Background. Previous work suggests that temporal lobe magnetic resonance imaging (MRI) can distinguish those with dementia of the Alzheimer type (DAT) from healthy age-matched controls. However, its specificity with regard to conditions such as vascular dementia, depression and other disorders associated with cognitive impairment has not been determined.

Methods. We studied 222 subjects using T1 weighted MRI with 5·1 mm coronal slices throughout the temporal lobe. Subjects included: healthy controls (N=40); DSM-III-R major depression (N=61); NINCDS/ADRDA DAT (N=77) and OTHER (N=44, comprising subjects with vascular dementia, Huntington's disease, schizophrenia, alcohol related cognitive impairment and a group of ‘memory complainers’). Hippocampus, amygdala, entorhinal cortex, parahippocampal gyrus and cerebral cortex were rated visually on a 0–3 scale by two experienced neuroradiologists blind to clinical diagnosis.

Results. Ratings of temporal lobe atrophy provided good separation between those with AD and all other groups. For example, anterior hippocampal atrophy had a sensitivity of 83% for detecting DAT, a specificity of 80% for controls, 87% for depressed subjects and 89% for OTHER. Other regions were less sensitive, but more specific for the diagnosis of DAT. In particular parahippocampal gyrus and entorhinal cortex had high specificity (97% for depressed subjects and 98% for OTHER). Because of an age-related increase in atrophy, sensitivity was highest for those over the age of 75, while specificity was highest for younger subjects. Significant correlations were observed between atrophy ratings of hippocampus, amygdala, entorhinal cortex and parahippocampal gyrus and CAMCOG memory score and length of history.

Conclusions. Temporal lobe MRI may have an important role in assisting with the clinical diagnosis of DAT, particularly its differentiation from depression and other disorders that may cause diagnostic difficulties in clinical practice.

The present study set out to examine the relationship between marital status, poverty and depression in a sample of inner-city women. Single and married mothers were followed up over a 2-year period during which time rates of psychosocial risk factors, onset of depression and experience of chronic episodes were measured. Risk of onset was double among single mothers. Single mothers were twice as likely as their married counterparts to be in financial hardship, despite being twice as likely to be in full-time employment. Both of these factors were independently associated with onset in single mothers. The link between them and onset was via their association with humiliating or entrapping severe life events. Single parents were at a much raised risk of experiencing these events. Onset was also more likely to follow such an event when women had poor self-esteem and lack of support, both of which were more common among single mothers. These risk factors were more frequently found among those in financial hardship. Financial hardship was also related to risk of having a chronic episode (lasting at least a year), of which single parents were also at greater risk. The majority of chronic episodes among single mothers had their origins in prior marital difficulties or widowhood and rates of chronicity reduced with length of time spent in single parenthood. Results are discussed in terms of an aetiological model of onset in which financial hardship probably influences outcome at a wide variety of points.

Background. Though previous studies have clearly shown that lithium affords prophylaxis in bipolar affective disorder, these studies have not demonstrated the persistence of this prophylactic effect beyond the first year of recovery.

Methods. One hundred and eighty-one patients with bipolar affective disorder recovered during 5 years of semi-annual follow-up. After 8 weeks of recovery, 139 were taking lithium prophylaxis and 42 were not. Analyses used drug status (lithium v. no-lithium) as a censoring variable to compare these two groups by interval-specific probabilities of recurrence.

Results. Recurrence was initially less likely in the lithium group but interval-specific probabilities of recurrence did not consistently favour either group after the first 32 weeks of recovery.

Conclusions. Biases in treatment decisions may have both reduced the size and altered the specificity of the lithium effects seen here. Nevertheless, the apparent transience of lithium prophylactic effects is unexplained and may reflect important, physiological differences between relapse and recurrence. This possibility invites a controlled lithium discontinuation study, with gradual taper, of patients who have had at least 8 months of sustained euthymia.

Background. The aims of this study were to explore the role of life events and difficulties in the onset of anorexia nervosa and bulimia nervosa and to find out whether events and difficulties with a specific meaning, i.e. those of a certain sexual nature, are important in the onset of anorexia nervosa.

Methods. Seventy-two patients with anorexia nervosa (AN) and 29 with bulimia nervosa (BN) were assessed with the life events and difficulties schedule (Brown & Harris, 1978), the year before onset was studied. A new dimension to measure specific meaning of life events and difficulties called ‘pudicity’ was developed. Subjects from two community cohorts were used as comparison groups (Brown & Harris, 1978; Andrews et al. 1990).

