There are strong moral overtones associated with eating behaviour and with this goes the contemporary assumption that anyone can choose their shape and weight if only they try hard enough. Arguably, it is this false gospel that has led to the recent increase in bulimia nervosa (BN). Women struggling to attain an idealized shape have drastically to subvert their bodies' homeostatic mechanisms: the battle is rarely won and eventually, the victim turns for help to escape the scars and trauma. On the other hand, the shimmering vision of anorexia nervosa (AN) appears to support the myth.

Although claims that the eating disorders have reached epidemic proportions in the West are clearly exaggerated (Fairburn & Beglin, 1990), anorexia and bulimia nervosa are among the commonest psychiatric disorders to affect young women in Western societies (Whitaker et al. 1990; Kendler et al. 1991). Because of the high morbidity and mortality associated with these disorders (for reviews see Hsu, 1990, 1991), there is no cause for complacency, and continued research into their pathogenesis, treatment and outcome is needed.

Background. Life events may play a role in precipitating the onset of bulimia nervosa. This study aimed to determine the rates of occurrence of certain life events during the year before onset of disordered eating in women with bulimia nervosa, and to compare them with the rates among age-matched normal controls.

Methods. The subjects were 102 women with bulimia nervosa and 204 women without an eating disorder, all recruited from the same community sample of young adult women. Interview measures were used for diagnosis and for assessment of life events.

Results. The bulimia nervosa cases reported more life events during the year before onset of disordered eating than were reported by controls of the same age. Events involving disruption of family or social relationships, or a threat to physical safety, were especially common among the bulimia nervosa cases.

Conclusions. These findings suggest that certain life events may play a role in precipitating the onset of bulimia nervosa. The study was retrospective in design. Prospective studies of the role of life events would be valuable, but difficult to perform.

Background. The aims of this study were to explore the role of life events and difficulties in the onset of anorexia nervosa and bulimia nervosa and to find out whether events and difficulties with a specific meaning, i.e. those of a certain sexual nature, are important in the onset of anorexia nervosa.

Methods. Seventy-two patients with anorexia nervosa (AN) and 29 with bulimia nervosa (BN) were assessed with the life events and difficulties schedule (Brown & Harris, 1978), the year before onset was studied. A new dimension to measure specific meaning of life events and difficulties called ‘pudicity’ was developed. Subjects from two community cohorts were used as comparison groups (Brown & Harris, 1978; Andrews et al. 1990).

Results. Anorexic patients, bulimic patients and community controls did not differ in the proportion of patients with at least one severe event; however, significantly more AN and BN patients than community controls had experienced a major difficulty. Sixty-seven per cent of anorexics and 76% of bulimia nervosa patients had either a severe event or a marked difficulty during the year before onset. In AN and BN the most common serious life stresses before onset concerned close relationships with family and friends with BN patients being significantly more often than AN patients directly involved in the problem (interpersonal events). Patients with anorexia nervosa had significantly more pudicity events before onset than BN patients or community controls.

Conclusion. While serious life stresses commonly precede the onset of anorexia nervosa and bulimia nervosa, problems with sexuality seem to be specific in triggering the onset of anorexia nervosa.

Background. Previous studies have examined childhood factors that appear to increase the risk of developing an eating disorder (e.g. sexual abuse and parental care). Studies have not yet examined whether the way in which women cope with these adversities in childhood influences the risk.

Method. Using a semi-structured interview, childhood helplessness and mastery were measured (based on behavioural indices) in women with and without a history of eating disorders.

Results. There was a higher rate of childhood helplessness and a lower rate of childhood mastery in women with eating disorders compared to those without. Furthermore, this difference did not appear to be a result of current psychiatric state.

Conclusion. It is concluded that it is not simply the presence of adversity in childhood which is of aetiological importance in the development of eating disorders but the way in which these are negotiated.

Background. Although overwhelming evidence suggests that genetic and environmental risk factors both contribute to the aetiology of major depression (MD), we know little of how these two risk factor domains inter-relate. In particular, can the genetic liability to MD increase the risk of experiencing stressful life events (SLEs)?

Methods. Using discrete time survival analysis in a population-based sample of 2164 female twins, we examined whether the risks for nine personal and three aggregate network SLEs were predicted by the level of genetic liability to MD, indexed by the lifetime history of MD in monozygotic and dizygotic co-twins.

