Tardive dyskinesia (TD) may be mediated through free radical damage to neurons. Plasma lipid peroxide levels are a measure of radical damage to fats. Vitamin E is a free radical scavenger.

One hundred and twenty-eight schizophrenic patients were examined for TD using the Abnormal Involuntary Movements Scale. Blood samples were taken to measure plasma lipid peroxide, serum vitamin E and cholesterol, and vitamin Exholesterol ratios. Twenty-four patients were also examined in October 1993, January 1994, and April 1994. Biochemical results were compared in 81 patients and 79 normal subjects.

Patients with and without TD did not differ in median plasma lipid peroxide and serum vitamin E levels, or vitamin Exholesterol ratios. Correlations between seasonal change scores in TD and biochemical measurements were low. Lipid peroxide levels were higher and vitamin Exholesterol ratios lower in patients than in normal subjects. Vitamin E levels were lowest in in-patients and in those living in supported accommodation.

The results do not support the hypothesis that TD is mediated through free radical damage to neurons, but suggest increased free radical activity in schizophrenia.

This paper supplements the cross-sectional outcome comparisons of the companion paper by providing a brief account of the longitudinal courses of the Maine and Vermont samples across several outcome domains.

A Life Chart method was used to document changes in individual lives over the domains of residence, work, income source, and use of community resources over a 20-year period. Reliability studies between states were conducted.

Throughout much of the period, more Vermont subjects lived independently, were working, and were less likely to use community resources compared to Maine subjects.

Differences in both policies and programmes contributed to course differences between the groups. System characteristics that may lead to better outcomes are discussed.

It was hypothesised that the size of the season-of-birth effect may have decreased in tandem with the apparent decline in the incidence of schizophrenia.

Through the Aberdeen Psychiatric Case Register, subjects were identified who had been diagnosed as schizophrenic and had been born between 1900 and 1969. The ratio of winter/spring to summer/autumn births was compared across the seven decades for both sexes together, for men, and for women.

For the 1935 men, but not for the 1620 women, there was a highly significant increase (P = 0.0009) in season-of-birth effect.

Non-seasonal factors have contributed to a declining incidence of schizophrenia in both sexes. ‘Seasonal’ factors to which female foetuses are more susceptible than male foetuses (such as infection or malnutrition) have also decreased in frequency, severity, or both, but this has not happened with factors affecting males, leading to an increase of their season-of-birth effect.

This study was carried out to measure bed occupancy in Greater London's psychiatric units, in response to the apparent shortage of admission beds.

The bed occupancy of London's 54 National Health Service (NHS) acute psychiatric units within 29 districts was ascertained by telephone on 16 bank holidays covering the period 1990–93.

The mean occupancy level for all London over the 4 years was 97.54% (95% CI = ±0.94%). The number of beds occupied in inner London was significantly greater (99.79 ± 1.11%) than in outer London (95.1 ± 1.49%) (t = 3.85, d.f. = 462, P < 0.001). Bed occupancy for inner London units was ≥ 100% on over 49% of occasions. There has been a steady decline in the number of beds over the four-year period. There was a clear correlation between occupancy levels and the Jarman UPA8 Underprivilege Score (r = 0.504) and between bed provision and the UPA8 (r = 0.67).

Occupancy rates have become unacceptably high and require careful monitoring. Corrective action may be required in order to prevent a breakdown in services.

This study examined the pattern of cerebral blood flow observed in chronic schizophrenic patients while they performed a paced verbal fluency task. Such tasks engage a distributed brain system associated with willed action. Since willed action is impaired in many chronic schizophrenic patients we hypothesised that task performance would be associated with an abnormal pattern of blood flow.

Positron emission tomography (PET) was applied to 18 chronic schizophrenic patients stratified into three groups on the basis of verbal fluency performance and current symptoms. Regional cerebral blood flow (rCBF) was measured while the patients performed (a) verbal fluency, (b) word categorisation, and (c) word repetition. Results were compared with six normal controls matched for age, sex and premorbid IQ. Analysis was restricted to six brain regions previously identified in studies of normal volunteers.

In five brain areas, including the left dorsolateral prefrontal cortex, the patients showed the same pattern of activation as control subjects. However, in the left superior temporal cortex, all patient groups failed to show the normal decrease in blood flow when verbal fluency was compared with word repetition.