Results. Anorexic patients, bulimic patients and community controls did not differ in the proportion of patients with at least one severe event; however, significantly more AN and BN patients than community controls had experienced a major difficulty. Sixty-seven per cent of anorexics and 76% of bulimia nervosa patients had either a severe event or a marked difficulty during the year before onset. In AN and BN the most common serious life stresses before onset concerned close relationships with family and friends with BN patients being significantly more often than AN patients directly involved in the problem (interpersonal events). Patients with anorexia nervosa had significantly more pudicity events before onset than BN patients or community controls.

Conclusion. While serious life stresses commonly precede the onset of anorexia nervosa and bulimia nervosa, problems with sexuality seem to be specific in triggering the onset of anorexia nervosa.

Background. An obstacle to the successful classification of attention deficit hyperactivity disorder (ADHD) is the frequently reported co-morbidity between ADHD and conduct disorder (CD). Prior work suggested that from a familial perspective, ADHD children with CD may be aetiologically distinct from those without CD.

Methods. Using family study methodology and three longitudinal assessments over 4 years, we tested hypotheses about patterns of familial association between ADHD, CD, oppositional defiant disorder (ODD) and adult antisocial personality disorder (ASPD).

Results. At the 4-year follow-up, there were 34 children with lifetime diagnoses of ADHD + CD, 59 with ADHD + ODD and 33 with ADHD only. These were compared with 92 non-ADHD, non-CD, non-ODD control probands. Familial risk analysis revealed the following: (1) relatives of each ADHD proband subgroup were at significantly greater risk for ADHD and ODD than relatives of normal controls; (2) rates of CD and ASPD were elevated among relatives of ADHD + CD probands only; (3) the co-aggregation of ADHD and the antisocial disorders could not be accounted for by marriages between ADHD and antisocial spouses; and (4) both ADHD and antisocial disorders occurred in the same relatives more often than expected by chance alone.

Conclusions. These findings suggest that ADHD with and without antisocial disorders may be aetiologically distinct disorders and provide evidence for the nosologic validity of ICD-10 hyperkinetic conduct disorder.

Background. The majority of patients presenting to cardiac clinics with chest pain who are reassured they do not have heart disease or other serious physical disorder continue to experience symptoms, worry about heart disease and restrict their activities. This randomized trial investigated the effectiveness of psychological treatment within routine cardiac care.

Methods. Consecutive patients presenting with chest pain and reassured by a cardiologist they do not have heart disease were reassessed 6 weeks later. Those with persistent limiting symptoms were offered the opportunity to participate in a trial of cognitive behavioural therapy.

Results. Thirty-seven subjects agreed to take part. A number of subjects were unenthusiastic about psychological intervention or, following explanation of the study, regarded further treatment as not being necessary. At 3 months there were significant differences between the treatment group and the control group on key outcome measures of symptoms, mood and activity. At 6 months there were fewer differences but significant advantages of treatment in terms of limitation of activities and worry about physical symptoms.

Conclusion. We conclude that there is a need for ‘stepped’ further care following reassurance in the cardiac clinic and that cognitive behavioural treatment is effective with those with persistent disabling symptoms.

Background. Studies on the direct and buffering effects of social support have not examined psychiatric sickness absence and few studies have considered support both at home and at work. This study addresses prospectively the effects of chronic stressors and social supports, at home and at work, on psychiatric sickness absence rates.

Methods. Sociodemographic factors, health and social support were measured at baseline, and short and long spells of sickness absence were measured prospectively over a 5-year period. The participants were a subsample of 4202 male and female civil servants, aged 35–55 years at baseline, from an occupational cohort, the Whitehall II Study, who completed detailed social support questions.

Results. Support from colleagues and supervisors at work is related to lower risk of short spells of psychiatric sickness absence, particularly for those also receiving high levels of negative aspects of close relationships from their closest person outside work. Negative aspects of close relationships from the closest person increase the risk of taking long spells of psychiatric sickness absence in men. High levels of material problems increase the risk of short spells of sickness absence.

Conclusions. Negative aspects of close relationships may have an aetiological role in non-psychotic psychiatric disorder. Social support at work appears to protect against short spells of psychiatric sickness absence. This potentially implies that levels of short spells of absence might be reduced by increasing support at work. Conversely, emotional support at home may influence absence-related behaviour and encourage a person to take absence at a time of illness.

