In March 1987, the P&O car ferry Herald of Free Enterprise capsized killing 193 passengers. Seventy-five survivors and relatives were referred by their solicitors to the authors for assessment of psychological injury.

Information was gathered retrospectively and systematically from clinical notes and legal reports.

The commonest symptoms suffered were sleep disturbance, loss of concentration and increased anger. The commonest diagnoses were post-traumatic stress disorder, other anxiety states and depression. Depressive symptoms were commoner in those who had been bereaved, anxiety symptoms were commoner in those who had not. Reluctance to discuss symptoms and to attend a psychiatric clinic was a common feature.

As expected, bereavement led to grief and depressive symptoms, whilst passengers who were not bereaved were more likely to suffer anxiety symptoms. Contrary to expectations, the degree of immersion during the accident did not influence the type or degree of symptoms. Those with worse symptoms were more likely to attend the clinic. Women showed more affective symptoms and men more substance abuse.

Comparisons were made between two groups of anorectic patients, ‘non-white’ and ‘white‘, on a variety of clinical and social characteristics.

The study is based on a 34-year long database (1960–93) associated with a national tertiary referral centre. Thirty-six non-white patients meeting DSM–III–R criteria for anorexia nervosa (AN) and five with ‘partial syndrome’ are compared with a white group comprising 944 patients with full syndrome.

The main finding is clinical similarity between the two groups, extending to social class and pathological patterns of family relationship. The non-whites are shorter in stature (P = 0.004) and report earlier menarche (P = 0.004); they are younger at presentation (P < 0.001), somewhat less emaciated, and practice veganism slightly more commonly; they less often acknowledge sensitivity to ‘fatness’ (P < 0.003). This sensitivity was exposed later whenever treatment involved substantial weight gain. The proportion of non-white cases accepted for assessment has not changed in respect of year of onset (around 6%) for the last 20 years, or year of presentation (around 6–7%) over the last 15 years. There was a tendency for non-white patients to be referred earlier in their illness.

The clinical and background profiles of non-white and white anorectics are generally similar. The numbers arising and presenting have not changed recently. Non-white patients apparently have as ready access as white patients to assessment and treatment by us.

This study examines whether cognitive dysfunction in chronic fatigue may be accounted for by depression and anxiety or is due to brain pathology evident on magnetic resonance imaging (MRI).

Twenty-six subjects with chronic fatigue, with and without coexisting depression, and 18 age-matched normal controls were recruited from primary care following a presumed viral illness six months previously. Comparison was made with 13 psychiatric controls with depressive illness on standardised cognitive tests. MRI determined the presence of cerebral white-matter lesions.

No substantial differences in performance were shown between subjects with chronic fatigue, most of whom met the criteria for chronic fatigue syndrome, and controls. Subjective cognitive dysfunction increased with psychopathology. White-matter lesions were found in a minority from all groups. Improvement in fatigue and depression coincided with improved performance on cognitive measures.

Subjective complaints of cognitive impairment are a prominent feature of chronic fatigue, but objective cognitive and MRI abnormalities are not. Such complaints probably reflect psychopathology rather than a post-viral process.

We examine the effects of cognitive-behavioural therapy (CBT) as an adjuvant to acute physical treatment and lithium maintenance therapy in reducing depression severity over a follow-up year in elderly depressed patients.

The study consists of three phases. During the acute treatment and continuation phase, 17 of 31 patients received CBT as an adjuvant to treatment as usual. During the maintenance phase of 1 year, subjects were entered into a double-blind, placebo-controlled study of low-dose lithium therapy.

Receiving adjuvant CBT significantly reduced patients' scores on the Hamilton Rating Scale for Depression during the follow-up year (repeated measures analyses of variance; P = 0.007). No significant differences were found between lithium and placebo maintenance therapy.

CBT can be adapted as an adjuvant therapy in the treatment of severely depressed elderly patients and reduces depression severity during follow-up. The prophylactic failure of long-term lithium therapy may be explained through poor compliance.

The aetiology of miscarriage is poorly understood. The aim of this study is to determine whether women admitted to hospital with miscarriage have experienced more psychosocial stress in early pregnancy than women whose pregnancies progress to labour.

Interviews of 48 case-control pairs, matched for known predictors of miscarriage risk, using the Life Events and Difficulties Schedule.