Results. Genetic liability to MD was associated with a significantly increased risk for six personal SLEs (assault, serious marital problems, divorce/breakup, job loss, serious illness and major financial problems) and one network SLE (trouble getting along with relatives/friends). This effect was not due to SLEs occurring during depressive episodes. Similar results were found using structural equation twin modelling. In contrast to the pattern observed with MD, the genetic liability to alcoholism impacted on the risk for being robbed and having trouble with the law.

Conclusion. In women, genetic risk factors for MD increase the probability of experiencing SLEs in the interpersonal and occupational/financial domains. Genes can probably impact on the risk for psychiatric illness by causing individuals to select themselves into high risk environments.

Background. To understand the relationship between parenting and psychopathology in offspring, it is critical to clarify the determinants of parenting behaviour itself.

Methods. A 16-item version of the Parental Bonding Instrument (PBI) was administered to parents of epidemiologically sampled adult female–female twin pairs, who reported on the parenting they provided to their twins, and to the twins themselves who reported on the parenting they and their co-twin had received (N=828 twin families). Using a mixed-model regression, we examined the impact on parenting, as retrospectively reported by parents and twins, of six variable domains: demographic factors, family characteristics, parental symptoms and personality, parental psychopathology, child vulnerability and childhood temperament.

Results. The PBI yielded three factors: warmth (W), protectiveness (P) and authoritarianism (A). W was most strongly predicted by parental personality and psychopathology, parental marital quality, and child temperament. P and A were both most strongly predicted by parental educational level and religious fundamentalism. In addition, P was predicted by neurotic/anxious traits in both parent and child. For a number of variables that predicted W, the strength of the association was stronger when twins were reporting than when parents were reporting.

Conclusions. Parenting is a complex, multi-determined set of behaviours that is influenced by parental personality, psychopathology, values and marital quality and by a range of child characteristics. W appears to be strongly influenced by parental and childhood temperament and vulnerability to psychiatric illness while P and A are more strongly influenced by ‘sociological’ factors such as religious affiliation and educational status.

Background. Experimentally induced depressed mood is a suggested model for retarded depression. We describe the neural response associated with induced mood and the locus of the interaction between systems mediating mood and cognitive function.

Methods. Normal subjects performed a verbal fluency task during induced elated and depressed mood states. Regional cerebral blood flow (rCBF) was measured as an index of neural activity using Positron Emission Tomography (PET).

Results. In both elated and depressed mood state rCBF was increased in lateral orbitofrontal cortex, rCBF was also increased in the midbrain in elated mood. In the depressed condition rCBF was decreased in rostral medial prefrontal cortex. Verbal fluency produced an expected increase of rCBF in left dorsolateral prefrontal, inferior frontal and premotor cortex, anterior cingulate and insula cortex bilaterally, the left supramarginal gyrus posteriorly and the thalamus. Activation in the verbal fluency task was attenuated throughout the left prefrontal, premotor and cingulate cortex and thalamus in both elated and depressed mood conditions. An attenuation of anterior cingulate activation was specific to depressed mood.

Conclusions. Alteration of mood is associated with activation of orbitofrontal cortex which may be critical to the experience of emotion. The mood induced modulation of verbal fluency induced activations is consistent with resting state findings of decreased function in these regions in depressed patients. The present data suggest that resting state rCBF profile may represent the modulation of spontaneous activity in this network by a core system that is dysfunctional in depression.

Background. The study attempts to recruit well known ‘cognitive’ event related potential measures as an objective estimate of cognitive and specific memory impairment in schizophrenia.

Methods. We examined 19 schizophrenic patients and 28 healthy controls using an auditory discrimination task to elicit event related potentials, and a number of neuropsychological tests, including tests of general intellectual ability, putative frontal lobe function and verbal memory.

Results. The late positive deflection presumed to be associated with stimulus evaluation (P300) was of lower amplitude and had a longer latency in the patients compared with controls of similar age and sex. We found correlations between P300 amplitude and latency, and neuropsychological performance scores in patients. There were correlations between decreased P300 amplitude and lower IQ and poorer memory performance, in particular, abnormal semantic clustering, discriminability and intrusion errors. Increased P300 latency was correlated with lower pre-morbid IQ, poorer total memory scores and serial clustering, but paradoxically less relative retrieval deficit and fewer intrusion errors.

