A prospective study was carried out to investigate the relationship between family attitudes and relapse in a cohort of 80 schizophrenic patients followed up for 2 years. A significant relationship was found between attitudes as measured by means of a semantic differential during hospitalization and later relapse. Lack of treatment compliance, negative symptoms, unemployment and poor pre-morbid adjustment were also associated with relapse. In a multivariate analysis some of these variables changed their predictive power but the association between attitudes and relapse was maintained.

This study explored the changes in complaint-related cognitions and anxiety of 110 consecutive out-patients with functional abdominal complaints (irritable bowel syndrome), during a series of consultations. Patients' anxiety, fear of cancer, somatic attribution concerning intestines or stomach and catastrophizing cognitions appeared to diminish significantly during the consulting period. Positive changes in patients' psychological attribution and somatic attribution appeared to be related to doctors' correct perceptions of these attributions. Catastrophizing cognitions diminished significantly more when patients saw the same doctor throughout the consultations. As changes in attributions and catastrophizing cognitions appeared to be related to doctor–patient interaction, it is conceivable that doctors could learn to influence cognitions even more.

Most family studies of psychiatric illness ascertain probands through treatment facilities. If psychiatric illness in relatives influences the probability of treatment seeking, then the risk of illness in the relatives of treated probands will not be representative of the risk of illness in all probands. We have investigated this question in a population-based sample of female twins with lifetime history of DSM-III-R defined major depression (MD) (N = 753), 36% of whom reported seeking professional help for their depression. Logistic and Cox regression methods were used. Treatment seeking for MD was significantly associated with age, education, comorbidity with anxiety disorders, degree of impairment and number of symptoms. Controlling for these predictors, treatment seeking was significantly predicted by the presence of one or more relatives with a lifetime diagnosis of MD (OR = 1·62). The probability of treatment seeking for MD in the proband was significantly increased if the affected relative: (i) had an onset of their MD prior that of the proband and; (ii) themselves sought treatment for their depression. Seeking treatment in this epidemiological sample of depressed women was associated with a 32% increase in risk of MD in relatives. Selecting probands for family studies from treated populations may select for families with an increased rate of illness. For MD, this artefact can explain only a modest proportion of the familial aggregation observed in prior family studies that utilized treated probands.

The psychological outcome for a random community sample of women who had experienced significant childhood sexual abuse was assessed, using two outcome measures: (i) psychiatric morbidity (measured with the short PSE); (ii) self-esteem. Sexual abused women with a good outcome, i.e. who were not a PSE ‘case’ or who had high self-esteem were compared with abused women with a poor outcome. This paper describes the post-abuse factors that modified the two outcomes.

In general, a range of variables, all correlated with each other in a complex manner, distinguished good outcome subjects from poor outcome subjects. Post-abuse adolescent variables included family factors (poor mother–father and parent–child relationships), high school factors (poor academic, sporting and social performance) and early pregnancy. Women who had a good adolescent relationship with their father did better than expected statistically. Sport emerged as an alternative at secondary school to academic achievement in catalysing a good psychological outcome.

Adult factors included the quality of relationship with partner, which was associated with a good outcome on both measures. Current paid employment was linked to high self-esteem but not to lowered psychiatric morbidity, while the converse applied for high socio-economic status. These findings imply that different processes operate for each outcome measure.

A clear recognition by the school of childhood sexual abuse may help to provide the opportunity for the girl to experience success in some arena; this in turn may protect her against the likely adult consequences of low self-esteem and increased psychiatric morbidity.

This paper examines structural brain abnormalities, as evaluated by the CT scan, in first episodes of schizophrenia and their association with sociodemographic, diagnostic and clinical variables. The investigation included all patients with a first episode of schizophrenia who, over a 2-year period, made contact with any of the public mental health services of the Autonomous Region of Cantabria in Northern Spain. Diagnostic and clinical characteristics were evaluated through the use of the Spanish version of the Present State Examination (PSE-9) and the Scales for the Assessment of Positive and Negative Symptoms (SANS and SAPS respectively). The study demonstrated the presence of structural brain abnormalities in this sample of first episode schizophrenics. These abnormalities were mainly expressed in the presence of larger VBR for schizophrenic patients than in the controls, these findings being more marked in women than in men. We failed to reveal, however, any evidence of an association of these brain abnormalities with diagnostic or clinical characteristics.

