Despite swings between over-valuation and rejection of psychotherapy on the part of some psychiatrists, there remains a valid and necessary place for psychotherapy in psychiatry. The essential elements of that place are described.

The dopamine hypothesis of schizophrenia implies that positive schizophrenic symptoms should be understandable by reference to brain structures receiving a dopamine innervation, or in terms of the functional role of dopamine itself. The basal ganglia, ventral striatum, septo-hippocampal system, and prefrontal cortex, sites of mesotelencephalic dopamine innervation, are examined and it is argued that their dysfunction could form the basis of particular schizophrenic symptom classes. The postulated involvement of dopamine in reinforcement processes might further assist such interpretations. This type of analysis can be extended to other categories of schizophrenic psychopathology.

Murray et al (1985) have proposed a method for using biological markers and information about family history to reduce the heterogeneity in a disease such as schizophrenia. They propose that families which are heavily loaded with illness are most likely to be segregating for a major locus and therefore should be used for studies of genetic marker or other biological traits that are thought to be related to a genetic etiology. They propose that patients without a family history (sporadics) of an illness should be investigated for hypothesised environmental components since they are the cases where environmental factors are most likely to play a large role. They give an example from their own data on Ventricular Brain Ratios (VBR) in a sample of schizophrenic twins (Reveley et al, 1984) where schizophrenic twins without any family history (FH-) of a major psychosis had significantly larger ventricles than did schizophrenic twins with a family history (FH+). They conclude that while there is a genetic determinant to ventricular size within the normal range, large ventricles reflect an environmental aetiology that is more important in sporadic cases than in those with a familial pattern to the illness. Subsequently, Reveley & Chitkara (1985) found that singleton schizophrenic patients who were FH-had a significantly larger VBR than did controls while FH+ patients had a mean midway between FH-patients and controls. While this is an attractive hypothesis for the structural brain changes seen in some schizophrenic patients, results of other studies are not consistent with these findings (Nasrallah et al, 1983; Schulsinger et al, 1984; Owens et al, 1985; DeLisi et al, 1986). For example, in our own data (DeLisi et al, 1986), ‘familial’ schizophrenics had larger ventricles than did controls and risk factors thought to be environmental (head injuries and birth complications) were found to be present in that sample.

The rationale and limitations of discriminating between cases of schizophrenia with and without a family history are reviewed. It is concluded from the evidence available that, by identifying subgroups of greater aetiological homogeneity, the strategy can be a useful starting point for research into likely causes.

Re-analyses of data presented by Macmillan et al (1986b) challenge their conclusions that high expressed emotion is not prognosticate significant for the course of schizophrenia or unrelated to the level of behavioural disturbance prior to admission. Several equally plausible models of causal relationships between EE and duration of untreated illness are presented. We conclude that our re-analyses of the Macmillan data do not warrant premature closure regarding the significance of the EE variable.

In the preceding paper, Mintz et al have raised a number of criticisms and points relating to our study, to which we are pleased to respond.

The psychopathology of acute organic psychosis was investigated by interviewing 74 patients using the Present State Examination (PSE). Their delusions, perceptual disturbance, thought disorder, and emotional disorder were categorised and then compared with those seen in 74 acute schizophrenics. In acute organic psychosis there was a particular pattern to the delusions, perceptual disturbance, and thought disorder, which was quite unlike that seen in acute schizophrenia. These results have implications for theories claiming that schizophrenia is an organic psychosis. It is suggested that the psychopathology in acute organic psychosis has very different origins from that seen in schizophrenia.

In a double-blind study of 38 chronic schizophrenic in-patients, haloperidol decanoate was compared with fluphenazine decanoate as maintenance therapy over 60 weeks. Both drugs were given by injection at 4-week intervals. Haloperidol and fluphenazine were assumed to be equipotent; the mean starting dose of the former was 127 mg and of the latter 106 mg. The number of withdrawals over 60 weeks was similar in both groups but relapses, strictly defined, were significantly more frequent in the haloperidol group. When patients were switched to haloperidol, Parkinsonism diminished more quickly than in the fluphenazine group, but after 60 weeks there was no difference in severity in the two drug groups. The higher relapse rate and the quicker reduction in Parkinsonism in the haloperidol group might be due to a misjudgement in equivalent doses of the two drugs. Plasma haloperidol steady state levels were reached in most patients by 8–12 weeks. Plasma neuroleptic and prolactin levels, week-by-week systemic drug availability and Parkinsonism showed less variation between injections with haloperidol than with fluphenazine.

Fluoxetine, a selective serotonin uptake inhibitor (mean dose 73 mg each morning) was compared with amitriptyline (mean dose 122 mg at night) in a double-blind study of 64 depressed out-patients. Fifty patients completed the 6-week trial. The drugs did not differ with respect to psychiatrists' ratings, but amitriptyline was slightly superior with respect to patients' ratings. The amitriptyline-treated group had complaints of dry mouth and dizziness on standing; the fluoxetine-treated group of sleep disturbances, nausea, and headaches.

A representative sample of elderly people residing in the community was examined to establish their psychiatric status. An interview with a close friend or relative, focusing on a one-week period in 1981, was used to investigate each subject's functional limitations and troublesome behaviour, these being the two components of the Social Breakdown Syndrome. The data from the sample were weighted to allow estimates of the characteristics of the general population. No cases of SBS at its most extreme were identified, and almost the entire population was found to be functioning at an adequate or near-adequate level: all cases of severe SBS were attributable to troublesome behaviour. Severe SBS was shown to increase with age and to be most common in non-white males. Persons with dementing disorders were more likely than their non-demented counterparts to show severe/moderate SBS, but in the majority of cases of SBS there was no mental disorder.