Background. Several studies have replicated the finding of increased incidence of schizophrenia and related psychoses in first and second generation migrants from the Caribbean. The finding has remained consistent in studies employing different methods, but concern has been expressed about indirect methods of calculating the population at risk. This study aims to overcome these shortcomings.

Method. A further prospective study was undertaken in Nottingham assembling an inception cohort of psychotic patients (N=168) presenting from a defined catchment area. The 1991 census, which includes codings for self-ascribed ethnic origin, was used to calculate the denominator, employing correction factors for potential under-enumeration. Case-ascertainment was based upon all service contacts and subjects had in-depth assessments including the SCAN. Collateral history was obtained from informants.

Results. Subjects born in the Caribbean, or who had one or both parents born in the Caribbean, had a greatly elevated risk (incidence ratios above 7) for all psychotic disorders and for ICD-10 (DCR)-defined F20 Schizophrenia.

Conclusions. The size of the increase and the methodological safeguards employed support the validity of this now highly replicated finding. A personal or family history of migration from the Caribbean is a major risk factor for psychosis; the consistency of this finding justifies a systematic evaluation of potential aetiological factors. Any hypothesis derived from the evidence so far must explain: increased incidence in first and second generation migrants; increased risk for all psychoses (including affective psychoses); and an effect specifically associated with a migration history from the Caribbean to Northern Europe.

Background. Previous studies have examined childhood factors that appear to increase the risk of developing an eating disorder (e.g. sexual abuse and parental care). Studies have not yet examined whether the way in which women cope with these adversities in childhood influences the risk.

Method. Using a semi-structured interview, childhood helplessness and mastery were measured (based on behavioural indices) in women with and without a history of eating disorders.

Results. There was a higher rate of childhood helplessness and a lower rate of childhood mastery in women with eating disorders compared to those without. Furthermore, this difference did not appear to be a result of current psychiatric state.

Conclusion. It is concluded that it is not simply the presence of adversity in childhood which is of aetiological importance in the development of eating disorders but the way in which these are negotiated.

Background. While neuropsychological studies have consistently reported impaired cognition in elderly patients with unipolar depression, studies of cognitive function in younger patients with depression have produced equivocal results. The aim of this study was to examine the presence and nature of cognitive deficits in young patients with depression.

Methods. Neuropsychological function was assessed in 20 young patients with unipolar depression, in comparison to 20 age-, education- and IQ- matched controls. Subtests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were employed, as this battery has proved sensitive to deficits in middle-aged and elderly patients with depression.

Results. The patients were not impaired for short-term memory capacity, spatial working memory, planning ability, cognitive speed, delayed matching to sample or recognition memory. Compared to controls, the patients showed impaired subsequent movement latencies on the Tower of London task, suggesting deficits in the ability to sustain motor responses in depression. The depression group were also impaired on the task of attentional set shifting, requiring more trials to criterion at the intradimensional stage of the task and being more likely to fail the task at the extradimensional shift stage than controls. Further analysis indicated that half of the depression group failed to complete all stages of the set shifting task. These patients were more likely to have required in-patient hospitalization at some time during their illness.

Conclusions. These results indicate that there are specific cognitive deficits in young patients with depression and that their presence may be related to a history of hospitalization.

Background. Patients who present with chest pain but have normal coronary angiography and who are told by their cardiologist that they do not have heart disease, have a poor symptomatic, psychological and quality of life outcome and remain concerned about a serious cause of their symptoms. They frequently complain they have not had enough information. The study aimed to test the effectiveness and acceptability of a brief psychological intervention based on cognitive behavioural principles.

Methods. Consecutive patients with chest pain and normal angiograms were assessed and invited to take part in a randomized controlled evaluation. The intervention consisted of an individualized information and discussion session by a specially trained cardiac nurse, together with a handout and cassette providing information and advice and telephone follow-up to discuss progress, answer questions and reiterate advice.

Results. The treatment proved to be unacceptable to some patients and there was no evidence of efficacy.

Conclusions. Implications for the preparation of patients undergoing angiography and for the timing and delivery of information and advice following a negative result are discussed.

Background. Reports of an increased incidence of schizophrenia in Afro-Caribbean immigrants to the UK are a matter of much debate. It is of interest, therefore, that in the 1970s and 1980s many immigrants from Surinam and The Netherlands Antilles have settled in The Netherlands. The purpose of our study was to compare the risk of a first admission for schizophrenia for Surinamese- and Antillean-born persons aged 15–39 years to that for their Dutch-born peers in the period 1983–1992.

