What we ordinarily call pain can arise either as a consequence of physical events or as a result of psychological processes. Both situations can be covered in one definition by treating pain as a word which applies only to subjective experience and not to nociception or to physiological processes. A definition of pain, framed in this fashion by the subcommittee on taxonomy of the International Association for the Study of Pain (IASP), was adopted by the IASP in 1979 and has been widely accepted since that date. Behavioural phenomena should not be confused with this definition. It implies a monistic view of the experience of pain and it is inappropriate to encumber it with concepts of “pain behaviour”. At the same time dual or multiple causes of pain are recognized. Thus physical causes, psychological causes or both may produce the unitary experience.

Like many phenomena which are located at the intersection between different disciplines, the complexity of alcoholism is difficult to comprehend, especially at an experimental level. In particular, pharmacological approaches towards alcoholism have emphasized the anxiety- and stress-reducing properties of ethanol, in spite of the limited clinical support for this hypothesis. In the same manner, the phenomenon of behavioral tolerance has mainly been approached from a pharmacological perspective, with little or no interest paid to the sensory stimuli possibly involved in the conditioning of drug effects. Comparative studies in animals selected for alcohol intake have concentrated on the biological responses to alcohol and have not investigated the possibility of genetic differences in sensitivity to environmental stimuli. Based on recent progress in the elucidation of the individual and environmental factors which play a key role in the development and stabilization of abnormal behavior in conflict situations, it is proposed that alcoholism is the result of a predisposition to react in a certain manner to environmental stimuli and social influences which is strengthened by the pharmacological effects of ethanol. The manner in which this hypothesis can be put to test has been discussed.

The aim of this study was to investigate relationships and differences between 2 scales assessing subject’s adaptative functioning. On the one hand, Axis V in the revised version of the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III-R) includes specific symptoms for each level of functioning described. On the other hand, the Psychosocial Aptitude Rating Scale (PARS) does not include clinical symptoms. A total of 78 psychiatric inpatients were rated independently with the 2 scales. The 2 ratings were correlated for the whole sample and for each diagnostic category. Diagnosis (Axis 1) explained 63.9% of the variance in the Global Assessment Functioning (GAF) Scale (Axis V) and only 23.8% in the Psychosocial Aptitude Rating Scale (PARS). Axis V is then made redundant by Axis 1 which is contrary to the aim of a multi-axial system. PARS describes aspects of the disorder that are distinct from clinical symptoms. These occupational and social aspects may be of great interest for a better overall evaluation of severity of mental disorders.

The contribution of biological psychiatry to research on schizophrenia should not be seen only in terms of discovery of biological markers or identification of definite etiological factors. Although biological research has failed up to now to identify such markers or factors, its influence on the clinical conceptualization of the illness has been considerable. On the other hand, biological research on schizophrenia has not been insensitive to the continuous re-shaping of the clinical concept of the illness which occurred during the last decades. There are at least three issues for which this reciprocal influence can be identified: 1), the question of the symptoms to be included in the definition of schizophrenia; 2), the problem of the relationship between “core” schizophrenia and mild non-psychotic conditions such as schizoid and schizotypal disorders; 3), the issue whether schizophrenia represents a mixture of different entities or a basically unitary condition.

The Composite International Diagnostic Interview (CIDI), the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the International Personality Disorder Examination (IPDE) constitute part of a family of instruments which have been designed for the assessment of mental disorders as defined by the explicit diagnostic criteria and algorithms in ICD 10 and DSM III-R. They have been developed at the request of the World Health Organization and the United States Alcohol, Drug Abuse, and Mental Health Administration to foster a common language in the mental health field, to facilitate comparisons of clinical and research findings from different settings, countries and cultures, and to improve the scientific basis of diagnosis and classification in psychiatry. This report describes the background, purpose and essential features of the three instruments.

The systems or lists that make up diagnostic criteria proposed by both classical and modern authors, as well as the usual national or international classifications constitute diagnostic instruments which allow: 1), classification of patients into the most homogeneous groups possible, according to absent-present criteria; 2), research on the propensity for certain criteria to appear, and on their stability; 3), a polydiagnostic approach, not limited to any one reference diagnostic system; 4), a group of psychiatrists to establish the capacity to construct empirical criteria for diagnosis and diagnostic-differential criteria of one or several nosological entities. If this group of psychiatrists is notably representative of a certain country or set of countries, these criteria allow for means of validation of the very empirical criteria established, as well as of the systems and classifications that integrate the instrument used, with their points of agreement and disagreement; 5), the establishment of a correspondence between empirical criteria and conceptual criteria, with predictions as to the application and way of using a new classification or of proposed projects, from the overall perspective of an empirical-conceptual relationship.

Density (Bmax) and affinity constant (Kd) values of tritiated imipramine binding sites were determined on platelets from patients suffering from major depression and from healthy, age-and sex-matched controls. Significantly lower Bmax values were found in the depressed patients, while the Kd values did not differ from those of controls. The results suggest that, in accordance with data from the literature, decrease in 3H-imipramine binding sites may be used as a state-dependent biological marker of depression in clinical practice.

