Despite current interest in attachment disorder, there is concern about its discrimination from other disorders and an unproven assumption of an environmental aetiology.

To test whether behaviours suggestive of attachment disorder are distinct from other childhood behavioural and emotional problems and are solely environmentally determined.

In a community sample of 13472 twins, we carried out factor analysis of questionnaire items encompassing behaviours indicative of attachment disorder, conduct problems, hyperactivity and emotional difficulties. We used behavioural genetic model-fitting analysis to explore the contribution of genes and environment.

Factor analysis showed clear discrimination between behaviours suggestive of attachment disorder, conduct problems, hyperactivity and emotional problems. Behavioural genetics analysis suggested a strong genetic influence to attachment disorder behaviour, with males showing higher heritability.

Behaviours suggestive of attachment disorder can be differentiated from common childhood emotional and behavioural problems and appear to be strongly genetically influenced, particularly in boys.

Delirium phenomenology is understudied.

To investigate the relationship between cognitive and non-cognitive delirium symptoms and test the primacy of inattention in delirium.

People with delirium (n=100) were assessed using the Delirium Rating Scale-Revised-98(DRS-R98)and Cognitive Test for Delirium (CTD).

Sleep-wake cycle abnormalities and inattention were most frequent, while disorientation was the least frequent cognitive deficit. Patients with psychosis had either perceptual disturbances or delusions but not both. Neither delusions nor hallucinations were associated with cognitive impairments. Inattention was associated with severity of other cognitive disturbances but not with non-cognitive items. CTD comprehension correlated most closely with non-cognitive features of delirium.

Delirium phenomenology is consistent with broad dysfunction of higher cortical centres, characterised in particular by inattention and sleep-wake cycle disturbance. Attention and comprehension together are the cognitive items that best account for the syndrome of delirium. Psychosis in delirium differs from that in functional psychoses.

A limited case-load size is considered crucial for some forms of intensive case management and many countries have undertaken extensive reorganisation of mental health services to achieve this. However, there has been limited empirical work to explore this specifically.

To test whether there is a discrete threshold for changes in intensive case management practice determined by case-load size.

‘Virtual’ case-load sizes were calculated for patients from their actual contacts over a 2-year period and were compared with the proportions of contacts devoted to medical and non-medical care (as a proxy for a more comprehensive service model).

There were 39 025 recordings for 545 patients over 2 years, with a mean rate of contacts per full-time case manager per month of 48 (range 35–60). There was no variation in the proportion of non-medical contacts when case-load sizes were over 1:20 but there was a convincing linear relationship when sizes were between 1:10 and 1:20.

Case-load size between 1:10 and 1:20 does affect the practice of case management. However, there is no support for a paradigm shift in practice at a discrete level.

Hallucinations are perceptions in the absence of a corresponding external sensory stimulus. However, during auditory verbal hallucinations, activation of the primary auditory cortex has been described.

The objective of this study was to investigate whether this activation of the auditory cortex contributes essentially to the character of hallucinations and attributes them to alien sources, or whether the auditory activation is a sign of increased general auditory attention to external sounds.

The responsiveness of the auditory cortex was investigated by auditory evoked potentials (N100) during the simultaneous occurrence of hallucinations and external stimuli. Evoked potentials were computed separately for periods with and without hallucinations; N100 power, topography and brain electrical sources were analysed.

Hallucinations lowered the N100 amplitudes and changed the topography, presumably due to a reduced left temporal responsivity.

This finding indicates competition between auditory stimuli and hallucinations for physiological resources in the primary auditory cortex. The abnormal activation of the primary auditory cortex may thus be a constituent of auditory hallucinations.

Children looked after by local authorities are at higher risk of poor psychosocial outcomes than children living in private households, but nationally representative and random samples of the two groups of children have not previously been compared.

To find explanations for the increased prevalence of psychiatric disorder in children looked after by local authorities.

We examined socio-demographic characteristics and psychopathology by type of placement among children looked after in Britain by local authorities (n = 1453), and compared these children with deprived and non-deprived children living in private households (n = 10 428).

Children looked after by local authorities had higher levels of psychopathology, educational difficulties and neurodevelopmental disorders, and ‘looked after’ status was independently associated with nearly all types of psychiatric disorder after adjusting for these educational and physical factors. The prevalence of psychiatric disorder was particularly high among those living in residential care and with many recent changes of placement.