Methods. We used data from the Dutch psychiatric registry. Age-adjusted relative risks were calculated using Poisson regression analysis.

Results. The risk for the immigrants was found to be three to four times higher than that for the Dutch-born. Age-adjusted relative risks were significantly higher for male than for female immigrants.

Conclusions. The results provide evidence of an increased incidence in these immigrant groups and support similar findings on Afro-Caribbeans in the UK. Migration from Surinam was on such a large scale that selective migration of persons at risk for the disorder is unlikely to account entirely for these findings.

Background. Although overwhelming evidence suggests that genetic and environmental risk factors both contribute to the aetiology of major depression (MD), we know little of how these two risk factor domains inter-relate. In particular, can the genetic liability to MD increase the risk of experiencing stressful life events (SLEs)?

Methods. Using discrete time survival analysis in a population-based sample of 2164 female twins, we examined whether the risks for nine personal and three aggregate network SLEs were predicted by the level of genetic liability to MD, indexed by the lifetime history of MD in monozygotic and dizygotic co-twins.

Results. Genetic liability to MD was associated with a significantly increased risk for six personal SLEs (assault, serious marital problems, divorce/breakup, job loss, serious illness and major financial problems) and one network SLE (trouble getting along with relatives/friends). This effect was not due to SLEs occurring during depressive episodes. Similar results were found using structural equation twin modelling. In contrast to the pattern observed with MD, the genetic liability to alcoholism impacted on the risk for being robbed and having trouble with the law.

Conclusion. In women, genetic risk factors for MD increase the probability of experiencing SLEs in the interpersonal and occupational/financial domains. Genes can probably impact on the risk for psychiatric illness by causing individuals to select themselves into high risk environments.

Background. This paper summarizes work with the Interview for Recent Life Events (IRLE), an instrument that has been used extensively but not previously reported in detail.

Methods. Rationale, development, organization, content, reliability, validity and applications are reviewed in full.

Results. The instrument covers a comprehensive range of recent life events, their timing and other important qualities. It has been found reliable and valid, and has been translated into a number of languages. It has been used by many research groups in different countries, in studies of psychiatric patients, medical patients and subjects in the general population.

Conclusions. The instrument is useful, has been widely applied and has the necessary qualities for ascertainment of life events in research studies.

Background. We investigated whether schizophrenic subjects are impaired in non-routine behaviour because of the dysfunction of a general executive component labelled, in neuropsychological terms, the supervisory system.

Methods. A specific verbal sequencing test was designed for this purpose. Subjects had to perform sequential reasoning with verbal material. Each test sequence consisted of a series of words presented in jumbled order. The construction of some sequences had to be done using familiar routine associations (valid conditions). In contrast, some other sequences required the overriding selection of familiar routine associations, which were inappropriate within the general context of the task (invalid conditions). Twenty verbal sequences (10 valid–10 invalid) were administered. Thirty-seven DMS-IV schizophrenic patients and 21 normal volunteers matched for age and educational level were recruited.

Results. Compared to the control group the schizophrenic group was impaired in both valid and invalid conditions. The number of ‘capture errors’ specific to supervisory system failure was significantly higher in the schizophrenic group and only the schizophrenic patients had significantly fewer correct sequences in invalid conditions than in valid conditions. Poor performance in invalid conditions alone was observed only among the schizophrenic subjects without a general cognitive defect.

Conclusions. These findings suggest that sequencing procedures requiring an executive input are impaired in schizophrenia.

As part of a longitudinal study of bereavement phenomena in three groups, bereaved spouses, bereaved adult children and bereaved parents, scale development was carried out using a pool of bereavement phenomenology questions administered prospectively. The items were derived from the literature, in particular studies dealing with the measurement of grief/bereavement, as well as from clinical experience. Factor analysis of theoretically grouped items produced seven subscales, three of which tapped frequently experienced phenomena in the bereaved. These three subscales formed the basis of a single measure, labelled the Core Bereavement Items (CBI), which demonstrated high reliability and sound face and discriminant validity. Preliminary analysis suggested that the CBI will prove to be a reliable and valid instrument with respect to the measure of core bereavement phenomena in commonly bereaved groups in Western society.

Background. Many women who undergo diagnostic laparoscopy for chronic pelvic pain do not have pelvic pathology. This has led to an interest in psychological factors that might contribute to their experience of pain. This study was designed to evaluate the effects of diagnostic laparoscopy on women with chronic pelvic pain and to explore possible psychological mechanisms.

