A randomised treatment design for 49 chronically obsessive–compulsive ritualising patients was devised and three controlled comparisons were made. 1. During 7 weeks of self-exposure instructions, clomipramine treatment improved some measures of rituals and depression significantly more than did placebo medication; this effect was transient and disappeared as drug treatment and exposure were continued for a further 15 weeks. 2. During 11–16 weeks of clomipramine treatment, self-exposure instructions yielded highly significantly more patient improvement than did anti-exposure instructions on nearly all measures of rituals and some of social adjustment. 3. Adding therapist-aided exposure (1.3 hours) to self-exposure instructions (3 hours) after 8 weeks had a barely significant transient effect of dubious clinical value, which was lost by the end of exposure (at week 23) and during follow-up assessments to week 52. We conclude that of the three therapeutic factors tested, self-exposure was the most potent; clomipramine played a limited adjuvant role, and therapist-aided exposure a marginal one.

Therapeutic factors operative in in-patient and out-patient therapy groups were compared. These settings differ greatly, both in terms of the patient population they serve and the overall systems within which they operate. The study revealed significant differences between the therapeutic factors operative in these two settings, and suggested that clinicians should modify their techniques for running psychotherapy groups across settings, to take account of these findings.

There is considerable disagreement on the classification of Asperger's syndrome and its relationship to autism. Unlike autism, Asperger's is not usually recognised before 30 months of age, and speech delay is not typical. However, if a child exhibits all the symptoms of autism apart from these two features, are these sufficient grounds for withholding a diagnosis of autism? This paper describes four boys and their father who, by presenting at various points on the autistic/Asperger spectrum, embody this dilemma for the diagnostician. The implications for research and clinical practice are discussed.

Beta-adrenergic-mediated cyclic AMP accumulation was reduced in lymphocytes obtained from depressed patients from that observed in an age- and sex-matched group of control subjects. Among the depressed patients, those not responding to treatment showed significantly lower pretreatment responses to isoproterenol compared with patients who exhibited significant clinical improvement during antidepressant treatment. Late-night (terminal) insomnia was significantly associated with the blunted response to beta-adrenergic stimulation. In depressed patients with the lowest isoproterenol response, the effect of forskolin (which acts distal to the receptor and directly stimulates the catalytic subunit) on cyclic AMP accumulation was also significantly decreased. This suggests that post-receptor modulations of signal amplification also play a role in the reduced response to beta-adrenergic stimulation in depression.

Eighty-four chronic phobic patients were randomly assigned to self-exposure in vivo instructed by either a psychiatrist, a computer or a book; mean therapy time per patient was respectively 3.1, 3.2 and 0 hours. Seventy-one patients completed treatment. All three groups improved substantially and similarly to 6 months follow-up, with no significant difference between them; self-exposure treatment was effective even without therapist contact. Among the three groups, initial expectation of help and positive attitude to the psychiatrist were equally high and related to subsequent rating of help received. All three groups rated the psychiatrist as more tolerant, reliable, and understanding than the computer or book, but these attitudes did not relate to outcome, were initially similar among all three groups, and changed minimally at 6 months follow-up.

This paper describes the demographic and clinical features of five non-white, normal body weight bulimics, all from the same catchment area. Comparisons with white bulimic referrals from the same area showed clinical similarities, but the non-white bulimics gave an account of gross emotional deprivation: all came from broken homes; four had been separated for long periods from their mothers; two had been subjected to incestuous abuse; and four had been cared for by white women. Response to treatment was poor. The ratio of non-white referral to white was at most one tenth of the ratio of non-white to white women in the catchment area.

Ninety patients with the Gilles de la Tourette syndrome were studied. A high incidence of depression, hostility, and obsessionality was found. Depression was not related to administered medication, while aggression, hostility, and obsessionality were significantly associated with some important features of the syndrome, namely copro- and echo-phenomena and a family history of tics or the Gilles de la Tourette syndrome. Links between psychopathology and neurological and electroencephalographic abnormalities were minimal.

Supervision of lithium treatment among three groups of patients treated in different settings – at a lithium clinic, as hospital out-patients, and by a GP – was studied. The lithium clinic maintained lower levels and checked these more frequently. Elevated lithium levels were most frequent in the GP-supervised group, which also included the 13 patients with the most impaired glomerular filtration. In hospital settings GFR-impaired patients received a lower daily dose of lithium; in general practice, affected patients had a higher mean serum lithium level and were more frequently prescribed lithium once daily. We conclude that patients with glomerular impairment who require lithium should be supervised by a specialist, or at least prescribed lithium in divided daily doses.

