In June 1637 William Harvey petitioned the Court of Wards and Liveries, a legal incompetency court in early modern England, for a grant of the custody of his mentally disabled nephew, William Fowke. ‘Idiocy’ and ‘lunacy’ were the two medico-legal categories for insanity used by the Court and Harvey requested that his nephew be inspected for idiocy. However, the legal and administrative history of the Court indicates that in the 1630s idiocy (but not lunacy) grants were prejudicial to the assets and economic security of retarded persons. Since petitioners' wishes, more than clinical status, usually determined the diagnostic label assigned to referred individuals, idiocy grants were not sought by persons of some social standing. Harvey's idiocy referral probably reflects his allegiance to his own clinical observations in the face of opposing social norms and family advantage.

Twenty-six elderly (> 60 yrs) patients with DSM-III major depression were compared to 13 patients with NINCDS/ADRDA probable Alzheimer's disease (AD), and to 31 screened normal controls. Subjects were matched on age and sex. Fifteen of the 26 depressed patients were cognitively impaired on the Mini-Mental State Examination (MMSE) upon admission, but after treatment returned to the normal range. These 15 patients were defined as having the dementia syndrome of depression (DOD). The remaining 11 depressed patients were termed depressed, cognitively normal (DCN). All subjects received standardized cranial CT scans for assessment of ventricular brain ratio (VBR) and CT attenuation numbers. Subjects also received neuropsychological evaluation.

CT values for the 26 depressed patients lay between those of AD patients and normal controls. CT values for the DOD subgroup clustered near those of AD patients. Patterns of cognitive deficits and correlations of CT attenuation values with cognitive measures were also similar in AD and DOD. Most patients were reassessed at a mean of two years after initial testing; of the 11 of the 15 DOD re-examined, only one had undergone cognitive decline. By contrast, all AD patients retested had declined significantly. Episodes of DOD and DCN tended to ‘breed true’. This study suggests that while patients with DOD may have underlying structural brain abnormalities, obvious short-term progression to AD does not commonly occur.

Ten patients with seasonal affective disorder received the following treatments for 5 days each: (a) artificial daylight (2500 lux) from 20.00 to 23.00 and from 07.00 to 10.00 hours; (b) red light (300 lux) from 20.00 to 23.00 and from 07.00 to 10.00 hours; (c) artificial daylight (2500 lux) from 22.00 to 23.00 and from 07.00 to 08.00 hours. The antidepressant effect of treatment (a) was superior to that of treatment (b), suggesting that the effect of light treatment in winter depression is more than that of a placebo. The antidepressant effect of treatment (a) was superior to that of treatment (c), although these two treatments equally suppressed plasma melatonin concentrations. Consequently, in these patients there is a dissociation between the effect of light treatment on melatonin and the reduction of depression ratings.

Evidence is presented here in support of the efficacy of carbamazepine (CBZ) in a variety of different psychiatric conditions. While there is now considerable evidence to support the use of CBZ in the acute treatment of mania and in the prophylaxis of bipolar affective disorder, particularly as a second-line drug, its usefulness in other conditions is less well documented. Overactivity, aggression and poor impulse control appear to improve in a variety of different diagnostic categories, and it may possibly be more appropriately prescribed to control or prevent these symptoms than as a treatment for a particular disease entity. The use of CBZ as an antidepressant is not well proven. Most of the adverse effects reported are due to rapid initial escalation of dosage, which can be avoided, or are reversible such as drug rashes. Severe adverse effects have been reported but are rare. Frequent monitoring of drug plasma concentration is not required. Some reports of synergism with lithium have appeared and combination therapy may be a useful strategy. Drug interactions, the need for clinical monitoring, and the possible pharmacological mode of action of CBZ are also discussed.

Cerebrospinal fluid somatostatin-like immunoreactivity (CSF SLI) was determined for 67 elderly patients who met the DSM-III criteria for delirium and for 19 age-matched controls. As a group, and also when subdivided according to the type of delirium, severity of cognitive decline or the type of central nervous system disease, the delirious patients showed significant reductions of SLI compared with the controls, together with a declining trend associated with increasing cognitive dysfunction. These findings are in accordance with previous observations that reduced CSF SLI is associated with diseases in which cognitive function is disturbed and they extend this finding to delirium.

