Background. Of the midline brain structures, abnormalities have been demonstrated in the corpus callosum and cerebellum in young schizophrenic patients. Whether similar abnormalities are also present in late-onset schizophrenia (LOS) is not known.

Methods. The mid-sagittal cross-sectional areas of brain regions, in particular the corpus callosum and cerebellum, on magnetic resonance imaging were examined in a group of patients with late-onset schizophrenia (N=25) and contrasted with two comparison groups – early-onset schizophrenia (EOS) (N=2524) and healthy volunteers (NC) (N=2530) matched for age and gender.

Results. While the mean corpus callosum area in the LOS group was smaller than in the EOS (by 10·2%) and NC (by 6·2%) groups, the three groups did not differ statistically in the corpus callosum area or the corpus callosum to cerebrum ratios. The cross-sectional cerebellar areas or the cerebellum: cerebrum ratios also did not differ across the groups. The brainstem was smaller in the schizophrenic groups because of smaller cross-sectional areas of the pons, a statistically significant difference which could not be accounted for by any gross lesions on visual inspection.

Conclusion. We found no abnormality in the mid-sagittal area of the corpus callosum and cerebellum in our early- or late-onset schizophrenia subjects. The significance of the finding of a smaller pontine cross-sectional area is unclear and speculation on it awaits independent replication using a volumetric measure.

Background. Olfactory identification ability has been associated with processing in the orbitofrontal cortex (OFC), an area that has been implicated in the pathophysiology of obsessive–compulsive disorder (OCD). Although olfactory sensitivity is normal in patients with OCD, no study has investigated olfactory identification in this disorder.

Methods. A group of 20 subjects with OCD and 23 age- and education-matched controls performed a standardized test of olfactory identification. They also performed computerized tests of spatial memory span, spatial working memory and spatial recognition memory that have been shown previously to be sensitive to cognitive deficits in patients with OCD.

Results. Performance on the olfactory identification task, spatial recognition task and spatial span task was significantly worse in the OCD group than controls.

Conclusions. While impairment in spatial cognition is consistent with previous studies of OCD, its significance for brain-behaviour models of OCD is unclear. However, the finding of abnormal olfactory identification in patients with OCD is consistent with the hypothesis that there is a disruption to processing at the level of the OFC in the disorder.

Background. Sleep-related eating disorder is a little-described syndrome combining features of sleep disorders and eating disorders. The behaviour consists of partial arousals from sleep followed by rapid ingestion of food, commonly with at least partial amnesia for the episode the following day. The aim of this study was to provide an estimate of the prevalence of sleep-related eating disorder.

Methods. The Inventory of Nocturnal Eating, a self-report questionnaire addressing nocturnal eating and sleep disturbance, was administered to out-patients (N=126) and in-patients (N=24) with eating disorders, obese subjects (N=126) in a trial of an anorexic agent, depressed subjects (N=207) in an antidepressant trial, and an unselected group (N=217) of college students. Sleep-related eating disorder was operationally defined as nocturnal eating with a self-reported reduced level of awareness, occurring at least once per week.

Results. Almost 5·0% (33/700) of the sample described symptoms consistent with sleep-related eating disorder. The in-patient eating disorders group had nearly twice the prevalence (16·7%) of the out-patient eating disorder sample (8·7%), which had nearly twice the prevalence of the next highest group, the student sample (4·6%). Subjects with sleep-related eating disorder endorsed more symptoms consistent with sleep disorders and had higher levels of depression and dissociation than those without nocturnal eating.

Conclusions. Sleep-related eating disorder is more common than is generally recognized, especially in those with a daytime eating disorder. Sleep disorder symptoms are often associated with sleep-related eating disorder, as are depression and dissociation. Evaluation of individuals with eating disorders should include assessment for sleep-related eating.

Background. The present study provides data on the reliability, validity and treatment sensitivity of the Liebowitz Social Anxiety Scale (LSAS), one of the most commonly used clinician-administered scales for the assessment of social phobia.

Method. Three hundred and eighty-two patients from several studies of the treatment of social phobia were evaluated. An independent assessor administered the LSAS to each patient prior to the initiation of treatment. Patients also completed other measures of social anxiety and avoidance, although the specific measures varied across samples.

