This issue features groups of papers on neuropsychology and neuroimaging of psychiatric disorders, adult attention deficit hyperactivity disorder, data from controlled treatment trials, epidemiology and longitudinal studies, eating disorders, together with an additional paper describing a specific disorder involving a desire for a limb amputation.

Background. Executive dysfunctions in relatives of schizophrenic patients may be trait markers of genetic liability and thus help us to elucidate the aetiology of schizophrenia. As a large amount of data has been published, a synthesis through a meta-analysis was needed to demonstrate the existence of executive impairments in relatives of schizophrenic patients and to assess their magnitude.

Method. We conducted a meta-analysis of articles that compared performances of controls and relatives of schizophrenic patients on the four tests most frequently used to assess executive functions: the Wisconsin Card Sorting Test (WCST), the Trail Making Test (TMT), the Stroop Test and the Verbal Fluency (VF) Test. When needed and possible, published data were supplemented with information from the authors. After assessing the homogeneity of the data, effect sizes were estimated and publication bias was tested by use of funnel plots.

Results. Relatives of schizophrenic patients performed less well than controls on all executive tests analysed. Effect estimates were in the small to moderate range (from 0·26 to 0·49) for Stroop, WCST and TMT, but were greater for the fluency tests (0·65 for phonological and 0·87 for semantic VF).

Conclusion. Relatives of schizophrenic patients appear to have wide, although not severe, executive dysfunctions. As the sensitivity of the different tests for impairments in relatives is not the same, the choice of test and method used should be carefully assessed.

Background. In patients with schizophrenia, passivity delusions are characterized by a difficulty in determining the agency of purposive actions. Neuropsychological and functional neuroimaging data suggest that passivity delusions are associated with dysfunction of the parietal lobe association cortex.

Method. Cortical volume calculated from magnetic resonance imaging data in a group of 12 patients with schizophrenia characterized by motor passivity delusions was compared statistically with the cortical volume of 11 patients without passivity delusions.

Results. Reduced cortical volume was observed in parietal and frontal association cortices in the passivity group.

Conclusions. These data provide direct evidence for the involvement of the parietal lobe in the pathophysiology of passivity delusions in schizophrenia.

Background. In the conditioned fear paradigm, repeated pairing of an aversive unconditioned stimulus (US) (e.g. electric shock) with a neutral conditioned stimulus (CS) (e.g. bright light) results in a conditioned fear response to the light alone. Animal studies have shown that the amygdala plays a critical role in acquisition of conditioned fear responses, while the medial prefrontal cortex (including anterior cingulate), through inhibition of amygdala responsiveness, has been hypothesized to play a role in extinction of fear responses. No studies have examined neural correlates of fear conditioning and extinction in patients with post-traumatic stress disorder (PTSD).

Method. Women with early childhood sexual-abuse-related PTSD (n=8) and women without abuse or PTSD (n=11) underwent measurement of psychophysiological (skin conductance) responding as well as positron emission tomographic (PET) measurement of cerebral blood flow during habituation, acquisition and extinction conditions. During habituation subjects were repeatedly exposed to a blue square on a screen. During acquisition, exposure to the blue square (CS) was paired with an electric shock to the forearm (US). With extinction, subjects were again exposed to the blue squares without shock. On a different day subjects went through the same procedure with electric shocks administered randomly in the absence of the blue square.

Results. Skin conductance responding to the CS was consistent with the development of conditioned responses with this paradigm. PTSD patients had increased left amygdala activation with fear acquisition, and decreased anterior cingulate function during extinction, relative to controls.

Conclusions. These findings implicate amygdala and anterior cingulate in the acquisition and extinction of fear responses, respectively, in PTSD.

Background. A lack of inhibitory control has been suggested to be the core deficit in children with attention deficit hyperactivity disorder (ADHD). This means that a primary deficit in behavioral inhibition mediates a cascade of secondary deficits in other executive functions, such as arousal regulation. Clinical observations have revealed that with increasing age symptoms of hyperactivity and impulsivity decline at a higher rate than those of inattention. This might imply that a deficit in attention rather than a lack of inhibitory control is the major feature in adult ADHD.

Method. To study whether an attentional or inhibitory deficit predominates, the stop-signal task and the stop-change task were presented to 24 adults with ADHD combined subtype and 24 controls.

Results. Relative to controls, the stop-signal reaction time (SSRT) was significantly more prolonged than the go-stimulus reaction time (RT) in patients with ADHD. This disproportionate elongation of the SSRT was comparable across tasks, even though the stop-change task exerted more complex (or at least different) demands on the inhibitory system than the stop-signal task. ADHD patients had a higher proportion of choice errors, possibly reflecting more premature responses. Specifically in the stop-change task, patients had more variable choice responses and made more inappropriate change responses, which may also reflect enhanced impulsivity.