The clinical course and outcome of anorexia nervosa are presented in a 10-year followup study of 76 severely ill females with anorexia nervosa who met specific diagnostic criteria and had participated in a well-documented hospital treatment study. Information was obtained on 100% of the subjects. A comprehensive assessment was made in 93% of the living subjects in specific categories of weight, eating and weight control behaviours, menstrual function, anorexic attitudes, and psychological, sexual, social and vocational adjustment. Five subjects had died, which gives a crude mortality rate of 6·6%. Standardized mortality rates demonstrated an almost 13-fold increase in mortality in the anorexia nervosa subjects. Only eighteen (23·7%) were fully recovered. Sixty-four per cent developed binge-eating at some time during their illness, 57% at least weekly. Twenty-nine (41%) were still bulimic at follow-up. The high frequency and chronicity of the bulimic symptoms plus the high rate of weight relapse (42% during the first year after hospital treatment) suggest that intensive intervention is needed to help anorexics restore and maintain their weight within a normal range and to decrease abnormal eating and weight control behaviours.

The characteristics of two samples of people with learning disabilities and severely challenging behaviour were examined. The experimental sample comprised subjects who had been referred to two specialist challenging behaviour services in separate counties. The comparison sample comprised subjects from the same counties who were not referred or accepted for specialist intervention. No significant differences were found between the samples in terms of age, gender, social impairment, dependency characteristics, ability levels and mental health. Significant differences between them were found in the nature and severity of aberrant behaviour presented, as assessed by their carers. The implications of these findings are discussed with regard to how the term ‘severely challenging behaviour’ is defined in practice.

Melancholia is most commonly distinguished from non-melancholic depression by the presence of psychomotor disturbance (PMD) and a set of ‘endogeneity’ symptoms. We examine the capacity of an operationalized clinician-rated measure of PMD (the CORE system) to predict diagnostic assignment to ‘melancholic/endogenous’ classes by the DSM-III-R and Newcastle systems. Examining a pre-established CORE cut-off score (≥ 8) against independent diagnostic assignment, PMD was present in 51% of those assigned as melancholic by DSM-III-R, and 85% of those assigned as endogenous by the Newcastle system, quantifying the extent to which it is ‘necessary’ to the two definitions of ‘melancholia’. Additionally, multivariate analyses established that the addition of a refined set of historically suggested endogeneity symptoms added only slightly to overall discrimination of melancholic and non-melancholic depressives. While only few endogeneity symptoms independent of psychomotor disturbance were suggested, their specific relevance varied against system definition of melancholia (appetite/weight loss and terminal insomnia being identified for DSM-III-R; anhedonia for Newcastle; and diurnal variation in mood and energy for both systems). Results allow consideration of the relative importance of two domains (psychomotor disturbance and ‘endogeneity’ symptoms) to clinical definition of melancholia, and have the potential to assist both classification and pursuit of neurobiological determinants. We interpret findings as suggesting a ‘core and mantle’ model for conceptualizing the clinical features of melancholia, with psychomotor disturbance as the core and with independent endogeneity symptoms as only a thin mantle.

This study examines the frequency of life events before admission and before deterioration in 70 dementia patients, in comparison with 50 dementia controls living in the community and 50 fit elderly people matched for age and sex. We hypothesized that there would be an excess of events connoting changes in routine and the social environment. Specific scales were developed to measure these aspects of events. Our results supported the initial hypothesis, confirming that it is the social disruptiveness of change rather than the threat implied by life events that is associated with deterioration. The findings are discussed in the light of current models of the dementia process.

A variety of sociocultural, familial and individual features associated with the eating disorders were examined in subjects with full syndrome (FS) and partial syndrome (PS) eating disorders and in normal high school students. The EAT-26 was administered to 995 high school students. This was followed by individual interviews with those who scored in the symptomatic range. Fifty-one students with PS eating disorders, 57 students without eating disorders (normal controls) and 30 hospital patients with FS, anorexia nervosa or bulimia nervosa were compared on subscales of the Eating Disorder Inventory, the Diagnostic Survey for Eating Disorders and the Beck Depression Inventory. The three groups displayed statistically significant differences on dimensions of EDI subscales Ineffectiveness and Interoceptive Awareness and also with respect to depression, history of being overweight and past history of emotional problems, as well as having mothers with medical illnesses. On these characteristics, the FS subjects displayed higher levels than the PS subjects, who in turn were higher than the NC subjects. The PS subjects displayed elevations on Body Dissatisfaction (EDI subscale), past medical illnesses, and mother's over-concern with eating and weight. These data support a continuum model of the eating disorders, but a continuum of multiple associated features rather than of dieting.