Our findings indicate a need for greater support of this vulnerable group of children.

Caring for relatives with advanced cancer may cause psychological and physical ill health.

To evaluate the effectiveness of increased support for distressed, informal carers of patients receiving palliative care.

The sample was composed of 271 informal carers who scored over 5 on the 28-item General Health Questionnaire (GHQ-28). The intervention comprised six weekly visits by a trained advisor. Primary outcome was carer distress (GHQ-28) at 4-week, 9-week and 12-week follow-up. Secondary outcomes were carer strain and quality of life, satisfaction with care, and bereavement outcome.

Scores on the GHQ-28 fell below the threshold of 5/6 in a third of participants in each trial arm at any follow-up point. Mean scores in the intervention group were lower at all time points but these differences were not significant. No difference was observed in secondary outcomes. Carers receiving the intervention reported qualitative benefit.

The intervention might have been too brief, and ongoing help might have had accruing benefits. Alternatively, informal carers of patients with cancer may already receive considerable input and the advisor's help gave little additional advantage; or caring for a dying relative is extremely stressful and no amount of support is going to make it much better.

Treatment within medium secure forensic psychiatry services is expected to reduce risk to the public.

To measure the period prevalence and incidence of offending following discharge and identify associated risk factors.

Follow-up of patients from 7 of 14 regional services in England and Wales who spent time at risk (n=1344) for a mean of 6.2 years. Outcome was obtained from offenders index, hospital case-files and the central register of deaths.

One in 8 men and 1 in 16 women were convicted of grave offences. Incidence rates indicated low density and most patients were not subsequently convicted. Offence predictors included gender, younger age, early-onset offending, previous convictions and a comorbid or primary diagnosis of personality disorder. Longer in-patient stay and restriction on discharge were protective.

Risks of reoffending remain for a subgroup of discharged patients. Future research should aim to improve their identification and risk management following discharge.

Impulsive aggression in adulthood is associated with disturbances in serotonergic function. In contrast, research examining this association in childhood has yielded inconsistent results.

The current study examined the prospective relationship between serotonergic function measured in childhood and the later emergence of antisocial personality disorder.

Hormonal response to fenfluramine, an index of serotonergic function, was assessed in 58 children with attention-deficit hyperactivity disorder between 1990 and 1997 when they were aged 7–11 years. Approximately 9 years later these individuals were evaluated for antisocial personality disorder.

Lower serotonergic responsivity assessed in childhood predicted the development of antisocial personality disorder (t (56)=2.25, P=0.028).

These results provide a critical link between the child and adult literature on the covariation of impulsive aggression and serotonergic function and suggest a potential explanation for inconsistencies in the childhood literature.

The assessment of personality disorder is currently inaccurate, largely unreliable, frequently wrong and in need of improvement.

To describe the errors inherent in the current systems and to indicate recent ways of improving personality assessment.

Historical review, description of recent developments, including temporal stability, and of studies using document-derived assessment.

Studies of interrater agreement and accuracy of diagnosis in complex patients with independently established personality status using document-derived assessment (PAS–DOC) with a four personality cluster classification, showed very good agreement between raters for the flamboyant cluster B group of personalities, generally good agreement for the anxious/dependent cluster C group and inhibited (obsessional) cluster D group, but only fair agreement for the withdrawn cluster A group. Overall diagnostic accuracy was 71%.

Personality function or diathesis, a fluctuating state, is a better description than personality disorder. The best form of assessment is one that uses longitudinal repeated measures using a four-dimensional system.

Interpersonal psychotherapy and cognitive–behavioural therapy (CBT) are established as effective treatments for major depression. Controversy remains regarding their effectiveness for severe and melancholic depression.

To compare the efficacy of interpersonal psychotherapy and CBT in people receiving out-patient treatment for depression and to explore response in severe depression (Montgomery–Åsberg Depression Rating Scale (MADRS) score above 30), and in melancholic depression.

Randomised clinical trial of 177 patients with a principal Axis I diagnosis of major depressive disorder receiving 16 weeks of therapy comprising 8–19 sessions. Primary outcome was improvement in MADRS score from baseline to end of treatment.