Conclusions. These findings suggest that abnormal P300 is generally more likely to occur in patients with memory impairment.

Background. The study examines the effect of an auditory discrimination task on regional brain perfusion in schizophrenic patients.

Methods. Twenty patients were examined with single photon emission tomography (SPET), both resting and performing an auditory two-tone ‘oddball’ discrimination task. Statistical parametric mapping (SPM'95) was used to identify local activation effects and correlations between event related potential measures and regional perfusion.

Results. Compared with rest, patients activated left superior temporal gyrus during the task, together with right caudate. There was a (negative) correlation between P300-amplitude and perfusion during the activation procedure in both caudate nuclei and in the left lingual gyrus. No correlations were observed with P300-latency. Compared with healthy volunteers examined in earlier studies, our patients showed no frontal activation. This might be due to slightly different task demands in this study, but more likely to activation-hypofrontality in schizophrenic patients compared with controls.

Conclusion. Auditory discrimination tasks can be used in schizophrenic patients to control their ‘mental set’ during brain perfusion studies with SPET. This approach can yield information about specific brain mechanisms associated with such tasks, and may make comparison with healthy volunteers easier.

Background. This study investigated factors contributing to suspected offending behaviour by adults with a history of learning disabilities taken into custody at a city police station.

Methods. Adults charged with offences, and/or leaving custody, during a defined period, were identified as having a possible learning disability using a four-item questionnaire (Lyall et al. 1995a). A comparison group, of similar age, sex and IQ, was identified from a database of young people with learning difficulties. Information was obtained on interview about each individual's medical, psychiatric, social and family histories and psychological assessments were undertaken.

Results. In contrast to the comparison group, those in the ‘offending’ group were more likely to have a history of the following: losing contact with their father, forensic contact in one or more family members, past homelessness, illicit drug use, experiencing an excess of recent life events, self-reported behavioural problems at school, truancy, childhood police contact and contact with probation services. All had histories of repeated offending. There was also an increased rate of drug/alcohol dependence. Only two subjects in the study group had a full-scale IQ below 70.

Conclusions. These differences would suggest that the presence of childhood behavioural problems, offending behaviour by other family members, family separation and other social disruption and the development of drug and alcohol related problems are potentially the most important factors in trying to understand why one group engaged in criminal behaviour. The offending group had many characteristics in common with general offending populations.

Background. For many years, it has been known that dementia can occur in people with learning disabilities, but there have been few research studies. Studies that do quote rates for dementia show these to be high, but this important fact has received remarkably little attention.

Method. Comprehensive psychiatric and medical assessments were undertaken on the whole population (ascertained as far as is possible) of people with learning disabilities aged 65 years and over living in Leicestershire, UK (N=134), in order to ascertain rates of DCR defined dementia, and associated factors.

Results. Dementia was diagnosed in 21·6%, against an expected prevalence of 5·7%, for a group with this age structure. The rate of dementia increased in successive age cohorts: 15·6% aged 65–74 years; 23·5% aged 65–84 years; and 70·0% aged 85–94 years. People with dementia tended to be older, female, with more poorly controlled epilepsy, a larger number of additional physical disorders, less likely to be smokers and had lower adaptive behaviour scores than did the elderly people without dementia. They were more likely to live in health service accommodation.

Conclusions. Dementia occurs at a much higher rate among elderly people with learning disabilities than it does among the general population; this is independent of the association between dementia and Down's syndrome. Whether this relates aetiologically to genetics, lack of brain ‘reserve’ or history of brain damage is yet to be determined.

Background. Assess the latent structure of the DSM-III somatization symptoms and the stability of symptom patterns over time.

Methods. Cross-sectional and longitudinal covariation of symptoms of somatization disorder were investigated using structural equation models in a population-based data set from the Epidemiologic Catchment Area study.

Results. Medically unexplained physical complaints were discovered to cluster into three separate factors, consistent with the DSM-IV definition of somatization disorder, but one dominant general factor was defined, consistent with the DSM-III conceptualization. Individual symptom prevalences and factor structures were different for men and women. The factor structures remained stable at 1 year follow-up. Variations in the threshold of number of somatization symptoms required for diagnosis affected prevalence, sex ratio and temporal stability of the diagnosis.

