A principal components analysis was conducted upon current symptoms and signs rated in a sample of 329 essentially unselected patients with schizophrenia. Three dimensions emerged clearly and closely resembled those previously described in smaller, more selected samples. The clearly defined psychotic dimensions were related in turn to: (i) other mental state variables; (ii) physical treatments administered; (iii) movement disorder; (iv) demographic and historical features; and (v) cognitive function. The correlates of the three dimensions were very different. The clarity of separation achieved in this investigation provides strong support for the view that the three psychotic dimensions of ‘poverty’, ‘hallucinations and delusions’ and ‘disorganization’ are valid and may well have different underlying pathophysiologies.

Basic cognitive function was assessed at initial and at 5- and 10-year follow-up assessments among 41 primarily middle-aged in-patients manifesting the severest form of schizophrenia; additionally, the presence and severity of tardive dyskinesia was evaluated on each occasion. Overall, there was a modest but significant deterioration in cognitive function over the decade, particularly among older men. Longitudinally, patients with persistent tardive (orofacial) dyskinesia continued to show poorer cognitive function than those consistently without such movement disorder, though within neither group did cognitive function change over the decade. Those patients demonstrating prospectively the emergence of orofacial dyskinesia showed a marked deterioration in their cognitive function over the same time-frame within which their movement disorder emerged, but this decline did not progress further thereafter. There appears to exist some modest, progressive deterioration in cognitive function even late in the chronic phase of severe schizophrenic illness which appears to derive primarily from patients showing de novo emergence of tardive orofacial dyskinesia.

Recent studies have found that the expressed emotion (EE) status of relatives of female schizophrenics may not possess the prognostic value found previously for male schizophrenics. In the present study, relatives of 110 recent onset schizophrenic patients were assessed using the Camberwell Family Interview (CFI-EE), the Five Minute Speech Sample Method (FMSS-EE) and a measure of Affective Style (AS) to determine whether affective attitudes or behaviours varied by patient gender. Brief Psychiatric Rating Scale (BPRS) ratings made during in-patient and outpatient periods were examined to assess patient symptomatology. No differences were found by patient gender for CFI-EE, FMSS-EE, or subcomponents of the CFI-EE measure. However, when the subcomponents on the FMSS associated with a high EE critical rating were examined, males were found to be recipients of more harsh criticism than female patients. Similarly, for the AS measure, there was a distinct subgroup of male patients who received a level of criticism not seen in female patients. When the concordance across the two EE measures was examined, relatives of males were more consistent in their affective attitudes than relatives of female patients. Analysis of the BPRS data from the in-patient to the out-patient periods suggested variations by patient gender which may explain some of the differences in relatives' affective attitudes.

Predictors of long-term (13 year) outcome of schizophrenia are reported for a representative cohort of ‘treated incidence’ patients ascertained on their first contact with Nottingham psychiatric services between 1978–80. An initial (baseline) model including previously reported predictors of 2-year outcome (age, gender, ever married, acuteness of onset) and length of untreated illness was used to predict a range of outcome measures covering the domains of disability, psychopathology, hospitalization, employment, social activity, and global outcome. This model demonstrated significant prognostic ability across all non-hospitalization outcomes under both ICD-10 and ICD-9 diagnoses of schizophrenia, but was attenuated under broad (ICD-9 and CATEGO S, P or O) and restrictive (S+) diagnostic classifications. Female gender predicted more favourable outcome under all diagnostic classifications except S+. In an extended analysis, the addition of initial 2-year course type substantially increased the prognostic ability of the model under all diagnostic classifications and enabled over 30% of the variance in global ratings of disability and symptoms to be predicted. In this extended model female gender predicted more favourable outcome over and above the effect of course type, across most domains under ICD-10, and for disability and psychopathology under other diagnostic classifications. The inclusion of measures of psychopathology at the time of first assessment, pre-morbid functioning, and duration of index admission conferred only marginal additional predictive ability for respective outcomes in the domains of psychopathology, social activity, employment and hospitalization. Hospitalization during the past year was the most difficult outcome to predict under any model suggesting that resource utilization represents the ‘administrative outcome’ of schizophrenia and serves as a poor proxy for broader concerns in the era of community care. These data demonstrate that key demographic variables and the mode of onset influence the long-term course of schizophrenia, but that early course type is a particularly strong predictor.