There was no difference between the two psychotherapies in the sample as a whole, but CBT was more effective than interpersonal psychotherapy in severe depression, and the response was comparable with that for mild and moder-ate depression. Melancholia did not predict poor response to either psychotherapy.

Both therapies are equally effective for depression but CBT maybe preferred in severe depression.

Actuarial risk assessment instruments (ARAIs) estimate the probability that individuals will engage in future violence.

To evaluate the ‘margins of error’ at the group and individual level for risk estimates made using ARAIs.

An established statistical method was used to construct 95% CI for group and individual risk estimates made using two popular ARAIs.

The 95% CI were large for risk estimates at the group level; at the individual level, they were so high as to render risk estimates virtually meaningless.

The ARAIs cannot be used to estimate an individual's risk for future violence with any reasonable degree of certainty and should be used with great caution or not at all. In theory, reasonably precise group estimates could be made using ARAIs if developers used very large construction samples and if the tests included few score categories with extreme risk estimates.

Interpersonal psychotherapy and cognitive–behavioural therapy are widely accepted as effective treatments for major depression. There is little evidence on how personality disorder or personality traits affect treatment response.

To determine whether personality disorder or traits have an adverse impact on treatment response to interpersonal psychotherapy or cognitive–behavioural therapy in people receiving out-patient treatment for depression.

The study was a randomised trial in a university-based clinical research unit for out-patients with depression.

Personality disorder did not adversely affect treatment response for patients with depression randomised to cognitive–behavioural therapy Conversely, personality disorder did adversely affect treatment response for patients randomised to interpersonal psychotherapy.

Despite the two therapies having comparable efficacy in patients with depression, response to interpersonal psychotherapy (but not cognitive–behavioural therapy) is affected by personality traits. This could suggest the two therapies are indicated for different patients or that they work by different mechanisms.

Measurement of health-related quality of life (HRQoL) with generic preference-based instruments enables comparisons of severity across different conditions and treatments. This is necessary for rational public health policy.

To measure HRQoL decrement and loss of quality-adjusted life-years (QALYs) associated with pure and comorbid forms of depressive and anxiety disorders and alcohol dependence.

A general population survey was conducted of Finns aged 30 years and over. Psychiatric disorders were diagnose with the Composite International Diagnostic Interview and HRQoL was measured with the 15D and EQ–5D questionnaires.

Dysthymia, generalised anxiety disorder and social phobia were associated with the largest loss of HRQoL on the individual level before and after adjusting for somatic and psychiatric comorbidity. On the population level, depressive disorders accounted for 55%, anxiety disorders 30%, and alcohol dependence for 15% of QALY loss identified in this study.

Chronic anxiety disorders and dysthymia are associated with poorer HRQoL than previously thought.

Service users with psychosis may not consent to sharing information with carers. However, carers require access to relevant information to support them in their role.

To inform clinical practice when service users withhold consent to share information with their carer.

Study data were derived from a synthesis of policy review (n=91), national survey (n=595) and individual interviews (n=24).

Key principles to guide information-sharing practices were identified. Service users highlighted confidentiality being guaranteed by consent processes. Carers suggested a ‘culture shift’ was required, with professionals trained to work with carers. Professionals emphasised mental capacity, professional judgement and the context of care. A best practice framework is proposed.

An important distinction is between general information, which can always be shared without consent, and personal information, which is new to the carer and where consent needs to be considered. Clinical judgement is central to balancing conflicting ethical imperatives in this area.

Despite the high prevalence of cannabis use in schizophrenia, few studies have examined the potential relationship between cannabis exposure and brain structural abnormalities in schizophrenia.

To investigate prefrontal grey and white matter regions in patients experiencing a first episode of schizophrenia with an additional diagnosis of cannabis use or dependence (n=20) compared with similar patients with no cannabis use (n=31) and healthy volunteers (n=56).

Volumes of the superior frontal gyrus, anterior cingulate gyrus and orbital frontal lobe were outlined manually from contiguous magnetic resonance images and automatically segmented into grey and white matter.

Patients who used cannabis had less anterior cingulate grey matter compared with both patients who did not use cannabis and healthy volunteers.

