Vascular dementia (VaD) is the second most common subtype of dementia in Western countries (Desmond, 1996) and, overall, may be the most common subtype of dementia in the world (Henderson, 1994). Furthermore, the recognition of some major risk factors of cerebrovascular disease makes VaD a form of ‘preventable senility’ (Hachinski, 1992). The last decade has seen a major re-evaluation of the concept of VaD (Erkinjuntti & Hachinski, 1993; Hachinski, 1994), with new diagnostic criteria having been proposed (World Health Organization, 1993; American Psychiatric Association, 1994) but without any consensus (Wetterling et al. 1996). Indeed, some investigators have called for the abandonment of the diagnosis of VaD and the adoption of alternative nosology (Hachinski, 1994). It is therefore time to re-examine the concept of VaD and evaluate its distinctive features.

Background. An association between social rhythm disruption (SRD) and onset of manic episodes has recently been observed. Whether other types of bipolar (depressive and cycling) or unipolar depressive episodes are similarly related to SRD is unclear, as is the association between severely threatening life events and onset of bipolar manic, depressed and cycling episodes.

Methods. Bipolar patients with purely manic (N = 21), purely depressed (N = 21) and cycling (N = 24) episodes, and 44 patients with recurrent unipolar depression, were interviewed with the Bedford College Life Events and Difficulties Schedule. The presence of severe and SRD events during the year prior to index episode onset was then determined.

Results. More manic than cycling and unipolar subjects experienced SRD events during 8- and 20-week pre-onset periods, and severe events during 20-week pre-onset periods. Controlling for age and prior number of episodes left most findings unchanged. An earlier finding of more manic subjects with SRD events in an 8-week pre-onset versus control period was also replicated.

Conclusions. It appears that manic onsets are influenced by stressful life events, especially those involving SRD, in a unique manner compared to onsets of other types of bipolar and unipolar episodes. Onset of bipolar cycling episodes, in contrast, seems to be relatively unaffected by SRD or severe life events. These findings refine the hypothesis that SRD may precipitate onset of affective episodes to be specific to manic onsets.

Background. Previous longitudinal studies of the association between depression and cognitive dysfunction have had relatively short follow-up periods. This report presents a long-term study of the association between baseline syndromal depression and cognitive outcome measured 9 to 12 years later.

Methods. Self-CARE (D) depression, cognitive function and pre-morbid intelligence were recorded on 1083 subjects on entry to the Medical Research Council trial of treatment of hypertension in older adults in 1983–5. In 1994–5, we aimed to re-interview all survivors to assess cognitive function using the MMSE. We used multivariate analysis to explore whether baseline depression predicted cognitive outcome after this long follow-up period.

Results. Baseline depression was crudely associated with poorer cognitive outcome at time 2. However, this long-term prospective association was no longer apparent after adjusting for baseline cognitive performance, which was associated with baseline depression and robustly predicted cognitive outcome at time 2. We found that gender modified the association between depression and poorer cognitive outcome, so that the association was statistically significant only among men.

Conclusion. Propensity for depression and failing cognition may have common determinants that still need to be established by future neurobiological investigations in conjunction with further long-term prospective epidemiological research.

Background. Although the traditional view of bipolar affective disorder is that the majority of patients have full remission between episodes, recent evidence suggests that residual cognitive deficits are present. The aim of this study was to determine whether memory and executive deficits were present in a well-defined clinically remitted group of patients.

Methods. This was a case–control study of bipolar patients in remission (N = 18). Subjects had to fulfil stringent clinical criteria for inclusion into the study and had to have been in remission for at least 4 months. Subjects also had no history of substance dependence. The cognitive battery examined memory and executive function.

Results. Patients in excellent clinical remission and who reported good social adaptation showed impairment on tests of visuospatial recognition memory. Accuracy on four tests of executive function was not impaired in patients in remission compared with controls, although response latency on these executive tests was still impaired.

