Background. This paper examines the emergence of ‘moral treatment’ in British psychiatry.

Method. Re-examining a range of largely well-known sources, this article begins by outlining the social and intellectual shifts entailed by the secularization of madness at around 1660. The boundaries of various schools of psychiatric treatment are distinguished according to: (a) how much moral autonomy they accord the insane patient; and (b) whether they promote ‘body’ or ‘mind’ first (are ‘somatopsychic’ or ‘psychosomatic’). I have also incorporated newly-discovered material that proves the existence of ‘classical moral treatment’, or therapeutic argumentation.

Results. The paper outlines four distinct models of psychiatric treatment: ‘classical moral treatment’; the ‘pious fraud’; ‘charismatic stewardship’; and ‘moral treatment’. Neither the ‘pious fraud’ nor ‘charismatic stewardship’ allowed that the patient was morally autonomous – rather, lunatics were stereotyped as animals. After the 1780s, some psychiatrists began practising in ways that understood the patient as being capable of some rationality. But none of these practitioners saw ‘moral’ therapies to be independent of the body's workings – they used: (a) psychological methods to ease the administration of physic; and/or (b) psychological and medical remedies interchangeably. The Tukes, who developed the famous asylum ‘The Retreat’ at York, were the first to find successful ways to make psychological means predominate in therapy.

Conclusion. The Tukes of York are reinstalled in their position as founders of moral treatment as a therapy aimed at the autonomous human mind.

Background. In this paper, data from the British National Survey of Psychiatric Morbidity are used to assess depressive disorders and markers of social disadvantage in women bringing up children on their own.

Method. The household component of the British National Surveys of Psychiatric Morbidity was based on a stratified random sample of >10000 subjects. This paper reports on 5281 women interviewed in person. Psychiatric symptoms and ICD-10 diagnoses were established by lay interviewers using the CIS-R. Results are presented in terms of depressive episode and mixed anxiety/depressive disorder. Housing tenure and access to a car were used as proxy measures of material status. The life event rate in the 6 months before interview was used to indicate overall exposure to stress, and subjects were asked in detail about perceived social support. Information was collected about various other sociodemographic attributes. Lone mothers were compared with supported mothers and with women not involved in care of children under 16.

Results. Lone mothers had prevalence rates of depressive episode of 7%, about three times higher than any other group. The milder condition, mixed anxiety/depression, was also increased in frequency. These increased rates of depressive conditions were no longer apparent after controlling for measures of social disadvantage, stress and isolation.

Conclusions. Lone mothers are increasing in numbers as marital stability declines. Their high rates of material disadvantage and of depressive disorder may have considerable implications for psychiatric and social policy.

Background. A recent US study presented data suggesting that depressed women are more likely to respond to selective serotonin reuptake inhibitor (SSRI) than tricyclic (TCA) antidepressant drug therapies. We have undertaken replication studies in two independent databases.

Method. We have examined for gender differences in SSRI and TCA antidepressant response in both retrospective and prospective naturalistic uncontrolled studies, and in subsets of melancholic and non-melancholic depressed subjects. As the US study had indicated that women under the age of 40 years were particularly likely to show a differential response to SSRIs, we examined for age, gender and interactional effects. In addition, we examined for differential SSRI and TCA responsiveness in a subset of patients who had received drugs from both classes.

Results. We failed to find evidence of women having a preferential response to SSRI medication or, conversely, of men having a superior response to TCA medication. Older age, however, was associated with a superior TCA response and younger age with a superior SSRI response.

Conclusion. As few studies have examined for differential gender and age effects in response to narrow action and broad action antidepressant drugs across major depressive subtypes, gender differential effects remain to be established.

Background. This study examined the relative contribution of adolescent self-concept, maternal weight and shape concerns (WSC), and mother–daughter relationships to eating disturbances among girls with type 1 diabetes mellitus (DM).

Method. Eighty-eight adolescent girls (mean=15·0 years, s.d.=2·2) and their mothers completed self-report measures of disordered eating and weight control behaviours, with teens also reporting on disturbed eating and body attitudes. Based on reported symptoms, adolescents were classified as highly (N=18), mildly (N=30) and non-eating disturbed (N=40). Self-concept was assessed by adolescent self-report. Mother–daughter relationships were assessed by adolescent self-report and by observed mother–daughter interactions that were rated using a macroanalytic coding system that assesses intimacy and autonomy in these relationships.

