‘Whether or not it is worthwhile to distinguish between “neurasthenia” and “dysthymic disorders” must depend either on the demonstration that such syndromes have different social covariates, or pursue a different course, or have particular responses to treatment. Until such studies are forthcoming, the distinction seems especially insubstantial.’ (Goldberg & Bridges, 1991)

Epidemiological studies now indicate that fatigue is one of the most common symptoms of ill-health in the community, primary care and other medical settings, and that syndromal diagnoses based on fatigue (including chronic fatigue and neurasthenia) are prevalent and major sources of health care utilization. Such syndromes are characterized by a combination of persistent and disabling fatigue and neuropsychological and neuromuscular symptoms (Lloyd et al. 1990; Angst & Koch, 1991; Sharpe et al. 1991; Fukuda et al. 1994). Essentially, the differences between these syndromes reflect variations in duration criteria rather than symptom constructs. Specifically, the Centers for Disease Control (CDC) defines ‘prolonged fatigue’ as a syndrome of at least 1 month's duration, and chronic fatigue (including idiopathic and chronic fatigue syndrome – CFS) as a fatigue syndrome of at least 6 months duration (Fukuda et al. 1994). The ICD-10 classification system (World Health Organization, 1992) now includes a formal diagnosis of neurasthenia (F48.0) based on mental and physical fatigue of at least 3 months duration. Despite the current international and epidemiological interest in these disorders, DSM-IV has simply included them within the ‘Undifferentiated Somatoform Disorders – 300.81’ category (American Psychiatric Association, 1994).

Chronic fatigue syndrome (CFS) is characterized by severe and prolonged fatigue, affecting both physical and mental functioning, exacerbated by relatively minor exertion (Fukuda et al. 1994). A variety of other symptoms such as impaired concentration and memory, disturbed sleep, depressed mood and anxiety are also often present. Alongside this emerging consensus describing the clinical features of chronic fatigue, controversy has raged as to its aetiology, particularly the relative importance of viruses and other infectious agents, the contribution of neuromuscular abnormalities and whether the association with psychiatric disorders is primary or secondary.

Background. The nature and correlates of hypochondriasis are still poorly understood, especially in settings other than those in North America and Western Europe.

Methods. A total of 25916 consecutive patients making ambulatory visits to primary care clinics at 15 sites in 14 countries were screened using the 12-item General Health Questionnaire (GHQ-12). Based on the screen-score performance, a stratified sample of 5447 of respondents was evaluated at the second-stage (response rate: 62%). Evaluation consisted of physician-rated physical and psychological health status and self-ratings of overall health, physical disability and GHQ-28. Interviewers conducted assessment of psychiatric status, using the Composite International Diagnostic Interview (CIDI) and occupational disability.

Results. Across the sites, the occurrence of ICD-10 hypochondriasis was 0·8% (95% Confidence Interval, 0·5–1·0%) and over 1·5% at only two sites. A less restrictively-defined form of the disorder had a pooled frequency of 2·2% (95% Confidence Interval, 1·8–2·6%) across the sites. Patients with this abridged hypochondriasis were more likely than those without to have co-morbid major depression and generalized anxiety disorder. They had a poorer perception of their health, were more physically disabled, were more impaired in the performance of occupational role, and were above-average utilizers of health service. Patients with ICD-10 hypochondriasis were no more impaired than those with abridged hypochondriasis.

Conclusion. Even though the ICD-10-defined hypochondriasis is rare, a form consisting of the triad of disease conviction, associated distress and medical help-seeking is present in primary-care settings in different cultures. This syndrome is associated with considerable psychiatric ill-health and functional disability.

Background. The aim of this study was to determine differences between patients attending primary-care clinics with somatic symptoms for which no organic cause can be found, and those with a clear organic basis for their complaints.

Methods. Physical and psychiatric morbidity was measured in 5447 subjects presenting for primary care in 14 countries. Subjects were recruited using a two-stage design from 26969 consecutive attenders and 25916 (96·5%) subjects were successfully screened using the General Health Questionnaire (GHQ-12). The response rate for the second-stage assessment was 63% and consisted of the Composite International Diagnostic Instrument adapted for use in primary care (CIDI-PHC), the 28-item GHQ, the Groningen Social Disability Schedule (GSDS) and GP ratings to assess physical psychiatric and social status. Patients who reached the threshold for the number of somatic symptoms (five or more symptoms) were then divided into two groups on the basis of whether their somatic symptoms were medically explained or not.

