The current economic recession in Europe and North America has led to a renewal of interest in the possible consequences of mass unemployment for the nation's health. This annotation assesses the relationship between unemployment and one indicator of morbidity: parasuicide (non-fatal deliberate self-harm). A previously published review of the literature is supplemented by more recent research, particularly from Edinburgh and Oxford.

From protozoa to mammals, organisms have been selectively bred for genetic differences in defensive behaviour which are accompanied by differences in brain and other biological functions. Studies of twins indicate some genetic control of normal human fear from infancy onwards, of anxiety as a symptom and as a syndrome, and of phobic and obsessive- compulsive phenomena. Anxiety disorders are more common among the relatives of affected probands than of controls, especially among female and first-degree relatives; alcoholism and secondary depression may also be over-represented. Familial influences have been found for panic disorder, agoraphobia, and obsessive-compulsive problems. Panic disorder in depressed probands increases the risk to their relatives of phobia as well as of panic disorder, major depression, and alcoholism. The strongest family history of all anxiety disorders is seen in blood-injury phobia; even though it can be successfully treated by exposure, its roots may lie in a genetically determined specific autonomic susceptibility. Some genetic effects can be modified by environmental means.

Three observations challenge Kraepelin's binary view of the functional psychoses: a bimodal distribution of the clinical features of manic-depressive illness and schizophrenia has not been demonstrated; affective illness appears to predispose to schizophrenia in later generations; and “schizoaffective’ illnesses cannot be separated in family studies from either of the prototypical psychoses. The alternative concept is that psychosis is a continuum extending from unipolar, through bipolar affective illness and schizoaffective psychosis, to typical schizophrenia, with increasing degrees of defect. According to this concept the genes predisposing to psychosis have a degree of stability that ensures that the form of the psychosis tends to remain the same within families, but there is also the possibility of change, implying that the genetic mechanisms themselves are variable. It is proposed that quantal changes in the “virogene’ are due to replications within the genome (e.g. the generation of tandem repeats of the element or a component of it); that such replications occur at a critical stage (e.g. gametogenesis, fertilisation, very early embryogenesis) in the course of reproduction; and that the “season of birth effect’ reflects the operation of the mechanism responsible for these replications.

A case is presented for regarding the Attachment Dynamic as a theoretical model for hypotheses on the aetiology and management of neuroses and personality disorders. It is proposed that man has a number of natural propensities, including: (1) attaining “companionable interactions' with peers, in which competence is affirmed, self-esteem enhanced, and a state of well-being (”assuagement’) is promoted. (2) when hindered in the pursuit of interests and companionable interaction, an urge to seek support through proximity to, and often “supportive interaction’ with support-givers. (3) severe psychological distress (”disassuagement’) when support-givers cannot be induced to act effectively, with a propensity to devise defensive strategies, supplemented by psychological defence mechanisms; when maladaptive, these strategies are the source of neurotic symptoms and antisocial traits. Through these propensities, movement between companionable interaction and effective support sustains the urge to develop skills and explore interests creatively. However, this movement is hindered by the experience of repeated disassuagement and the need to maintain maladaptive defensive strategies.

Positive and negative syndromes were studied in relation to demographic, historical, genealogical, clinical, psychometric, extrapyramidal, and follow-up measures of 101 chronic schizophrenic patients. The criterion scales proved to be reliable, normally distributed, and strongly correlated with general psychopathology, but otherwise inversely related to one another. Multiple regression analysis identified sets of 4–6 independent variables that explained 74%-81 % of the scales' variance. A positive syndrome was associated chiefly with productive features, family history of sociopathy, more previous hospital admissions, and longer in-patient stay during the 30-month follow-up period. A negative syndrome correlated with deficits in cognitive, affective, social, and motor spheres, higher incidence of major psychiatric illness but less affective disorder among relatives, lower education, and greater cognitive developmental impairment. The results underscore the importance of genetic and biodevelopmental variables for understanding schizophrenic syndromes.

The priorities accorded severely disabled or disturbed long-stay patients in Regional and District planning strategies vary enormously. A scheme to cater for the needs of this group is described. The scheme includes: non-stigmatising housing; a domestic regime, daytime occupation and leisure activities offering forms of enabling and caring that foster the highest possible levels of functioning; a secure home; private and peaceful outdoor space; and graduated steps towards independence that allow for the possibility of relapse. The central concept is the establishment of a Community for people with severe difficulties in making social contacts. The importance of integrating the scheme into a comprehensive District psychiatric service is emphasised.

There has recently been an increased interest in providing relatives of schizophrenic patients with information about the illness and how to manage the patient at home, due partly to the development of psychosocial intervention programmes (which frequently include an educational component) and a consumer demand for such information in an era of community care. Studies which describe the effects of such educational programmes are reviewed, and two different models of information acquisition are contrasted. These models have different implications, in terms of outcome measures, on how educational programmes should be evaluated. Guidelines are offered for practitioners wishing to give information to relatives.