The miscarriage group were more likely to have experienced a “severe life event” in the three months preceding miscarriage (35% v. 15%; P < 005); more likely to have been experiencing a “major social difficulty” (31% v. 4%; P < 0.002); and more likely to have experienced “life events of severe short-term threat” in the fortnight immediately beforehand (31% v. 4%; P < 0.002). Fifty-four per cent of the miscarriage group had experienced at least one of the above indicators of psychosocial stress before miscarrying, compared with 15% of controls (P = 0.0001). Other factors significantly associated with miscarriage included childhood maternal separation; non-UK European origin; poorer reported relationships with partners, and fewer social contacts.

Psychosocial stress may be a factor in the aetiology of miscarriage. Alternatively, there may be a common determinant (e.g. personality, lifestyle or environmental) predisposing to both stress and miscarriage.

There are many reports of adolescents with periodic episodes each followed by complete remission within 2 weeks, but the nosology and long-term prognosis of such cases have not been elucidated.

A prospective follow-up study on 11 cases (nine girls and two boys) meeting predetermined criteria is reported.

The first several episodes were found to meet ICD–10 symptomatic criteria for recurrent depressive disorder in all cases, and, except for two cases, showed psychotic features. The episodes were linked to one phase of the menstrual cycle in only two of six girls with regular menses. There were no recurrences while on lithium in eight of nine cases. Of eight patients followed up 5–14 years after the first onset, three had been well, three had become bipolar and two were still suffering from brief depressive episodes.

Recurrent brief episodes in adolescence tend to show a near-monthly rhythm and psychotic features. Most of them appear to be manifestations of affective illness and may be treated and prevented as such.

A susceptibility locus for schizophrenia in the pseudoautosomal region has been proposed on the basis of a possible excess of sex chromosome aneuploidies among patients with schizophrenia and an increased sex concordance in affected sib pairs. Several studies investigating this hypothesis have produced conflicting evidence.

In a series of Icelandic and British families, we used lod score and sib pair linkage analyses with markers for the MIC2 and DXYS14 loci on the pseudoautosomal XY region.

Lod and sib pair linkage analysis with these markers produced strongly negative scores. Heterogeneity testing also produced negative results.

We conclude that the present study provides no support for the involvement of either the pseudoautosomal region or the nearby region of the sex chromosomes in the aetiology of schizophrenia.

Twenty-six young men admitted to an Accident and Emergency Department for observation following a minor closed head injury (post-traumatic amnesia (PTA) less than 12 hours) were investigated within 24 hours of admission (day 0) and followed up at 10 days, 6 weeks and 1 year after the trauma.

Investigations at day 0 included physical examination, completion of post-concussional symptom and stress-arousal checklists, computerised EEG (CEEG) and auditory brainstem evoked potential (BAEP) recordings. These were repeated at ten days and six weeks. At 12 months follow-up, the Present State Examination (PSE) was carried out and a further post-concussional symptom checklist completed.

Post-concussional symptomatology declined progressively from day 0 but half had residual symptoms at 1 year. Seventy-two per cent ran an acute course with recovery by 6 weeks, 8% a chronic unremitting course and 20% initially improved but had an exacerbation of symptoms between 6 weeks and 12 months. The CEEG alpha-theta ratios decreased significantly between days 0 and 10, reaching a baseline thereafter. Measures of CEEG recovery from all channels correlated with symptom counts at six weeks; the slower the recovery the greater the symptoms. A relative delay in left temporal recovery was associated with residual psychiatric morbidity (PSE ID scores) at 12 months. Prolonged central brainstem conduction times occurred in 27% of patients at day 0. These correlated positively with PTA and degree of psychiatric morbidity (PSE ID scores) at 12 months.

Symptom chronicity was accompanied by continuing brainstem dysfunction, while the degree of transient cortical dysfunction appeared to have a direct influence in the intensity of early organic symptom reaction to the trauma. Levels of perceived stress at the time of the injury, or afterwards, were not related to symptom formation.

The detailed effects of mercury poisoning on cognitive function, brain anatomy and regional brain function are largely unknown. We report the case of a 38-year-old man who was exposed to toxic levels of inorganic mercury.

Four years after exposure, the patient was assessed using magnetic resonance imaging (MRI), single-photon emission computerised tomography (SPECT) and detailed neuropsychological evaluation.

The patient developed a myriad of physical and psychiatric complaints, including stomatitis, muscle spasm, tremor, skin rash and the psychiatric syndrome known as ‘erythism’ (Mad Hatter's disease). Neuropsychological evaluation revealed marked and significant deficits of attention concentration, particularly when under time pressure. The MRI scan was unremarkable; however, SPECT revealed hypermetabolism of the posterior cingulate cortex.