Facial behaviour may be an important determinant in clinical ratings of psychopathology. A standardized objective technique was used to quantify measures of facial behaviour in 21 chronic schizophrenic subjects, in comparison with control groups of depressed, demented and Parkinsonian subjects. Facial behaviours were counted and timed from video-recordings of each subjects' face during a clinical interview. Separate measurement of behaviours were obtained while subjects were speaking and silent. For most variables, the amount of facial behaviour was significantly less in schizophrenic subjects than in control groups. The groups differed significantly on a number of measures, but schizophrenics could not be reliably identified by a single facial behaviour variable. However, using a discriminant function analysis with measures for eye contact while speaking and silent, broad smiles and small smiles, discrimination between groups was good, with over 80% correctly classified as either schizophrenic, or not schizophrenic. These techniques may increase our understanding of psychopathological signs and the mechanisms that underly them.

This paper reviews the evidence for changing patterns of mental health over time in childhood and youth in Western societies. The evidence suggests that the prevalence of major depression, substance abuse and offending behaviour, as well as the incidence of suicide, is increasing in adolescent populations, particularly among males. There are also indications that problem behaviours among younger children are becoming more common. There is no evidence of a deterioration in the adjustment of the pre-school population.

This study aimed to compare the costs of treatment by community-based and hospitalbased psychiatric services. The design entailed random allocation of patients presenting with psychiatric emergencies over a subsequent 3-month period to one of two services, followed by retrospective quantification of service use and its cost for each group. One hundred patients with emergency presentations to the psychiatric service via the Accident and Emergency Department, liaison psychiatrist and approved social worker were included in the study. Their use of a range of items of service was recorded and disaggregated costings of these items of service was calculated. The use of non-psychiatric services was similar for both groups, but the use of psychiatric services differed, with the hospital group making greater use of in-patient beds and the community group employing more frequent home-based interventions. The total cost of treatment for the community group (£56000) was much lower than for the hospital group (£130000), although the median patient cost was 50% higher in the community group (£938 v. £610), and a greater proportion of the community service expenditure (10% v. 2%) was due to failed contacts. Taken together with clinical outcome, which showed no advantages for the hospital-based service over the community-based service, our findings suggest that this form of community psychiatric service is a cost-efficient alternative to hospital-based care for this group of patients.

Coping has attracted much attention in research as a possible mediator of the psychological impact of cancer. Yet, conceptual ambiguity and methodological limitations have resulted in weak and contradictory findings. A major shortcoming has been the use of designs which do not represent adequately the complexity or the diversity of demands which arise from the diagnosis and treatment of cancer. The neglect of appraisal in the assessment of the relationship between coping and mental health is of particular concern, given the role it has been found to play in the onset and maintenance of affective disorders.

In a prospective study 673 newly diagnosed cancer patients were interviewed 4 to 8 weeks and 1 year later to assess the effects of their appraisals, coping responses and resolution of any concerns on subsequent mental health. Logistic regression analyses, adjusted for possible confounding variables, were used to investigate the relationships between coping variables and affective disorders. When examined separately the degree of threat appraised, the reporting of a helpless response and perceived success of primary responses in resolving concerns all predicted subsequent affective disorder. However, in a multivariate model only appraisal and success of the response in resolving the concern were significant. No response was found to prevent affective disorders, however certain types of responses were associated with the resolution of specific concerns. The results highlight the importance of assessing the whole coping process and the need to address the complex and multifaceted characteristics of cancer demands. On the basis of our findings we describe a maladaptive cycle of coping, which we believe contributes to the later onset of affective disorders in cancer patients.

The aim of the study was to investigate the recovery and frequency of physician contact in patients with unexplained physical symptoms and to identify factors associated with persistent disorder. Of 100 consecutive patients who presented with medically unexplained symptoms to a general medical out-patient clinic, 81 participated in a follow-up study. The mean follow-up time was 15·2 months (S.D. 4·0). At follow-up, many of the patients with unexplained physical symptoms reported that they had recovered (30%) or improved (46%) with regard to their presenting symptoms. Female sex and a high number of symptoms predicted a bad outcome in terms of recovery. Persistence of symptoms was not related to the duration of the symptoms, type of presenting complaint or the presence of psychiatric disorder. Forty per cent of patients with unexplained symptoms did not visit their general practitioner on their own initiative in the year following the initial visit to the clinic. Medical care utilization appeared to be associated with female sex, age, number and duration of symptoms, fatigue and psychiatric disorder, especially somatoform disorders. However, the association of a high frequency of physican contact with female sex and psychiatric disorder was not sustained after controlling for possible confounding factors.