These observations suggest that (a) chronic schizophrenic patients can show a normal magnitude of frontal activation when matched for performance with controls, and (b) they fail to show the expected reductions of activity in the superior temporal cortex. This latter result may reflect abnormal functional connectivity between frontal and temporal cortex.

Admission statistics for mania frequently show an increase in the summer. The present two-centre study was designed to test the hypothesis, in a representative sample of bipolar patients, that manic and depressive relapses show a seasonal pattern.

Two cohorts of bipolar I patients, one in London, England (n = 86), the other in Dunedin, New Zealand (n = 58), were tracked retrospectively during 1985–88 and prospectively during 1989–91, with the onset of all relapses being carefully dated.

In the London cohort there were 221 episodes of mania and 76 of depression; in the Dunedin cohort there were 201 of mania and 61 of depression. No consistent seasonal pattern of mania was detected in either centre. There was an autumn preponderance of depressive episodes in both centres.

Relapse of bipolar depression, but not of mania, appears to be determined in part by seasonal factors.

This investigation compared the effectiveness and cross-cultural applicability of behavioural family management (BFM) and standard case management in preventing exacerbation of symptoms and relapse in schizophrenia.

Forty low-income Spanish-speaking people with a diagnosis of schizophrenia were randomly assigned to receive standard case management or behavioural family management after stabilisation with neuroleptic medication.

Survival analyses indicated that among the less acculturated patients BFM was significantly related to greater risk of exacerbation of symptoms. Among the more acculturated patients, risk of exacerbation could be predicted by medication compliance but not by type of intervention. In analyses of symptom severity and functional status at 1-year follow-up, the level of patient acculturation was found to be significantly related to various measures of treatment outcome.

Sociocultural factors affect responses to different types of intervention. The results did not support earlier findings of a beneficial effect of BFM when applied to a socioculturally diverse population.

Neurological soft signs (NSS) such as a disturbed finger-to-thumb opposition are frequently found in schizophrenia. To identify the underlying cerebral changes we investigated sensorimotor cortex and supplementary motor area (SMA) activation during finger-to-thumb opposition using functional magnetic resonance imaging (fMRI).

Ten DSM–III–R schizophrenics and seven healthy controls were included. All subjects were right-handed. fMRI was carried out in a resting condition followed by an activation state (finger-to-thumb opposition) and the activities in the sensorimotor cortices and SMA recorded.

All subjects showed a significant activation of the SMA and both ipsilateral and contralateral sensorimotor cortices. In the controls, ipsilateral finger-to-thumb opposition was associated with a greater left than right hemispheric sensorimotor cortex coactivation. When compared with the healthy controls, the schizophrenic patients showed a decreased activation of both sensorimotor cortices and SMA, as well as a reversed lateralisation effect.

Sensorimotor cortex and SMA dysfunction are associated with motor disturbances in schizophrenia.

This study examined the effect of emotional salience on the severity of thought disorder in schizophrenic patients.

Ten thought disordered and ten non-thought disordered schizophrenic patients were interviewed under two conditions: a personal interview involving material which was emotionally salient and an impersonal interview involving material which was not emotionally salient.

Both groups exhibited some thought disorder during both interviews. The thought disordered patients exhibited significantly more thought disorder during the emotionally salient interview.

Thought disorder in schizophrenic patients is affected by the emotional salience of the material being discussed. Clinical implications are discussed.

Patients with schizophrenia differ from controls in several measures of brain structure and function, but it is uncertain how these relate to clinical features of the illness. We dichotomised patient groups by treatment response to test the hypothesis that treatment-resistant patients exhibit more marked biological abnormalities than treatment-responsive parients.

Twenty treatment-responsive and 20 treatment-resistant patients with schizophrenia, matched for sex, age, and illness duration, were compared by magnetic resonance imaging, single photon emission tomography, and detailed neuropsychological assessment.

Brain-imaging variables were not statistically related to treatment response, although poorly responsive patients had lower volumes of most brain structures. Several highly significant differences emerged between patient groups on neuropsychological testing. Episodic memory functioning distinguished patient groups even after we controlled for global cognitive impairment.

Cerebral structure and blood flow have a limited effect on treatment response in schizophrenia, but long-term episodic memory impairment is associated with, and may predict, poor prognosis.

Dysphoric reactions to antipsychotic medication are well recognised in association with akathisia, but can also occur independently.

Fifty-one healthy volunteers were given haloperidol 5 mg in two consecutive pharmacokinetic studies.

