Background. Psychotherapy's equivalence paradox is that treatments have equivalently positive outcomes despite non-equivalent theories and techniques. We compared the outcomes of contrasting approaches practised in routine care.

Method. Patients (n=1309) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) and psychodynamic therapy (PDT) at one of 58 National Health Service (NHS) primary and secondary care sites in the UK during a 3-year period completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. Therapists indicated which treatment approaches were used on an End of Therapy form. We compared outcomes of six groups: three treated with CBT, PCT or PDT only, and three treated with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1, PCT+1 or PDT+1 respectively.

Results. All six groups averaged marked improvement (pre–post effect size=1·36). Treatment approach and degree of purity (‘only’ vs. ‘+1’) each accounted for statistically significant but comparatively tiny proportions of the variance in CORE-OM scores (respectively 1% and 0·5% as much as pre–post change). Distributions of change scores were largely overlapping.

Conclusions. Results for these three treatment approaches as practised routinely across a range of NHS settings were generally consistent with previous findings that theoretically different approaches tend to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, lack of a control group, missing data and other issues.

Background. In order to elucidate further the cognitive processes underlying auditory hallucinations, an experiment investigating delayed and immediate source monitoring for positive, negative and neutral verbal material was conducted with schizophrenic patients.

Methods. Patients experiencing auditory hallucinations, patients not experiencing auditory hallucinations and normal subjects participated in a word association task, rating their responses for how much a self-generated thought was their own, how controllable and involuntary it was and their confidence in these ratings. A delayed source monitoring test in which subjects had to recall the source (self or experimenter) of the words from the association task was also administered.

Results. Hallucinators showed a greater bias towards external attribution of their thoughts compared with both control groups for immediate attributions of source, but not for delayed attributions. Hallucinators showed a bias towards external attribution of emotional material for immediate source monitoring and all subjects showed a bias towards misattribution of positive material to an external source and negative material to an internal source for the delayed source monitoring task.

Conclusions. These findings appear to be most consistent with theories proposing that hallucinations result from an external attributional bias for internal events. The implications of these results for research and practice are also discussed.

Background. Depersonalization has long been considered a syndrome but there is poor agreement on its constituent symptoms.

Method. In order to establish whether different symptoms of depersonalization represent the expression of a single or several underlying dimensions, an exploratory factor analysis on the Cambridge Depersonalization Scale (CDS) was carried out on 138 consecutive patients diagnosed with depersonalization disorder.

Results. Four well determined factors accounting for 73·3% of the variance were extracted. These were labelled ‘Anomalous Body Experience’; ‘Emotional Numbing’; ‘Anomalous Subjective Recall’ and ‘Alienation from Surroundings’.

Conclusions. Symptoms of depersonalization belong to distinct but related psychopathological domains.

Background. For people with intellectual disabilities there is a difficult balance to be struck between empowering people to claim their sexual rights and protecting them from abuse. Hypothetically, services should be guided by whether a particular person with intellectual disabilities has the capacity to consent to sexual relationships. However, there has been little agreement on how to define such capacity. This study examines the issue of capacity to consent to sexual relationships using a functional approach.

Method. Adults with intellectual disabilities (n=60) and young people presumed in law able to consent (n=60) were assessed for their sexual knowledge and vulnerability to abuse.

Results. Adults with intellectual disabilities were significantly less knowledgeable about almost all aspects of sex and appeared significantly more vulnerable to abuse, having difficulty at times distinguishing abusive from consenting relationships. Nevertheless, some adults with intellectual disabilities scored highly on all measures, especially if they had relatively high IQs and had had sex education.

Conclusions. The reasons for the poorer knowledge and increased vulnerability of people with intellectual disabilities are discussed and it is recommended that they should have on-going access to sex education. Implications of the findings for definitions of capacity to consent to sexual relationships are considered.

As part of a longitudinal study of bereavement phenomena in three groups, bereaved spouses, bereaved adult children and bereaved parents, scale development was carried out using a pool of bereavement phenomenology questions administered prospectively. The items were derived from the literature, in particular studies dealing with the measurement of grief/bereavement, as well as from clinical experience. Factor analysis of theoretically grouped items produced seven subscales, three of which tapped frequently experienced phenomena in the bereaved. These three subscales formed the basis of a single measure, labelled the Core Bereavement Items (CBI), which demonstrated high reliability and sound face and discriminant validity. Preliminary analysis suggested that the CBI will prove to be a reliable and valid instrument with respect to the measure of core bereavement phenomena in commonly bereaved groups in Western society.

