Family therapy for schizophrenia began in the early 1950s, inspired by theories that located the cause of the illness in family dysfunction. The family pathology was seen as stemming from disturbed relationships (Fromm-Reichmann, 1948; Lidz et al, 1956; Laing & Esterson, 1964) and / or distorted communication (Bateson et al, 1956; Wynne & Singer, 1963).

Gender dysphoric disorders are currently attracting a great amount of attention. Generally, this attention is appropriately scientific and not condemnatory. This is possibly because of changing attitudes, but also because of the dissemination of information about what may be done to help people with these disorders. People are coming forward to request such help. Whether the surge of applicants to gender identity clinics (GICs) is due entirely to the change in attitude or whether there is a true increase in incidence of these disorders is at present undetermined. The fact, however, remains that prior to the second half of the present century little professional attention was paid to gender dysphoria (Bullogh, 1975).

The future of psychiatry lies not only with advances in treatment, but also with the number and quality of undergraduates attracted into psychiatry. As the quality of teaching of psychiatry to undergraduates is probably one of the factors determining choice of a career in psychiatry (Sierles & Taylor, 1995), it is to be hoped that improved quality of teaching will not only enhance clinical practice and patient care, but also lead to an increase in the numbers of medical students who choose a career in psychiatry.

Irrespective of whether one considers official statistics, the proliferation of clinical referrals, research initiatives, review articles or even media attention, the problem of children and adolescents who sexually abuse other children has become a subject of increased attention. Given the proportion of young abusers who are themselves victims of sexual abuse, understanding the continuities between sexual victimisation and sexually abusive behaviour has been important. Despite the paucity of reliable evidence, it is clear that the majority of children who are sexually abused do not become abusers. Moreover, we know that around half of all young abusers have not themselves been victims of abuse. This paper sets out to consider these issues and highlight potentially important factors in understanding the origins and development of sexually abusive behaviour at an early age.

I have enjoyed reading Buchanan's paper very much. It is clear, thoughtful and contains much valuable information. As I read it, I began to think it would make a good foundation for a short factual leaflet for carers. However, they are unlikely to read it in its present form, since many would find the scientific style and wording hard going. Words such as compliance, drugs and intrusive have connotations and need to be used with care by professionals. The National Schizophrenia Fellowship uses the term adherence instead of compliance.

We describe the case of a child presenting with what initially appeared as a pervasive developmental disorder (ICD F84.1) associated with, and in our view, induced by, schizophrenic illness in the mother. Important issues are raised for both adult and child psychiatry, in particular that the failure of the Mental Health Act (1983) to address the mother's needs adequately, left the child vulnerable to her untreated illness.

The term hypochondriasis was first coined over 2000 years ago to describe a physical illness afflicting the hypochondrium. Subsequently the term was used for a variety of physical illnesses, until the 17th century when forms of melancholia were labelled as hypochondriasis. Since then a very large number of psychiatric disorders have been given the term hypochondriasis, for example, a form of schizophrenia, anxiety neurosis and malingering (Kellner, 1986).

Dementia with cortical Lewy bodies (LBD) was first described by Okazaki et al in 1961 and is now recognised as a relatively common cause of the dementia syndrome. The true prevalence of LBD is unknown. In post-mortem studies of patients diagnosed as having dementia in life, the mean frequency of Lewy body dementia is 12.5% (Byrne, 1997). Clinically diagnosed LBD (using operational clinical criteria) is found in 10–23% of patients presenting to, or in the care of, psychogeriatric services (Collerton et al, 1996). What is not yet certain is its nosological status; opinion is divided between regarding it as a variety of Alzheimer's disease (the Lewy body variant), a distinct disease (senile dementia of the Lewy body type) or a spectrum disorder related to both Parkinson's disease and to Alzheimer's disease (Byrne, 1992).