The political role psychiatry plays in mental health strategies in the 20th century is discussed as well as the dangers of abuse when totalitarian ideologies rule supreme. The author comments on positive developments in the sectors of applied psychiatry and psychotherapy after World War II and the implementation of uniform requirements for the classification of psychopathological disorders as well as their limitations. Psychiatry as a scientific discipline relies on two fundaments: the conclusions drawn from the collective, present and past experience of psychiatric medicine and the impulses given by neighbouring disciplines such as neurobiology, psychology and sociology. These influences are necessary for the advancement of psychiatry, but can be restrictive in that they lead to tunnel vision by giving simple explanations for mental disorders of complex or unknown etiology. A multidimensional approach is required for the elaboration of adequate therapies and research must avoid dogmatism and short-sightedness.

Junior doctors who trained in psychiatry at the Maudsley Hospital between 1965 to 1975 were followed up at a mean of 17 years to ascertain whether pre-psychiatric experience or performance during training could predict future career paths. The most consistent predictor of a career in academic psychiatry was involvement in research during training.

Healing through emotional arousal is an ancient idea. Abreaction may yield lasting, brief, or no improvement, or alternatively sensitization. The predictors of outcome are unclear. The emotional experience of relevant exposure therapy yields more reliable improvement; forgotten traumas may surface, which ease as exposure proceeds. High arousal does not enhance the gains, but emotional engagement in exposure seems crucial for habituation to occur. Habituation is specific to the fear cues presented, marked generalization being unusual. Emotional experience irrelevant to a phobia can also improve the phobia, but the duration of such relief is unclear and different mechanisms may be involved. Fear-reduction is unreliable with non-exposure methods. Though counterproductive during exposure, dissociation and denial may have some uses. Optimal gains may come from being able to modulate activation or suppression to suit particular circumstances.

Benzodiazepines were first used in schizophrenia because of their anxiolytic properties. At high doses, or in association with neuroleptics, diazepam and estazolam also appears to exhibit an antihallucinatory effect, whereas alprazolam preferably acts on negative symptomatology due to its antidepressant properties.

We present the construction of an expert system (ES) for the diagnosis of Obsessive-Compulsive Disorders (OCD). It concerns an artificial intelligence tool, in Lisp language compatible with any personal computer (PC) with a hard disk. The ES asks the user 50 questions in natural language, on the patient or on a clinical history. It is provided with 115 rules of reasoning. Using single or multivaluate variables, the ES reaches the diagnosis of the Obsessive-Compulsive Disorders or the recommendations of differential diagnosis with related patterns or involucred with obsessive pathology: phobic, affective, schizophrenic and Gilles de la Tourette disorders. Finally, the perspectives for the utilisation of the ES in psychopathology are disscussed, in conjunction with the 2 serious problems created, design difficulty and user acceptance.

Several reviews on social functioning measurements using structured interviews or questionnaires have been published in recent years. This report examines Weissman and Brugha’s report on these tools and the respective interest of self-rating scales or interviews. In the elderly, multidimensional tools such as MAI or CARE have proven to be very useful. Questionnaires may be the best tools for assessing social adaptation in the elderly: a short self-rating scale that aims to assess social adaptation in the elderly in the community has therefore been presented. The SII Q is derived from the Multilevel Assessment Instrument (MAI) and the Index of Social Support (ISS). A principal component analysis of this new Social Integration and Independence Questionnaire (17 items) elicited four factors accounting for 48.8% of the variance, representing four parameters of social functioning: independence, social integration, familial interaction and depression.

In an empirical study on the classification of the psychoses, 302 patients were rated using the Longitudinal Psychopathology Schedule. The data were condensed by factor analysis, which yielded 10 factors - mania and schizomania, depression and suicidal activity, and 6 factors concerned with psychotic symptoms (verbal hallucinosis/passivity, delusion formation, defect symptoms, social decline, cycloid symptomatology and a factor loading depressive auditory hallucinations and visual hallucinations). Provisional diagnostic groups were obtained using DSM III. Discriminant function analyses showed that the only clearly distinct diagnostic group was bipolar disorder, and this was true for various definitions. Canonical variate analyses were performed using 3- and 4-criterion groups. These showed that a group corresponding approximately to cycloid psychosis also met criteria for being a distinct group. The most detailed examination pf the data, using 4-criterion groups and serial reclassification, suggested that the psychoses might fall into 5 groups - bipolar disorder, cycloid psychosis, depression, defect states and schizoaffective depression.