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. Repeated, self-damaging behaviour occurring in the context of borderline personality disorder (BPD) may reflect impairments in decision-making and planning cognition. However, there has been no systematic neuropsychological examination of these particular cognitive functions in patients diagnosed with BPD. Such investigations may improve our understanding of the possible role of brain dysfunction in BPD and improve the characterization of the psychological difficulties associated with this disorder.

Method. Forty-two psychiatric patients with a diagnosis of DSM-III-R BPD (41 of whom gave a history of self-harm), without a history of specified ‘psychoses’ or current major affective disorder, were clinically assessed before completing computerized tasks of decision-making and planning previously shown to be sensitive to frontal lobe dysfunction, and tests of spatial and pattern visual recognition memory previously shown to be sensitive to frontal lobe damage and temporal lobe damage respectively. The performance of the BPD patient group was compared with that of a non-clinical control group consisting of 42 subjects.

Results. The performance of the BPD patients on the decision-making task was characterized by a pattern of delayed and maladaptive choices when choosing between competing actions, and by impulsive, disinhibited responding when gambling on the outcome of their decisions. BPD patients also showed impairments on the planning task. There was no evidence of impaired visual recognition memory. Additional analyses suggested only limited effects of current medication and history of previous substance use disorder.

Conclusions. These findings suggest that BPD is associated with complex impairments in dissociable cognitive processes mediated by circuitry encompassing the frontal lobes. These impairments may mediate some of the behavioural changes evident in BPD. Further work is needed to examine the specificity of these findings.

Background. Neuroticism and self-esteem, two commonly used personality constructs, are thought to reflect a person's underlying vulnerability to major depression. The relative strength of these predictors is not known.

Method. Information was gathered on 2163 individual women from an epidemiological sample of female–female twin pairs. Neuroticism was assessed by the Eysenck Personality Questionnaire and global self-esteem by the Rosenberg Self-Esteem Scale. Major depression (DSM-III-R criteria) and stressful life events were also assessed. The personality constructs were studied in relation to major depression by logistic regression and structural equation modelling.

Results. Both cross-sectionally and prospectively, examined individually, neuroticism was a stronger predictor of risk for major depression than was self-esteem. When examined together, the predictive power of neuroticism remained substantial, while that of self-esteem largely disappeared. The same pattern of findings was obtained when a subset of subjects who had recently experienced stressful life events was analysed. By trivariate twin modelling, we found that the covariation of self-esteem, neuroticism and major depression was due largely to genetic factors. When self-esteem was the ‘upstream’ variable, a substantial genetic correlation remained between neuroticism and major depression. By contrast, when neuroticism was the ‘upstream’ variable, the genetic correlation between self-esteem and major depression disappeared.

Conclusions. The personality construct of neuroticism is a substantially better index of a woman's underlying vulnerability to major depression than is self-esteem. These findings suggest that overall emotionality or emotional reactivity to the environment reflects risk for depression better than does global self-concept.

Background. A prospective epidemiology study evaluated the role of specific social and psychological variables in the prediction of depressive symptomatology and disorders following childbirth in a community sample. Measures of social support used previously in clinically depressed populations facilitated further comparison.

Methods. Nulliparous pregnant women (N=507) were interviewed during pregnancy with the Interview Measure of Social Relationships (IMSR) and a contextual assessment of pregnancy-related support and adversity and 427 were followed up at 3 months postpartum with the 30-item GHQ, including six depression items. To establish the clinical representativeness of the GHQ, high GHQ scorers and a random subsample of low scorers were interviewed using the SCAN. Regression models were developed using the GHQ Depression scale (GHQ-D), the IMSR and other risk factor data.

Results. GHQ-D after childbirth was predicted by lack of perceived support from members of the woman's primary group and lack of support in relation to the event becoming pregnant; this held even after controlling for antenatal depression, neuroticism, family and personal psychiatric history and adversity. Informant-rated deficits in provision of social support also predicted later depression. The size of the primary social network group previously found to be related to depression in women, did not predict depressive symptom development.

Conclusion. Predictors of depressive symptom development differ from predictors of recovery from clinical depression in women. Interventions should be designed to reduce specific deficits in social support observed in particular study populations.

Background. Whereas a number of studies have suggested that parental loss is associated with increased risk for major depression (MD), much less is known about possible gender differences, diagnostic specificity and the time course of the impact of loss.

