In the ‘fashionable’ field of eating disorders, there has been a notable gap in the historiography of rumination, allowing considerable scope for constructing a comprehensive historical profile of this disorder.

A wide-ranging examination of printed material, both etymological and medical, backed by a Medline computer search, uncovered extensive sources, some of considerable rarity, including case reports from the early 17th century onwards. Extracted data focused on incidence, sex distribution, age range, outcome and causation, and the findings are discussed in relation to diagnostic criteria in DSM–III–R and ICD–10.

While confirming the frequency of rumination in infants and the mentally retarded, the study demonstrated, particularly, the need to recognise its occurrence in normal adults, occasionally as a collateral behaviour in anorexia and bulimia nervosa, and suggested that its prevalence, distorted by secrecy, exceeded estimated levels.

In future reviews of classification, existing anomalies and inadequacies in the status and description of rumination would benefit from integrating some of the historical conclusions.

We test the hypotheses that (a) cognitive therapy is of comparable efficacy to psychodynamic psychotherapy, (b) 8–10 sessions of therapy is as effective as 16–20 sessions, and (c) brief therapist training is as effective as intensive training.

Of 178 out-patients referred to a clinical trial of psychological treatment for generalised anxiety, 110 patients met DSM–III–R criteria for generalised anxiety disorder and were randomly assigned to three different forms of psychotherapy. The main comparison was between cognitive therapy and analytic psychotherapy, delivered by experienced therapists at weekly or fortnightly intervals over six months. A third treatment, anxiety management training, was delivered at fortnightly intervals by registrars in psychiatry after a brief period of training. Eighty patients completed treatment and were assessed before treatment, after treatment, and at six-month follow-up.

Cognitive therapy was significantly more effective than analytic psychotherapy, with about 50% of patients considerably better at follow-up. Analytic psychotherapy gave significant improvement but to a lesser degree than cognitive therapy. There was no significant effect for level of contact. Patients receiving anxiety management training showed similar improvements to cognitive therapy after treatment, with rather lower proportions showing clinically significant change.

Cognitive therapy is likely to be more effective than psychodynamic psychotherapy with chronically anxious patients. Significant improvements in symptoms can be achieved by trainee psychiatrists after only brief instruction in behaviourally based anxiety management. However, the superiority of cognitive therapy at follow-up suggests that the greater investment of resources required for this approach is likely to pay off in terms of more sustained improvement. There is no evidence that 16–20 sessions of treatment is more effective, on average, than 8–10 sessions.

Current clinical classifications do not contain specific diagnostic categories for patients with senile dementia of the Lewy body type (SDLT), recently proposed as the second commonest neuropathological cause of dementia in the elderly. This study determines how existing clinical diagnosis systems label SDLT patients and suggests how such patients may be identified.

A range of clinical diagnostic criteria for dementia were applied to case notes of autopsy-confirmed SDLT (n = 20), dementia of Alzheimer type (DAT; n = 21) and multi-infarct dementia (MID; n = 9) patients who had received psychogeriatric assessment. The predictive validity of each set of clinical criteria was calculated against the external criterion of neuropathological diagnosis.

Many SDLT patients erroneously met criteria for MID (35% with Hachinski scores ≥ 7) or for DAT (15% by NINCDS ‘probable AD’, 35% by DSM–III–R DAT and 50% by NINCDS ‘possible AD’). Up to 85% of SDLT cases could be correctly identified using recently published specific criteria.

DLT usually has a discernible clinical syndrome and existing clinical classifications may need revision to diagnose correctly such patients.

This study investigated biological correlates of depression in patients with idiopathic Parkinson's disease (PD). We tested the hypothesis that in patients with PD and depression, there was regional dysfunction involving brain areas previously implicated in functional imaging studies of patients with primary depression.

Using positron emission tomographic measurements of regional cerebral blood flow (rCBF), patterns of resting rCBF were measured in ten patiens with PD and major depression, and ten patients with PD alone. The results were compared with findings from ten patients with primary depression and ten normal controls, scanned using identical methods as part of an earlier study. Groups were matched for age, sex and symptom severity.

Bilateral decreases in rCBF were observed in anteromedial regions of the medial frontal cortex and the cingulate cortex (Brodmann's areas (BA) 9 and 32) in the depressed PD group, compared with those with PD alone and compared with normal controls. This regional disturbance overlapped that observed in patients with primary depression.

The findings indicate that the medial prefrontal cortex is a common area of neural dysfunction in the manifestation of both primary depression and depression in PD.

The aim was to examine in a population of schizophrenic patients the clinical correlates of ‘neurodevelopmental’ schizophrenia and their relationship to putative aetiological factors.

Premorbid social adjustment, premorbid schizoid and schizotypal personality traits, and the obstetric history of 40 schizophrenic patients and their 102 sibs were assessed through interviews with their mothers. Patients' premorbid level of intelligence was assessed by the National Adult Reading Test and current symptoms by the Positive and Negative Syndrome Scale and the Subjective Deficit Syndrome Scale.