Conclusions. These population-based results support dimensional models of somatization. Implications for changing the threshold of the categorical diagnosis of somatization disorder and providing better care for these patients are given.

Background. Increasing attention has been directed in recent years to the detection and treatment of psychiatric co-morbidity among depressed individuals. The overlap of social phobia (SP) and avoidant personality disorder (APD) has been well recognized and a relationship between these disorders and depression has been suggested.

Methods. The pattern and clinical implications of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed by DSM-III-R criteria, were studied among 243 out-patients presenting with depression.

Results. Overall, 26·7% of adults in our sample with MDD met criteria for SP and 28·4% for APD. Almost two-thirds of depressed adults meeting criteria for social phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed adults who met criteria for both SP+APD exhibited a significantly higher proportion of atypical depression (54·8%) compared with those with neither SP nor APD (31·1%). Among depressed patients, the co-occurrence of SP with APD was also associated with an earlier age of onset of MDD, a greater number of co-morbid Axis I diagnoses, and greater impairment of social adjustment and assertiveness.

Conclusions. Results confirm the overlap of SP and APD in a depressed population and the high prevalence of these disorders in MDD. They suggest that depressed individuals with both SP and APD but not SP alone are at particularly high risk for atypical depression and for social dysfunction in excess of that caused by a current major depression.

Background. Cognitive neuropsychological theories hypothesize a role for frontal lobe executive deficits in the aetiology of schizophrenic symptoms. The study examined the performance of a schizophrenic group on the Behavioural Assessment of the Dysexecutive Syndrome (BADS; Wilson et al. 1996), a test battery which assesses the ‘everyday’ difficulties associated with the dysexecutive syndrome. Performance of the schizophrenics was contrasted with that of brain injured and healthy volunteer groups.

Methods. Matched groups of 31 schizophrenic patients, 35 patients with brain injuries and 26 healthy volunteers were administered the BADS. Patients were also given tests of general intelligence and memory. Patients and their relatives/carers also completed a questionnaire rating day-to-day failures of executive functioning.

Results. Schizophrenic and brain-injured patients showed impairment on the BADS, compared to healthy controls. There were no significant differences between the two patient groups. Significant impairment was found in a subgroup of 16 schizophrenics who showed otherwise intact general intellectual functioning, suggesting the existence of a specific executive deficit. Among the schizophrenic patient group there was evidence of a dissociation between executive and memory impairments. A significant correlation existed between performance on the BADS and relatives ratings of executive problems for the brain injured group, but not for the schizophrenic group.

Conclusions. The BADS is a useful tool for identifying executive deficits in people with a diagnosis of schizophrenia, especially those who are otherwise generally intellectually intact. This is particularly important in the context of rehabilitation and community transition programmes.

Background. Past research and instrument development in caregiving have focused on specific aspects of caregiving or specific disability groups. This paper reports the scale characteristics of a new generic instrument developed to assess the experience of caregiving, and the social and emotional well-being of caregivers and a comparison group of ‘non-caregivers’.

Methods. Using computer-assisted telephone technology, a random survey of 26000 households was conducted in Victoria, Australia to identify and interview 976 caregivers of people who were aged or had a long-term illness or disability of any kind, and 219 non-caregivers. Both groups were re-interviewed after 15 months. Scales administered on each occasion to caregivers and non-caregivers included life satisfaction, positive and negative affect, social support and overload; and to caregivers, caring role satisfaction, resentment and anger, and, in relation to the care recipient, measures of help provided and needed, severity of disability and behaviour problems.

Results. On each occasion and with each sample all scales demonstrated a satisfactory reliability. With a subsample of caregiver–care–recipient dyads (N = 67), caregiver reports of severity of disability, level of helped needed and provided were validated externally by clinician assessments.

Conclusions. A comprehensive instrument to assess the experience of caregiving was developed. It is relevant to a broad range of ages, levels and types of disability and care provided; and, in assessing health and well-being, to both caregivers and non-caregivers. Scales, including both positive and negative dimensions, have demonstrated good internal consistency on two occasions. The instrument is potentially useful in a range of research and practical settings.