The natural history-including psychiatric symptoms, precipitating factors, onset and course of illness, and personality characteristics-of 47 social phobics, 80 agoraphobics, and 72 simple phobics was examined. The social phobia group differed from the agoraphobia group by having a lower mean age, fewer females and married members, and a higher educational and occupational status. They were less fearful generally, less obsessive, and less likely to follow a fluctuating or phasic course. There was overlap between the two groups with regard to main phobias, and they were similar with regard to adjacent symptomatology. Both the social and agoraphobia groups differed in similar and significant ways from simple phobics.

Fifty-five cases of suicide by doctors under the age of 40 were studied because of concern about deaths among anaesthetists in training. The excess mortality of doctors from suicide was confirmed, suggesting that risk factors associated with being a member of the medical profession continue to operate, although mortality for young male doctors from accidental poisoning is falling. Analysis of the branches of medicine in which the doctors were working showed no definite specialty predominance. There was a somewhat greater risk for women doctors born overseas.

Twelve women with bulimia participated in a study in which they binged and vomited on the day after hospital admission. Caloric intake, time spent bingeing and vomiting, and selfreported mood ratings demonstrated much variation from subject to subject. Both subjective and objective ratings of mood indicated that anxiety decreased more frequently and to a greater extent than depression, both during and after bingeing and vomiting. The present data, obtained in a controlled setting, tend to confirm previous information on binge episodes obtained by self-report from bulimic patients. Bingeing and vomiting episodes may provide bulimic patients with a physiological mechanism for temporarily relieving a dysphoric mood state.

The present study describes the results of a 7-month and a 15-month follow-up of 32 agoraphobic patients treated with exposure in vivo or applied relaxation. During the followup period, all patients were given self-exposure instructions. Assessments were made in three response systems-subjective-cognitive, behavioural, and physiological-at the follow-up points. The study showed overall maintenance of treatment results in all three response systems for exposure-treated patients. For applied relaxation/self-exposure, there was a relapse on Δ heart-rate at 7 months for physiologically reactive patients, but the improvement was regained at the 15 month follow-up. Furthermore, a large proportion of the total improvement occurred during the follow-up period: 36% and 22% for exposure and applied relaxation/self-exposure respectively. The proportion of patients reaching a clinically significant improvement was 50% at the end of treatment and 66% at the 15 month follow-up.

Patients attending a regional head and neck Oncology Unit were assessed for depression and anxiety (using the Leeds self-assessment scales) before diagnostic biopsy investigations. At the time of the assessments, neither patients nor investigators knew the biopsy results. Patients whose biopsies subsequently proved positive (showing the presence of a tumour) had significantly higher depression scores than those whose biopsies were negative. Differences in mean anxiety scores did not differ between groups. It is suggested that depression is part of the clinical picture of head and neck cancer.

Post-ECT blood pressure rise and its relationship to cognitive and affective change were studied in 29 depressed patients, using the Benton Visual Retention Test, the Hamilton Rating Scale for Depression, and the Leeds Self-Assessment Scale for Depression and Anxiety. No real difference was established in the Benton Test error scores before and after ECT, no correlation between rise in blood pressure and change in Benton Test error score with ECT was found, and no correlation was found between blood pressure rise and affective improvement following ECT. Previous studies which reported such correlations are not supported.

Patients who discontinued lithium after a mean of 29 ± 21 months prophylaxis were compared with a similar group who were not taking the drug; all had only been in hospital once, and satisfied DSM-III criteria for mania. During the first three months following withdrawal of lithium, significantly more patients relapsed than in the control group; after this period, the rate was identical. These findings suggest that lithium withdrawal exists as a clinical phenomenon and that a period of lithium treatment does not improve the long-term prognosis, once the drug has been stopped.

Sodium bicarbonate abuse is unusual, and rarely reported. A patient was extensively investigated at several hospitals for a recurrent hypokalaemic metabolic alkalosis; it transpired that she had been abusing sodium bicarbonate for 8 years and had gained hospital admission at will by taking large amounts. She also showed features of the Munchausen syndrome.

The Koro syndrome, a “special cultural psychiatric syndrome’, is encountered in South China, Malaysia and Indonesia, especially among people of Chinese origin. There are only eight case reports of Koro from the Western hemisphere. We present a typical primary Koro patient from Israel. Jewish cultural mores are a possible contributory factor.

A 28 year-old woman, blind since the age of two, had become anorexic at 21. She had eating problems as a child, and weight preoccupation from her teens onwards. Psychiatric admission with other anorexic patients preceded the illness. Inability to see oneself does not pretect against anorexia nervosa.

In genetically proven identical female twins, discordant for presenile dementia of the Alzheimer type, the affected twin began to dement at the age of 49, and died 15 years later; the diagnosis was confirmed at post-mortem. The surviving twin remains clinically unaffected 20 years after the onset of dementia in her sister. Environmental aetiological factors are postulated to account for this discordance.

The use of art in the context of a therapy group in a day hospital setting is described, and the literature on art and factors influencing such groups discussed.