Results. Hierarchical regressions illustrated that adolescent self-concept deficits, maternal WSC, and impaired mother–daughter relationships significantly predicted eating disturbances in girls with DM, accounting for 57% of the variance. Mothers who engaged in dieting and binge-eating were more impaired in their ability to support their daughters' emerging autonomy. The quality of mother–daughter relationships partly mediated the influence of maternal WSC on adolescent eating disturbances. Moreover, the impact of maternal WSC and mother–daughter relationships on eating disturbances was mediated by adolescent self-concept.

Conclusions. Findings illustrate two pathways through which mother–daughter relationships may impact upon risk of eating disturbances in girls with DM and highlight the need to evaluate family-based interventions specifically tailored for this high-risk population.

Background. Prader-Willi syndrome (PWS) is a genetic disorder resulting in obesity, short stature, cryptorchidism, learning disabilities (mental retardation) and severe neonatal hypotonia. Associated with the syndrome are a number of behaviours that are sufficiently distinctive that the syndrome is considered to have a specific ‘behavioural phenotype’.

Methods. Through multiple sources we attempted to identify all people with PWS living in one region in the UK. This cohort was augmented by people with PWS from other regions, and a contrast group of people with learning disabilities of varied aetiologies. The main carers were interviewed, using structured and semi-structured interview schedules, to establish the presence and severity of specific behaviours, and PWS diagnostic criteria. The intellectual functioning and attainments of all were determined. Blood samples were obtained for genetic diagnosis from all consenting participants.

Results. Although excessive eating was recognized as a potentially severe problem in those with PWS, it was almost universally controlled by food restriction, and therefore not seen as a ‘problem behaviour’. Those with PWS differed from a learning disabled group of other aetiologies in the prevalence rates of skin picking, temper tantrums, compulsive behaviours and mood fluctuations, and also in the profile of their adaptive behaviours.

Conclusions. The study confirms the distinct behavioural phenotype of PWS. Specific behaviours occurred significantly more frequently in PWS, compared with an age and BMI matched learning disabled comparison group. A factor analysis of the behaviours involved resulted in three factors that we hypothesized to be independent, and to arise from different mechanisms.

Background. It has been proposed that inferences about the mental states of others are drawn after a referral to autobiographical memory. This study explored the relationship between autobiographical memory retrieval and performance on tests of theory of mind in people with schizophrenia.

Method. Fifty-nine people with a DSM-IV diagnosis of schizophrenia and 44 healthy participants matched for age, sex and estimated IQ were given the Autobiographical Memory Interview (AMI), two measures of theory of mind (ToM) and a logical memory test.

Results. There was clear evidence that the people with schizophrenia were under-performing on all tasks. Within the schizophrenia sample, robust relationships existed between the total scores achieved on the AMI and the ToM tasks. Furthermore, there was evidence that the participants with schizophrenia had a tendency to recollect odd or negative events when prompted by the standard questions of the AMI.

Conclusions. The results of this study indicate that when people with schizophrenia attempt to think about the beliefs and intentions of others they use analogical reasoning. Whether this approach is also adopted by other clinical and normal adult groups is a question for future research.

Background. The aims of this research were to examine the associations between the personality trait of neuroticism in adolescence and later psychotic symptoms, taking into account potential confounding factors.

Method. Data were gathered over the course of a longitudinal study of a birth cohort of New Zealand born young people (N=1265). Over the course of the study, data were gathered on: (a) neuroticism at age 14; (b) psychotic symptoms predominantly subclinical, assessed on the Symptom Checklist (SCL-90), at ages 18 and 21; (c) a range of potential confounding factors including measures of childhood adversity and co-morbid mental disorders.

Results. Young people in the highest quartile of neuroticism at age 14 had rates of psychotic symptoms that were two to three times higher than those in the lowest quartile. After statistical adjustment for confounding factors, including childhood adversity and co-morbid mental disorders, the association between neuroticism and later psychotic symptoms reduced but remained statistically significant (P<0·05). After adjustment for confounding, young people with high levels of neuroticism had rates of psychotic symptoms that were between 1·5 to 1·8 times higher than those with low levels of neuroticism.

Conclusions. Early neuroticism may be a precursor to the onset of psychotic symptoms. The mechanisms underlying this association are unclear, but may relate to overlapping features between prodromal phases of psychosis and items that measure neuroticism.