Patients had more schizoid and schizotypal traits than their sibs. They showed a deterioration in social adjustment between childhood and adolescence; sibs' social adjustment improved. There were statistically significant associations between current negative schizophrenic symptoms, premorbid deterioration in social adjustment, and schizoid and schizotypal personality traits, and between an early age of onset of illness and the same premorbid assessments. There was no evidence that patients with a family history of severe mental illness leading to hospitalisation, or a history of definite obstetric complications, had poorer premorbid functioning or more severe current symptoms.

We have confirmed clinical correlates of ‘neurodevelopmental’ schizophrenia but found no association between these and obstetric complications or a family history of severe mental disorder.

A population of adult schizophrenic patients was assessed to discover how the patients viewed their childhood, whether their view differed from non-schizophrenic adults, and to determine any association between parental rearing practices as perceived by the patient, childhood personality as perceived by the mother, and current symptoms. Type and level of expressed emotion shown by parents towards patients was also examined.

Parental attitudes, as perceived by 50 schizophrenic patients, were assessed by the EMBU scale. Patients' premorbid personality and social adjustment were assessed through interviews with patients' mothers by the Scale for the Assessment of Premorbid Schizoid and Schizotypal Traits and the Premorbid Social Adjustment Scale. Current symptoms were assessed by the Positive and Negative Syndrome Scale and Subjective Deficit Syndrome Scale.

Patients saw little difference between fathers' and mothers' attitudes. There was a positive correlation between parental rejection and overprotection, and a negative correlation between rejection and warmth. There were no significant correlations between parental rearing attitudes and patients' childhood personality; there was a significant correlation between parental attitudes and current symptoms. Rejection and overprotection were associated with more severe, warmth with less severe symptoms, especially so for positive schizophrenic symptoms and general psychopathology. Although there was no association between the general level of expressed emotion shown by the parent towards the adult patient, and patients' perceived parental rearing attitudes, parents with high expressed emotion on the basis of hostility had higher rejection scores on the parental rearing attitudes scale.

Schizophrenic patients saw their parents as showing much less warmth, and the severity of current symptoms was associated with perceived parental rearing attitudes. The hostility component of high expressed emotion may be a parental trait which exists before the illness begins.

Recently, several investigators have reported an association between influenza epidemics and increased birth rates of ‘preschizophrenic’ individuals some four to six months later. Here we examine whether maternal exposure to other infectious diseases can also predispose the foetus to later schizophrenia.

Two independent sets of dates of birth of first admission schizophrenic patients, born between 1938 and 1965 in England and Wales, were obtained from the Mental Health Enquiry in England and Wales. Data on the number of deaths per month from 16 infectious diseases between 1937 and 1965 in England and Wales were also collected. We used a Poisson regression model to examine the relationship between deaths from infectious diseases and schizophrenic births.

In the two separate data sets, increased national deaths from bronchopneumonia preceded, by three and five months respectively, increased numbers of schizophrenic births. We did not find any other significant associations between schizophrenic births and any of the other 15 infectious diseases.

The association between deaths from bronchopneumonia and increased schizophrenic births some months later may be a reflection of the fact that bronchopneumonia deaths increase markedly during influenza epidemics.

Low birth weight has been postulated to be a risk factor for schizophrenia.

Obstetric history, premorbid adjustment, and cognitive function during admission were assessed in 167 patients with DSM–III schizophrenia or affective psychosis.

A birth weight of less than 2500 g was significantly more common in patients with schizophrenia than in those with affective psychosis. Schizophrenic patients as a group had significantly lower mean birth weight, a finding which was particularly marked after controlling for sociodemographic confounders. In schizophrenic men, lower birth weight was highly significantly correlated with poorer premorbid social and cognitive ability, and with impairment of adult cognitive function.

Neurodevelopmental impairment may cause poor foetal growth, and schizophrenia in adult life.

The co-occurrence of panic disorder and major depression in the same individual is common. A question to be answered is whether the comorbid disorder is a distinct one or may resemble one or other disorder. In this paper we examine whether the comorbid disorder is a distinct condition.

We examined the symptom profiles and rates of comorbidity of panic attacks and DIS/DSM–III major depressive disorder in a population-based sample from four sites of the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Program (n = 12 668).

The co-occurrence of panic attacks and major depression over the lifetime was 11 times higher than expected by chance (OR = 11.4, 95% CI 9.5 to 13.6). Subjects with both panic and depression had worse symptoms than those who had only one disorder. However, the pattern of symptoms was remarkably similar, after overall severity was taken into account. Depressive symptoms associated with more severe forms of depression (e.g. guilt, suicidal thoughts or attempts, and motor disturbance) were more frequent in the comorbid group.

These findings may indicate a worse severity when the two disorders occur in the same individual.

The role of clonidine in the management of opioid-dependent individuals undergoing gradual detoxification.

A double-blind placebo-controlled trial was conducted on 86 voluntary in-patients (59 male, 27 female) aged 18–47 years, at a specialist drug-dependence treatment unit. Patients entered the trial when on 40 mg of methadone daily or less, and were randomised to receive incremental doses of clonidine (increasing from 0.2 mg daily to 1.2 mg daily) during a 14-day period of gradual methadone detoxification and for four weeks thereafter. Blood pressure was monitored and severity of opioid abstinence was assessed by questionnaire and by clinical examination.

