Studies which examine patients with and without dementia during life and then examine brain tissue after death are extremely difficult to conduct. There are now several such studies published, representing a major contribution to the understanding of the pathologies of the dementias. These studies were not designed to represent population samples and, from an epidemiological viewpoint, they are flawed because none are population-based and none represent the full range of function observed during life. It is therefore important to examine the available studies for their contributions and biases.

Psychiatry is becoming increasingly confident about defining the benefits to be expected from each treatment (World Health Organization, 1991). The World Health Organization has published a list of essential drug treatments, but neither it nor any national regulatory body has ever examined non-drug treatments. This article examines the utility of the psychotherapies as treatments for persons with psychiatric disorders, and within a health service, whether supported by private insurance or by public taxation. It is not about the utility of psychotherapy paid for by an individual, for what people do with their own money is their own business. However, when deciding how to apportion a limited health budget, one should choose treatments that are more effective, safer, and cheaper than competing alternatives. Precisely how effectiveness, safety, and cost efficiency should be traded off against each other is a moot point, but there is agreement that treatments that are ineffective, harmful, and costly should not be used.

The physical complications of anorexia nervosa are common and can be life threatening, but psychiatrists and the increasing number of non-medical therapists involved in treatment programmes often overlook these complications. Cardiovascular complications are the most common, and the most likely to result in fatalities, particularly in those patients who vomit, purge or abuse diuretics, because of the electrolyte abnormalities induced. Osteoporosis is an early and perhaps irreversible consequence of severe weight loss. Further, there are dangers in rapid intravenous hyperalimentation.

A postal questionnaire was sent to 195 senior British psychiatrists who were asked about their attitudes towards the DSM-III-R diagnosis of somatisation disorder (SD) and the ICD-10 diagnosis of multiple somatisation disorder. Of the 148 respondents, 98 (66%) had experience of liaison psychiatry, and these psychiatrists used the diagnosis significantly more often than those without liaison sessions. More than half the respondents perceived SD as both a personality disorder and a mental state disorder, although 27% thought that patients with SD had an undiagnosed physical disease. The marked discrepancy between British and North American psychiatrists in diagnostic practices was perceived to be a consequence of both the difference in health care systems and the interest shown in the disorder by North American psychiatrists, rather than a reflection of genuine differences in prevalence.

Liaison psychiatrists need to interview somatising patients in a way which allows a full assessment of the problem. This can best be achieved if the psychiatrist has already discussed with the referring physician the reason for referral and what the patient has been told about it. The medical notes should always be reviewed in detail and independent data obtained from a relative or other informant. During the interview itself the psychiatrist must be prepared to use techniques which deepen rapport with the patient, who may be initially wary or hostile. The psychiatrist should attempt to establish early a treatment alliance. Special aspects of the mental state need to be noted, including the patient's attitude to his/her symptoms and the strength with which somatic beliefs are held. Different approaches may be used according to the nature of the problem and the therapeutic style of the doctor. An awareness of these interview techniques would greatly reduce the chances of fruitless interviews with a hostile patient who believes the symptoms are being dismissed as being ‘all in the mind’.

‘Somatisation’ is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. In some patients this process becomes chronic (in excess of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history, doctors should be aware of psychosocial cues; thereafter they should be consistent and unambiguous in their management. An agenda should be set early on, with limits on investigations. Failure to manage this group of patients is costly, and further intervention studies are required not only to reduce health service and other costs, but also to relieve the nonmonetary burden of physical and psychosocial disability on patients and their relatives.

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.

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.

The study consisted of a prospective investigation of 45 consecutively admitted patients who had sustained a mild head injury. In all cases the duration of post-traumatic amnesia was less than 24 hours. Head injury patients had an average of three adverse life events in the year preceding injury compared with 1.5 for controls. Using the PSE, 39% of the group were diagnosed psychiatric cases at six weeks after the injury. For cases the mean level of chronic social difficulties (3.3) was four times that for non-cases (0.8). Six months after injury, 28% of the head injury group had three or more symptoms. These chronic cases were on average ten years older than those whose symptoms had remitted. Chronic cases had, on average, three social difficulties, twice as many as found among those whose symptoms had remitted. The emergence and persistence of the postconcussional syndrome are associated with social adversity before the accident. While young men are most at risk of minor head injury, older women are most at risk of chronic sequelae.

Service response to problems in 20 clinical and social competence areas was assessed in 156 long-stay in-patients, using the Needs for Care Assessment (NFC). Although there were few unmet needs for treatment, over 200 instances of unmet needs for the assessment of social skills were found, and reasons for this are discussed, as is the importance of social-skills assessment in this group. In around a third of the sample most of the social-skill areas in the NFC were not applicable.