Results. The presence of somatic symptoms, irrespective of aetiology, was associated with increased social and psychiatric morbidity. In the case of non-medically explained symptoms there was a clear linear relationship while with medically explained symptoms psychiatric morbidity rose sharply in the presence of more than 11 symptoms. Patients who had five or more non-medically explained symptoms were significantly younger, had greater psychiatric morbidity, were at greater risk of harmful use of alcohol and reported greater social disability than those with a medical explanation for their somatic symptoms. Patients who had an excess of somatic symptoms in both categories had especially high rates of social and psychiatric morbidity.

Conclusions. These results show a strong association between somatic symptoms irrespective of aetiology and psychiatric morbidity across disparate cultures.

Background. The majority of patients presenting to cardiac clinics with chest pain who are reassured they do not have heart disease or other serious physical disorder continue to experience symptoms, worry about heart disease and restrict their activities. This randomized trial investigated the effectiveness of psychological treatment within routine cardiac care.

Methods. Consecutive patients presenting with chest pain and reassured by a cardiologist they do not have heart disease were reassessed 6 weeks later. Those with persistent limiting symptoms were offered the opportunity to participate in a trial of cognitive behavioural therapy.

Results. Thirty-seven subjects agreed to take part. A number of subjects were unenthusiastic about psychological intervention or, following explanation of the study, regarded further treatment as not being necessary. At 3 months there were significant differences between the treatment group and the control group on key outcome measures of symptoms, mood and activity. At 6 months there were fewer differences but significant advantages of treatment in terms of limitation of activities and worry about physical symptoms.

Conclusion. We conclude that there is a need for ‘stepped’ further care following reassurance in the cardiac clinic and that cognitive behavioural treatment is effective with those with persistent disabling symptoms.

Background. Patients who present with chest pain but have normal coronary angiography and who are told by their cardiologist that they do not have heart disease, have a poor symptomatic, psychological and quality of life outcome and remain concerned about a serious cause of their symptoms. They frequently complain they have not had enough information. The study aimed to test the effectiveness and acceptability of a brief psychological intervention based on cognitive behavioural principles.

Methods. Consecutive patients with chest pain and normal angiograms were assessed and invited to take part in a randomized controlled evaluation. The intervention consisted of an individualized information and discussion session by a specially trained cardiac nurse, together with a handout and cassette providing information and advice and telephone follow-up to discuss progress, answer questions and reiterate advice.

Results. The treatment proved to be unacceptable to some patients and there was no evidence of efficacy.

Conclusions. Implications for the preparation of patients undergoing angiography and for the timing and delivery of information and advice following a negative result are discussed.

Background. Many women who undergo diagnostic laparoscopy for chronic pelvic pain do not have pelvic pathology. This has led to an interest in psychological factors that might contribute to their experience of pain. This study was designed to evaluate the effects of diagnostic laparoscopy on women with chronic pelvic pain and to explore possible psychological mechanisms.

Methods. Seventy-one women undergoing laparoscopy for chronic pelvic pain were randomly allocated to one of two groups waiting different lengths of time for laparoscopy. Women were interviewed before laparoscopy and were followed up 1 week, 3 months and 6 months afterwards. Pain was assessed with an interview measure, diaries and visual analogue scales.

Results. Pain reductions were observed from before to after diagnostic laparoscopy. Regression analysis was used to identify factors which predicted improvements in pain. The hypothesis that psychological factors would predict improvements in pain was confirmed. Pain improvements after laparoscopy were predicted by beliefs about pain and the change in each woman's evaluation of the seriousness of her condition. Other than baseline pain, these psychological variables were the only ones to emerge as predictors of pain change despite exploratory analysis of over 40 other variables.