Thirty (33%) of 90 patients with the Gilles de la Tourette syndrome exhibited selfinjurious behaviour. Fourteen were head bangers, of whom two had cavum septum pellucidum. Clinical correlates of self-injury were the severity of Gilles de la Tourette syndrome symptoms and psychopathology, with special reference to obsessionality and hostility. We discuss an additional patient who died from a subdural haematoma as a result of head banging, and three who had permanent vision impairment from self inflicted eye injuries.

Repetition of other person's activities is, to some extent, part of normal human behaviour. However, in some circumstances it becomes pathological and symptomatic of an underlying disease process. The pathogenesis of this type of behaviour is very diverse. The circumstances in which echoing can be expected to occur are reviewed.

The first degree relatives of three groups of women were interviewed; 51 women who had had an illness within two weeks of childbirth and no non-puerperal episodes (the puerperal group), 33 who had puerperal and non-puerperal episodes (the mixed group), and 19 women with bipolar manic-depressive disorder who had non-puerperal episodes only (the manic-depressive group).

Over 60% of the affected relatives in all three groups had affective illnesses; in the main these were not puerperal. There were significantly more first degree relatives who had had general practitioner or hospital treatment for psychiatric illness in the puerperal group and in the mixed group than in the manic-depressive group. The puerperal patients had a better prognosis in terms of their illness (number of relapses and time on medication), work functioning and social functioning than the manic-depressive group and the mixed group. The mixed group had an earlier age of onset than the manic-depressive group and the puerperal group. The hypothesis that puerperal psychosis is the same as bipolar manic-depressive disorder was not upheld. The mixed group and the puerperal group were similar with respect to the risk in first degree relatives but differed in terms of prognosis.

There were no significant differences between the groups with respect to puerperal episodes in first-degree relatives, although the rate of puerperal psychosis in the first-degree relatives of the puerperal patients was significantly greater than in the general population. The hypothesis that there is a specific genetically determined puerperal psychosis was not supported. Women who had had an illness with an onset within two weeks of childbirth (mixed and puerperal) subsequently had an illness following 36% of their childbirths. In women who had had puerperal and non-puerperal episodes (mixed) the risk was higher; over 50 % of deliveries in these women were followed by psychiatric illness.

Recognition of prodromal symptoms of schizophrenia offers the potential of early intervention to avert relapse and re-hospitalization (Carpenter & Heinrichs, 1983). The present study investigated how a strategy to detect prodromal signs might be effectively applied in the clinical setting. A standard monitoring system was developed involving completion of a new early signs scale (ESS) measuring changes in key symptoms phenomenologically (self-report) and behaviourally (observer report). The ESS was subject to rigorous psychometric evaluation and tested in a prospective pilot investigation. The ESS reliably identified early signs and predicted relapse with an overall accuracy of 79%. Several different patterns of relapse were identified. Observer reports compensated for loss of insight in some patients. In two cases where early signs indices were detected, prompt increases in medication appeared to arrest relapse and avert readmission. The ESS offers itself as a reliable, valid and administratively feasible measure and demonstrates considerable potential as a cost-effective procedure for secondary prevention.

There have been relatively few reported cases of psychosis due to khat usage despite its heavy consumption in certain East African and Arabian countries. Four cases have been reported in the UK. We report here on three further cases of psychotic reactions to this substance in Somalian males, and emphasize the need to be aware of khat as a potential substance of abuse, with both medical and psychiatric complications. The features of khat psychoses are described and the relationship to amphetamine and ephedrine psychoses is discussed. The forensic aspects of two of the cases which involved homicide and combined homicide and suicide are highlighted, as is the possible role of social dislocation from the culture of origin.

