One week after Sir William Gull read his seminal report on anorexia nervosa to the Clinical Society of London, a brief account was published (Anonymous, 1873). In Paris, Charles Lasègue, editor of Archives Générales de Médecine read the report and printed an immediate editorial riposte, parts of which will be quoted in this communication.

Eight patients with endogenous depression who had received no antidepressant treatment for the previous year were treated with the noradrenaline (NA) uptake inhibitor, desipramine (DMI). Pre-treatment plasma melatonin concentrations were normal. After one day of DMI treatment plasma melatonin concentrations were increased but the response was impaired compared to normal subjects. The acute effect of DMI on plasma melatonin persisted after six weeks of treatment. These findings question the hypothesis that beta adrenoceptors are supersensitive in depression and that antidepressant drugs act by down-regulating these receptors.

Several authors have reported attenuated adrenocorticotropin hormone (ACTH) responses to corticotropin releasing factor (CRF) administration in melancholic patients as compared with healthy controls. In order to explore the integrity of the hypothalamic–pituitary–adrenal (HPA)-axis in melancholics, we examined the following parameters in 98 subjects: the ACTH; β-endorphin; and cortisol responses to ovine CRF (oCRF) (100 μg/i.v.); and the postdexamethasone cortisol values. We found significant lower CRF-induced ACTH responses in melancholic patients as opposed to healthy controls and minor depressives, while major depressives occupied an intermediate position. The psychopathological correlates of the blunted CRF-induced ACTH responses were feelings of worthlessness, self-reproach, or excessive guilt. The CRF-stimulated β-endorphin and cortisol response did not differ between the study samples. Higher baseline plasma cortisol was associated with attenuated CRF-induced ACTH responses, but these effects were not pertinent to melancholia. There were no relationships between the disordered oCRF test results, and postdexamethasone cortisol values, age, body size, sex and severity of illness. The diagnostic power of the oCRF and the dexamethasone suppression test for melancholia is enhanced when both test results are combined.

Three hundred and twenty-six consecutively admitted patients with functional psychotic illnesses to which no diagnostic classification had been applied were followed up after 2·5 years. They were examined in social, clinical and psychological terms and the CATEGO programme and DSM-III criteria were applied to data concerning the index episode to derive diagnostic classifications. The deterioration in occupational functioning and the hospital careers of patients with diagnostic classifications of schizophrenia were worse than those in the other groups and positive and negative features were also more severe in patients with a classification of schizophrenia. By contrast, no differences in psychological test performance were found between the groups based upon diagnostic classification. Impaired psychological test performance was found and it was strongly related to concurrent mental state abnormalities, particularly negative symptoms. It is concluded that the diagnostic classifications used were of limited value in predicting outcome in functional psychosis.

The schizophrenic patient's early psychological response to neuroleptic treatment has been demonstrated to be a significant predictor of treatment response. The validity of the construct of subjective response is evaluated by comparison of two measures. Fifty-five recently admitted and unmedicated schizophrenic patients were randomly allocated to chlorpromazine or haloperidol. Subjective responses at 24 and 48 hours as assessed by two different scales, the Van Putten & May scale and the self-administered Drug Attitude Inventory, were strongly correlated with outcome at three weeks. Early emergence of extrapyramidal symptoms was not related to subjective response, but dysphoric patients had a greater incidence of EPS by the end of treatment than did non-dysphoric patients. The two measures showed high concordance in identification of early drug dysphoria.

Schizophrenic subjects performed significantly worse on neuropsychological tests of frontal lobe function but not on tests of non-frontal lobe function when compared to a matched group of normal subjects. Correlations expected between frontal lobe neuropsychological test performance and negative symptoms were not found.

Using the Scale for the Assessment of Negative Symptoms (SANS), affective blunting, alogia, and attentional impairment were assessed in 30 manic patients with chronic impairment of inter-episode instrumental functioning and 85 chronic schizophrenic patients. The schizophrenic patients had markedly higher ratings on all three negative symptom dimensions. When negative symptoms were examined categorically, no manic patient was rated to show prominent affective flattening or alogia. This relative specificity may not apply to attentional impairment which was rated as prominent in 17% of the manic patients and in 55% of the schizophrenic patients.