Results. The LSAS and its subscales were normally distributed and demonstrated excellent internal consistency. The convergent validity of the LSAS was demonstrated via significant correlations with other commonly-used measures of social anxiety and avoidance. These correlations also tended to be larger than correlations with measures of depression, especially after treatment. However, the pattern of correlations of LSAS subscales with one another and with the other measures suggest that the fear subscales and the avoidance subscales may not be sufficiently distinct in clinical samples. The LSAS was also demonstrated to be sensitive to the effects of pharmacological treatments of social phobia over time and in comparison to double-blind pill placebo.

Conclusion. The LSAS appears to be a reliable, valid and treatment sensitive measure of social phobia. Further study of the LSAS, both in samples with severe social phobia and in community samples, is needed.

Background. The common legacy of severe degrees of traumatic brain injury is varying degrees and types of impairments, which impact significantly upon the individual's resumption of pre-morbid psychosocial roles. Yet there are few data to indicate the relative contribution of these and other non-injury related variables.

Methods. Seventy individuals with varying levels of disability after severe traumatic brain injury were examined neurologically and neuropsychologically, on average at 6 years post-trauma. A range of biographical, injury, impairment and psychological variables were examined with multiple regression analyses to identify those that contributed to successful psychosocial reintegration.

Results. Severity of injury and impairments, along with chronicity and level of self-esteem were significant predictors of psychosocial adjustment. Further analyses revealed that within the neuropsychological domain, the variable measuring behavioural regulation of abilities was the most significant. Examination of specific domains of psychosocial functioning (occupational activities, interpersonal relationships and independent living skills) revealed different patterns of significant predictor variables, in addition to indices of the severity of initial injury: neurophysical impairments and memory functioning predicted successful occupational activities; chronicity, cognitive speed and behavioural regulation predicted success in interpersonal relationships; and neurophysical impairments, behavioural regulation and memory functioning predicted independent living skills.

Conclusions. These results reinforce the overriding importance of injury severity and neurological factors (both neurophysical as well as neuropsychological) in predicting psychosocial adjustment after traumatic brain injury. Support for the contribution of non-neurological factors was also found.

Background. Apathy is a frequent neurobehavioural sequel in patients with acquired brain damage and it may seriously affect outcome of rehabilitation.

Methods. Patients with traumatic brain injury, cerebrovascular insults and hypoxic brain injury, categorized into four lesion localization groups: left hemisphere damage (LHD); right hemisphere damage (RHD); bilateral hemispheric damage (BHD); and subcortical damage (SCD) were assessed with the Apathy Evaluation Scale (AES) and Montgomery and Åsberg Depression Rating Scale (MADRS). Heart rate and electrodermal activity were recorded in an experimental situation that exposed the patients to mental stressors in order to measure psychophysiological reactivity.

Results. Significant differences in level of apathy were found between diagnostic groups as well as between localization subgroups. SCD and RHD patients displayed most apathy. Factor analysis of MADRS revealed a three-factor solution; depressed mood, somatic symptoms and negative symptoms. Apathy was significantly correlated with negative symptoms in all localization subgroups, except among the BHD patients. Apathy was not correlated with depressed mood or somatic symptoms. Moreover, apathy was significantly correlated with heart rate reactivity, but not with electrodermal reactivity.

Conclusion. Apathy is common, its severity depending on diagnosis and localization of lesion. Apathy and depression in brain damaged patients share common features, but may be differentiated. The significant relationship between apathy and heart rate may provide a psychophysiological correlation of the disengagement, lack of interest and absence of emotional responsivity typically seen in apathy. The results have implications for the theoretical understanding of apathy and related negative symptoms, and for rehabilitation practice.

Background. According to DSM-III-R V-code conditions refer to marital relationships, family circumstances, interpersonal relationships, or stressful life events that are not attributable to a mental disorder but that are the focus of treatment. The purpose of the present study was to assess the prevalence and patient and treatment characteristics of adult psychiatric out-patients diagnosed with V-code conditions.

Methods. The records of all 5660 consecutive admissions to a psychiatric out-patient clinic over a 12-year period were studied retrospectively. On the basis of both primary and secondary DSM-III-R diagnoses on Axis I, two subgroups of patients were compared: (1) patients with V-code conditions; and (2) patients with mental disorders.

