The development of the hospital and community versions of the Patient Attitude Questionnaire is described. The instrument rates the attitudes of psychiatric patients towards their treatment settings and staff, and is framed specifically to assess attitudinal change during the transfer of patients from hospital. For the items rated using the kappa coefficient of agreement, the mean test-retest reliability value was 0.51, and the average inter-rater value was 0.82. This study shows that long-term psychiatric patients are able to give clear and consistent views about their living arrangements - views that should be sought and respected by staff.

One of us has hypothesised that the ‘voices' of schizophrenic patients reflect altered preconscious planning of discourse that can produce involuntary ‘inner speech’ as well as incoherent overt speech. Some schizophrenic patients reporting voices do not, however, have disorganised speech. We hypothesise that these ‘counterexample’ patients compensate for impairments of discourse planning by reducing language complexity and relying on highly rehearsed topics. A ‘language therapy’ designed to challenge and enhance novel discourse planning was administered to four such patients; three had significant albeit temporary reductions in the severity of their voices. These clinical findings provide further evidence that alterations of discourse planning may underlie hallucinated voices.

The parents of Gujarati and English children were interviewed and their attitudes to a wide range of child behaviour elicited. Differences in their ideas of normal and deviant behaviour were found in areas such as conduct and bedwetting, but not in self-care.

Sixty-seven patients with bulimia nervosa and 29 patients with anorexia nervosa completed the Impulsiveness Questionnaire and questionnaires detailing severity of eating disorder. Bulimic patients had higher impulsivity scores than anorexic patients. Bulimics with high impulsivity scores did not have more severe eating disorders than low scorers. When 39 bulimics and 25 anorexics were interviewed about other impulsive behaviour, 51 % of bulimics and 28% of anorexics reported at least one other impulsive behaviour. Patients with so-called ‘multiimpulsive’ bulimia reported more severe eating disturbance, but this was not reflected on more reliable measures of symptoms. Thirty-nine bulimics entered an eight-week treatment trial and their progress was assessed at eight weeks, 16 weeks and one year. ‘Non-impulsive’ bulimics had a more rapid response than ‘impulsives' during treatment, but there was no difference at follow-up. There was no evidence of an association between high impulsivity trait scores and poor treatment response. It is concluded that impulsivity may shape the expression of eating disorders, but that ‘multi-impulsives' do not constitute a categorically distinct subgroup of bulimics.

As part of the TAPS project, the baseline long-stay populations of Friern and Claybury Hospitals were compared using the TAPS assessment schedules. Each hospital has reduced bed numbers by two-thirds, and although the two have been subjected to different influences, their remaining long-stay patients were similar, and characterised by severe problems with hygiene, florid psychotic symptoms, a high prevalence of negative symptoms, and impoverished social networks.

Psychiatric symptoms and cognition were assessed in 13 patients with schizophrenia, one patient with schizoaffective disorder, and one patient with psychosis not otherwise specified while they received a conventional neuroleptic and again after an average of 15 months on clozapine. Despite improvements in psychiatric symptoms, attention, memory, and higher-level problem-solving were essentially unchanged. This suggests that certain cognitive deficits are relatively independent of psychotic symptoms in schizophrenia, and are probably central and enduring features of the disorder. Cognitive disability appeared to have been rate-limiting in the sample's rehabilitation, as patients' social and vocational adjustment remained marginal during the study. We also observed that treatment with clozapine was associated with a decline in some memory functions; the potent anticholinergic properties of the drug may have been responsible for this.

The summaries of clinical data on children attending the Maudsley Hospital during the years 1968-72 were used to identify 80 children meeting operational criteria for depression, and 80 matched psychiatric control children. At follow-up, on average 18 years after the initial contact, information was obtained on the adult outcomes of 62 of the depressed children and 69 of the controls. At least one first-degree relative of 111 (85%) of these probands was interviewed; the great majority of interviews with relatives were conducted ‘blind’ to the proband's symptoms in both childhood and adulthood. The lifetime prevalence of RDC depression was significantly higher in the 128 interviewed relatives of the depressed children than in the 151 relatives of the controls. Higher rates of depression were found among the female relatives of both the depressed and control probands. These findings suggest that depression in young people resembles depression in adults in two key respects: it tends to run in families, and there are higher rates of depression among the female than among the male first-degree relatives.

