK, R. (1984) Transient global amnesia: a presentation of Revised.SanAntonio, Texas:The PsychologicalCorporation. subarachnoid haemorrhage. Journal of Neurology, 231, 283- 284. N. Kapur, BA, PhD, DipPsych,Consu!tant Neuropsy ScHAcrER, D. L., WANG, P. L., TULVING,E., etal(1982) Functional retrogradeamnesia:aquantitativecasestudy.Neuropsychologia,chologist, Wesse.xNeuro!ogica!Centre,Southampton 20,523—352. Genera!Hospita!, Southampton S09 4XY

Reflex Tics in Two Patients with Gilles de la

M. COMMANDER, J. CORBETT, M. PRENDERGAST and C. RIDLEY

Two patientswith GillesdeIaTourettesyndrome(GTS) and sniffing. When she heard these noises she would showedtics triggeredby externalstimuli.Thisunusual experience an irresistible urge to tic. This upset her and feature Is of significanceto the aetlologyof GTS and she made people avoid coughing or sniffing in her In particular the relationship between GTS and the presence. startle response. Thereisno familyhistoryof GTSor obsessive-compulsive British Journa! of Psychiatry (1991), 159, 877—879 disorder (OCD). The patient lives alone with her mother. Her elder sister is married and her father died suddenly of a myocardial infarction when the patient was 14. Her early schoolingwasuneventfulandalthoughlaterteasedby other The Gilles de Ia Tourette syndrome (GTS) is a children she performed wellacademicallyand was meticulous characterised by both motor and in her work. vocal tics. Its aetiology is as yet unknown but Physical examination and investigations were normal. evidence is mounting for a subtle interaction between Once the diagnosis was confirmed she was commenced on biological and environmental factors operating haloperidol. This was gradually increased to 0.5 mg six particularly during vulnerable periods in develop times daily but she showed a poor response and a year later ment (e.g. Robertson, 1989). was switched to sulpiride. On a fmal dose of 1400mg daily We describe two patients with GTS whose tics were there was an improvement in all except the reflex tics. After triggered by external stimuli. This feature has not the death of her father these became such a problem that she stopped attending school. She was admitted to hospital been well documented previously, and its presence in and over the next six months her response to sulpiride, these subjects sheds light on the mechanisms involved pimozide and clonidine was assessed. Sulpiride, 300mg in tic production and provides an opportunity to daily, proved to be the most effective. This was combined reassess the relationship between GTS and the startle with supportive psychotherapy as well as counselling for response - a polysynaptic alerting reflex occurring in the patient's mother. response to a sudden powerful stimulus (Landis & P is now 16. She has been discharged from hospital Hunt, 1939). for 18 months. Her tics are well controlled. She still experiences reflex tics but these are less troublesome and she has been attending school regularly. Her main Case reports problems are compulsive phenomena and side-effects to sulpiride.She has amenorrheoa and galactorrhoea due to Case 1 hyperprolactinaemia (serum prolactin level 1800m.i.u./ml) and is on procyclidinefor shortlivedoculogyricepisodes. P first exhibited features of GTS at the age of six years In addition she has lost weightduring the past year. No whenshestartedto twitchher nose.Shewenton to develop organic basis for this has been identified and although she a variety of motor and vocal tics as well as echolalia. denies trying to lose weight or any concerns about her body Diagnosisof GTS was made when she was 12, at which image she has responded to treatment for an eating timeit wasnotedthat theticscouldbetriggeredbycoughing disorder. Amnesia in relation to fugue states--distinguishing a neurological from a psychogenic basis. N Kapur BJP 1991, 159:872-877. Access the most recent version at DOI: 10.1192/bjp.159.6.872

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