Results. Fourteen per cent of the patients had a V-code condition and no mental disorder, while the remaining patients were diagnosed with mental disorder (with or without an additional V-code condition). Comparisons of sociodemographic and clinical severity characteristics of the two groups indicated that patients with V-code conditions tended to have a higher socio-economic status and to present with less severe problems as assessed both by the primary therapist and the Symptom-Checklist-90. With respect to service use and treatment outcome variables, it appeared that V-code patients tended to be more frequently treated by couple/family therapy and to receive a slightly lower number of treatment sessions.

Conclusions. The pattern of results in The Netherlands seems comparable to results of previous North American studies. Implications of these findings for future studies and for use of mental health services are discussed.

Background. Dysregulation of corticotropin (ACTH) and cortisol response after corticotropin-releasing hormone (CRH) stimulation has been reported in bipolar patients. Most findings involve the pathophysiology of the depressive phase of the illness and its prediction. However, the possible predictive value of the CRH challenge test with respect to manic episodes remains unknown.

Methods. The ACTH and free cortisol response to the injection of 100 μg of synthetic human CRH and plasma cortisol-binding globulin levels were measured in 42 lithium-treated patients suffering from Research Diagnostic Criteria bipolar I disorder in remission, and 21 age- and sex-matched normal controls. A 1-year follow-up was conducted to assess any possible relationship between outcome and the hormonal response.

Results. Bipolar patients showed higher baseline and peak ACTH concentrations than control subjects. A higher area under ACTH concentration curve after CRH stimulation predicted manic/hypomanic relapse within 6 months by multiple regression analysis.

Conclusion. Bipolar patients in remission show mild abnormalities in ACTH levels before and after CRH stimulation. CRH challenge may be a potentially good predictor of manic or hypomanic relapse in remitted bipolar patients.

Background. Neuropsychological function and cognitive correlates of depression have not previously been examined in a rigorously defined population of patients suffering from premenstrual dysphoric disorder (PMDD).

Method. Mood, neuropsychological function and cognition were measured in 10 PMDD patients and 10 age-matched controls in both phases of the menstrual cycle in a random order, counter-balanced design.

Results. The BDI was significantly elevated in the luteal phase of PMDD patients only while other cognitive measures showed no significant differences. Working memory was impaired in the luteal phase of the menstrual cycle with no significant differences between PMDD and control subjects.

Conclusion. Despite the small sample size, these results show that the BDI is sensitive to the mood fluctuations of PMDD patients. An impairment in working memory was also found although this is a general menstrual cycle effect.

Background. The aim of the study was to confirm the predictive relationship between socio-economic factors and psychiatric admissions at a fine grain geographical level. The strength of association was compared with those of other studies that have looked at separate diagnostic groups.

Method. Psychiatric admissions were from electoral wards of the County of South Glamorgan, which encompasses the capital city of Wales, Cardiff. Standardized psychiatric admission ratios (SAR) for different diagnostic groups were calculated for a 5-year period. The ecological association with deprivation indices and with single variables at the level of electoral ward was examined. Of a total of 15266 psychiatric admissions, 11296 were analysed.

Results. Psychiatric morbidity, reflected in SAR was inversely related to socio-economic deprivation for both sexes. This applied to all diagnostic groups except organic disorders. The relationship was most marked for schizophrenia, delusional disorders and substance abuse, closely followed by personality disorders, and less for affective and neurotic disorders. Little difference existed between three composite indices of deprivation (Carstairs, Jarman, Townsend), but the marginally best predictor was that designed by Jarman. However, low rates of car ownership and high unemployment were as good at predicting SAR as any of the compound indices.

Conclusion. Socio-economic factors account for almost 50% of the variance in psychiatric admission rates between electoral wards. The degree of association between psychiatric morbidity and deprivation varies between diagnostic groups, arguing against a common factor linking deprivation and psychiatric admissions generally. Frequently updated unemployment figures provide nearly as useful and more immediate information than 10-yearly Census data used to calculate the deprivation indices. These figures may be used for needs assessment and targeting resources at a local level.

Background. This article provides evidence about the relationship between psychiatric disorders, physical disorders and hospital use in the general medical sector using a broadly based survey of the US population.