Conclusions. As our group and others have shown, patients with mania and unipolar depression show generalized impairment on tests of memory and executive function. In comparison, this study has demonstrated that patients in remission show a relatively specific impairment in memory with recovery of accuracy measures on executive function task. The increased response latency on the executive tasks suggests a possible small residual impairment. These findings suggest that in neuroanatomical terms, more posterior cortical function (temporal lobe) has not improved but there is at least some recovery of frontal lobe function in remission.

Background. Patients with obsessive–compulsive disorder (OCD) have symptoms that pre-dominantly concern washing (washers) or checking (checkers), or both. Functional neuroimaging has been used to identify the neural correlates of the urge to ritualize but has not distinguished between washing and checking symptoms in OCD. We used functional magnetic resonance imaging to compare the neural response to emotive pictures in washers and checkers.

Methods. In one of two 5-minute experiments, washers (N = 7), checkers (N = 7) and age-matched normal controls (N = 14) were scanned while viewing alternating blocks of normally disgusting (rated as disgusting by all subjects) and neutral pictures. In the other experiment, all patients and a normal subgroup (N = 8) viewed alternating blocks of washer-relevant (rated as more disgusting by washers than normal controls or checkers) and neutral pictures.

Results. In all subjects, normally disgusting pictures activated visual regions implicated in perception of aversive stimuli and the insula, important in disgust perception. Only in washers were similar regions activated by washer-relevant pictures. In checkers, these pictures activated fronto-striatal regions associated with the urge to ritualize in OCD. Normal controls were more similar in neural response to checkers than washers to these pictures. Both normal controls and checkers had frontal regions activated significantly more by washer-relevant than normally disgusting pictures, and had these regions activated significantly more than washers by washer-relevant pictures.

Conclusions. We demonstrate a differential neural response to washer-relevant disgust in washers and checkers: only washers demonstrate a neural response to washer-relevant disgust associated with emotion perception rather than attention to non-emotive visual detail.

Background. Somatoform disorders such as neurasthenia and chronic fatigue syndrome are characterized by a combination of prolonged mental and physical fatigue. This study aimed to investigate the heritability of somatic distress and determine whether this dimension is aetiologically distinct from measures of depression and anxiety.

Method. Measures of anxiety, depression, phobic anxiety, somatic distress and sleep difficulty were administered in a self-report questionnaire to a community-based sample of 3469 Australian twin individuals aged 18 to 28 years. Factor analysis using a Promax rotation, produced four factors: depression, phobic anxiety, somatic distress and sleep disturbance. Multivariate and univariate genetic analyses of the raw categorical data scores for depression, phobic anxiety and depression were then analysed in Mx1.47.

Results. Univariate genetic analysis revealed that an additive genetic and non-shared environmental (AE) model best explained individual differences in depression and phobic anxiety scores, for male and female twins alike, but could not resolve whether additive genes or shared environment were responsible for significant familial aggregation in somatic distress. However, multivariate genetic analysis showed that an additive genetic and non-shared environment (AE) model best explained the covariation between the three factors. Furthermore, 33% of the genetic variance in somatic distress was due to specific gene action unrelated to depression or phobic anxiety. In addition, 74% of the individual environmental influence on somatic distress was also unrelated to depression or phobic anxiety.

Conclusion. These results support previous findings that somatic symptoms are relatively aetiologically distinct both genetically and environmentally from symptoms of anxiety and depression.

Background. Previous research suggests that childhood sexual abuse is associated with high rates of retrospectively reported medical utilization and medical problems as an adult. The goal of this study was to determine if abused females have higher rates of medical utilization using self-report and objective measures, compared with non-abused females. A further goal was to determine whether findings of prior research would be replicated when childhood physical abuse level was controlled. This study also examined the moderating impact of depressed mood on current health measures in this population.

Methods. Six hundred and eight women recruited from a health maintenance organization completed self-report measures of health symptoms for the previous month and doctor visits for the previous year. Objective doctor records over a 2 year period were examined for a subset of 136 of these women.