Dysphoria occurred in about 40% of the subjects on both occasions, but akathisia was only detected in 8% (first study) and 16% (second study). All adverse effects were transient and were abolished in nine of the ten subjects given procyclidine.

While dysphoria is a well-recognised reaction in healthy volunteers, it is probably insufficiently recognised in patients, particularly if it occurs in the absence of akathisia. Better detection could improve compliance in patients.

Clinicians see many more nonagenarian patients now and there is a need for epidemiological data relating to this group. The aim of the present study was to investigate the prevalence of depressive symptoms and syndromes in this age group.

The DSM–IV and the ICD–10 criteria for depression were used and correlated with physical health, disability in daily life, gender, use of drugs, social circumstances and cognitive dysfunction. Data were derived from 329 persons aged 90 and over, registered in a parish of Stockholm, who had been extensively examined by physicians and nurses.

The prevalence of Major Depressive Episode as defined in DSM–IV was 7.9%; and of mild, moderate and severe Depressive Episode (combined); as defined in ICD–10 9.1%. No gender difference was found. Disability in daily life and the use of psychotropic drugs were found to correlate with depressive symptoms and syndromes.

Delusions relating to the body, a ready source of information about the immediate experiences of psychotic patients, have not been systematically studied. We attempted an account of the phenomena, looking for differences between diagnostic groupings in the type and lateralisation of such phenomena, and for evidence of localisation.

Somatic delusions elicited at interview with 550 Research Diagnostic Criteria-diagnosed psychotic patients were categorised according to content, and the results were compared across diagnostic groupings.

Significant differences were demonstrated, both at the level of individual delusions and in the nature and overall pattern of such delusions. There were also differences between diagnostic groups in the choice of body parts involved. Among male patients there were significant differences in laterality between the groups, with schizophrenic subjects locating abnormal phenomena principally on the left and depressive subjects on the right. A provisional taxonomy of bodily delusions was developed.

Phenomenological differences between the psychoses were demonstrated and the results offer some support for current hypotheses of localisation of brain dysfunction in the psychotic illnesses.

It is reported that patients from ethnic minority groups, in particular Afro-Caribbeans, are more likely to enter less desirable pathways to psychiatric care. We aimed to determine whether ethnicity significantly affected time to presentation, type of first contact, rates of compulsory admission and police and primary care involvement, in patients with their first episode of psychosis.

As part of a prospective epidemiological study, patients and their carers were interviewed using a semi-structured questionnaire to trace the various persons and agencies seen en route to their first contact with psychiatric services.

While compulsory admission was more likely for Black patients, the excess was less striking than in previous studies. Black patients were no more likely than other patients to have police involvement. The most important factors in avoiding an adverse pathway were having a supportive family member or friend and the presence of a general practitioner to assist in gaining access to psychiatric services.

The routes to psychiatric services for first onset patients are different to those for chronic patients. Variables associated with social support were more important than ethnicity in determining pathways to care. Police involvement and compulsory admissions were strongly associated with the absence of GP involvement and the absence of help-seeking by a friend or relative. It may be that ethnicity becomes an important variable after the patient has come into contact with psychiatric services.

Insight has recently re-emerged as an important aspect of psychopathology amenable to empirical study. We sought to examine the relationship between various aspects of insight into illness and clinical, sociodemographic and neuropsychological variables.

From an inner-London catchment area population, 150 in-patients with recent onset of psychosis were assessed on a variety of measures, including the Present State Examination (PSE). Subjects were followed up for a mean of four years and reassessed.

High IQ was associated with better insight as rated on the PSE, while gender, ethnicity and a diagnosis of schizophrenia appeared to be unrelated. At follow-up, similar associations were found, as well as correlations with attitudes to treatment and a more elaborate measure of insight. Cerebral ventricular enlargement and tests of frontal lobe function did not correlate with insight, but there was a curious, strong association with left-handedness at both assessment points. Initial insight correlated significantly but weakly with insight at follow-up.

The assessment of insight in psychosis has concurrent validity and is a distinct aspect of psychotic phenomenology. It may, in part, have a neuropsychological basis.

Cyproheptadine, an antiserotonergic agent, was used to treat neuroleptic-induced akathisia.

In an open clinical trial 17 neuroleptic-treated patients with akathisia were administered cyproheptadine (16 mg/day) over 4 days. Assessment of akathisia, psychosis and depression were monitored by BAS, BPRS and HAM-D.