Background. It has been well established in the literature that a strong genetic component exists for schizophrenia. Available data are compatible with the hypothesis that for most cases of schizophrenia, the genetic component consists of multiple genes acting in an additive manner with the genotype for schizophrenia being present when the number of genes is greater than a threshold number. Twin studies suggest that the genotype for schizophrenia is unexpressed in some individuals who carry it. This phenomenon of reduced penetrance has led to a diversity of hypotheses concerning the aetiology of schizophrenia. Based on a review of the literature a neuro-developmental model is proposed for schizophrenia that involves the actions of the schizophrenia genotype, canalization and stochastic events.

Conclusions. The schizophrenia genotype is programmed to disrupt the migration of neuronal cells in the developing cortex during the second trimester, resulting in impaired embryogenesis. The presence of a specific lesion is the reason for the onset of schizophrenia later in life. The genotype for schizophrenia often remains unexpressed, or demonstrates variable expressivity, because of the actions of canalization and stochastic events that may allow migrating neuronal cells to reach or approach the target data. Stochastic events also influence whether canalization will be successful, therefore, chance plays a major role under normal conditions in determining whether the schizophrenia genotype will be expressed. Certain environmental factors acting during early development, such as high temperatures resulting from maternal illness, may increase the penetrance of the schizophrenia genotype.

Background. In order to elucidate further the cognitive processes underlying auditory hallucinations, an experiment investigating delayed and immediate source monitoring for positive, negative and neutral verbal material was conducted with schizophrenic patients.

Methods. Patients experiencing auditory hallucinations, patients not experiencing auditory hallucinations and normal subjects participated in a word association task, rating their responses for how much a self-generated thought was their own, how controllable and involuntary it was and their confidence in these ratings. A delayed source monitoring test in which subjects had to recall the source (self or experimenter) of the words from the association task was also administered.

Results. Hallucinators showed a greater bias towards external attribution of their thoughts compared with both control groups for immediate attributions of source, but not for delayed attributions. Hallucinators showed a bias towards external attribution of emotional material for immediate source monitoring and all subjects showed a bias towards misattribution of positive material to an external source and negative material to an internal source for the delayed source monitoring task.

Conclusions. These findings appear to be most consistent with theories proposing that hallucinations result from an external attributional bias for internal events. The implications of these results for research and practice are also discussed.

Background. Altering the balance of provision between hospital and community care is a key and often contentious component of mental health care policy in many countries. Implementation of this policy in the UK has been slowed by the apparent shortage of suitable community accommodation for people with long-term needs for care and support. Among the consequences could be the silting up of hospital beds by people who could be supported more appropriately elsewhere, in turn denying in-patient treatment to people with acute psychiatric problems and unnecessarily pushing up health service expenditure.

Methods. Using data collected in a survey of hospital and residential accommodation services and their residents in eight areas of England and Wales, the cost components of today's balance of care were explored. Comprehensive costs were calculated and their associations with resident characteristics examined using multiple regression analyses.

Results. On a like-with-like basis, the costs of hospital in-patient treatment for inappropriately placed patients greatly exceeded the costs of community-based care.

Conclusion. Further reduction of hospital beds, however, is not the panacea for an appropriate balance of mental health care, given the unknown but potentially considerable extent of unmet demand, as well as the impact of previous in-patient bed reductions apparent in the services surveyed. Rather, service providers and purchasers should focus on developing community-based care (including increased provision of 24-hour nursed beds) by ensuring that resources released through earlier closure programmes have been redeployed for their intended use and by accessing additional pump-priming or bridging resources.

Background. Prior evidence on the relationship between hostility and minor health problems is limited to cross-sectional self-report studies. In the present study, this relationship was examined prospectively.

Methods. Hostility of 1077 municipal employees was measured by a questionnaire survey and minor health problems by using 4-year register-based absence data including medically certificated diagnoses.

Results. High hostility predicted a high total number of long-term sickness absence spells among men, but not among women. In separate diagnostic categories (musculo-skeletal, traumas and injuries, respiratory), hostility related positively and linearly to absences due to traumatic causes and curvilinearly (U-shape) to absences due to musculo-skeletal causes. Controlling the effects of health risk behaviour and demographic background did not significantly change these figures. However, health risk behaviour moderated the relations of hostility to overall long-term sickness absences, and to traumatic and musculo-skeletal absences, being significantly stronger in high-risk groups. No association was found between hostility and non-certificated short-term absence spells.

Conclusions. The results suggest that hostility plays a role in the aetiology of minor health problems.