Results. Results showed significantly more self-reported health symptoms and more self-reported doctor visits in abused participants compared with those who reported no childhood history of sexual abuse. Objective doctor visits demonstrated the same pattern with abused participants exhibiting more visits related to out-patient surgery and out-patient internal medicine. In addition, persons who were both sexually abused and depressed tended to visit the emergency room more frequently and to have more in-patient internal medicine and ophthalmology visits than sexually abused participants who reported low depressed mood and non-abused controls.

Conclusions. These results replicate prior studies and suggest that current depression may moderate the relationship between sexual abuse and medical problems in adulthood.

Background. Previous studies have implicated emotional suppression, in particular suppression of anger, in the onset and progression of breast cancer. Many of these studies used non-standardized measures and failed to control for the effects of age and/or possible knowledge of diagnosis. The present study aimed to avoid these methodological errors in investigating the relationship of emotional suppression to a diagnosis of breast cancer in a large mammography screened population.

Method. Data were collected from 1151 women with suspicious mammograms recalled to a breast screening programme. Prior to multidisciplinary assessment women were asked to complete the Courtauld Emotional Control Scale. Imaging assessment outcome data and biopsy results were collected.

Results. Fifteen per cent of this population subsequently were diagnosed with breast cancer. There were no significant associations between a cancer outcome and emotional suppression before or after the highly significant effect of age was taken into account.

Conclusions. These results suggest that suppression of emotion may not be relevant to the development of breast cancer. Its role in the progression of existing disease requires clarification.

Background. A cohort of 60 adolescent eating-disordered patients that was consecutively admitted between 1979 and 1988 to a child and adolescent psychiatric university department in Berlin, Germany was followed up at a mean of 5·0 years and for a second time at a mean of 11·5 years.

Methods. Each patient was personally interviewed and findings dealing with eating disorder symptoms and psychosocial functioning were rated on four-point scales. In addition, the duration of both in-patient and out-patient treatment and the Body Mass Index (BMI) were recorded.

Results. Patients were in treatment for a mean of 33% of the initial 5-year follow-up period, but this has dropped to a mean of 17% of the entire 11-year follow-up period. No predictors of treatment duration were found. The mortality rate was 8·3% at the second follow-up. The distribution of abnormal BMIs (<17·5) reflected a trend of improvement with increasing duration of follow-up. In comparison to the 5-year follow-up, fewer patients suffered from symptoms of the full clinical picture of an eating disorder at the 11-year follow-up. Among the surviving patients 80% recovered during the long-term course. There were few specific predictors of three different outcome criteria.

Conclusion. This outcome study of adolescent eating disorders provides further evidence that the long-term course of the disorders in terms of the eating pathology is better than can be expected after a few years. Very little can be said with regard to individual prognosis.

Background. Several recent studies have pointed to a dysfunction of serotonin transmission in patients with eating disorders. Notwithstanding, it is not known whether serotonergic abnormalities are related primarily to eating and/or purging behaviour, nutritional status or general psychopathological dimensions. Therefore, by using a validated neuroendocrine strategy, we investigated central serotonergic function in patients with anorexia nervosa, bulimia nervosa or binge-eating disorder who differ on the above parameters.

Methods. Plasma prolactin response to D-fenfluramine (30 mg p.o.) or placebo was measured in 58 drug-free female volunteers, comprising 15 underweight anorexic women, 18 bulimic women, 10 women with binge-eating disorder and 15 female healthy controls. Behavioural assessment included ratings of eating disorder symptoms, depression, aggression and food-related obsessions and compulsions.

Results. A significantly decreased prolactin response to D-fenfluramine was found in underweight anorexic women and in bulimics with high frequency bingeing ([ges ]2 binge episodes/day), but not in patients with binge-eating disorder or in bulimics with low frequency bingeing ([les ]1 binge episode/day). In the whole bulimic group, a negative correlation emerged between frequency of bingeing and prolactin response. No significant correlation was found between physical or psychopathological measures and the hormonal response in any group.

