I am satisfied one of the results, if not the objective, of medical education is for doctors to judge their success, or the state of progress of any branch of medicine, against a pathological rather than a sociological criterion. This is the inevitable effect of the amount of time and attention given to pathology in the medical curriculum, and is further reinforced by what is asked in examinations.

Traditionally, the problem for the doctor is to try to determine the pathological lesion, using this term at best in a wide sense, and to control this if he can; and the pathological criterion of disease he has in mind is an objective physical criterion, demonstrable in life or after death.

As we all know, no pathological lesion in this traditional sense is demonstrable in a large number of patients who go, or are brought, to see doctors. All physical examinations and investigations prove negative. Medicine is therefore faced with the dilemma in these cases of either (a) coming to the conclusion that there is nothing wrong, which is often clearly untenable, or (b) of expanding its scope almost indefinitely to cover every type of maladjustment.

Individuals who speak one or more languages in addition to English comprise a small but important proportion of the general population of this country. In most clinical situations, provided verbal communication is adequate, proficiency in a second language has little medical relevance. Studies of neuropsychiatric disorder in bilinguals and polyglots have, however, demonstrated that their cerebral organization and utilization of language is different to that observed in monolinguals. Such differences have important implications in the clinical presentation and management of neuropsychiatric illness in bilingual patients.

A case of Koro is described in an elderly person with associated inguinal hernia and schizophrenia. Its aetiology and origin are traced in Chinese culture, to the Chin Dynasty. A nosology for the classification of Koro Syndrome is proposed.

Personal construct theory and repertory grid methodology were applied to a study of psychological change experienced by a sample of ten neurotic depressives and their matched controls during short-term hospitalization. All subjects completed a repertory grid and the Zung depression scale on admission to hospital. Depressives were characterized by lower self-esteem, more negative social perception and higher scores on the Zung scale. Both measures were repeated at the time of discharge from hospital. Depressives showed a significant reduction in depressive mood, more positive social perception, and a change in the construing of the self; controls showed no changes. It is argued that the use of a quantitative assessment technique reinforced by a theoretical framework results in a more refined understanding of psychological change.

‘A striking and specific loss of the messenger RNA that encodes a non-N-methyl D-aspartate (non-NMDA) glutamate receptor was found in hippocampal tissue obtained at necropsy from 6 patients with schizophrenia, when compared to specimens from 8 controls without neurological or psychiatric signs or symptoms. These findings support suggestions of aberrant glutamatergic function in schizophrenia. Evidence that gene expression may be abnormal in schizophrenia, with decreased production of an excitatory neurotransmitter receptor, may have therapeutic as well as pathogenetic implications.’

Most authorities now agree that a genetic contribution is the best established aetiological factor in manic-depressive illness (McGuffin & Katz, 1989) and schizophrenia (Gottesman & Shields, 1982). In both cases the size of the genetic contribution is substantial, as reflected in estimates of broad heritability (the proportion of total phenotypic variance accounted for by genes) of 60–80%. However, the evidence in favour of a genetic contribution from family, twin and adoption studies tells us that we are dealing with complex conditions which do not have simple Mendelian modes of transmission and in which environmental influences almost certainly play a part. The main debate about mode of transmission has centred upon whether it is entirely polygenic (i.e. dependent upon the action of many different genes, each of small effect) or whether for each of the major psychoses there is a gene of major effect.

From an original cohort of 471 admissions of male schizophrenics (260 individuals) to Leverndale Hospital, Glasgow, in the years 1967–70 inclusive, 39 patients were found who in December 1973 had become long-term residents by virtue of over three years' stay. These patients were followed up two years later, when it was found that 33 remained. Three had died and two had been discharged, though one was later admitted elsewhere. Those remaining had an average age of 45.4 years, and an average duration of illness of 15 years. The patients are considered in terms of their clinical state, management problems, accommodation, occupational grade, and social circumstances. It is concluded that they represent a hard core and that very few of them are likely to be suitable for such alternative forms of care as are at present available.