This paper describes a modified version of the MRC Needs for Care Schedule (the Cardinal Needs Schedule), for measuring needs for psychiatric and social care amongst patients with severe psychiatric disorders. The modified schedule has three new features: (i) it is quick and easy to use; (ii) it takes systematic account of the views of patients and their carers; (iii) it defines and identifies need in a way that is concise and easy to interpret. The paper describes why the three new features were considered necessary, and then gives an overview of the structure of the Cardinal Needs Schedule, together with a description of how the three new features were developed. During a study of social services care management the practicality of the modified schedule was investigated and further data were obtained on the reliability and validity of the standardized approach to measuring need, in domains not previously investigated. Because of its speed and simplicity, the Cardinal Needs Schedule offers a new choice to researchers who wish to use a standardized and practical assessment of need in evaluative studies of community care. Examples of the usage of the modified schedule are given in an Appendix.

We compared 71 patients with irritable bowel syndrome (IBS) and 40 patients with inflammatory bowel disease (IBD) using structured interviews for psychiatric, gastrointestinal and sexual/physical victimization histories, as well as self-reported measures of personality, functional disability and dissociation. IBS patients had significantly higher lifetime prevalence rates of major depression, current panic disorder, and childhood sexual abuse. Despite the absence of organic pathology, IBS patients had significantly higher numbers of medically unexplained physical symptoms and disability ratings equal to, or greater than, those of patients with severe organic gastrointestinal disease.

We have attempted to clarify clinical differentiating features of psychotic depression. Forty-six depressed subjects meeting DSM-III-R criteria for major depression with psychotic features were compared with (i) DSM-defined melancholic, (ii) Newcastle-defined endogenous, and (iii) a residual DSM-defined major depressive episode group. Additionally, a ‘bottom up’ latent class analysis (LCA) suggested a larger sample of 82 ‘psychotic depressive’ subjects, and multivariate analyses contrasted these subjects with both LCA-identified melancholic and all residual depressed subjects. Analyses suggested that, in addition to two features with absolute specificity (delusions and hallucinations), both the DSM-defined and LCA-defined ‘psychotic depressive’ subjects were significantly more likely to demonstrate marked psychomotor disturbance, to report two morbid cognitions (feeling sinful and guilty; feeling deserving of punishment), as well as be more likely to report constipation, terminal insomnia, appetite/weight loss and (variable across the defined ‘psychotic depressive’ groups) loss of interest and pleasure. The study identifies a wider set of potentially discriminating clinical variables than previous studies, as well as both indicating the existence and assisting identification of ‘true’ psychotic depression in the absence of formal psychotic features being acknowledged or elicited.

The prevalence of culture-bound syndromes such as eating disorders in the countries of Central and Eastern Europe is unclear and comparative epidemiological studies are lacking. Before the political changes in 1989 we therefore investigated eating disorders, eating attitudes and psychological health in two Eastern European countries and in one Western democracy. A total of 1225 female and male medical students in Hungary, the German Democratic Republic (GDR) and Austria were surveyed. The instruments included the Eating Disorder Inventory and the GHQ. The prevalence of eating disorders was calculated on the basis of simulated DSM-III-R diagnosis. In females, bulimia nervosa prevalence rates of 0·6% (95% CI 0·02, 3·46), 1% (0·2, 2·95) and 0% (0, 2·07) were calculated for Austria, Hungary and the GDR, respectively. For subclinical bulimia nervosa, the rate for Hungary (3·8%; 1·95, 6·72) was twice as high as for Austria (1·9%; 0·39, 5·5) and the GDR (1·7%; 0·36, 4·88). Hungarian subjects indicated more psychiatric ‘caseness’ than their GDR or Austrian counterparts. We conclude that eating disorders represented at least as common a problem in Eastern as Western Europe before the changes in political organization. This may be due to an identification process with Western values. A further increase of eating disorders in these countries induced by the recent changes may be possible.

Smooth pursuit performance in schizophrenia and affective disorders has generally been found to be abnormal using a variety of measures. The purpose of this study was to assess patients with these disorders and normal controls in order to compare the different measures across diagnoses. Smooth pursuit was assessed using quantitative specific measures (gain, catch-up saccade rate and amplitude, square-wave jerk rate, number of anticipatory saccades and total time scored), as well as two global measures: root mean-square error (RMS) and qualitative rating. As previously reported, patients with schizophrenia had low gain, increased catch-up saccade rate and spent less time engaged in scoreable smooth pursuit than normal controls. Patients with affective disorders were not statistically different from controls on any of these measures, and had significantly higher gain than patients with schizophrenia. RMS error and qualitative rating measures were highly correlated (r = 0·87). In linear regression analyses, the quantitative specific measures were highly significant predictors of both RMS error and qualitative ratings (P < 0·0001). Linear regression analyses and a modelling study indicated that one quantitative specific measure, the percent of time engaged in scoreable smooth pursuit (total time scored), was most related to global ratings. However, RMS error and qualitative ratings were less sensitive than total time scored to the difference between controls and patients with schizophrenia. These data indicate two smooth pursuit performance deficits in schizophrenia: patients spend less time engaged in scoreable smooth pursuit and have low gain (accompanied by increased compensatory saccades) when the smooth pursuit is engaged.