Method. First-onsets for MD and alcohol dependence (AD) were assessed at personal interviews in 5070 twins from same-sex (SS) and 2118 from opposite-sex (OS) twin pairs ascertained from a population-based registry. Cox Proportional Hazard (PH) and Non-Proportional Hazard (NPH) models, examining first onsets of MD and AD, were used with twins from SS pairs and conditional logistic regression for OS pairs. Parent–child separations prior to age 17 were divided into death and separation from other causes.

Results. The PH assumptions of constant increased risk were rejected for the impact of loss on risk for MD but not for AD. NPH models found significantly increased risk for MD after both death and separation with the risk lasting much longer for separations. For AD, the PH model found significantly increased risk after parental separation but not death. In both SS and OS twin pairs, no sex differences were seen in the impact of parental loss on risk for MD whereas the association between separation and risk for AD was significantly stronger in females than in males.

Conclusion. Consistent sex differences in the association with parental loss were seen for AD but not MD. The analysis of the time-course of increased risk after loss suggests three different patterns which may reflect different relationships: parental death and MD (return to baseline within ∼12 years), separation and MD (return to baseline within ∼30 years) and separation and AD (no change in risk over time).

Background. Psychiatric disorders and being overweight are major health problems with increasing prevalence. The purpose of this study was to test the hypothesis that being overweight is associated with a range of psychiatric conditions including minor and atypical depressive disorders, binge eating, and aggression.

Method. Prospective community-based cohort study of young adults (n=591) followed between ages 19 and 40. Information derived from six subsequent semi-structured diagnostic interviews conducted by professionals over twenty years. Outcomes were being overweight [body-mass index (BMI)>25] and average yearly weight change between ages 20 and 40 (BMI slope).

Results. 18·9% of the participants were classified as being overweight. Being overweight turned out to be a stable trait: 77·7% of subjects were assigned to the same weight class at each interview. Atypical depression and binge eating were positively associated with both, increased weight gain and being overweight, while psychiatric conditions associated with aggressive behaviors (aggressive personality traits, sociopathy) were positively associated with being overweight, but were not related to the rate of weight change. Generalized anxiety disorder was negatively associated with overweight. These results persisted after controlling for substance use, levels of physical activity, demographic variables and family history of weight problems.

Conclusions. This study shows relatively strong associations between eating-related and aggressive psychopathology and being overweight. Given the high prevalence rates of these conditions, this study encourages further research on the causality of psychopathology-overweight associations that might provide insight on novel preventive approaches for major health problems.

The Brief Social Phobia Scale (BSPS) is an observer-rated scale designed to assess the characteristic symptoms of social phobia, using three subscales – fear, avoidance, and physiological arousal – which may be combined into a total score. Each of 18 BSPS items is anchored to a 5-point rating scale. Psychometric evaluation of the BSPS in a sample of 275 social-phobia patients yielded a high level of reliability and validity. Test–retest reliability was excellent, as was internal consistency. The fear and avoidance subscales demonstrated highly significant correlations with remaining item totals; however, the physiological subscale did not. The BSPS also demonstrated significant relationships with other established scales that assess anxiety and disability, and it proved sensitive to treatment effects in a trial of a 5-HT3 antagonist and placebo. Factor analysis yielded six meaningful factors. We conclude that the BSPS provides a reliable, valid, and sensitive measure for the evaluation of social phobia.

Previous studies based on probands from clinical samples suggest that panic disorder aggregates strongly in families and may be due to a highly penetrant single major locus. In this study we examine panic disorder as assessed at blind, structured psychiatric interview in 2163 women from a population-based twin registry. DSM-III-R diagnoses were assigned at a narrow and at a broad level both by clinician review and by computer algorithm. The familial aggregation of panic disorder in this sample was only modest. The relatively small number of affected individuals prevented a definitive resolution of competing genetic and non-genetic models of familial transmission. Although there was some inconsistency across diagnostic approaches, most results suggested that the familial aggregation of panic disorder was due largely to genetic factors. Using a multifactorial-threshold model, the best estimates of the heritability of liability ranged from 30 to 40%. From a familial perspective, panic disorder with phobic avoidance appears to represent a more severe form of the syndrome than panic disorder without avoidance. Our results, which suggest that in the general population panic disorder is only a moderately heritable condition, are at variance with results from several previous investigations based on clinically ascertained samples.