Mercury poisoning appeared to result in a dysregulation of posterior cingulate cortex, which was associated with attention/concentration deficits and marked anxiety/agitation.

Stress responses of bereaved parents (mothers 194, fathers 143) who experienced infant loss were compared with parents (mothers 203, fathers 157) with a live born child.

Psychological distress using scales of anxiety, depression and alcohol use was compared at 2, 8, 15 and 30 months post-loss.

Bereaved mothers showed significantly more anxiety/depression than controls at all four interviews. For bereaved fathers, anxiety/depression differed significantly from controls only at two months. Heavy alcohol use was significantly more prevalent at 2 and 30 months. Relative risks showed significant gender differences between bereaved parents at all four interviews for anxiety/depression. When this outcome was extended to include heavy drinking in addition to anxiety/depression, these differences diminished and were significant only at 2 and 8 months.

Female responses are longer lasting and reflected by elevated levels of anxiety/depression. Male responses equally involve anxiety, depression and heavy alcohol consumption.

Pre-morbid intelligence level is routinely assessed in Alzheimer's disease using the National Adult Reading Test (NART). This practice is based on the assumption that pronunciation of irregular words remains unaffected by the disease process. Recent reports have suggested that reading ability may become compromised in moderately demented subjects.

Sixty-eight probable Alzheimer patients were classified into stages of severity (minimal, mild and moderate) using the Mini-Mental State Examination (MMSE). NART and demographic equations were used to estimate pre-morbid ability.

A significant correlation emerged between dementia severity and reading ability, NART v. MMSE scores, r = 0.46, P < 0.01. When the total sample was subdivided into moderate, mild and minimal subgroups, significant between-group differences emerged, despite the groups being well matched for age, sex, and years of full-time education. Pre-morbid IQ, as estimated by demographic regression equations, did not correlate with dementia severity.

NART performance is compromised in moderate Alzheimer disease, and the measure provides a serious underestimate of pre-morbid IQ in patients with an MMSE of 13 or less.

Animal experimental studies suggest that the amino acid valine may decrease brain serotonin (5-HT) function by inhibiting the transport of the 5-HT precursor, L-tryptophan, across the blood barrier. The aim of the present study was to assess whether valine could decrease brain 5-HT function in healthy subjects and provoke symptomatic relapse in recently remitted depressed patients taking antidepressant drug treatment.

We studied the effect of valine (30 g) on the prolactin (PRL) response to the 5-HT releasing agent, d-fenfluramine, in healthy male subjects and on the mood of 12 remitted depressed patients taking either selective serotonin re-uptake inhibitors (n = 10) or lithium and amitriptyline (n = 2).

Valine significantly lowered the PRL response to d-fenfluramine in healthy subjects. In the remitted depressives, valine caused a mild but detectable lowering of mood on a number of measures but only one patient experienced a significant relapse in mood.

Valine administration may decrease brain 5-HT neurotransmission in humans. This effect could explain the mild increase in depressive symptoms in patients taking 5-HT-potentiating drugs.

This paper describes a study of non-cognitive features of dementia in a population of 105 people over 50 years of age, with learning disability.

The study involved psychiatric assessment using the Psychiatric Assessment Schedule for Adults with a Developmental Disability (PAS-ADD), a semi-structured psychiatric interview developed specifically for people who have learning disability. Dementia was diagnosed using a combination of informant interviewing and observation of cognitive change over a three year period.

Sample members with definite dementia had higher levels of sleep difficulty, hypersomnia, irritability, inefficient thought, loss of interest and anhedonia. Discriminant function analysis showed that non-cognitive features could help discriminate between definite and probable cases.

Results support the previously reported observation for the general population that cognitive and non-cognitive features are only weakly related. The study suggests that psychiatric symptom information may be useful in screening for dementia in people with learning disability.

The study sought to quantify psychiatric morbidity among survivors of a major air crash and to identify aetiological factors linked with post-traumatic stress disorder (PTSD).

Sixty-eight of the 79 survivors (86%) were assessed at a clinical interview within one year of the disaster. The majority also completed the General Health Questionnaire, the Impact of Events Scale (IES) and the Zung Anxiety and Depression Scales.

Fifty-four of the study group (79%) met DSM–III–R criteria for a psychiatric disorder within one year of the disaster, of whom 27 (50%) had PTSD. Those who saw injured or dead people at the scene, or had sustained less severe injuries as measured by their Injury Severity Scores, or were under 35 years old, were significantly more likely to develop PTSD.