One hundred and eighteen subjects with an admission diagnosis of schizophrenia were reassessed after 12 months to establish whether hospital readmission had occurred. All subjects were rated at baseline and after 12 months on the Life Skills Profile (LSP), a 39-item measure of disability, with scores demonstrating moderate stability. The baseline LSP score was a significant predictor of readmission, both in univariate and multivariate analyses. By contrast, several univariate variables (e.g. unemployment and non-compliance with medication over the review period) did not maintain their predictive capacity in multivariate analyses, suggesting that they were manifestations or consequences of significant disability, rather than independent contributors to poor outcome.

We describe the development of a clinical algorithm to differentiate melancholic from non-melancholic depression, using refined sets of ‘endogeneity’ symptoms together with clinician-rated CORE scores assessing psychomotor disturbance. Assignment by the empirically developed algorithm is contrasted with assignment by DSM-III-R and with several other melancholia subtyping indices. Both the numbers of ‘melancholies’ assigned by the several systems and their capacity to distinguish ‘melancholics’ on clinical, demographic and a biological index test (the DST) varied across the systems with the algorithm being as ‘successful’ as several systems that include inter-episode and treatment response variables. Analyses provide information on the criteria set developed for DSM-IV definition of ‘melancholia’.

Previous analyses with a sample of female twins sampled from the general population in Virginia have suggested that generalized anxiety disorder (GAD) and major depression (MD) share their genetic determinants but have partly different environmental determinants. The goal of this report is to examine whether these findings apply to samples that include male as well as female twins and contain high proportions of subjects who had been hospitalized for MD.

The subjects were ascertained through two different sources: (i) index probands were ascertained through the Swedish Psychiatric Twin Registry for a diagnosis of unipolar or bipolar affective illness; (ii) control twin probands were ascertained through the Swedish Twin Registry. Subjects were sent questionnaires for the assessment of lifetime history of GAD and MD. Positing multinormal distribution of the liability for GAD and MD, we fitted bivariate models to examine the sources of comorbidity.

The full model included additive genetic effects, shared environment and individual-specific environment, as well as scalar and non-scalar sex limitations and different thresholds across genders. The best-fitting model included: (i) a genetic correlation of unity; (ii) no common environment; (iii) an individual-specific environmental correlation of 0·28; (iv) different thresholds across genders, but neither scalar nor non-scalar sex-limitations. A model that included additive and dominant genetic effects and individual-specific environment, with correlation of unity for both additive and dominant genetic effects, provided an equivalent fit.

These analyses confirm that GAD and MD share the same genetic factors but that their environmental determinants are mostly distinct. Moreover, the present report supports the feasibility of combining clinically ascertained and general-population samples into a single bivariate analysis.

The present study aimed to examine memories of early separation anxiety symptoms in a community sample of women at heightened risk to neurotic disorder. The chief finding was that subjects with a lifetime history of panic disorder–agoraphobia (PD–Ag) returned statistically higher scores on a retrospective measure of early separation anxiety compared to subjects with either generalized anxiety or other phobic disorders, a result which was not accounted for by differences in neuroticism or General Health Questionnaire scores. Although limited by its retrospective design and the problem of co-morbidity in subclassifying the anxiety disorders, the present study does provide added support for the hypothesis – endorsed by DSM-III-R – that there is a developmental link between early separation anxiety and panic disorder.

In this study we assessed the accuracy of the General Health Questionnaire in detecting psychiatric disorders in general medical out-patients. A total of 290 newly referred patients were interviewed with the Present State Examination. Prior to the interview, 112 patients completed the full GHQ-60, 100 completed the GHQ-30 and 78 completed the GHQ-12. Data from the first group were used to study the full GHQ-60, together with the GHQ-30 and and GHQ-12, when disembedded from the full questionnaire. In a comparison between the disembedded and the separate versions of the GHQ-30 and GHQ-12 we observed considerable variation in the cut-off scores where a certain sensitivity and specificity was attained. In ROC-analysis, the versions were not materially different in their discriminatory capacity (area under the curve). The use of different criteria to define a ‘case’ demonstrated that case severity was another source of increasing cut-off scores. Our data demonstrate that the use of disembedded or separate versions of the questionnaire, together with variation in the case criteria can be a major explanation for variation in cut-off scores that was observed in previous studies.