We observed 15 ‘new’ long-stay patients in wards in a District General Hospital Unit and a mental hospital, and again when they had lived for a year in a new hospital-hostel. There were significant changes in time spent in the community, social interaction, activity and abnormal behaviour. Residents believed they had more freedom and none wanted to return to wards. Six patients remained on wards. They showed no comparable changes and all wanted to live elsewhere.

Bimodality in a distribution of symptoms is often claimed to be convincing evidence that a disorder is categorical, a discrete disease entity, rather than the extreme on a continuous dimension. However, using concepts from contemporary psychometric theory it is shown that bimodality can arise from the dimensional viewpoint. In fact, contrary to the usual belief, bimodality would be expected to occur in many research contexts if the dimensional alternative were correct.

Examining the impact of natural disasters on psychological health provides an opportunity to study the role played by extreme adversity in the onset of psychiatric disorder. Four hundred and sixty-nine fire-fighters who had been intensely exposed to an Australian bushfire disaster completed a detailed inventory of their experiences four months later. They also completed a brief life events schedule and the 12-item General Health Questionnaire. Only 9% of the GHQ score variance could be accounted for by the disaster and other life events; the effects of the disaster appeared to be separate and additive. This is similar to the relationship between life events and psychiatric illness found in other settings. It is suggested that vulnerability is a more important factor in breakdown than the degree of stress experienced.

In order to establish whether the maternity blues is peculiar to the puerperium a selfrating blues questionnaire was administered to women after childbirth and after surgery. A period of dysphoria, similar in many respects to the maternity blues, was experienced by women post-operatively. The main difference between maternity and post-operative patterns of dysphoria seemed to lie in the timing of the blues, but on closer analysis many post-operative dysphoric symptoms peaked in a similar way to those in the maternity group. In the search for the cause of the maternity blues it may be helpful to study the same parameters in post-operative dysphoria.

This paper reports on a study of psychiatric morbidity in 920 patients attending 18 General Practitioners in Lewisham, South East London. Two indices of morbidity were computed on the basis of the patients responses to the General Health Questionnaire (GHQ) and the GPs' own estimates. Indices of the GPs' detection ability were found by comparing questionnaire and GP rating. The results are compared to those obtained by other workers in a sample of Manchester GPs. The GHQ gave a prevalence estimate of 42.9% which is comparable to that of 39.6% obtained in the Manchester study. In addition, the variation in caseness across sociodemographic groups was consistent with the Manchester findings. The GPs' estimates of morbidity, while much lower than those obtained in Manchester, have similar sociodemographic profiles. The results support the use of the GHQ as a screening device in epidemiological studies, and suggest the need for further investigation of the individual GP's performance as a case detector.

Fifty-five dependent (DSM-III) male alcoholics, chosen for good social adjustment, were personally followed up about 20 years after their first admission to hospital. The conditions of all the alcoholics were evaluated with a multidimensional diagnostic schedule when first admitted. At the follow-up, 11 were abstainers, 11 reported a change to social drinking via abstinence, and 10 reported a change to social drinking by gradual stages. Improvement after the age of 45 was mainly due to gradual change to social drinking. This type of improvement was in half of the cases attributed to a decreased tolerance for alcohol. In the present sample, there were no indications of any relationship between premature ageing and gradual change to social drinking. It is hypothesised that physiological processes of normal ageing with concomitant changes in reactions to alcohol may be of importance for remission from alcoholism in middle-aged and older alcoholics. The relationships of personality, social factors and the degree of alcohol-dependence to patterns of successful long-term adjustment are discussed.

Recent studies raise questions regarding use or abuse of alcohol by phobics, and about compatibility of behaviour therapy and benzodiazepine use. In this study 40 patients, referred with mainly anxiety-related problems to a nurse behaviour therapist, and a comparison group of 40 psychiatric nurses completed a self-administered questionnaire assessing use of alcohol, sedative drugs and tobacco, and their perceived anxiolytic effectiveness. The paper confirms earlier findings that the patients, in general, drank less than the general public. They also drank less than the nurses, but used more sedative drugs and were heavier smokers. Alcohol was an unreliable anxiolytic. A few patients, including two agoraphobics, drank heavily and did not enter treatment made conditional on stopping drinking. Implications for case management are discussed.

A high incidence of brief schizophrenia-like psychosis in Africa and other parts of the developing world has been repeatedly documented by many psychiatrists working in these regions (Dembovitz, 1945; Carothers, 1953; Jilek & Jilek-Aall, 1970; German, 1972; Leighton et al, 1963). This report does not deny that typical schizophrenia occurs in these countries, but the common culturally based schizophrenia like psychosis may be misdiagnosed as schizophrenia, and thus inflate prevalence and improve prognosis data.

An occurrence of Gilles de la Tourette's syndrome in a 13-year-old Saudi female patient is documented, and treatment is described. It is thought that the improvement noted may be attributed to the hospital environment and reduced contact with the family.

Male sex hormones are ascribed a great importance in the literature from the point of view of sexual activity and aggressive behaviour. Two cases of sexually motivated murder are described, committed by delinquents with low levels of testosterone in plasma: one a patient with Klinefelter's syndrome; the other a man after castration. Even a decreased level of androgens, either primary or secondary, is not an absolute prevention of sexually aggressive behaviour.