High rates of psychiatric morbidity are found in survivors of transportation disasters. Further studies are needed to identify those at most risk and to evaluate the benefits of psychological intervention.

Although it is acknowledged that obsessive-compulsive (OC) patients may be slower than healthy controls in performing neuropsychological tests, speed has usually been treated as a confounding variable. It is possible, however, that the slower performance of OC patients is itself the result of a dysfunction of specific neural circuits (in particular of fronto-subcortical systems).

A neuropsychological battery including tests sensitive to fronto- and temporo-subcortical dysfunction was administered to a group of OC patients and a group of healthy controls. Each test provided independent indices of accuracy and speed.

OC patients were significantly slower than controls only when performing tasks involving the fronto-subcortical systems, whereas they did not differ from controls with respect to accuracy indices.

It may be that neuropsychological slowness of OC patients is not merely an epiphenomenon of meticulous concern for correct test execution or intrusion of obsessive thoughts, but reflects the dysfunction of fronto-subcortical systems.

The growth hormone (GH) response to apomorphine, thought to reflect central dopaminergic receptor sensitivity, has been reported as enhanced in acute schizophrenia. We investigated this response in relation to the psychotic episodes associated with Parkinson's disease (PD).

The GH response to apomorphine was measured in three groups of patients with Parkinson's disease: those currently psychotic (n = 9), those with a past history of psychosis (n = 7) and those who had never been psychotic (n = 8).

Apomorphine-induced GH response was not related to psychosis but was unexpectedly associated with measures of depression.

Visual hallucinations were a prominent feature in the psychotic patients and the atypical nature of these psychoses might explain why we found no evidence of dopaminergic sensitivity. Serotonergic dysfunction would be in keeping with this. Dopaminergic mechanisms may contribute to the minor depressive symptomatology seen in PD.

We investigated whether reported psychiatric morbidity was increased after termination of pregnancy compared with other outcomes of an unplanned pregnancy.

This was a prospective cohort study of 13 261 women with an unplanned pregnancy. Psychiatric morbidity reported by GPs after the conclusion of the pregnancy was compared in four groups: women who had a termination of pregnancy (6410), women who did not request a termination (6151), women who were refused a termination (379), and women who changed their minds before the termination was performed (321).

Rates of total reported psychiatric disorder were no higher after termination of pregnancy than after childbirth. Women with a previous history of psychiatric illness were most at risk of disorder after the end of their pregnancy, whatever its outcome. Women without a previous history of psychosis had an apparently lower risk of psychosis after termination than postpartum (relative risk RR = 0.4, 95% confidence interval CI = 0.3–0.7), but rates of psychosis leading to hospital admission were similar. In women with no previous history of psychiatric illness, deliberate self-harm (DSH) was more common in those who had a termination (RR 1.7, 95%CI 1.1–2.6), or who were refused a termination (RR 2.9, 95%CI 1.3–6.3).

The findings on DSH are probably explicable by confounding variables, such as adverse social factors, associated both with the request for termination and with subsequent self-harm. No overall increase in reported psychiatric morbidity was found.

Hedonic tone and its absence, anhedonia, are important in psychopathological research, but instruments for their assessment are lengthy and probably culturally biased.

A new scale was constructed from the responses of a large sample of the general population to a request to list six situations which afforded pleasure. The most frequent items were reviewed and those likely to be affected by cultural setting, age, or sex were removed. A pilot study led to an abbreviated scale of 14 items, covering four domains of pleasure response. This questionnaire was subjected to psychometric evaluation in new samples from the general population and psychiatric patients.

The scale was found to have a score range that would distinguish a ‘normal’ from an ‘abnormal’ response. Validity and reliability were found to be satisfactory.

The new scale, the Snaith-Hamilton Pleasure Scale (SHAPS), is an instrument which may be recommended for psychopathological research.

Many studies have shown hospitalised mentally ill patients to have a higher mortality risk than the general population.

Data of patients with organic mental disorders of ICD–9 categories 290, 293, 294 and 310 from seven psychiatric hospitals with defined catchment areas were analysed. During an observation period of 2.5 years 1821 treatment periods in these diagnostic categories were recorded.

During hospitalisation 137 patients died from natural causes. The age- and sex-adjusted mortality rates show an increased mortality risk of 7.5 times, compared to the general population. The odds ratio of a logistic regression demonstrate the overwhelming influence of the medical diagnosis.

Medical factors, particularly pneumonias, contribute most to the excess mortality.