Conclusions. These results confirm our previous findings of an impaired serotonergic transmission in underweight anorexics and in bulimics with high frequency bingeing, but not in patients with less severe bulimia nervosa. Moreover, they show, for the first time, that the hypothalamic serotonergic system is not altered in women with binge-eating disorder.

Background. Studies of groups of individuals who have a genetically high risk of developing schizophrenia, have found neuropsychological impairments that highlight likely trait markers of the schizophrenic genotype. This paper describes the change in neuropsychological function and associations with psychiatric state of high risk participants during the first two assessments of the Edinburgh High Risk Study.

Methods. Seventy-eight high risk participants and 22 normal controls, age and sex matched completed two neuropsychological assessments 18 months to 2 years apart. The areas of function assessed include intellectual function, executive function, learning and memory, and verbal ability and language.

Results. The high risk participants performed significantly worse on particular tests of verbal memory and executive function over the two assessments than matched controls. Those high risk participants who experienced psychotic symptoms were found to exhibit a decline in IQ and perform worse on tests of verbal memory and executive function than those without symptoms. An increase in psychotic symptoms between the two assessments in the high risk group was found to be associated with an apparent decline in IQ and memory.

Conclusions. The results suggest that the development of psychotic symptoms is preceded by a decline in IQ and memory. This may reflect a general and a more specific disease process respectively.

Background. While some cognitive accounts of disorganized speech, or thought disorder, in schizophrenia have emphasized failures in working memory/discourse planning or selective attention, we have suggested that thought disorder resides in the semantic system. In this study we assessed the effect of neuroleptic medication on thought disorder and semantic processing.

Methods. Seventeen patients with schizophrenia were assessed while receiving neuroleptic medications and in crossover fashion, placebo. A number of measures were obtained: clinically rated thought disorder (using the Thought, Language and Communication Scale); working memory (letter number span); lexical integrity (naming and receptive vocabulary); and, semantic priming of intracategorical word pairs.

Results. Semantic priming measures improved with neuroleptic medication, as did clinically rated thought disorder. No other measure changed significantly. Priming selectively covaried with changes in thought disorder.

Conclusion. Changes in spreading semantic activation, measured in a semantic priming paradigm and presumably brought about by neuroleptics' influence on dopaminergic neuromodulatory systems, might reflect changes in the biases of pre-existing associative networks that favour or increase the accessibility of representations related by shared features. This study also has implications for the architecture of normal language in that a dissociation between the lexical and semantic levels was observed, due to the selective compromise of tasks demanding semantic processing.

Background. To test the hypothesis that certain psychotic symptomatology is due to a defect in self- monitoring, we investigated the ability of groups of psychiatric patients to differentiate perceptually between self-produced and externally produced tactile stimuli.

Methods. Responses to tactile stimulation were assessed in three groups of subjects: schizophrenic patients; patients with bipolar affective disorder or depression; and normal control subjects. Within the psychiatric groups subjects were divided on the basis of the presence or absence of auditory hallucinations and/or passivity experiences. The subjects were asked to rate the perception of a tactile sensation on the palm of their left hand. The tactile stimulation was either self-produced by movement of the subject's right hand or externally produced by the experimenter.

Results. Normal control subjects and those psychiatric patients with neither auditory hallucinations nor passivity phenomena experienced self-produced stimuli as less intense, tickly and pleasant than identical, externally produced tactile stimuli. In contrast, psychiatric patients with these symptoms did not show a decrease in their perceptual ratings for tactile stimuli produced by themselves as compared with those produced by the experimenter. This failure to show a difference in perception between self-produced and externally produced stimuli appears to relate to the presence of auditory hallucinations and/or passivity experiences rather than to the diagnosis of schizophrenia.

Conclusions. We propose that auditory hallucinations and passivity experiences are associated with an abnormality in the self-monitoring mechanism that normally allows us to distinguish self-produced from externally produced sensations.