The term ‘pseudohallucination’ is currently used to name imaginal experiences whose relationship to one another and to hallucinations ‘proper’ remains obscure. Clinicians, including specialists in psychopathology, disagree on how pseudohallucination must be defined and on its diagnostic role. Empirical research is unlikely to help as the term does not have a stable referent. Historical and conceptual analyses, on the other hand, are of great use to show how this untidy state of affairs has obtained. This paper includes a full account of the history of pseudohallucination and concludes that: (a) the problem has resulted from the fact that the history of the word, concept (s) and putative behaviour (s) failed to ‘converge’ (i.e. there never has been a time when the three components have formed a stable complex); (b) failure to converge has been caused by the fact that the concept of pseudohallucination is parasitical upon that of hallucination, and that the latter has proved to be far more unstable than what is usually recognized; (c) hence, pseudohallucination is a vicarious construct (i.e. one created by a temporary conceptual need, and which is not associated with a biological invariant); (d) pseudohallucination is used as the ‘joker’ in a poker game (i.e. made to take diagnostic values according to clinical need) – this has led to diagnostic complacency and retarded important decisions as to the nature and definition of hallucinations; and (e) the language of current descriptive psychopathology is not fine-grained enough to generate a stable frame for pseudohallucination. This suggests that its boundaries and usage will remain fuzzy and unbridled.

A group of 72 long-term patients, who were retained in Friern Hospital until the final stage of its closure programme, underwent a comprehensive psychiatric and social assessment shortly before moving to other hospitals. These patients were then compared with the rest of the long-stay patients who were considered suitable for community placement.

The residual group consisted of younger patients with shorter duration of stay, compared with the rest of the hospital population. Although not excessively disabled functionally or physically, the residual patients were slightly more disturbed in mental state in comparison with the rest, with notably higher levels of subjective anxiety.

A range of 13 problem behaviours were designated by staff as a direct impediment to placing a patient in a community setting. Most common problem areas were aggressiveness, non-compliance with medication and inappropriate sexual behaviour. Fourteen per cent of the residual group had none of these special problems. Some other patients have remained in hospital solely because they refused to leave.

It is argued that a distinction should be made between the residual patients who were actually transferred to other hospitals, and a core group of extremely disturbed patients for whom further hospitalization is likely to be the only alternative.

We examined the reliability of the OPCRIT system from ratings produced by 30 USA and European clinicians involved in molecular genetic research. The OPCRIT system facilitates a polydiagnostic approach to research on severe psychiatric disorders. OPCRIT comprises a 90-item checklist of signs and symptoms and a suite of computer programs, which together generate diagnoses according to the operational criteria of 12 major classificatory systems (e.g. DSM-III, DSM-III-R, RDC, ICD-10). Thirty summaries of actual cases ranging in signs and symptoms, taken from independent sources, were rated by participants from research centres across Europe and the USA using the OPCRIT system. Each rating was then compared to a standard rating using a kappa statistic. Good levels of reliability were observed within all classifications (e.g. DSM-III-R, kappa = 0·73, RDC, kappa = 0·71; ICD-10, kappa = 0·70) and a similar pattern of ratings was found in both the European and USA samples. We conclude that the OPCRIT system, is both flexible and practicable retaining the ‘top-down’ advantage of operational definitions as well as the ‘bottom-up’ potential offered by well defined signs, symptoms and other component items. Within the limitations of an international, multicentre design this study shows that the OPCRIT system affords good reliability with raters from a variety of geographical and theoretical backgrounds.

Dementia scores in the population of very old subjects (70 to > 95) do not demonstrate an obviously bimodal distribution. Heterogeneity analysis shows that the assumption of two distributions explains the data significantly better than a one-distribution model. The first distribution component can be regarded as representing the normal range of scores and the second the pathological range. An additional finding shows the normal range distribution shifting to the pathological range with increasing age.

Thirty-eight subjects identified in a large community survey were found to attribute their fatigue to ‘myalgic encephalomyelitis’ (ME). They were matched randomly to two other groups of subjects who attributed their fatigue to either psychological or social factors. All three groups were followed up 18 months later and were asked to complete a series of questionnaires that examined fatigue, psychological distress, number of symptoms, attributional style and levels of disability. At onset the ‘ME’ group were found to be more fatigued, had been tired for longer but were less psychologically distressed than the other two groups. At follow-up the ‘ME’ group were more handicapped in relation to home, work, social and private leisure activities, even when controlling for both duration of fatigue and fatigue at time 1, but were less psychologically distressed. The relationships between psychological distress, specific illness attributions, attributional style and their effect on the experience of illness and its prognosis are discussed. Attributing fatigue to social reasons appears to be most protective.