The finding that seizures can be precipitated in some epileptic patients by stimuli which originate from outside the central nervous system is not new. The influence of psychological changes on seizure frequency has, however, been much more difficult to determine. Patients who become aware of such associations may gain some control over their seizures. One hundred randomly selected out-patients with epilepsy were asked about their awareness of such associations and whether, as a consequence, they believed they had any control of their seizures. Ninety-two reported associations between seizures and facilitators or precipitants. The group who had made associations between independent states or stimuli and their seizures were more likely to have poorly controlled seizures and to be taking more anticonvulsants. Many had used this knowledge to control their seizures.

Data are presented from 157 monozygotic and 143 dizygotic female twin pairs of reproductive age who completed a self-report questionnaire on the premenstrual syndrome (PMS). For global PMS scores, the correlation coefficient for the monozygotic twins (0.55) was double that of the dizygotic ones (0.28). The results are consistent with the hypothesis that aggregation for global PMS scores is determined by genetic factors acting additively over a number of loci. Two alternative explanations are suggested: that monozygotic twins share greater environmental similarities than dizygotic ones; or that PMS scores may be a reflection of some other underlying characteristic (such as neuroticism), which is itself genetically determined.

Bereavement by murder or manslaughter is often associated with a high incidence of factors which increase the risk of lasting psychological problems after bereavement. In this study it appears that self-perpetuating vicious circles often accounted for the persistence of symptoms, which fitted the diagnostic categories of post-traumatic stress disorders, anxiety states, panic syndromes, obsessive revenge-seeking, and depression. Therapeutic approaches should be aimed at interrupting these vicious circles and fostering the work of grieving.

Obsessional slowness is regarded as an uncommon but severely disabling variant of obsessive-compulsive disorder. This paper examines the psychopathology, classification, pathophysiology and treatment of obsessional slowness. It argues that primary obsessional slowness does not require classification as a separate syndrome because it can be found to be secondary to recognised phenomena of obsessive-compulsive disorder or anankastic personality disorder. The treatment described in the literature is not thought to be successful in the long term, and controlled trials are required to evaluate new strategies and antidepressant medication.

Thirty-four patients with tricyclic-resistant depressive illness took part in a nine-week, doubleblind, placebo-controlled trial of lithium augmentation. In addition to the maximum tolerated doses of their tricyclic antidepressant, the experimental group (n = 16) received 250 mg lithium daily for three weeks, followed by 750 mg lithium daily for six weeks, while the controls (n = 18) received placebo for three weeks followed by three weeks each of 250 mg lithium daily and 750 mg lithium daily. There was no significant difference between placebo and 250 mg lithium for weeks 0-3 of the trial. However, there was a significantly greater improvement on the MADRS for weeks 3-6 for those subjects on 750 mg lithium than for those on 250 mg lithium. In addition, using a 50% fall in the HRSD as a criterion of drug responsiveness, 22% responded to placebo, 18% to 250 mg lithium, and 44% to 750mg lithium. Thus, lithium in normal, but not in low, dose has a significant antidepressant effect in TCA-resistant depression. Further controlled studies using lithium in normal dose in trials which have a greater duration of placebo exposure are required to confirm the lithium augmentation effect.

The selection of patients for community reprovision during the first three years of an active closure programme at two large mental hospitals in the North East Thames Regional Health Authority was studied. It was found that a strong selection bias was operating: the patients selected were significantly younger, had spent less time in full-time psychiatric care, were less likely to have a diagnosis of schizophrenia, had larger social networks, and were more likely to want to leave hospital.