Background. Intellectual impairments are a recognized feature of tuberous sclerosis complex (TSC), but the frequency and degree of intellectual impairments has not been systematically studied in large epidemiological samples using standardized measures. As such, the form of the IQ distribution (uni- or bi-modal) has not been established and the relationship between IQ and other features (e.g. epilepsy history) is poorly delineated. To address these shortcomings, we assessed the intellectual abilities of a large epidemiological sample of individuals with TSC, drawn from the ‘Wessex’ area of SW England and compared them with the abilities of their unaffected siblings.

Method. Standardized tests were used to estimate the abilities of 108 (56 males, 52 females, median age=25, range=4–75) individuals with TSC and 29 unaffected siblings (14 males, 15 females, median age=18, range=6–55). Seizure history was obtained from informants and medical records.

Results. Estimated IQ was bi-modally distributed: 55·5% had an IQ in the normal range; 14% had mild to severe impairments; and 30·5% had profound disability (IQ<21). Forty-four per cent of the individuals with TSC had an IQ<70. In the subset of normally intelligent individuals with TSC, IQ was normally distributed with a mean of 93·6. This mean was significantly lower than the mean IQ of unaffected siblings (IQ=105·6). All individuals with learning disability had a history of seizures that usually commenced before 12 months of age and that often presented as infantile spasms. Multivariate analyses indicated that a history of seizures as well as a history of infantile spasms was predictive of the degree of intellectual impairment.

Conclusions. Intellectual abilities were bi-modally distributed in a representative sample of individuals with TSC. The likelihood of impairment was associated with a history of seizures, particularly infantile spasms. The genetic and brain basis of these findings requires further investigation.

Background. Although patients with schizophrenia have increased rates of neurological soft signs, few studies have examined prospectively their trait or state characteristics in relation to psychopathology.

Method. In a prospective study of 97 patients with first-episode schizophrenia (DSM-IV criteria) we assessed neurological soft signs and psychopathology at presentation and at 6 month follow-up for 73 cases. To establish whether soft signs were associated with variations in clinical state, neurological soft signs were measured using two validated examinations (Neurological Evaluation Scale and Condensed Neurological Examination); psychopathology was assessed using the Positive and Negative Syndrome Scale.

Results. There was significant improvement in overall neurological function, primarily in motor-related and cortical signs, which were associated with improvement in psychopathology. Conversely, ‘harder’ signs were unrelated to improvement in psychopathology.

Conclusions. Neurological soft signs in schizophrenia are heterogenous. Motor and cortical signs evidence state-like characteristics and vary with clinical course, while ‘harder’ signs evidence more static, trait-like characteristics in accordance with a neurodevelopmental basis.

Background. The Vulnerable Attachment Style Questionnaire (VASQ) was developed to provide a brief self-report tool to assess adult attachment style in relation to depression and validated against an existing investigator-based interview (Attachment Style Interview – ASI). This paper describes the development and scoring of the VASQ and its relationship to poor support and major depression.

Method. Items for the VASQ reflected behaviours, emotions and attitudes relating to attachment relationship style, drawn directly from the ASI. The VASQ was validated against the ASI for 262 community-based subjects. Test–retest was determined on 38 subjects.

Results. Factor analysis derived two factors, labelled ‘insecurity’ and ‘proximity-seeking’. The VASQ insecurity dimension had highest mean scores for those with interview-based Angry-dismissive and Fearful styles and was significantly correlated with degree of interview-based insecurity. The proximity-seeking VASQ scores had highest mean for those with Enmeshed interview attachment style and was uncorrelated with ASI insecurity. VASQ scores were highly correlated with a well-known self-report measure of insecure attachment (Relationship Questionnaire) and text–retest reliability of the VASQ was satisfactory. The total VASQ score and the insecurity subscale proved highly related to poor support and to depressive disorder. This was not the case for the proximity-seeking subscale.

Conclusion. The VASQ is a brief self-report measure that distinguishes individuals with attachment styles vulnerable for depressive disorder. The use of the measure for screening in research and clinical contexts is discussed.

Background. The role of allelic variation in APOE, the genetic locus for apolipoprotein E, in geriatric depression is poorly understood. There are conflicting reports as to an association between the ε4 allele and depression in late life.

Method. Using a community based study of non-demented elders in Cache County, Utah, that included many very old individuals, we examined the relationship between APOE and late-onset (age >60) depression, with particular attention to possible age effects.

Results. There was no overall association between APOE and depression. However, there was a significant interaction effect of APOE and age such that the relationship of late-onset depression with respect to presence of the ε4 allele was larger among those 80 and older compared with those below age 80. Consistent with previous studies, women were more likely to experience late-onset depression than men.