There is controversy over how best to classify eating disorders in which there is recurrent binge eating. Many patients with recurrent binge eating do not meet diagnostic criteria for either of the two established eating disorders, anorexia nervosa or bulimia nervosa. The present study was designed to derive an empirically based, and clinically meaningful, diagnostic scheme by identifying subgroups from among those with recurrent binge eating, testing the validity of these subgroups and comparing their predictive validity with that of the DSM-IV scheme.

A general population sample of 250 young women with recurrent binge eating was recruited using a two-stage design. Four subgroups among the sample were identified using a Ward's cluster analysis. The first subgroup had either objective or subjective bulimic episodes and vomiting or laxative misuse; the second had objective bulimic episodes and low levels of vomiting or laxative misuse; the third had subjective bulimic episodes and low levels of vomiting or laxative misuse; and the fourth was heterogeneous in character. This cluster solution was robust to replication. It had good descriptive and predictive validity and partial construct validity.

The results support the concept of bulimia nervosa and its division into purging and non-purging subtypes. They also suggest a possible new binge eating syndrome. Binge eating disorder, listed as an example of Eating Disorder Not Otherwise Specified within DSM-IV, did not emerge from the cluster analysis.

Until recently, life events were considered as chance occurrences. However, there is now increasing evidence that reported life events, at least in adult life are not random. Life events not only tend to cluster in families but also appear to be influenced by genetic factors. The aim of this study was to investigate whether genetic factors also influence reported life events in childhood using a systematically ascertained sample of 376 twin pairs aged 8 to 17. Overall, reported life events in this younger population were found to be heritable. However, the degree of genetic and environmental influence appeared to vary across the sexes, at least for parent-rated life events and according to whether life events were rated by the parents or the children themselves. Genetic influences appeared to be more important for self reports, suggesting that individual differences in cognition play a role in reporting life events.

High expressed emotion in relatives has been shown to predict a poorer outcome in a range of disorders and cultures. However, variation in predictive power is considerable, and this could partly be due to low inter-rater reliability. Sixty-nine relatives of 47 acutely admitted schizophrenic patients were interviewed using the Camberwell Family Interview. Audiotapes were assessed by pairs of raters drawn from a group of seven approved raters. Inter-rater reliability was good for criticism, hostility, emotional over-involvement (as a six level scale) and expressed emotion index (EOI cut-off score 2–3); and it was fair, but unsatisfactory, for emotional over-involvement (binary scales), warmth, positive remarks and expressed emotion (EOI cut-off score 3–4). These findings suggest that the warmth scale and the dichotomized versions of the EOI scale should be used with caution. The influence of warmth on the outcome in schizophrenia may have been underestimated because of low reliability.

Survivors from a nationally representative sample of elderly people originally screened in 1985 were reassessed in 1989 and again in 1993. On each occasion respondents were rated as cognitively impaired, borderline impaired or unimpaired (using a brief information/orientation scale), with the validity of these ratings assessed in subsequent clinical interviews. Where follow-up screening was not possible, information was derived from death certificates and hospital case-notes. Over 8 years (1985–93) the overall incidence rate per person–year at risk was 1·58%, giving age-specific rates of 0·72, 1·32, 1·63, 3·46, 2·55 and 1·41% for the age groups 65–69, 70–74, 75–79, 80–84, 85–89 and ≥ 90 respectively. Of 43 individuals classified at screening as borderline impaired in 1985 and 1989, 19 were diagnosed as demented at clinical interviews conducted within 16 weeks of screening. Four-year follow-ups among the remaining 24 showed that 15 had died, while 6 showed a worsened cognitive status. Controlling for both age and sex, aggregated 4-year mortality was significantly higher among those defined at screening in 1985 and 1989 as either impaired or borderline, when compared with the unimpaired.

The reliability and criterion validity of Russian versions of three psychiatric screening questionnaires (the General Health Questionnaire, 12-item version; the Goldberg scales for anxiety and depression; and, the Bradford Somatic Inventory) were assessed in the Gomel region (Belarus), one of the most severely contaminated areas that resulted from the nuclear power plant explosion at Chernobyl in 1986. All instruments were found to have good internal reliability indices. Retest reliability of the GHQ, not tested for in the other instruments, was modest. Criterion validity, using a semi-structured interview on the basis of the Munich Diagnostic Checklist for DSM-III-R as external criterion, was good for the Goldberg scales, but modest for the two other instruments.