One hundred and sixty-four 16–35-year-old offspring of parents with drinking problems, recruited from a variety of clinical and community sources, were compared with 80 respondents of similar ages from similar sources who did not have parents with drinking problems. Each was interviewed using a semistructured interview. Adult adjustment was similar in the two groups, but the offspring of parents with drinking problems did report considerably more disharmony in their families of origin, and many more childhood difficulties. Factor analysis of the adult adjustment data for the samples combined showed four factors which accounted for 41% of the variance; these factors differed little in their effect in the two groups. The groups' reports of the drinking problems of their siblings, however, suggests that this sample might be unrepresentative of the true risk to the children of parents with drinking problems for the development of alcohol-related (although not other) difficulties in adulthood: 16% of this group reported a sibling with a drink problem and a further 9% were unsure, but only one member of the comparison group reported a sibling with a drink problem, and one was unsure. Path analysis showed that both parental problem drinking and family disharmony are related in complex ways to adjustment difficulties in adulthood. ‘Demoralisation’, the largest of the four factors, was particularly related to disharmony in the family of origin: in the absence of disharmony, offspring versus comparison status was negatively correlated to demoralisation in adulthood, suggesting that having a parent with a drinking problem might sometimes be a strengthening experience.

Head circumference, body weight, body length, and shoulder circumference at birth were studied in 70 RDC schizophrenic patients and 70 demographically matched controls from the same delivery series, using information recorded in the medical records at the time of birth. With preterm babies removed from both samples, only head circumference among preschizophrenic infants was significantly smaller than that of controls. Preschizophrenic infants also had a disproportionately smaller head circumference in relation to body length than did controls. Among the former, a small head circumference was systematically related to an absence of family history of psychosis, but was not related to season of birth or recorded pregnancy complications. The findings were strongest for females. The results suggest there is an unidentified non-genetic factor in schizophrenia that disturbs prenatal cerebral development.

Despite neuroleptic medication, many schizophrenic patients continue to experience residual positive psychotic symptoms. These residual symptoms cause distress and disability. We report a controlled trial of two cognitive-behavioural treatments to alleviate residual hallucinations and delusions. Forty-nine patients were recruited into the trial, of whom 27 entered the trial and completed post-treatment assessment, and 23 were reassessed at six-month follow-up. Patients were randomly allocated to either coping strategy enhancement (CSE) or problem solving (PS). Half the patients were allocated to a high-expectancy positive demand condition and half to a counterdemand condition to evaluate expectation of improvement. Patients receiving either cognitive-behavioural treatment showed significant reductions in pyschotic symptoms compared with those in the waiting period, who showed no improvement. There was some evidence, although equivocal, that patients receiving CSE improved more than those receiving PS. There was no evidence that improvements generalised to negative symptoms or social functioning, nor was there evidence that expectancy of treatment benefit contributed to the treatment effect.

It is ironic, in a field with many other ironies, that a number of studies (Johnstone et al, 1981; Mathai & Gopinath, 1985; Curson et al, 1992) have questioned what Mathai & Gopinath call “the hitherto inviolate (and ingenious) concept of institutionalisation”, at a time when massive deinstitutionalisation is casting into relief some of the practices to which it refers (Team for the Assessment of Psychiatric Services, 1990; Murphy, 1991; Abrahamson, 1993). However, the gap that this creates between theory and practice may be risky for the future. It would certainly be a major failure if the institutional era with which psychiatry's early professional identity was so intimately bound up were to end in unresolved contradictions. With this background, it will be argued here that re-examination of institutionalisation in the context of the longitudinal course of schizophrenic disorders both confirms the validity of the concept and sets a demanding agenda for alternative care in the community.

“It is proposed that happiness be classified as a psychiatric disorder and be included in future editions of the major diagnostic manuals under the new name: major affective disorder, pleasant type. In a review of the relevant literature it is shown that happiness is statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system. One possible objection to this proposal remains - that happiness is not negatively valued. However, this objection is dismissed as scientificaly irrelevant.”

In a double-blind crossover study of 26 long-stay schizophrenic patients, no correlation was found between caffeine consumption and levels of anxiety and depression. No significant changes in patients' behaviour or levels of anxiety and depression occurred when the wards changed to decaffeinated products. Serum caffeine levels confirmed compliance. No evidence was found to support a removal of caffeinated products from this group of patients.

A case of Munchausen's syndrome was probably caused by brain damage sustained during a necessary cholecystectomy. Doctors should not be discouraged from seeking treatable disorder because of such patients' behaviour.

As yet, there is no satisfactory model with which to understand steroid-induced mental disorder. It is suggested that a case of prednisone-induced psychosis in an adolescent female with Chrohn's disease can be best understood in terms of behavioural sensitisation to steroid therapy.

We describe a case of marked increases in serum creatine phosphokinase (CPK) associated with a dramatic exacerbation of tardive dyskinesia (TD). Chart review of eight additional patients with severe TD revealed three cases with mild CPK elevations. These cases suggest that TD, especially when accompanied by dystonia, may be associated with pathology of striated muscle.

A dramatic improvement in a patient with tardive dystonia was obtained with verapamil after the failure of other medicines. The use of verapamil or other calcium-channel blockers should be considered when treating drug-induced movement disorders.