Conclusions. Because we excluded prevalent cases of dementia, this pattern of relative risk with age may reflect the appearance of depressive symptoms as a prodrome of Alzheimer's disease or vascular dementia. Longitudinal studies should help to confirm or refute this explanation of the data.

Background. Peace-keeping duties are associated with unique stresses for military personnel. There have been few reports on the effects of peace-keeping on psychological health.

Method. We used data from a cross-sectional study originally established to examine health effects of service in the Gulf War, which included a control group who had been deployed in Bosnia (N=2049). This group was examined to establish which demographic, occupational, and deployment-related risk factors were associated with psychological distress measured on the General Health Questionnaire (GHQ-12) and stress symptoms akin to a post-traumatic stress reactions.

Results. The main risk factors for stress symptoms in the Bosnia group were – lower rank, being deployed early in the campaign, having more deployment-related exposures, and serving on staff duties. There was no protective effect of previous deployments to the Falklands or Northern Ireland, and time off following deployment was not protective. For GHQ-12 cases, the main risk factors were: female gender, lower rank, increased deployment-related exposures and serving on staff duties.

Conclusions. This study suggests that stress symptoms and GHQ-12 cases, are strongly predicted both by experiences during deployment and demographic factors.

Background. Autism and schizophrenia are considered to be substantially influenced by genetic factors. The endophenotype of both disorders probably also includes deficits in affect perception. The objective of this study was to examine the capacity to detect facially expressed emotion in autistic and schizophrenic subjects, their parents and siblings.

Method. Thirty-five subjects with autism and 102 of their relatives, 21 schizophrenic subjects and 46 relatives from simplex (one child affected) and multiplex (more than one child affected) families, as well as an unaffected control sample consisting of 22 probands completed a 50-item computer-based test to assess the ability to recognize basic emotions.

Results. The autistic subjects showed a poorer performance on the facial recognition test than did the schizophrenic and the unaffected individuals. In addition, there was a tendency for subjects from multiplex families with autistic loading to score lower on the test than individuals from simplex families with autistic loading. Schizophrenic subjects and their relatives as well as siblings and parents of autistic subjects did not differ from the sample of unaffected subjects in their ability to judge facial affect.

Conclusions. Findings corroborate the assumption that emotion detection deficits are part of the endophenotype of autism. In families with autistic children, the extent of facial recognition deficits probably indexes an elevation in familial burden. It seems unlikely that problems in emotion perception form a consistent part of the endophenotype of schizophrenia or the broader phenotype in relatives of patients with psychosis or autism.

Background. Although urban place of birth has been identified as a risk factor for schizophrenia, the extent to which this association is mediated by socially patterned risk factors such as obstetric complications and childhood socio-economic position is unclear. The diagnostic specificity of the association within the clinical psychotic syndromes is also unclear.

Method. A population cohort of 696025 males and females, born in Sweden between 1973 and 1980 and with linked birth and socio-economic data was followed up from age 16 for up to 9·8 years. Hospitalized cases of schizophrenia and other non-affective psychosis were identified from the Swedish Inpatient Discharge Register. We examined associations of these disorders with a three-level measure of urbanicity of birthplace before and after controlling for measures of foetal nutrition, obstetric complications and level of maternal education.

Results. Urban compared to rural birthplace was associated both with increased risk of adult onset schizophrenia (hazard ratio 1·34, CI 0·91–1·96) and other non-affective psychoses (hazard ratio 1·63, CI 1·18–2·26). None of these associations was greatly affected by adjustment for obstetric complications or maternal educational level. In the group of other non-affective psychoses urban–rural differences in disease risk were strongest among those born in the winter months.

Conclusion. Urbanization of birthplace is associated with increased risk of non-affective psychosis but this is not confined to narrowly defined cases. The magnitude of the association in Sweden is lower than that reported in other studies. Causal factors underlying this association appear to operate independently of risks associated with obstetric complications and parental educational status.

Background. Objective data regarding adverse cognitive deficits associated with maintenance electroconvulsive therapy (M-ECT) are lacking. This study examined the cognitive state of depressive patients during M-ECT.

Method. A cross-sectional study was carried out in 11 depressive patients in remission, all with a DSM-IV diagnosis of major depressive disorder. The mean number of previous ECT sessions was 36·1, and the mean intersession interval was 52·7 days. A group of 11 patients who had not received ECT was selected for comparison and matched for diagnosis, sex, age and years of schooling. All subjects were assessed using a complete neuropsychological battery including memory, attention and frontal function tests.