We studied circadian thyrotropin (TSH) and prolactin (PRL) response to synthetic thyrotropin-releasing-hormone (protirelin) infusion (200μg IV) at 8 am and 11 pm in 35 drug-free inpatients with DSM III-R Major Depressive Episode and in 22 hospitalized controls. In each group, maximum TSH and PRL responses were lower at 8 am than at 11 pm. The difference between 11 pm-ΔTSH and 8 am-ΔJTSH (ΔΔTSH) was significantly lower in depressed patients compared to controls. No such blunting was observed in PRL responses to protirelin in depressed patients. In the overall population, TSH response to protirelin (ie8 am-ΔTSH, 11 pm-ΔTSH, ΔΔTSH) correlated significantly with TSH circadian parameters (ie mesor and amplitude). These correlations were also observed with PRL (except for ΔΔPRL). TSH mesor and amplitude were lower in depressives than in controls. In contrast, PRL mesor and amplitude were not significantly different between diagnostic groups. ΔΔTSH is thus a chronobiological refinement to the measure of thyroid axis dysfunction in major depression. The blunted TSH response to protirelin suggests that the TRH receptors of the pituitary thyrotrophs are hyposensitive in major depression.

In patients with chronic idiopathic pain disorders we have analysed the construct validity of the Melancholia Scale as compared to the results with the scale in primary depression. The patients (n= 253) were treated in a placebo controlled trial with either clomipramine or mianserin independently of the Melancholia score. The construct validity of the Melancholia Scale was further analysed by the testing of the intensity model of depression versus anxiety using the Beck Depression Inventory, the Hamilton Anxiety Scale, the Spielberger State-Trait Anxiety Scale, and the Melancholia Scale. The construct validity in terms of scale homogeneity was analysed by Loevinger coefficients which can be considered as a latent structure evaluation. The Melancholia Scale showed acceptable homogeneity, while the Hamilton Anxiety Scale lacked sufficient homogeneity. In total, 33% of the patients had a score of 10 or more on the Melancholia Scale (corresponding to 13 or more on the Hamilton Depression Scale). The predictive validity of the Melancholia Scale was evaluated using active treatment versus placebo response after 6 weeks of therapy. It was shown that in patients with a Melancholia Scale score of 10 or more (corresponding to “less than major depression”) 72% had full recovery when treated with clomipramine, while 36% of the placebo treated patients obtained a full recovery (P≤0.05). The patients treated with mianserin obtained a full recovery in 52%. The group of patients with a Melancholia Scale score of 10 or more scored higher also on the anxiety scales indicating that the relation between depression and anxiety is a matter of severity. The depressed patients had significantly lower imipramine binding sites than the non-depressed patients.

The cortical metabolic patterns of 12 schizophrenics experiencing hallucinations and/or pseudo-hallucinations were investigated using positron tomography and 18F-fluoro-deoxy-glucose. Andreasen's scales were scored and the patients (all “mixed“) were classified in a “positive” or a “negative” group and compared to a group of 6 normal controls. The data were analyzed across groups for absolute metabolic rates, metabolic indices (cortical region/whole studied cortex), and specific indices exploring the sensory non-association/posterior parietal association and the prefrontal association/posterior parietal association dimensions. Whole-cortex metabolic rate in the negative group was found to be lower than both the control (P=0.02) and the positive group (P = 0.002) while the positive group did not differ significantly from the controls. We found “hypofrontality” to be without difference between the positive and the negative group (controls: 7±0.7, positive: 5.9±0.2, negative: 4.9±0.15, mean±SEM in mg/min/100 g). However, the prefrontal association/posterior parietal association ratio was increased in the negative group (P=0.02). A major finding was an increase in the posterior non-association/posterior parietal association ratio in the whole schizophrenic group as compared to the controls (P = 0.004), this being more marked in the negative (P=0.01) than in the positive group. Arguments are given to support the hypothesis that this particular increase could be related to the hallucinatory activity of the patients.

The present study was carried out in 2 successive phases. In the first, 91 inpatients admitted for opioid dependence were evaluated. All were treated with α2-agonists during the withdrawal period. Shortly after admission, a urine sample was taken and analyzed (EMIT and GC/MS). The presence of the cocaine metabolite benzoilecgonine in urine was a predictor of dropout probability during hospitalization (P < 0.01). A second study on a sample of 612 inpatients later admitted for similar reasons was carried out according to a simpler protocol (using only EMIT) in order to replicate the previous results. Again, the presence of benzoilecgonine in urine indicated dropout probability (P = 0.00004). Thus, the use of cocaine prior to admission for a treatment of opiate withdrawal syndrome with α2-agonists seems to predict therapeutic failure.

The interest in social adjustment of psychiatric patients has increased since potent therapeutic strategies have become available, allowing patient treatment within their natural social habitat. DSM III has formally recognized the need to evaluate social variables for each patient, introducing Axis V into its multiaxial system. This is of particular relevance for personality disorders where the main pathology is manifested within the social context. In this study, 94 patients with a DSM III-R diagnosis of Panic Disorder, Major Depression, and Generalized Anxiety Disorder have been evaluated with PDE (Personality Disorders Examination) to detect the presence of DSM III personality disorders, and with SAS (Social Adjustment Scale) to assess social adjustment. Results have shown that both Axis I and Axis II diagnoses affect social adjustment, though in a slightly different manner.