Methods. The data are from the 1989 National Health Interview Survey. This survey contains medical and mental health evaluations for the entire sample. In a multivariate framework, the author estimates the effect of mental illness on the probability of being admitted to a general hospital, the number of admissions and the length of stay.

Results. Hospital use in the general medical sector is significantly higher for persons with coexisting physical and psychiatric conditions than for those with no psychiatric disorders. For a wide range of medical conditions, the predicted number of hospital admissions and the length of a hospital stay increase substantially when the physical illness is accompanied by a psychiatric condition.

Conclusions. One implication of this finding is that economic evaluations of alternative psychiatric treatments should consider any differences in hospital costs related to the treatment of coexisting medical conditions. Another implication pertains to health care systems where insurers have some discretion over which individuals to insure. In the absence of adequate adjustments in insurance payments for high-risk potential enrollees, psychiatrically disabled persons may have more limited access to health insurance.

Background. Current mental health legislation in the UK makes provision for the use of certain treatments in severely ill patients who are unable, or unwilling, to give informed consent. Under the terms of this legislation, electroconvulsive therapy (ECT) may be used, usually to treat severely depressed patients. A number of organizations have challenged this practice, stating that ECT should only be given with fully informed consent: it has been implied that patients receiving compulsory ECT (given without the patient's consent, under the terms of mental health legislation) find the treatment damaging and unhelpful.

Methods. A series of 150 patients receiving ECT in Aberdeen was studied. A proportion of the series (approximately 7%) received compulsory ECT. The views and treatment outcomes of compulsory patients were compared with those of patients giving informed consent for treatment.

Results. More than 80% of patients in both consenting and compulsory groups considered ECT to have helped them. Clinical outcome did not differ between the groups. Patients' views showed marked concordance with independent medical evaluation of outcome.

Conclusions. Outcome following ECT in non-consenting patients is equivalent to that seen in consenting patients whether rated by the patients themselves or by clinicians. Overall outcome is good, with more than 80% of patients benefiting from treatment. A ban on compulsory ECT would deny the access of seriously ill patients to an effective and acceptable treatment.

The task of improving the ability of clinicians to predict which of their patients will be violent has come to be seen as one of establishing the relative merits of actuarial and clinical prediction. The meaning of these terms is unclear. ‘Clinical’ is usually defined by exclusion, that is, as something other than actuarial. The term ‘actuarial’ is often used to refer to the techniques of risk prediction in financial services. In the psychiatric and psychological literature relating to the assessment of dangerousness, three further meanings have emerged. That whereby actuarial refers to any mathematical means of combining information is the most widely accepted. Whichever definition is employed, the conclusion of most reviews has been that the future is actuarial. It is argued here that, while mathematical approaches have been successful in showing that risk factors for violence in the general population apply also to the mentally disordered, important questions remain unanswered. Mathematical methods address only one form of probability, that which arises from chance. A development of another form of probability, that which arises from causes, offers the prospect of improved risk assessment in psychiatry. It also offers a definition of clinical prediction that is not based on exclusion.

Background. There is evidence for an association between two different polymorphisms of the human serotonin transporter gene (5-HTT) and the personality trait of neuroticism and affective disorder.

Methods. We studied the association between neuroticism and polymorphisms in the 5HTT-linked promoter region and in a variable number tandem repeat region (VNTR) of the 5-HTT gene in 204 people aged over 60 derived from a random sample of men and women in the general population. Approximately half of the subjects were in the top 20% of neuroticism scorers and half in the bottom 20%.

Results. There were no significant differences in allelic or genotypic frequencies between the high and low neuroticism scorers. There was highly significant linkage disequilibrium between the two 5-HTT gene polymorphisms, and haplotype analysis showed no association between neuroticism level and haplotype.

Conclusions. Reports of an association between two 5-HTT gene polymorphisms and the personality trait of neuroticism are not supported by these results.

Background. Although the ‘high interpersonal sensitivity’ type of personality has repeatedly been shown to be related to depression by case–control studies, no studies have confirmed whether this association also exists in a non-clinical sample.