Conclusions. Diagnostic laparoscopy can have beneficial effects in women with chronic pelvic pain. These effects appear to be the result of psychological mechanisms. Further investigation of these mechanisms could help in the understanding and treatment of women with chronic pelvic pain.

Background. Since depressive disorders are now eminently treatable and early detection and treatment could bring substantial benefits, it is critical to address alternative presentations of depression in the general medical setting. Concern regarding under-diagnosis of depression in general medical settings has given rise to the question of whether the clinical disorder of depression differs qualitatively or only quantitatively across care settings.

Methods. Symptom profiles of depression were compared across care sectors to investigate how the presentation of depression among general medical service users might differ qualitatively from speciality mental health service users. Data on depression symptoms within 6 months of interview gathered in three community surveys that were part of the NIMH Epidemiologic Catchment Area Program were analysed using methods developed to assess item bias. The subjects were 4931 and 363 persons who reported a visit to the general medical sector or to speciality mental health respectively, within 6 months of interview.

Results. Compared with speciality mental health service users, general medical service users were less likely to present dysphoria (adjusted Odds Ratio, aOR=0·57; 95% Confidence Interval, CI=0·38–0·84) and feeling worthless, sinful, or guilty (aOR=0·63; 95% CI=0·40–0·98), but were more likely to present fatigue (aOR=1·71; 95% CI=1·09–2·69), even after holding constant other characteristics that might influence reporting of symptoms as well as level of depression.

Conclusions. These results suggest that there are qualitative differences in depression presenting in general medical care compared with speciality mental health care and call for a reconceptualization of depression in the general medical setting.

Background. This study describes the differences in psychological distress, disability and psychosocial resources between types of major medical conditions and sensory impairments (collectively denoted as CMCs); and tests whether disability and psychosocial resources mediate CMC-specific mental health effects.

Methods. Data were obtained from a population-based, cross-sectional survey of 5078 non-institutionalized, late middle-aged and older Dutch persons. The predictors were 16 types of CMCs, including all major chronic medical diseases as well as impairment of hearing, vision, and cognition. The outcomes were assessed in terms of psychological distress as measured by the Hospital Anxiety and Depression Scale. Two aspects of disability were measured (namely, physical and role functioning) and also three psychosocial resources (namely, mastery, self-efficacy and social support).

Results. Level of psychological distress varied across type of CMC. Hearing impairment, neurological disease, vision impairment, and lung and heart disease had particularly strong associations with distress. The level of distress in patients with hearing impairment was 0·45 standard deviation higher than in those without hearing impairment (adjusted for demographics and all other CMCs). Roughly similar patterns of association were found between type of CMC and disability, and also, but to a lesser extent, mastery and self-efficacy. Stepwise multiple regression revealed that type of CMC accounted for 9%of the variance in distress initially, but this fell to 1% after the variance due to disability, mastery and self-efficacy was taken out. Social support was not a mediator. Disability and psychosocial resources accounted for 13% and 14% of the variance in distress, respectively.

Conclusion. These results support the conventional wisdom that it is not the nature of the condition that determines psychological distress, but instead the severity of the disability and loss of psychological resources associated with the condition on the one hand and the psychological characteristics of the patient on the other.

Background. Data are presented on the general population epidemiology of DSM-III-R bipolar I disorder in the United States.

Methods. Data come from the US National Comorbidity Survey (NCS), a general population survey of DSM-III-R disorders. A modified version of the Composite International Diagnostic Interview was used to make diagnoses.

Results. A small (N=59) clinical reappraisal study showed that the only manic symptom profile that could validly be assessed with the CIDI is characterized by euphoria, grandiosity and the ability to maintain energy without sleep, which described approximately half of all clinically validated bipolar I cases in the NCS. Further analysis focused on this symptom profile, which involved N=29 cases in the total sample. Lifetime prevalence was estimated to be 0·4% and 12-month prevalence only slightly lower. Caseness was negatively related to income, education and age, positively related to urbanicity, and elevated among the previously married, never married and non-whites. All cases reported at least one other NCS/DSM-III-R disorder and 59·3% reported that their episode of bipolar disorder (either mania or depression) occurred at a later age than at least one other NCS/DSM-III-R disorder. Although 93·2% of lifetime cases reported some lifetime treatment, only 44·7% of recent cases were in treatment.