Background. High expressed emotion (EE) in families reliably predicts relapse in schizophrenia leading to the assumption that high EE stresses patients and is the cause of relapse. Attempts at validating the stressful properties of high EE using autonomic skin conductance measures have been inconclusive. Since memory loaded vigilance tasks are sensitive to stress, we used a memory loaded version of the Continuous Performance Test (CPT) to see if test performance would change in the presence and absence of high or low EE relatives. If high EE was stressful, performance should decline in their presence of high EE relatives. If low EE was protective against stress performance should improve in the presence of low EE relatives.

Methods. The CPT was administered to 41 schizophrenic and 51 normal control participants. CPT testing was conducted in the absence, then presence, then absence of high or low EE relatives.

Results. Control participants had significantly greater CPT scores than schizophrenic participants; there was no effect of the relative's presence or absence on CPT performance for either the high or low EE group. Schizophrenic participants from high EE homes demonstrated significantly better, rather than worse, CPT scores than those in low EE homes.

Conclusions. These findings fail to support the notion of high EE as stressor, but show that high EE and low EE patient groups perform a vigilance task significantly differently. We propose that patients from low EE groups may be underaroused relative to their high EE counterparts and that this underarousal leads to less than optimal performance on the CPT.

Background. This paper focuses on the long-term course of social disability in schizophrenia assessed at first onset, and after 1, 2 and 15 years in incidence cohorts in six European centres in Bulgaria, Germany, Ireland, The Netherlands, the Czech Republic and the United Kingdom. The study population comprises 349 patients comprising 75% of the original cohorts.

Methods. Social disability was assessed in a standardized way with the WHO Disability Assessment Schedule.

Results. Social disability in schizophrenia appears to be a persistent phenomenon. Its severity decreased overall in the period of follow-up, but this was not so in a small group traced to hospital or sheltered accommodation. Only 17% of subjects had no disability and 24% still suffered from severe disability. The great majority lived with their family, a partner, or alone. A deteriorating course was more frequent than late improvement. Gender, age, onset, duration of untreated psychosis or type of remission during the first 2 years did not predict the long-term outcome of disability. Severity of disability at the first three assessments of the illness contributed significantly to the explanation of its variance at 15 years.

Conclusion. Disability generally ameliorates, but less than expected or hoped. It needs continuing attention and care in this era of de-institutionalization.

Background. Linguistic processing was explored in normally intelligent adults with either autism or Asperger's syndrome, to test if global coherence was impaired. Global coherence is the ability to establish causal connections and interrelate local chunks into higher-order chunks so that most linguistic elements are linked together thematically. Since individuals with autism are hypothesized to have weak central coherence then one would predict that the clinical groups would have difficulty integrating information globally so as to derive full meaning.

Methods. Two experiments were designed to test global coherence. Experiment 1 investigated whether individuals on the autism spectrum condition could arrange sentences coherently. Experiment 2 investigated whether they were less able to use context to make a global inference.

Results. The clinical groups were less able to arrange sentences coherently and use context to make a global inference.

Conclusions. The results suggest that individuals on the autism spectrum have impaired global coherence. Arranging sentences and making global inferences correlated highly, suggesting that central coherence may be a unitary force in these different tasks. Of the two clinical groups, the autism group had the greater deficit. The effect that such a deficit would have on one's daily life is discussed, along with possible explanations for the clinical groups' greater difficulty, and suggestions for future research.

Background. Higher rates of suicidal behaviour have been reported among staff in mental health care than in the general population. However, no studies of these two groups have been carried out simultaneously, using the same methods. This study aims to investigate whether they differ in terms of age- and sex-standardized prevalence of suicidal behaviour.

Methods. Identical questions about suicidal behaviour were addressed in the same year to a random sample of the general population and to mental health-care staff in Stockholm. Life weariness among the latter was also investigated.

Results. Age- and sex-standardized past year prevalences of suicidal thoughts and suicide attempts were found to be similar among mental health-care staff and the general population. Lifetime prevalence of both suicidal thoughts and suicide attempts was significantly higher among mental health-care staff than among the general population. Psychologists/social workers have a higher probability of: lifetime thoughts of life is not worth living; death wishes; and, suicidal thoughts, than nurses/assistant nurses.