All subjects showed improvement in the severity of akathisia, which in the majority (15/17) was of a marked degree. There was no aggravation of psychosis or depression. Symptoms of akathisia returned when cyproheptadine was discontinued.

Cyproheptadine may be useful in neuroleptic-induced akathisia.

This randomised controlled study tested whether adding imagined to live exposure plus ritual prevention would enhance gains in obsessive-compulsive disorder (OCD).

Out-patients with OCD were randomly allocated to either have nine sessions of daily live self-exposure and ritual prevention to external cues alone (Ex) (n = 23) or to have, in addition to Ex, daily self-exposure to the imagined internal cues of the consequences of not ritualising (group Exi) (n = 23). All patients had the same sessional exposure time of 1 h 30 min (Exi 1 h live, 30 min imagined; Ex 1 h 30 min live), and had to practise either Exi or Ex daily for the same duration and to keep diaries of that self-exposure homework throughout treatment. Patients were followed up to week 32. Outcome measures were YBOCS for rituals and obsessions, compulsion checklist, target rituals and obsession, general anxiety, depression (Beck, Hamilton), work and social disability, clinical global impression (CGI).

At weeks 4, 9, 20 and 32 the two groups improved similarly with no significant difference between them, neither for washers nor for checkers. Imagined exposure was more difficult to do than live exposure and there were more drop-outs.

Daily imagined exposure to internal cues did not enhance exposure to external cues. Perhaps longer imagined exposure would have been more enhancing.

There has been evidence that psychopathology in schizophrenia consists of three separable syndromes: reality distortion, disorganisation, and psychomotor poverty. The objective of this study was to explore the relationship between planning and execution of movement and each of the syndromes in schizophrenia.

Twenty-one right handed DSM–III–R schizophrenic patients performed a total of 80 trials of a motor movement task, varying distance of movement × size of the target × hand. Times taken to plan the movement (RT) and to carry it out (MT) were examined for their relationship with contemporaneous as well as lifetime profiles of the three syndromes in schizophrenia.

Significant correlations are reported between RT and current as well as lifetime measures of disorganisation syndrome. Somewhat weaker correlations are reported between RT and psychomotor poverty, but only for the right-handed tasks. Partial correlations suggest that the influence of neuroleptic medication explains all but one of the correlations between psychomotor poverty and RT, but does not account for the relationship between disorganisation and RT. No other relationship emerged between any of the movement and symptom measures.

These findings indicate that dysfunction in movement planning is related primarily to concurrent disorganisation, as well as to the prominence of disorganisation over the patient's history.

We tested whether cortical and subcortical regional cerebral blood flow (rCBF) differs between patients with obsessive-compulsive disorder (OCD) and healthy controls. We then explored the relationship between rCBF and OCD mental state.

Thirty out-patients from the Maudsley Hospital with OCD as defined in DSM–III–R were scanned at rest using brain-dedicated, high-resolution, single photon emission tomography. RCBF was measured as uptake of 99mTc-HMPAO in 15 regions of interest and compared with rCBF data in 30 healthy people matched for age, sex and handedness. Symptom ratings were obtained using standard measures on the scanning day. Principal components factor analysis identified two distinct clinical dimensions: obsessive–compulsive (OC) and anxious–avoidant (AA). These were correlated with patients' rCBF measurements, using Spearman's rank correlation coefficient, and multiple regression coefficients calculated.

We found significant reductions in rCBF measurements of OCD patients compared with resting, healthy controls (F = 1.92, P = 0.04) in seven brain regions: the right and left superior frontal cortex, right inferior frontal cortex, left temporal cortex, left parietal cortex, right caudate nucleus and right thalamus. Regional differences were not secondary to generalised reduction in patients' brain perfusion. Reduced blood flow to the right inferior frontal cortex correlated significantly with illness severity (r = 0.37, P = 0.02). There was no relationship with age, age-of-onset, sex, handedness, depression or medication status. OC clinical dimension, concerning obsessions, compulsions and low mood, was significantly negatively correlated with left inferior frontal, medial frontal and right parietal rCBF. AA dimension, concerning anxiety and avoidance, was significantly positively associated with left and right superior frontal, right inferior frontal, medial frontal cortical, and right and left caudate and thalamic rCBF.

rCBF differs significantly between resting OCD patients and healthy controls, and separate clinical dimensions are associated with functionally distinct rCBF patterns.