Conclusions. The type of bipolar disorder examined here is highly chronic, co-morbid and impairing. Increased efforts are required to attract current cases into appropriate treatment. Methodological research is needed to develop more accurate measures of other bipolar symptom profiles for use in general population epidemiological studies.

Background. Patients suffering from bipolar affective disorders are generally reported to be able to detect prodromes. Insight is also said to be desirable for a good outcome. However, very little is known about the effect of insight and patients' spontaneous strategies for coping with prodromes on their social functioning.

Method. In a cross-sectional study 40 bipolar patients, who were not in an acute episode, were interviewed about their prodromes of depression and mania, their coping strategies for these prodromes, their levels of insight and their levels of social functioning.

Results. A quarter of subjects reported that they could not detect any early warnings of depression compared with only 7·5% of subjects who reported that they could not detect prodromes of mania. Subjects reported both spontaneous cognitive and behavioural strategies for coping with prodromes of depression but only behavioural strategies for prodromes of mania. Subjects' current levels of depression, how they coped with prodromes of mania and their ability to recognize early warnings for depression contributed significantly to their level of social functioning. Insight also had a weaker but significant contribution.

Conclusion. No causal link was made in this study. However, it did show that patients' level of social functioning was related to their level of insight, and to how well they coped with the prodromes of mania and whether they could detect prodromes of depression. The results suggest that it is worth exploring ways of teaching patients to monitor their moods and to promote insight and good strategies for coping with their prodromes.

Background. Survey data are presented on the associations between retrospectively reported childhood adversities and subsequent onset and persistence of DSM-III-R disorders.

Methods. Data come from the US National Comorbidity Survey, a large survey of the US household population.

Results. Twenty-six adversities were considered, including loss events (e.g. parental divorce), parental psychopathologies (e.g. maternal depression), interpersonal traumas (e.g. rape) and other adversities (e.g. natural disaster). These adversities were consistently associated with onset, but not persistence, of DSM-III-R mood disorders, anxiety disorders, addictive disorders and acting out disorders. Most bivariate associations with onset attenuated in models that controlled for clustering of adversities and for lifetime co-morbidities among psychiatric disorders. Multivariate effects of adversities in logistic models were additive, which means that they have multiplicative effects on probability of disorder onset. Adversities showed little specificity. An analysis of time decay showed that the effects of childhood adversities on disorder onset persist beyond childhood.

Conclusions. The existence of strong clustering among childhood adversities and lifetime co-morbidity among adult disorders means that caution is needed in interpreting the results of previous single-adversity single-disorder studies as documenting unique effects of specific childhood adversities on specific adult disorders. Future studies need to assess a broader range of adversities and disorders and to explore the existence and effects of commonly occurring adversity clusters. Replication is needed to verify that the effects of childhood adversities are mostly on first onset rather than on the creation of vulnerabilities that lead to increased risk of persistence.

Background. Many studies have reported a negative impact of divorce and separation on health although it is still unclear to what extent this is due to early vulnerability, the material and social consequences of divorce or to its direct emotional effects.

Method. Measures of anxiety and depression and potential alcohol abuse at age 43 were compared in 2085 participants from the MRC National Survey of Health and Development who were either married and never divorced or separated, or who had divorced or separated at least once. Analyses were adjusted for sociodemographic features, early vulnerability factors and current stressors.

Results. Divorce and separation were associated with increased anxiety and depression, and increased risk of alcohol abuse. This was the case after adjusting for educational attainment, age at first marriage, parental divorce, childhood aggression and neuroticism, and current financial hardship, lack of a confidante and frequency of social contact with friends or family. The association between divorce and risk of alcohol abuse became non-significant when the latter variable was controlled for. Associations between divorce and psychopathology were observed even though half of those separated or divorced were re-married or reunited with their spouses at the time of the analysis. There was, furthermore, no association between these mental health measures and time since first separation or divorce.

Conclusions. Divorce and separation have a specific and long-term impact on mental health.