The case notes of 1069 children and teenagers admitted to Bethlem Royal Hospital (‘Bedlam’) in the 19th century were analysed with particular reference to the frequency and types of delusions. Delusions were present in 700 (65%), among whom there were significantly more boys than girls. There was a statistically significant rise in the frequency of delusions from 1830 to the end of the century. Sixty-six per cent of the patients were discharged cured and, taken overall, the presence of delusions did not affect the prognosis: specifically, delusions did not worsen the prognosis in those diagnosed as suffering from mania or melancholia. Nevertheless, the prognosis was worse in boys with single paranoid delusions, or paranoid delusions in combination with auditory hallucinations of people, and worse for girls with delusions of exaltation in combination with other types of delusions.

Incubation is the process by which life events influence the onset of psychiatric disorder after an appreciable delay. It has long been recognised clinically. In this paper we use data from the Camberwell Collaborative Depression Study to see whether incubation effects can be demonstrated in depressive illness. We used a novel adaptation of survival analysis for this purpose. The results suggest that incubation does occur in depressive disorder, that it is much less important than the effect of life events close to onset, that it is apparent in women but not in men, and that it is no more evident preceding endogenous than neurotic symptom patterns.

Thirty-nine female out-patients with bulimia nervosa were assessed for personality disorders using the PAS. All subjects then entered a therapeutic trial, comprising eight weeks of cognitive-behavioural therapy with follow-up after eight weeks and at one year. Thirty-nine per cent of the patients were diagnosed as having personality disorders. Patients with personality disorders were more depressed and had a lower BMI than those without. They also had a significantly poorer response to treatment, but the difference between groups did not reach significance when mood and BMI were controlled for. Personality disorder alone does not predict a poor response to treatment, but comorbidity with depression and low weight increases the likelihood of a poor response; these patients are unlikely to respond to brief psychotherapeutic interventions.

The case notes documenting the psychological well-being of 100 survivors of torture and other forms of organised state violence were analysed retrospectively. The most common diagnoses were post-traumatic stress disorder (PTSD), major depression, and somatoform disorders. Of these, PTSD showed the strongest association with experience of torture. It is possible that PTSD has a dimensional nature, and that reactions to different stressors are heterogeneous.

A preliminary study of the repetitive mood swings of 72 female psychopaths with a DSM-III diagnosis of borderline personality disorder demonstrated considerable complexity and specificity in what has been previously considered a criterion of personality disorder. A principal-components analysis of the symptom profile for these affective disturbances revealed four factors (anxiety, anger, depression, and tension) which showed individual patterns of association with additional lifetime diagnoses of major mental illness and other personality disorders. The women also had multiple mood-related behavioural disorders, enacted with a feeling of compulsion, which appeared to relieve the original affective symptoms. It is hypothesised that these women could have a distinct affective syndrome that has not previously been described in the literature.

Sexual abuse appears to be causally linked to eating disorders, particularly those involving bulimic features. However, the psychological factors that mediate between these two phenomena are not understood. Recent findings suggest that borderline personality disorder may explain some of the association. The present research investigates the potential links between reported sexual abuse, borderline personality disorder, and eating psychopathology in a case series of 100 women with eating disorders. The results suggest that borderline personality disorder is a psychological factor that explains a small part of the causal link between sexual abuse and bulimic behaviour - especially frequency of bingeing. However, other factors are likely to be involved, and further research is suggested to investigate these.

The increase in referrals to a new consultant psychiatrist within a teaching hospital was documented. During 1987/88 there were 279 consecutive referrals from physicians and surgeons (159 out-patients and 120 ward-consultation requests) which were compared with 184 consecutive GP referrals over the same period. Hospital referrals tended to be older, and less socially disadvantaged, but with psychiatric disorder of similar severity to GP referrals. They were more likely to have a concurrent physical diagnosis, and demonstrate somatisation. The latter was not confined to patients without physical disorder; half of the patients classified as ‘psychological reaction to physical disorder’ showed somatisation. ICD–10 appeared to perform better than ICD–9 or DSM–III for somatoform disorders, but a comprehensive classification system is still needed for liaison psychiatry. Personal discussion with the referring doctor was most common among the ward-consultation requests; in this situation the referring doctor usually continued primary management of the patient.