Twenty-three drug-free patients with agoraphobia and panic disorder (DSM-III criteria) had, at rest, lower mean end-tidal PCo2 (32 v. 36 mmHg) and higher mean heart rate (92 v. 83 bpm) than did 18 controls. During 5 min of listening to fear talk, only eight (35 %) patients and three (16 %) controls panicked, but panic was associated with marked physiological changes in only two patients and one control. Patients said that breathlessness began slightly more often before than after panic. In 59 % of patients the symptoms from voluntary hyperventilation (VHV) were very similar or identical to those of their usual panics. Compared with the remainder, these patients felt more unpleasant during hyperventilation (HV); in such patients HV may aggravate somatic symptoms. Agoraphobics with panic differed from controls in having higher baseline arousal, but were not more reactive than controls to HV or fear talk.

The psychological well-being of forty-four breast cancer patients was assessed shortly before and after surgery, and at three and twelve months post-operatively. Regression analysis revealed type of treatment, control over treatment and concern for appearance as significant predictors of nature of subsequent mood state. Results are discussed with reference to the theoretical position that type of severe life event can predict the nature of ensuing psychological disorder.

Forty-two consecutively identified Afro-Caribbean patients with a first episode of psychosis were compared with a similar group of non-Caribbean patients. A number of differences emerged, although the same proportion of patients in each group had symptoms for 6 months or more prior to psychiatric contact. Afro-Caribbean patients showed greater delay in seeking help, more ‘disturbance’ later in the course of their illness and were more likely to be admitted compulsorily. The social geography of the two groups suggests that the high rates of schizophrenia and related psychoses that we previously reported cannot be explained simply by differences in area of residence at the time of presentation.

The basic symptoms of minor psychiatric morbidity (MPM) reported elsewhere were also found in a community survey in Taiwan. However, differences in the patterns of and manifestations of the symptoms were evident. Contrary to most Western surveys, the prevalence of anxiety (24·7 %) was found to be higher than that of depression (8·3 %) in Taiwan. Possible explanations based on sociocultural characteristics of the Chinese family were proposed. The notion of somatization as a predominant symptom in Chinese neurotic patients advocated by some research workers was not supported in this study. As a result of findings in community cases, it is argued that the importance of somatization has been considerably overemphasized as a factor in the illness behaviour of neurotic cases in Chinese and other cultures, and it is therefore not a culturespecific disease phenomenon. It is also suggested that certain culture-specific neurotic syndromes reported in Chinese, such as shen-ching-shuai-jo (neurasthenia) and shen-k'uei (semen loss syndrome), are clinically equivalent to MPM. Implications of the present findings on crosscultural research and management of MPM were discussed.

A model for the systematic adaptation of psychological questionnaires for epidemiological use is presented. Application of the model is illustrated using variants of the Bortner Type A scale in a representative age/sex stratified sample of 256 persons. Through the application of the model the Bortner scale was adapted to compare the effects of scale direction, scale format and example position. Overall the Bortner scale was shown to provide robust measurement which was little affected by response rate, age, sex or by the adaptations of the scale. An association was found of sex with response rate. Interaction effects of sex and scale direction on mean Type A scores, and of example position and scale format on both response rate and Type A score variability were also found. In identifying critical aspects of questionnaire performance, and in providing a coherent framework for their interrelationship, the model acts as a guide to the systematic assessment of questionnaire performance. The use of this model will, therefore, facilitate greater confidence in the interpretation of questionnaire data in epidemiological studies.

This epidemiological study examines the contribution of childbearing to the sex difference in first admission rates for affective psychosis. The effects of sex, age, marital status and parity on first admission rates are examined in 114 patients admitted from a defined catchment area. The rate of first admission in females is almost twice that in males. Using logistic regression analysis one significant factor accounting for this sex difference emerges: female parity. The effect of parity is evident up to the age of 54, and it entirely accounts for the sex difference in relative risk. Non-parous females have a lower relative risk of admission than males. An apparent effect of marital status is only significant in females, and is accounted for by parity and age.

We report the results of a survey of the burdens and needs for items of care of 45 supporters of long-term users of psychiatric day care facilities in Camberwell. The supporters reported high levels of disturbed behaviour and low levels of self-care skills in the attenders. They were also subject to high levels of social and economic burden, not all of which could be attributed to the attenders' problems. The needs assessment identified a large number of unmet needs, although the supporters themselves were largely resigned to their situation and expressed little dissatisfaction with the services they were offered. The advantage of conducting this kind of assessment of supporters' needs as a routine part of clinical practice was discussed.