Methods. Scores on the Interpersonal Sensitivity Measure (IPSM) were compared between employed Japanese adults with and without a lifetime diagnosis of major depressive disorder. The diagnosis was provided by the Inventory to Diagnose Depression, Lifetime version. A multiple logistic regression analysis estimated the odds ratios for having a lifetime diagnosis of depression.

Results. The scores on the IPSM were higher in the subjects with a lifetime history of depression than those without a lifetime history of depression. On the five subscales of the IPSM, the subjects with a lifetime history of depression showed higher scores on ‘interpersonal awareness’, ‘need for approval’, and ‘separation anxiety’ than those without a lifetime history of depression. The multiple logistic regression analysis showed that the subjects with the high interpersonal sensitivity type of personality had an increased risk for experiencing lifetime depression.

Conclusions. The results suggest that high interpersonal sensitivity is a risk factor for depression even in a non-clinical sample from non-Western culture.

Background. Little is known about the effects of depression on the mortality rates of elderly subjects with dementia.

Methods. Logistic regression analysis, adjusting for possible confounders, was used to study the associations between GMS-AGECAT derived syndrome and symptom measures and 12-month mortality rates in a cohort of 73 elderly subjects who met the DSM-III-R criteria of dementia with a median MMSE score of 19.

Results. Twenty-three subjects (32%) died within the 12 month follow-up period. A baseline diagnosis of syndromal or subsyndromal depression was associated with increased mortality. At the symptom level mortality was predicted by higher scores on the factor ‘mood symptoms’. The effects of interactions between depression measures and severity of dementia were not significant.

Conclusions. Short-term mortality in elderly subjects with less severe dementia is predicted by the presence of (sub) syndromal depression and by mood symptoms. The effects of depression and severity of dementia on the mortality rates seem to be largely independent.

Background. The human serotonin transporter gene (5-HTT) is a strong candidate for involvement in the pathogenesis of mood disorders. Two common polymorphisms have been identified in the gene: a VNTR in intron 2 and a functional deletion/insertion in the promoter region. In previous studies we proposed that allele 12 of the VNTR might increase susceptibility for bipolar disorder.

Methods. We have genotyped 122 parent–offspring trios of British Caucasian origin where the proband had DSM-IV Bipolar I disorder (BPI). The results were analysed with the transmission/disequilibrium test (TDT), which examines whether particular alleles are preferentially transmitted from heterozygous parents to affected offspring.

Results. The 12 repeat in the VNTR in intron 2 was transmitted 72 times and not transmitted 56 times (χ2 = 2·0, 1 df, P=0·16). If we exclude 24 families in which the proband was a case in our published case–control studies (Collier et al. 1996a; Rees et al. 1997), the excess transmission of allele 12 reaches conventional levels of statistical significance: χ2 = 3·85, 1 df, P<0·05. The deletion/insertion polymorphism in the promoter region was not associated with BPI: 66 parents transmitted the inserted (L) allele and 59 parents transmitted the deleted (S) allele (χ2 = 0·39, 1 df, P=0·53).

Conclusions. The 12 repeat of the VNTR in intron 2 of the serotonin transporter gene might be a susceptibility factor in bipolar affective disorder. The genetic effect, if true, is likely to be small, and requires confirmation in further studies using parental controls.

Background. African-Caribbean patients have less desirable routes of entry into the psychiatric services than other ethnic groups in Britain but this may not apply to the first contact with services.

Methods. Patients' pathways to care, type of admission or referral and sectioning details were recorded for all first contact patients presenting to south London psychiatric services over a 2-year period. We also conducted a retrospective analysis of data from the Camberwell Register, comparing rates of compulsory admission between ‘Whites’ and ‘African-Caribbeans’ for first and readmissions, over a 20-year period.

Results. Our first contact sample comprised 38 White, 38 African-Caribbean and 24 Asian patients with CATEGO defined broad schizophrenia. GP referral was found to be the most common mode of contact and there were no significant differences between the ethnic groups with regard to compulsory admission. Similarly, data from the Camberwell Register showed no significant difference in rates of compulsory admission between first admission White and African-Caribbean patients. However, when all readmissions were examined, African-Caribbeans were more likely to be admitted involuntarily.

Conclusions. Our findings suggest that reports of less desirable routes of entry for African-Caribbean patients into the psychiatric service do not apply to their first admission but are likely to develop over time and repeated contact with the services.