Background. Many social and demographic correlates of psychiatric disorder have shown marked secular changes in recent decades. This study was designed to explore some of the implications of these trends, focusing on the illustrative case of teenage motherhood.

Method. Prospective data from two British birth cohort studies (the 1946 and 1958 cohorts) were used to examine the social, educational and behavioural precursors of teenage versus older age at motherhood, and the implications of teenage motherhood for women's later marital and social circumstances and risks of psychiatric morbidity, in samples born 12 years apart.

Results. Educational and social disadvantage were associated with similarly increased risks of teenage motherhood in both cohorts, but the findings suggested an additional association with teacher-rated adolescent conduct problems in the more recent sample. Rates of teacher-rated emotional problems were not elevated among teenage mothers in either cohort. In adult life, teenage motherhood was associated with a range of adverse social outcomes, including partnership breakdowns, large family size, and poorer housing conditions. Relative risks of these adult adversities were similar for teenage mothers in the two cohorts, but absolute levels of adversity were higher in the more recent sample, reflecting general secular changes in many of the indicators involved. In the later, but not the earlier, cohort, teenage motherhood was also associated with increased risks for psychiatric morbidity in adulthood.

Conclusions. The findings underline the importance of taking account of secular trends in examining the impact of psychosocial risks.

Background. Little is known about the extent and correlates of unmet need for mental health services in community samples of children and adolescents.

Methods. Data were obtained from the 1285 parent/youth pairs interviewed at four sites in the USA and Puerto Rico in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Unmet need was defined to exist if psychopathology and associated functional impairment were present but no mental health services had been received in the previous 6 months.

Results. Of the total sample, 17·1% had unmet need. Adjusting for demographic variables, logistic regression analyses revealed that unmet need was significantly associated with: indicators of economic disadvantage, such as being on public assistance and not being covered by health insurance; opinions of the parents and children or adolescents that the latter had poor mental health; parental psychopathology; poor school grades; and parent-reported access barriers such as concern that the child would want to solve the problem unassisted, would refuse to attend mental health services, or would be hospitalized or taken away against the parent's will. No youth-reported access barriers were significantly associated with unmet need.

Conclusions. The economic correlates of unmet need may attain increased importance in the light of current reform in health care financing in the USA. Access may be facilitated by increasing parental knowledge of mental health services and enabling children and adolescents to initiate contact with services independently of their families.

Background. Evidence suggests that schizophrenia may be a disorder with origins in early intrauterine mal-development. We have constructed a comprehensive anthropometric scale for the evaluation of dysmorphic features as an index of the nature and timing of developmental disturbance.

Method. A detailed set of craniofacial and bodily measures was compiled and applied to 174 patients with schizophrenia and 80 matched control subjects.

Results. Patients had significantly higher scores on this scale and displayed multiple anomalies of the craniofacial region with an overall narrowing and elongation of the mid-face and lower face. Twelve craniofacial anomalies independently distinguished patients from controls and these variables correctly classified 95% of patients and 80% of control subjects.

Conclusions. This new scale, while procedurally more exacting than the Waldrop scale, more clearly defines the topography of anomalies previously suspected in individuals with schizophrenia. These findings constitute direct evidence for disturbed craniofacial development in schizophrenia and indicate origins in the foetal period during which the characteristic human facial pattern evolves in close association with brain differentiation.

Background. Negative associations between religion and suicide, in individuals and countries, may be mediated by the degree to which suicide is tolerated.

Methods. Linear regression was used to examine ecological associations between suicide tolerance, religion and suicide rates in 19 Western countries in 1989/90. Logistic regression was used to study associations between suicide tolerance and strength of religious belief in 28085 individuals in these countries. The concept of effect modifying function was used to examine whether the strength of the association between suicide tolerance and religious belief in individuals depended on the extent of religious belief in their country.

Results. Higher female suicide rates were associated with lower aggregate levels of religious belief and, less strongly, religious attendance. These associations were mostly attributable to the association between higher tolerance of suicide and higher suicide rates. In the 28085 subjects suicide tolerance and the strength of religious belief were negatively associated even after adjustment for other religious and sociodemographic variables and general tolerance levels (odds ratios: men 0·74 (95% CI 0·58–0·94), women 0·72 (95% CI 0·60–0·86)). This negative individual-level association was more pronounced in more highly religious countries but this modifying effect of the religious context was apparent for men only.