Conclusions. Reports on lifetime prevalence of suicidal behaviour may be biased in populations that are not reminded of these problems in everyday life. Data on past year prevalence of suicidal behaviour show clearly the similarity between the general population and the mental health-care staff.

Background. The incidence of deliberate self-harm (DSH) in Britain has increased markedly over the last 30 years. Reasons for this rise are not clear. We have investigated whether changes in the social and economic environment underlie any of the recent increase in DSH incidence.

Methods. An ecological analysis was used to assess associations between changes in census-based measures of the social and economic environment – the Townsend Deprivation Index and a three-factor social fragmentation index – and changes in age- and sex-specific hospital attendance rates for DSH for the 28 wards of the city of Bristol between 1972–3 and 1995–6.

Results. There were significant cross-sectional associations between the Townsend Index and rates of DSH in both males and females in both time periods. Increases in Townsend Index were also associated with increases in DSH. This association was statistically significant at the 5% level in 25–34 year-old females. Associations with the social fragmentation index were weak, although our index was based on rather limited data.

Conclusions. This analysis suggests that changes in levels of socio-economic deprivation may influence area-specific patterns of DSH and such changes may have contributed to recent rises in DSH.

Background. The growing movement in many European countries towards capitation-based systems for financing mental health care has generated increasing interest in developing appropriate models capitation formulae. The aims of the study were: to detect and compare any differences in service costs between patients with different diagnoses; and to analyse the associations between patient characteristics and service costs.

Methods. All patients in contact with the South-Verona Community Mental Health Service during the last quarter of 1996 were included in the study. Clinical and service-related variables were collected at first index contact; 3 months later, patients were interviewed using the Client Services Recipient Interview. For those who completed both the clinical assessments and the services receipt schedule (N = 339), 1-year psychiatric and non-psychiatric direct care costs were calculated. Weighted backward regression analyses were performed.

Results. The most significant variables associated with psychiatric costs were: admission to hospital in the previous year; intensity and duration of previous contacts with South-Verona CMHS; being unemployed; having a diagnosis of affective disorder; and, Global Assessment of Functioning score. The final model explained 66% of the variation in costs of psychiatric care and 13% of variation in non-psychiatric medical costs.

Conclusions. The model presented in this study explains a higher degree of cost variance than previously published studies. In community-based services more resources are targeted towards the most disabled patients. Previous psychiatric history (number of admissions in the previous year and intensity of psychiatric contacts lifetime) is strongly associated with psychiatric costs.

Background. There has been growing interest in factors that might influence the prescription of psychotropic drugs in general practice.

Method. This was a multi-centre study using a two-phase stratified sampling strategy in primary care facilities from 14 different countries to determine factors associated with the prescription of psychotropic drugs.

Results. A total of 1763 consecutive GP attenders aged between 16 and 65 years of age were recruited. Although antidepressants were used more for depressive disorders and anxiolytics for patients with anxiety, the differential diagnosis was otherwise not an important factor in prescribing behaviour. Antidepressants and anxiolytics were prescribed twice as frequently in client centred clinics following a ‘personal physician model’ as opposed to non-client centred settings, where care was less personalized. The reverse was true of hypnotics (adjusted odds ratio of 0·5). General practitioners with a positive view of their undergraduate psychiatric training and who had had further postgraduate experience in the speciality were significantly less likely to prescribe medication, and if they did they were more likely to use antidepressants. Older patients were significantly more likely to be prescribed psychotropic medication. Several other patient factors emerged when individual classes of medication were considered; these included the loss of a spouse and the absence of physical ill health in the case of antidepressants, and female sex, fewer years of schooling and unemployment in the case of anxiolytics.

Conclusions. Social, health care and GP factors are at least as important as clinical features in the prescription and choice of psychotropic medication.