Conclusions. The results support a core deficit in behavioral inhibition in adults with ADHD. We further suggest that there is more evidence for a critical role of deficient inhibitory control in adults than in children with ADHD.

Background. Follow-up studies of childhood ADHD have shown persistence of the disorder into adulthood, but no epidemiological data are yet available.

Method. ADHD DSM-IV symptoms were obtained by self-report in an adult population-based sample of 1813 adults (aged 18–75 years), that was drawn from an automated general practitioner system used in Nijmegen, The Netherlands. The structure of ADHD symptoms was analysed by means of confirmatory factor analyses. Other data used in this report are the General Health Questionnaire (GHQ-28), information about the presence of three core symptoms of ADHD in childhood, and about current psychosocial impairment.

Results. The three-factor model that allowed for cross-loadings provided the best fit in the entire sample. This result was replicated across gender and age subsamples. Inattentive and hyperactivity symptom scores were significantly associated with measures of impairment, even after controlling for the GHQ-28. Subjects with four or more inattentive or hyperactive–impulsive symptoms were significantly more impaired than subjects with two, one and no symptoms. The prevalence of ADHD in adults was 1·0% (95% CI 0·6–1·6) and 2·5% (1·9–3·4) using a cutoff of six and four current symptoms respectively, and requiring the presence of all three core symptoms in childhood.

Conclusions. These results support the internal and external validity of ADHD in adults between 18 and 75 years. ADHD is not merely a child psychiatric disorder that persists into young adulthood, but an important and unique manifestation of psychopathology across the lifespan.

Background. Several small-N, uncontrolled reports have demonstrated that the behavioral technique of attention shaping has significantly increased attention span among severely ill schizophrenia patients.

Method. In this study, we evaluated the effectiveness of using an individually administered intervention for improving sustained attention, Attention Process Training (APT), followed by an attention-shaping procedure within the context of an ongoing skills training group. Patients were randomly assigned to receive either the APT and attention-shaping sequence (n=18) or equivalent hours of treatment in the same intensive behavioral rehabilitation program (n=13).

Results. Results indicated dramatic improvements in attentiveness in the cognitive rehabilitation condition compared with the control condition, which demonstrated essentially no change in attentiveness over the 12 weeks of treatment. The attention-shaping intervention appeared to account for the majority of the effect. In contrast to the observational data, performance on neuropsychological tests was unaffected by the cognitive interventions.

Conclusions. This two-phase intervention demonstrated effectiveness in promoting attentive behavior among chronic schizophrenia patients with severe attentional impairment.

Background. Despite their impact on outcomes, the effect of patient treatment attitudes on the cost-effectiveness of health-care interventions is not widely studied. This study estimated the impact of patient receptivity to antidepressant medication on the cost-effectiveness of an evidence-based primary-care depression intervention.

Method. Twelve community primary-care practices were stratified and then randomized to enhanced (intervention) or usual care. Subjects included 211 patients beginning a new treatment episode for major depression. At baseline, 111 (52·6%) and 145 (68·7%) reported receptivity to antidepressant medication and counseling respectively. The intervention trained the primary-care teams to assess, educate, and monitor depressed patients. Twelve-month incremental (enhanced minus usual care) total costs and quality-adjusted life years (QALYs) were calculated.

Results. Among patients receptive to antidepressants, the mean incremental cost-effectiveness ratio was $5864 per QALY (sensitivity analyses up to $14689 per QALY). For patients not receptive to antidepressants, the mean incremental QALY score was negative (for both main and sensitivity analyses), or the intervention was at least no more effective than usual care.

Conclusions. These findings suggest a re-thinking of the ‘one size fits all’ depression intervention, given that half of depressed primary-care patients may be non-receptive to antidepressant medication treatment. A brief assessment of treatment receptivity should occur early in the treatment process to identify patients most likely to benefit from primary-care quality improvement efforts for depression treatment. Patient treatment preferences are also important for the development, design, and analysis of depression interventions.

Background. Few epidemiological studies have investigated incidence by age or age at onset distributions for mania or bipolar disorder. The current study aimed to determine these in a defined area in south-east London, over a 35-year period.

Method. All cases of first-episode mania presenting to psychiatric services in Camberwell, south-east London, between 1965 and 1999 were identified. Incidence rates by age, using 5-year age-at-onset bands, were estimated and the structure of the age-at-onset distribution for first-episode mania was investigated using finite mixture distributions (admixture analysis).

Results. The incidence of DSM-IV bipolar I disorder (BP I), first manic episode peaked in early adult life (16·38/100000 population per year in the 21–25 years band) with a much smaller peak in mid-life. A two-component normal mixture distribution fitted age at onset better than either a single normal distribution or a three-component mixture, implying the existence of early and later onset subgroups. The early onset group had a stronger family history of bipolar disorder, and showed more acute, severe and atypical symptoms during their first manic episode.