A defect in the anterior cingulate is associated with a history of cannabis use among patients experiencing a first episode of schizophrenia and could have a role in poor decision-making and in choosing more risky outcomes.

Little is currently known about functioning and impairment during adulthood associated with the course of personality disorders.

To investigate the association of personality disorder stability from adolescence through middle adulthood with measures of global functioning and impairment, using prospective epidemiological data.

A community-based sample of 658 individuals was interviewed at mean ages 14, 16, 22 and 33 years.

Individuals with persistent personality disorder had markedly poorer functioning and greater impairment at mean age 33 years than did those who had never been identified as having such disorder or who had a personality disorder that was in remission, after co-occurring Axis I disorders at age 33 years were taken into account. Remitted disorder was associated with mild long-term impairment. Adult-onset personality disorders, however, were also associated with significant impairment.

Persistent and adult-onset personality disorders are associated with functional impairment among adults in the community. These effects are independent of co-occurring Axis 1 disorders.

Although electroconvulsive therapy (ECT) is widely used to treat psychiatric disorders such as depression, its precise neural mechanisms remain unknown.

To investigate the time course of changes in cerebral blood flow during acute ECT.

Cerebral blood flow was quantified serially prior to, during and after acute ECT in six patients with depression under anaesthesia using [15O]H2O positron emission tomography (PET).

Cerebral blood flow during ECT increased particularly in the basal ganglia, brain-stem, diencephalon, amygdala, vermis and the frontal, temporal and parietal cortices compared with that before ECT. The flow increased in the thalamus and decreased in the anterior cingulate and medial frontal cortex soon after ECT compared with that before ECT.

These results suggest a relationship between the centrencephalic system and seizure generalisation. Further, they suggest that some neural mechanisms of action of ECT are mediated via brain regions including the anterior cingulate and medial frontal cortex and thalamus.

Burden on the relatives of patients with schizophrenia may be influenced not only by patient and caregiver characteristics, but also by differences in mental health service provision.

To analyse whether family burden is affected by national differences in the provision of mental health services.

Patients with schizophrenia and their key relatives were examined in Germany (n=333) and Britain (n = 170). Differences in family burden in both countries were analysed with regression models controlling for patient and caregiver characteristics.

Family burden was associated with patients' symptoms, male gender, unemployment and marital status, as well as caregivers' coping abilities, patient contact and being a patient's parent. However, even when these attributes were controlled for, British caregivers reported more burden than German caregivers.

National differences in family burden may be related to different healthcare systems in Germany and Britain. Support for patients with schizophrenia may be shifted from the professional to the informal healthcare sector more in Britain than in Germany.

A risk-reduction treatment programme complemented by a focused assessment, both guided by the risk–need–responsivity principles, is suggested as the preferred treatment for violence-prone individuals with personality disorder.

Violence Reduction Programme (VRP) and Violence Risk Scale (VRS) were used to illustrate the design and implementation of such an approach. Participants from a similarly designed Aggressive Behaviour Control Programme were used to illustrate the principles discussed and to test programme efficacy.

The VRS was used to assess risk/need and treatment readiness, and DSM–III/IV psychiatric diagnoses of 203 federal offenders.

Participants had a high probability of violent recidivism and many violence-linked criminogenic needs, similar to offenders with high PCL–R scores. Most had antisocial personality disorder and substance use disorders; in terms of treatment-readiness, most were in the contemplation stage of change. Outcome evaluation results support the objectives of the VRP.

Integrating risk–need–responsivity principles in assessment and treatment can provide useful guidelines for intervention with violence-prone forensic clients with personality disorder.

Forensic psychiatry services are expanding in England and Wales but require support from general services for patient after-care.

To compare outcomes following community after-care from forensic or general adult psychiatry services.

An observational comparison was made of case management following discharge from medium security in seven pre-reorganisation health regions of England and Wales, by forensic services (n=409) and general adult services (n=652). Criminal convictions, hospital readmissions and deaths were compared over a mean follow-up period of 6.2 years, adjusting for difference in case mix.

Forensic services did not supervise more high-risk patients in the community. Neither service was superior in outcome. More patients managed by general services died from natural causes.

Neither service was superior on measures of subsequent offending or hospitalisation. Specialist forensic after-care conveyed no added benefit. Case management may have been the same in both services.