Methods. Seventy-one women undergoing laparoscopy for chronic pelvic pain were randomly allocated to one of two groups waiting different lengths of time for laparoscopy. Women were interviewed before laparoscopy and were followed up 1 week, 3 months and 6 months afterwards. Pain was assessed with an interview measure, diaries and visual analogue scales.

Results. Pain reductions were observed from before to after diagnostic laparoscopy. Regression analysis was used to identify factors which predicted improvements in pain. The hypothesis that psychological factors would predict improvements in pain was confirmed. Pain improvements after laparoscopy were predicted by beliefs about pain and the change in each woman's evaluation of the seriousness of her condition. Other than baseline pain, these psychological variables were the only ones to emerge as predictors of pain change despite exploratory analysis of over 40 other variables.

Conclusions. Diagnostic laparoscopy can have beneficial effects in women with chronic pelvic pain. These effects appear to be the result of psychological mechanisms. Further investigation of these mechanisms could help in the understanding and treatment of women with chronic pelvic pain.

Background. To understand the relationship between parenting and psychopathology in offspring, it is critical to clarify the determinants of parenting behaviour itself.

Methods. A 16-item version of the Parental Bonding Instrument (PBI) was administered to parents of epidemiologically sampled adult female–female twin pairs, who reported on the parenting they provided to their twins, and to the twins themselves who reported on the parenting they and their co-twin had received (N=828 twin families). Using a mixed-model regression, we examined the impact on parenting, as retrospectively reported by parents and twins, of six variable domains: demographic factors, family characteristics, parental symptoms and personality, parental psychopathology, child vulnerability and childhood temperament.

Results. The PBI yielded three factors: warmth (W), protectiveness (P) and authoritarianism (A). W was most strongly predicted by parental personality and psychopathology, parental marital quality, and child temperament. P and A were both most strongly predicted by parental educational level and religious fundamentalism. In addition, P was predicted by neurotic/anxious traits in both parent and child. For a number of variables that predicted W, the strength of the association was stronger when twins were reporting than when parents were reporting.

Conclusions. Parenting is a complex, multi-determined set of behaviours that is influenced by parental personality, psychopathology, values and marital quality and by a range of child characteristics. W appears to be strongly influenced by parental and childhood temperament and vulnerability to psychiatric illness while P and A are more strongly influenced by ‘sociological’ factors such as religious affiliation and educational status.

One hundred and seventy-two women randomly selected from a Zimbabwean township were interviewed with a Shona screen for mental disorders and a semi-structured interview to assess symptoms suggestive of emotional distress, followed by the Present State Examination. Using criteria slightly stricter than threshold level 5 of the PSE-CATEGO-ID system, 30·8% of women had a depressive or anxiety disorder during the previous year. Nearly all disorders met Bedford College criteria for depression; 65% of these also had anxiety features. Only 0·6% of women had a ‘pure’ anxiety disorder not preceded by or associated with depression in the study year. Compared with London, the higher annual prevalence of disorders in Harare could mostly be accounted for by an excess of onset cases in the study year, 70% of which made a full or partial recovery within 12 months. The women's own words for these episodes included ‘thinking too much’, ‘deep sadness’ and a variety of terms describing heart discomfort, interpretation showing many of the latter to be expressions for grief, fear, or the possession of an insoluble problem, and 73% explained their symptoms as caused by a specific social stressor.

Background. The disorganization pattern in schizophrenia, which involves formal thought disorders, is thought to be correlated with a deficit in integrative processes of contextual information. We tested the hypothesis that thought disordered schizophrenics, unlike non-thought disordered schizophrenics, would present a deficit in the processing of the context during a task which involves these integrative processes.

Methods. A group of 22 schizophrenic patients diagnosed in accordance with DSM-III-R criteria and a group of 11 control subjects were compared using a semantic priming version of the lexical decision task. The experimental design used low-level structuration of verbal material to reveal the difficulty that schizophrenic patients encounter in using semantic regularities.

Results. A significant difference in priming effect was found between the three groups. Control subjects and non-thought disordered schizophrenics exhibit a priming effect for related word pairs when compared with unrelated pairs (respectively F(1,10)=17·7; P<0·002 and F(1,10)=14·5; P>0·003) but thought disordered schizophrenics did not (F(1,10)<1; NS).

Conclusions. This finding provides evidence for the cognitive heterogeneity of schizophrenic subjects. This absence of priming effect in thought-disordered schizophrenic subjects supports the hypothesis that these patients present a deficit in the post-lexical controlled information processing that permits the integration of semantic information.