Conclusions. The incidence of mania peaks in early adult life but there is clear evidence of early and later onset subgroups which may represent different forms of disorder.

Background. Major depression is a prevalent mental disorder in the general population, with a multi-factorial etiology. However, work stress as a risk factor for major depression has not been well studied.

Method. Using a longitudinal study design, this analysis investigated the association between the levels of work stress and major depressive episode(s) in the Canadian working population, aged 18 to 64 years. Data from the longitudinal cohort of the Canadian National Population Health Survey (NPHS) were used (n=6663). The NPHS participants who did not have major depressive episodes (MDE) at baseline (1994–1995 NPHS) were classified into four groups by the quartile values of the baseline work stress scores. The proportion of MDE of each group was calculated using the 1996–1997 NPHS data.

Results. The first three quartile groups had a similar risk of MDE. Those who had a work stress score above the 75th percentile had an elevated risk of MDE (7·1%). Using the 75th percentile as a cut-off, work stress was significantly associated with the risk of MDE in multivariate analysis (odds ratio=2·35, 95% confidence interval 1·54–3·77). Other factors associated with MDE in multivariate analysis included educational level, number of chronic medical illnesses and child and adulthood traumatic events. There was no evidence of effect modification between work stress and selected sociodemographic, clinical and psychosocial variables.

Conclusions. Work stress is an independent risk factor for the development of MDE in the working population. Strategies to improve working environment are needed to keep workers mentally healthy and productive.

Background. Suicide rates are higher in certain educational groups. The highest rates are generally found in the medical and allied professions, but the empirical evidence for high suicide rates may be questionable. This study compares the rate of suicide among trained physicians, dentists, nurses, police officers and theologians with the rate among other university graduates and the general population according to sex, age and time period.

Method. Census data from 1960, 1970, 1980 and 1990 relating to education were linked to suicide as cause of death data from Statistics Norway, and followed up for the period 1960–2000, comprising 46 and 49 million person-years among men and women respectively.

Results. Physicians still have a higher rate compared with other graduates and the general population, both among males [43·0, 95% confidence interval (CI) 35·3–52·5] and females (26·1, 95% CI 15·1–44·9). Suicide rates increased steeply by age among physicians and other graduates, whereas for non-graduates the rate was highest in the 40–60 years age group. The suicide rate among female nurses was also elevated, whereas police officers seemed to have an intermediate suicide risk. The rate among theologians was low (7·0, 95% CI 2·9–16·9). The suicide rates in the 1990s were significantly lower than in the 1980s.

Conclusions. The high suicide rates among physicians and elderly graduates are of concern. The reasons why graduates are more vulnerable than others when getting older and the low rate among theologians warrant further study.

Background. The objectives of the study were to examine linkages between exposure to childhood abuse and interparental violence and the subsequent development of panic attacks and panic disorder using data gathered on a birth cohort of 1265 New Zealand young people studied to the age of 21 years.

Method. Data on: (a) exposure to child abuse and interparental violence; (b) the development of panic attacks and panic disorder; and (c) other childhood and related factors were gathered over the course of a 21-year longitudinal study.

Results. After adjustment for childhood and related factors, exposure to childhood physical abuse was associated with a significantly increased risk of later panic attack (OR 2·3, 95% CI 1·1–4·9) and panic disorder (OR 3·0, 95% CI 1·1–7·9); childhood sexual abuse was associated with a significantly increased risk of panic attack (OR 4·1, 95% CI 2·3–7·2) and a marginally significant increase risk of panic disorder (OR 2·2; 95% CI 0·98–5·0). Exposure to interparental violence was unrelated to later panic attack or disorder after adjustment.

Conclusions. Exposure to childhood sexual and physical abuse was associated with increased risks of later panic attack/disorder even after adjustment for prospectively assessed confounding factors. However, exposure to interparental violence during childhood was not related to increased risk of later panic attack/disorder after adjustment. These data suggest the need for clinicians to be aware that patients with histories of childhood physical and sexual abuse may be at increased risk for panic during young adulthood.

Background. Little is known about the long-term outcome of personality disorder traits. The purpose of this study was to investigate, in a community-residing population, the longitudinal relationship between psychiatrist-assessed personality disorder scores and global functioning 13–18 years later.

Method. A stratified random sample of residents of east Baltimore were examined by psychiatrists in 1981 and asssessed for DSM-III personality disorders using a semi-structured instrument, the Standardized Psychiatric Examination. A total of 292 persons were re-examined by different psychiatrists during 1994–1999 using the Schedules for the Assessment of Neuropsychiatry (SCAN). After completion of the SCAN, the subjects' functional status was evaluated using the Global Assessment of Functioning (GAF). The relationships between personality dimensions and follow-up GAF scores were evaluated using linear regression models.