Half the subjects were withdrawn or defaulted from the trial by the end of two weeks, those receiving clonidine earlier than those receiving dummy medication (9 of the former and only one of the latter because of systemic hypotension). Similar proportions of subjects completed detoxification in the two groups. In those who completed detoxification, clonidine did not significantly reduce either the symptoms or objective signs of opioid withdrawal.

These findings suggest that clonidine has no place as an adjunct to a programme of gradual opioid detoxification.

Seasonal variation in suicide and parasuicide has previously been reported. Few investigations have examined whether meteorological factors could influence suicidal behaviour, and the inconclusive results produced may be due to a variety of methodological problems. The present study overcomes some previous difficulties and tested whether parasuicide admisson rate is related to weather variables.

Over 12 000 admissions for parasuicide were analysed by month, season, and in relation to meteorological data, which were measured close to the admitting hospital.

Marked seasonal (P < 0.001) and monthly (P < 0.001) variations in mean daily parasuicide numbers were seen in women but not men. Small but highly significant correlations were demonstrated between parasuicide rate and weather parameters (P < 0.01), which were more marked in women (P < 0.01). These effects were additional to the monthly variation (P < 0.05).

Weather has a small influence on parasuicide. Gender differences in body temperature regulation might account for the sex difference seen.

The objective was to investigate the occurrence and characteristics of oculogyric spasm (OGS) in an Asian country.

All 2035 Asian (88% Chinese, 7% Malays and 5% Indonesians) psychiatric in-patients in the state psychiatric hospital in Singapore were surveyed for occurrence of oculogyric spasm (OGS) over a two-month period.

Thirty-four patients (1.7%) developed OGS (53% male and 47% female). All the 34 patients had been on maintenance antipsychotic drugs for more than five months. Eighteen patients had recurrent attacks. The mean chlorpromazine equivalent daily dose for those patients with recurrent OGS was 511 mg. This was significantly higher (P < 0.05) than the 277 mg daily dose received by those without recurrent OGS. Most (68%) of the attacks occurred between 1400–2000 h suggesting that OGS may have a diurnal variation.

GS presenting as tardive dystonia may be due to a relative increase in cholinergic activity.

The presence of dysphoric symptoms associated with neuroleptic medication is commonly reported.

Neuroleptic treatment of a segmental dystonia resulted in a disabling depressive illness, which when treated with antidepressants led to the return of the involuntary movements.

The use of several different antidepressants and neuroleptics confirmed the association between drugs and symptoms. Genetic studies excluded “poor metaboliser status” as a reason for the patient's sensitivity to these drugs.

The case illustrates a delicate imbalance between dose of neuroleptic medication and depressive symptoms. We should be aware of the possibility of mood changes in patients treated with neuroleptics for a variety of conditions.

An Indian man now in Britain explained his criminal behaviour as episodic ghost possession. Traditional exorcisms failed to help.

‘Western’ diagnosis of dissociative state or paranoid schizophrenia was made. Treatment commenced using trifluoperazine and clopenthixol.

The patient underwent remission during neuroleptic treatment, despite previous evidence of genuine possession.

Many cultures give rise to apparently genuine cases of ghost possession. Neuroleptics may relieve symptoms of exorcism-resistant possession.

Case reports suggest that recurrent nightmares are alleviated by behavioural treatment. We have administered such treatment to a client by post.

The frequency of nightmares was recorded by the client before and during treatment, and at one and six months follow-up. Nightmare problem and target scales, and treatment expectation were recorded at the end of each period. Treatment was by rehearsal relief, self-administered using written instructions.

A reduction in nightmare frequency from 5.5 per week in the baseline period to an average of one per week resulted after treatment.

The client's chronic nightmares were lastingly relieved after self-administered exposure treatment. A controlled trial is underway.

3,4-methylenedioxymethamphetamine (MDMA or ‘Ecstasy’) has become one of the most widely used illicit substances in the UK. Little is known of the psychiatric morbidity which may be associated with its use. We have examined this association by collecting a series of psychiatric cases in which MDMA use was a prominent feature.

Patients presenting between 1990 and 1992 with psychiatric symptoms which developed in the context of MDMA use (n = 13) were interviewed, and their psychiatric, medical and drug history, sociodemographic background and mental state were examined in detail. The psychopathology of cases with psychosis (n = 8) was assessed with the Present State Examination and compared with that of substance-naïve psychotic controls (n = 40).

Eight patients presented with psychotic syndromes, two experienced visual illusions, hallucinations and palinopsia, one had panic attacks, one suffered from depression, and one described chronic depersonalisation and derealisation. The psychopathology of the patients with psychoses was very similar to that of controls.

Use of MDMA may be associated with a broader spectrum of psychiatric morbidity than heretofore suspected. Cases with psychosis may be clinically similar to psychotic patients with no history of substance use.