Results. Groups did not present differences in long delay verbal recall. Encoding of new information and results on the frontal function tests were significantly lower in the M-ECT patients.

Conclusion. Depressed patients preserve long-term memory, but suffer short-term memory impairment and frontal function alteration during M-ECT. Further longitudinal studies are necessary to determine the influence of M-ECT on non-memory functions and different memory subtypes.

Background. Psychiatric co-morbidity is thought to be an important problem in suicide, but it has been little investigated. This study aims to investigate patterns of co-morbidity in a group of male suicide completers.

Method. One hundred and fifteen male suicide completers from the Greater Montreal Area and 82 matched community controls were assessed using proxy-based diagnostic interviews. Patterns of co-morbidity were investigated using latent class analysis.

Results. Three subgroups of male suicide completers were identified (L2=171·62, df=2012, P<0·05), they differed significantly in the amount of co-morbidity (Kruskal–Wallis χ2=71·227, df=2, P<0·000) and exhibited different diagnostic profiles. Co-morbidity was particularly found in subjects with disorders characterized by impulsive and impulsive–aggressive traits, whereas subjects without those traits had levels of co-morbidity which were not significantly different from those of controls (χ2=8·17, df=4, P=0·086).

Conclusions. Suicide completers can be divided into at least three subgroups according to co-morbidity: a low co-morbidity group, a substance-dependent group and a group exhibiting childhood onset of psychopathology.

Background. The purpose of this study was to evaluate the clinical correlates of agoraphobic fear and avoidance and panic disorder in a non-clinical sample of adolescents.

Method. In a sample of 2365 high school students, combined data from a questionnaire and a structured clinical interview were used to classify subjects with agoraphobic fear and avoidance. Panic symptoms, major depression, childhood separation anxiety disorder, anxiety sensitivity and negative affectivity were also assessed.

Results. Fifteen subjects met study criteria for agoraphobic fear and avoidance in the past year. Only three (20%) of those with agoraphobia symptoms reported histories of panic attacks and there was no overlap between those with agoraphobic fear and avoidance and the 12 subjects who met DSM-III-R criteria for panic disorder. However, subjects with agoraphobia symptoms and those with panic disorder reported similar levels of anxiety sensitivity and negative affectivity. Childhood separation anxiety disorder was more common among those with agoraphobic fear and avoidance compared to those without.

Conclusion. Agoraphobic avoidance is rare in non-clinical samples of adolescents and usually not associated with panic attacks. However, adolescents with agoraphobia symptoms and those with panic disorder have similar clinical correlates consistent with a panic/agoraphobia spectrum model.

Background. The statement that past behaviour is the best predictor of future behaviour has empirical support in respect of whether an individual will, or will not, commit a criminal offence. People who have offended in the past are more likely to offend in the future. The aims of this study were to develop an instrument and to examine whether the same statement applies in respect of the nature and circumstances of successive offences committed by the same person.

Method. A rating instrument to describe seven variables relating to the nature and circumstances of a serious offence, the SODI, was developed by the authors. Inter-rater reliability was measured when the instrument was applied to 80 offences committed by 40 patients leaving high secure hospitals. The data were examined for evidence of similarity in the nature and circumstances of successive offences.

Results. For five of the seven items of the instrument the kappa coefficients for inter-rater reliability were >0·65. No significant associations, in terms of SODI ratings, were found between the offence that led to hospital admission and that which was committed after discharge.

Conclusions. The SODI is a reliable instrument for the description of serious offences committed by this group. Risk assessments in psychiatry should be informed by an awareness that in only a proportion of cases will the nature and circumstances of any serious re-offence resemble the nature and circumstances of the offence which contributed to a patient's admission to hospital.

Background. There have been numerous reports of seasonal trends in psychotic illnesses. In schizophrenia, seasonal trends in incidence have been shown to be especially apparent in first-episode cases. Most previous research has used date of admission as a proxy for date of incidence of disorder; we present results of an investigation into seasonal trends in dates of onset of symptoms in a group of 295 first-episode cases of schizophrenia and schizophreniform disorder.

Method. Data were analysed using statistical methods appropriate for detecting seasonal trends in pooled data over 6 years.

Results. Only male cases of schizophrenia and schizophreniform disorder showed a significant seasonal distribution to dates of onset of symptoms, with a peak in August (winter).

Conclusion. True seasonal patterns are present in schizophrenia incidence, but their consistency with other published studies and wider significance, is difficult to ascertain because of different methods used in dating incidence of disorder.