Results. All of the personality disorder scales measured in 1981 were inversely related to functioning 13–18 years later, with the exception of narcissistic and compulsive scales. After controlling for Axis I disorders diagnosed contemporaneously with GAF assessment, schizoid, antisocial, borderline, histrionic, and avoidant personality disorder scores significantly predicted GAF scores.

Conclusions. Most dimensions of DSM-III personality disorder traits were significantly associated with global functioning after an interval of 15 years. However, only schizoid, antisocial, borderline, histrionic, and avoidant personality disorder traits had long-term effects on functioning when Axis I disorders at follow-up were controlled. This suggests that the functional effect of the other personality disorder traits may be mediated through their relationship with Axis I disorders. Future research is needed using more specific and sensitive outcome measures.

Background. Several lines of evidence indicate a role of the brain-derived neurotrophic factor (BDNF) in the modulation of eating behaviour. Therefore, alterations in the physiology of this neurotrophin may be involved in the pathogenesis of eating disorders. In the present study, we investigated serum levels of BDNF in patients with anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED).

Method. Ninety-nine drug-free women (27 with AN, 24 with BN, 24 with BED and 24 healthy controls) underwent both a blood sample collection in the morning and diagnostic and psychopathological assessments by means of structured clinical interviews and ad-hoc rating scales. Serum levels of BDNF, 17β-oestradiol, FT3 and FT4 were measured.

Results. Compared to healthy controls, serum levels of BDNF were significantly reduced in underweight AN women and in normal weight BN women, but not in overweight BED women. Changes in circulating BDNF levels were not affected by the presence of co-morbid depressive disorders. No significant correlation emerged between neurotrophin concentrations and psychopathological, nutritional, demographic and hormonal variables.

Conclusions. These findings evidentiate alterations in serum BDNF levels in malnourished patients with AN or BN, but not in well-nourished individuals with BED. Since BDNF seems to exert a satiety effect, its reduction may represent an adaptive change to counteract the decreased calorie ingestion of AN and BN individuals.

Background. This study sought to identify in white women risk factors specific to binge-eating disorder (BED) and for psychiatric disorders in general, and to compare black and white women on risk factors for BED.

Method. A case-control design was used. Participants were recruited from the community and included 162 women who met DSM-IV criteria for BED and two comparison groups of women with no history of clinically significant eating disorder symptoms. The comparison women were matched to BED women on age, education and ethnicity and divided into a healthy comparison (HC) group, who had no current psychiatric disorder, and a psychiatric comparison (PC) group, who had a diagnosis of a DSM-IV Axis I psychiatric disorder. The study sample size was determined by the group with the least members (PC), including 107 women with BED and 214 matched comparison women. A broad range of risk factors was assessed with a Risk Factor Interview and the Parental Bonding Instrument.

Results. No significant effects for ethnicity by diagnostic group were found. BED women reported higher exposure to childhood obesity, family overeating or binge-eating, family discord, and high parental demands than PC women. The combined BED and PC group scored significantly higher than the HC group on measures of negative affect, parental mood and substance disorders, perfectionism, separation from parents, and maternal problems with parenting.

Conclusions. These findings indicate that childhood obesity and familial eating problems are reliable specific risk factors for BED. Ethnicity does not appear to moderate risk for BED.

Background. The objective of this paper is to describe and conceptualize an unusual and probably rare condition: the intense longstanding desire to have an amputation.

Method. Structured interviews were conducted by telephone of 52 subjects (mean age: 48·6, range 23–77 years; 47 male, 4 female, 1 intersexed) self-identified as having had a desire to have an amputation.

Results. Seventeen per cent (n=9) had an arm or leg amputated with two-thirds using methods that put the subject at risk of death and one-third enlisting a surgeon to amputate their healthy limb. The most common reported reason for wanting an amputation was the subject's feeling that it would correct a mismatch between the person's anatomy and sense of his or her ‘true’ self (identity). None were delusional. For all but one subject age at onset was during childhood or early adolescence. For those who had psychotherapy or medication there was no change in the intensity of the desire for amputation. The six subjects who had an amputation at their desired site reported that following the amputation they felt better than they ever had and no longer had a desire for an amputation.

Conclusions. These preliminary results suggest the existence of an extremely unusual clinically distinct condition characterized by a lifelong desire to have an amputation of a particular limb. The condition is associated with serious negative consequences: amputation attempts, impairment and marked distress. Reflecting similarities between Gender Identity Disorder and this condition, the author suggests that it may be conceptualized as an unusual dysfunction in the development one's fundamental sense of anatomical (body) identity.