Conclusions. Ecological associations between religious variables and suicide rates are stronger for women than men, stronger for measures of belief than observance and mediated by tolerance of suicide. In individuals, stronger religious beliefs are associated with lower tolerance of suicide. Personal religious beliefs and, for men, exposure to a religious environment, may protect against suicide by reducing its acceptability.

Background. This paper seeks to explain an excess of psychological distress previously found among groups of British South Asians (with ancestry from the Indian subcontinent) living in Glasgow, compared with the general population. The excess was found on a psychosomatic measure and a measure of self-assessed distress but not on a clinically validated measure (the General Health Questionnaire or GHQ). The paper investigates whether South Asians are subject to stressful situations to which the GHQ is less sensitive than the other two measures.

Methods. Random samples of 159 South Asians aged 30–40, mean age 35, and 319 from the general population, all aged 35, were interviewed in Glasgow, using the 12-item General Health Questionnaire (GHQ-12), a psychosomatic symptom scale (PSS) and a self-assessment of distress. Subcultural groupings were differentiated by South Asian origin, English fluency, religion, and gender. Stressful situations assessed were experience of assault, stress/dissatisfaction with work, overcrowding, low standard of living, absence of family and absence of confidants.

Results. The GHQ-12 was less sensitive to certain stressful situations than the other two measures. The PSS and/or self-assessed distress were more sensitive to low standard of living, self-rated stress in work around the house and possibly experience of assault. In a combined analysis, the relation between distress on the PSS or self-assessed measure and subcultural groupings became non-significant, while the relation between distress and key stressful situations remained significant.

Conclusions. The greater distress of women, Muslims and limited English speakers is largely explained by the stressful situations they experience. The GHQ-12 under-estimates distress related to situations experienced particularly by ethnic minorities and by women.

Background. Most studies of social support appear to assume that it is something that the external environment provides to an individual. However, longitudinal and genetic studies are beginning to question this assumption. The purpose of the present study is to differentiate quantitatively the intra-individual determinants of social support from its extra-individual components.

Methods. The subjects were 103 high school exchange students who were enrolled in a 1-year placement with a host family in various countries of the world. The People In Your Life scale, a reliable and validated self-report measure of perceived social support, was administered before their departure from home, after 6 months of stay in a completely unfamiliar foreign community and 6 months after their return home. Structural equation models were examined that partitioned the intra-individual and extra-individual components of social support, and the best fitting models were selected.

Results. Between 24% and 69%, or up to 86% depending on the situation, of the variances of social support measures were stable across situations and considered intra-individual; 31% to 76% of what is measured as social support was of extra-individual origin. Moderately strong correlations were noted between the intra-individual components and the trait extraversion.

Conclusions. Measures of social support, which is usually tacitly understood as something extrinsic to an individual, in fact may not be measures of the external environment only.

Background. The Parental Bonding Instrument (PBI) measures fundamental parenting dimensions (care and over-protection), but does not directly assess abusive parenting.

Methods. We describe the development of the Measure of Parenting Style (the MOPS), comprising refined PBI scales assessing parental indifference and over-control, as well as a scale assessing parental abuse.

Results. We examine psychometric properties of the MOPS, while several analyses build to the concurrent validity of the abuse scale as an experiential measure. We examine the extent to which both the PBI and the MOPS scales showed specificity of dysfunctional parenting to the non-melancholic depressive subtype, and across a range of anxiety disorders. Non-melancholic depressed patients returned anomalous parenting scale scores (compared to melancholic subjects), but only when such subtyping decisions were clinician-generated. Those receiving DSM-III-R lifetime anxiety diagnoses of panic disorder and of social phobia returned higher PBI protection and MOPS over-control scores than non-anxious subjects, while differences were not established for those with generalized anxiety disorder or obsessive compulsive disorder.

Conclusions. We consider the likely utility of the MOPS scale and note the module capacity of separate MOPS and PBI scales, which allow a set of options for assessing perceived parenting characteristics.