There are interesting parallels between sleep disorders and the epilepsies. Firstly, both terms refer to a group of conditions differing in cause, clinical manifestation, natural history and impact on the lives of patients and their relatives. Secondly, the investigation and management of both sets of conditions require a combined physical and psychological approach. Thirdly, neither field is usually covered systematically (if at all) in medical education, although some initiative has been taken in the USA for the introduction of these areas into the curriculum of medical schools (Medical School Curriculum Task Force, 1988). This relative neglect no doubt explains the fourth parallel – that in both sleep disorders and the epilepsies misdiagnosis or inadequate diagnosis appears to be common.

The fortuitous detection of SIADH is described in a patient receiving clomipramine therapy.

The terms positive and negative symptoms have slipped into the language of contemporary psychiatry with comparative ease. It is not uncommon for these expressions to be used with little explanation, both at meeting and in written communications, with the implicit understanding that their meaning is understood and that somehow they are of value to our knowledge of psychopathology. However, that there are no clear guide-lines at present for our use of these terms is shown from a recent survey of psychiatrists' opinions from a market research company (Martin Hamblin Research-Personal Communication). As part of a series of questions asked to many psychiatrists of differing age, geographical location, and status, they were asked about the meaning of these terms, positive and negative symptoms and the proportion of schizophrenic patients having them. Of the categories quoted by Crow (1980–81) as positive symptoms, 68% considered that delusions were positive symptoms, 63% hallucinations, and only 35% thought disorder. In contrast, 18% thought that behaviour disturbance was a positive symptom, a similar figure (15%) being given for passivity feelings. Considerable variation was noted, however, with hallucinations being considered positive by only 33% of London psychiatrists, thought disorder by only 11% of those qualified 16–25 years, and one-quarter of all registrars and psychiatrists from Midland Health Districts considered passivity feelings to fall into this category. Even greater disagreement was recorded for negative symptoms. Thus, the symptom most often associated with this category was apathy, by 52% of respondents. Only 26% considered that withdrawal was a negative symptom, the percentage data for lack of motivation and blunting of affect being 37% and 15% respectively.

The Munchausen syndrome was first described by a physician (Asher, 1951), the classical criteria being exaggerated symptoms, factitious physical signs, and the tendency to wander between hospitals (Bursten, 1965).

A case of tuberous sclerosis presenting with autistic behaviour is described. Although tuberous sclerosis is a rare cause of the autistic syndrome, it should be more strongly suspected when autistic behaviour is associated with seizures in a young child.

The monoamineoxidase inhibitor drugs are now widely used in the treatment of depression, and complications occurring in patients so treated have been reported with varying frequency. The drugs most frequently implicated have been tranylcypromine (Parnate), tranylcypromine plus trifluoperazine (Parstelin) and phenelzine (Nardil) in decreasing order of frequency. These complications may be divided into three symptom-complexes which may merge one into the other, as they have the common basis of rapid elevation of systemic blood pressure.

The beneficial clinical effects of stereotactic lesions in the ventrolateral nucleus of the thalamus in the treatment of Parkinsonism are well established. Studies of the cognitive and personality changes, however, have given contradictory results. This may be due to the great variety of tests used, to lack of control groups and to the fact that some investigators have studied only unilateral operations, whereas others have included some patients operated on bilaterally. Changes, presumably permanent, have been reported in intelligence (Jurko and Andy, 1961; Lenshoek and Manem, 1960; Niehbuhr, 1962; Jurko and Andy, 1964); concept formation (Jurko and Andy, 1961); extraversion (Fortin, 1960; Jurko and Andy, 1961); and anxiety (Niehbuhr, 1962). Transient changes have been reported in intelligence (Riklan, 1961; Levita et al., 1964); human figure drawing (Riklan et al., 1962); integrity of personality (Fortin et al., 1961; Fortin, 1960; Riklan, 1961); and somatosensory status (Proctor et al., 1963). In other studies no change was found following the operation (Bravo and Cooper, 1959; Gillingham et al., 1960; Gillingham et al., 1964; Levita and Riklan, 1965; Muller and Yasargil, 1959; Riklan, 1962).