Warwick's paper shows how recent advances have completely altered the previous therapeutic nihilism expressed in the above quotation. Physicians and surgeons have long been aware that medical and surgical problems turn out to have no organic cause. Joyce et al (1986) from New Zealand examined 105 people with abdominal pain who had been admitted to a surgical ward. They found that the most common surgical diagnosis was non-specific abdominal pain, closely followed by appendicitis. Those with non-specific abdominal pain contained a very interesting group of patients: they were predominantly female, did not have any physical findings, and were more anxious and conformed to the pattern of patients showing fear of illness. This group presented, in the words of the New Zealand team:

This study is presented to encourage recognition and early intervention with cycles of physical, sexual and emotional abuse, both within institutions (whether the family, hospital, residential care, residential schools or penal institutions) or within the community at large.

There are many different course designs for the teaching of old age psychiatry. It may be taught in blocks or spread over the undergraduate curriculum and/or integrated with either psychiatry or medicine for the elderly. Whichever approach is used, at the end of their undergraduate training, students should have the same core knowledge, skills and attitudes.

Traditionally, delusions have been viewed as false, unshakeable beliefs which arise out of internal morbid processes and are out of keeping with a person's educational and cultural background (Hamilton, 1978). Primary delusions appear to arise without understandable cause, and secondary delusions appear more understandable in relation to the prevailing affective state or cultural climate (Sims, 1995), for example. However, during the cognitive therapy process we would expect that even primary delusions might become more understandable as the patient's life history and belief profile are gradually disclosed.

The article by Byrne gives a general overview of dementia with Lewy bodies (LBD) and discusses treatment in terms of modulation of neurotransmitter systems, treatment of psychotic symptoms and extrapyramidal features. However, as is the case with Alzheimer's disease, the dementia is related to underlying pathological processes which result in death and/or malfunction of neurons. Prevention or amelioration of this neuronal loss is therefore the ultimate aim of treatment. Such treatment is not yet available and the possibility of its development is likely to depend on further elucidation of the underlying pathological process. The relationship of LBD to Alzheimer's disease and Parkinson's disease should be considered, as this is important for the determination of the underlying pathological processes in LBD.

Byrne provides an excellent clinical overview. However, I have selected four areas of clinical interest for more detailed consideration.

In 1961 Parkes and his colleagues followed 100 people with schizophrenia for a year after their discharge from hospitals in south London and found that the general practitioner (GP) was the professional most frequently in contact with people. Only 56% attended as psychiatric out-patients, most being seen fewer than five times in the year, while 70% were in regular contact with their GPs, and when problems developed it was usually the GP who was involved first (Parkes et al, 1962).

The key messages emerging from this paper are the need for early intervention in all cases of known or suspected child abuse, and the necessity for practitioners to remain alert to the possible early traumatic origins of adult symptomatology. These clear messages are amply supported by research (Lindberg & Distad, 1985; Browne & Finklehor, 1986; Briere, 1992; Mendel, 1995; Styron & Janoff-Bulman, 1997). The paper suggests that services for both victims and perpetrators could be identified and provided much sooner if the process is started with an ‘overall statement of risk’ or risk assessment. Given the connections between child abuse, family violence and various physical, psychosomatic and emotional problems presenting to doctors in all specialities, it is clear that “The likelihood of a clinician encountering past or current abuse is overwhelming” (p. 109). The message here is that all doctors, not just psychiatrists, should be alert to the possibility of abuse in the past history or present symptomatology of their patients.

Turkington & Siddle's article is written in a way that most helpfully allows comment from a range of perspectives; indeed, I was specifically invited to ‘broaden its scope’. They clearly describe to readers the useful techniques by which cognitive therapy can diminish the power and domination of delusions in some patients with schizophrenia.

Beck's cognitive therapy originally developed as a short-term treatment for depression (Beck et al, 1979). It has been shown to be effective with a range of other disorders including panic disorder, generalised anxiety disorder, social phobia, eating disorders and sexual dysfunction (Roth et al, 1996). It is promising in the treatment of yet more disorders, many of which have traditionally been thought relatively impervious to psychotherapy, for example, bipolar disorder, chronic fatigue and psychosis (Clark & Fairburn, 1997). However, not everyone responds well to short-term cognitive therapy. In particular, it has been proposed that people with multiple, chronic problems that are apparently expressions of personality, rather than temporary responses to adverse life experiences, require more extended therapy (Beck et al, 1990).