Results from a 15–20-year follow-up study of 35 7–12–year-old children with school refusal and 35 age- and sex-matched comparison children are reported. The school refusal cases had applied for out-patient adult psychiatric care more often than comparison children. Also they had fewer children of their own. In respect of overall social adjustment and severe psychiatric disorders requiring in-patient treatment, there were no important differences.

Rhinoplasty patients and matched elective-surgery controls completed the Facial Appearance Sorting Test, the General Health Questionnaire, a Repertory Grid and the Masculinity/Femininity Scale. Rhinoplasty applicants perceived appearance similarly to, and downrated their own appearance to the same extent as, controls. Impaired appearance and psychiatric symptoms are integral parts of the ‘rhinoplasty applicant syndrome’, but the degree to which they occur is not positively correlated. Interviews and tests were repeated 6 months after operation, when marked improvement in appearance was reported by the rhinoplasty patients, associated with the reduction of psychiatric-symptom scores. Control subjects showed no change.

Earlier, we reported that true hallucinations may present as a conversion symptom. We here reiterate this and suggest that cultural sanction may be one factor that can lead to hallucinations being classified as true in non-psychotic psychiatric states.

We compared the general distribution of diagnoses in 20 895 patients at the Maudsley Hospital with that of 504 patients born twins, including 117 twins where the co-twin had died before the age of 15. Significant differences in diagnostic distribution were found in the co-twin-dead compared with the co-twin-alive group; the former received diagnoses of schizophrenia, personality disorder, or substance abuse more often than the latter. While there were no overall differences between twins and non-twins, there were relatively more twins in the above three diagnostic groups. We suggest that the factors leading to the death of one twin are implicated in the later psychiatric morbidity of the survivor.

A rare opportunity to study deprivation and criminality across generations arose from the follow-up of the families who participated in the Newcastle Thousand Family Survey. The data on these families had been preserved and it was possible, using criminal records, to examine longitudinally whether children who grew up in ‘deprived’ rather than ‘non-deprived’ families were more at risk of offending during later childhood and beyond. The results of this study suggest that this is indeed so.

Illness phobia and hypochondriasis can be associated with severe disability and requests for reassurance. Exposure to illness cues and prevention of reassurance produced rapid improvement in both health anxiety and in social functioning. Our uncontrolled results warrant a controlled prospective trial with follow-up.

In the present study, two raters, a psychologist and a nurse, each made five independent ratings of 30 different video-recorded patient-examinations. Having thus excluded patient fluctuation, individual-rater consistency and between-rater agreement over the 6 weeks of the study are examined. While between-rater agreement was apparently being maintained, mean AIMS scores steadily increased. In the hands of these raters, AIMS items 2 and 4 emerged as very reliable, while items 1, 6, and 7 showed high variability. Some patients appeared to be hard to rate. Differences between the study raters and the author JB highlight the issue: how reproducible is an AIMS rating?

Thirteen black patients were referred over 5 years to the eating-disorders unit at the Maudsley Hospital. Two suffered from anorexia nervosa and 11 from bulimia nervosa. This group was compared with a matched white control group from the total clinic population during that period. The Blacks had more commonly experienced parental divorce or separation, and premorbid obesity, and were more likely to be referred by the emergency services. Their lower educational achievements, and fathers of lower socio-economic status, reflected variation among the general black and white populations in this country, but their educational levels and social statuses were higher than in the general black population.

Five chronically disabled dysmorphophobic patients with disturbed bodily perception improved with systematic exposure to avoided situations that evoked dysmorphophobic discomfort, and refraining from behaviours which reduced that discomfort. As avoidance and anxiety improved with exposure, so did associated bodily delusions. Four of the patients had additional problems, for which three cases had drugs at some time. The encouraging pilot results warrant a controlled study of exposure for dysmorphophobic avoidance and anxiety.

Among the mentally ill, those with well-developed delusions are more likely to commit violent crimes against persons than those with chronic, undifferentiated psychoses. Reports of violence associated with delusional misidentification are reviewed and four patients described who were either perpetrators or victims of assaults as a consequence of the syndromes of Frégoli, lntermetamorphosis, Subjective Doubles and Capgras. The cases illustrate the multiplicity of factors which have to be taken into consideration in order to predict whether an individual will act in a violent manner on these delusions.