More than a decade ago, a series of retrospective studies examined the concordance between proliferating definitions of severe psychiatric disorder. The European response has been a polydiagnostic one, which has attempted to maintain interest in a broad range of psychiatric phenomena in the psychoses. In North America a more convergent approach has emerged, resulting in a series of operational definitions evolving from one another, and a correspondingly limited capacity to allow alternative perspectives to co-exist. The present study uses a prospective design as well as recent improvements in the clinical validity of psychopathology assessment to re-evaluate the relationships between competing concepts of psychotic illness in a broad sample (N = 176) of recent-onset psychotic patients. In the schizophrenic group, concordance was predictably highest among recent North American ‘cousins’, and lowest among various historical concepts. There was a moderately high concordance between selected schizoaffective and atypical psychosis definitions, indicating that this component is an important area for further studies of descriptive validity. These interrelationships may be used as a starting point to explore latent classes underlying the phenomena of functional psychosis.

Co-morbid substance use and abuse is common in schizophrenic patients, and the role of substance abuse in initiating and maintaining psychosis has important definitional and aetiological implications. We investigated the issue in a cohort of 131 schizophrenic patients. We found non-users (N = 67) were similar to pathological users (N = 64) in current symptomatology and clinical history. The pathological users did, however, have better pre-morbid adjustment levels. Only alcohol use and to some extent cannabis use contributed to this effect; use of stimulants or hallucinogens did not. These results indicate the importance of evaluating the various types of substance used when attempting to explore the significance of co-morbidity. The results also suggest that co-morbidity of substance abuse and schizophrenia may be explained by a common factor antecedent to both: better pre-morbid adjustment. A two-stage model is proposed to explain these findings: increased sociability increases exposure to opportunities of substance use in a subset of patients; subsequent onset of psychotic illness accelerates the use to a pathological level as the individual attempts to cope with the stress of the developing mental illness.

This paper describes the second stage (years 4, 5 and 6) of a prospective follow-up of a sample of chronic patients which was designed to investigate the in service use. It also tested the relative predictive power of variables which included demographic, symptomatic and behavioural factors as well as a novel reaction time variable which reflects response processing time.

During the six years of the study 91% of the patients in the sample changed either the degree of their day and/or night care. Many moved to more independence but, a number did also become more dependent on psychiatric services. There were no differences in outcome between a schizophrenic group and patients with other diagnoses. These results suggest a level of flexibility in outcome even in a severely disabled chronic group.

The main predictor of future service use at each stage of the follow-up for the whole group was chronicity at entry to the study. But, when the group was divided into schizophrenic patients and ‘others’, the response processing measure was a significant predictor of service use in the schizophrenic group and accounted for between 17% and 30% of the variance. For the ‘other’ diagnostic group, the age of the patient seemed to be the major determinant of care.

The reaction time variable seems to be an extra class correlate of a strict diagnosis of schizophrenia. It may also be a stable or episodic vulnerability factor, but as well as these promising hypotheses, which have yet to be justified, this measure does seem to have pragmatic value in predicting outcome in a rehabilitation network.

Recent research has noted the tendency of parasuicide patients to retrieve over-general autobiographical memories. Separate studies suggest problem-solving deficits within this group.

The present study was concerned first with replicating these findings and, secondly, with developing a model of the relationship between over-general memory recall and poor problem-solving abilities in parasuicide patients. Anger and hopelessness were measured as markers for mood.

In line with the hypotheses, the parasuicide group (N = 12) produced significantly over-general memories in contrast to a matched control group (N = 12). This occurred significantly in relation to positive cues, and latency to first responses was significantly delayed in the parasuicide group. The parasuicide group also provided fewer and less-effective problem-solving strategies than the control group, and a significant association was found between low effectiveness of problem-solving strategies and over-general memory recall in the parasuicide group. Anger and hopelessness levels were significantly higher within the parasuicide group in line with previous findings.

The clinical implications of these findings are discussed.

People have jumped (or fallen) in front of trains on the London Underground system in increasing numbers throughout the twentieth century. During the past decade there have been about 100 such incidents each year, of which around 90 would involve the train driver witnessing his train strike the person on the track. Most are suicides or attempts at suicide. They represent major unexpected and violent events in the lives of the train drivers and it might be expected that some of them would respond by developing a post-traumatic stress reaction of the type identified by Horowitz (1976) or other adverse psychological reactions or both. The research reported in this paper was designed to characterize the range of responses of drivers to the experiences of killing or injuring members of the public during the course of their daily work. It was found that 16·3% of the drivers involved in incidents did develop post-traumatic stress disorder and that other diagnoses, e.g. depression and phobic states, were present in 39·5% of drivers when interviewed one month after the incident.

General methodological and design issues in research on psychosocial outcome predictors of clinical depression are discussed, and the first stage of a study of discharged depressed in-patients is presented. It involved 115 recovered and 75 non-recovered such patients who were compared regarding stress factors, social support, personality and coping styles. While there were few differences between recovered and non-recovered patients with respect to stable personality traits, recovered patients were less likely to have had severe long-term life difficulties, and their coping style differed: it was characterized by more negative appraisals of stressful situations, greater problem avoidance, less palliative activities, and a lesser inclination to solicit social support. Whereas among women without partners, as well as men, non-recovery was also associated with less support from friends, in particular psychological-emotional support in crises, non-recovered women with partners had much more such support. The results are discussed with reference to the existing literature on outcome correlates of clinical depression.

Data from a case-control study of Alzheimer's disease (AD) were analysed in relation to age of onset and familial/sporadic status. The analyses were restricted to environmental exposures which might injure the brain. Later-onset AD was found to be positively associated with starvation/malnutrition and with nose-picking and negatively with analgesics, while earlier-onset was associated with physical underactivity and nervous breakdown more than 10 years before. Sporadic AD was associated with starvation/malnutrition and with head injury. These analyses merit replication in other large case-control studies of AD.

The memory deficit in Alzheimer's disease (AD) has been characterized as consisting of multiple components. The purpose of this study was to confirm the utility of a two-process model, and to examine changes in the nature and extent of the neuropsychological deficits after a one-year interval. The results replicate the initial observation that the memory loss in AD can be described as consisting of a focal amnesic syndrome and a dysexecutive syndrome characterized by failure of rapid information processing and search of both episodic and semantic memory. One year after the initial observation, all dysexecutive patients and the majority of the amnesic patients had become non-focal. No patient developed a dysexecutive syndrome, but 18 patients developed amnesic syndromes. These results suggest that, like other aspects of the cognitive deficits of AD, the memory loss is multifactorial. These results have implications for understanding the pathophysiology of AD, and for designing pharmacotherapeutic intervention.

This prospective study of 2163 women attending a breast-screening clinic, or for a routine medical check-up, indicates that there is a statistically small but potentially important clinical link between the methods used to cope with stressful situations and breast disease.

Ninety-four patients were asked about the presence of psychiatric symptoms on admission to hospital using the revised Psychiatric Assessment Schedule. Three months later they were asked to recall their symptoms at admission using the same instrument retrospectively. The results of the initial and retrospective interviews showed good rates of agreement in terms of PAS score, ID level, psychiatric ‘caseness’ and both CATEGO and DSM-III-R diagnoses. The study demonstrates that it is possible to make reliable measurements of the mental status of three months previously, simultaneously with assessments of current mental status. The uses of such a measuring instrument are discussed.

Many of the standardized interviews currently used in psychiatry require the interviewer to use expert psychiatric judgements in deciding upon the presence or absence of psychopathology. However, when case definitions are standardized it is customary for clinical judgements to be replaced with rules. The Clinical Interview Schedule was therefore revised, in order to increase standardization, and to make it suitable for use by ‘lay’ interviewers in assessing minor psychiatric disorder in community, general hospital, occupational and primary care research.

Two reliability studies of the revised Clinical Interview Schedule (CIS-R) were conducted in primary health care clinics in London and Santiago, Chile. Both studies compared psychiatrically trained interviewer(s) with lay interviewer(s). Estimates of the reliability of the CIS-R compared favourably with the results of studies of other standardized interviews. In addition, the lay interviewers were as reliable as the psychiatrists and did not show any bias in their use of the CIS-R. Confirmatory factor analysis models were also used to estimate the reliabilities of the CIS-R and self-administered questionnaires and indicated that traditional measures of reliability are probably overestimates.