The advent of new imaging techniques is broadening our understanding of the major psychiatric illnesses. The increased knowledge of brain function will have consequences for the expert medical witness who has to give evidence in court. Both the insanity defence and the defence of automatism depend on disorders of the mind. Psychiatry is now able in many cases to produce evidence that these are consequent upon disorders of the brain. In presenting evidence in court there is an apparent conflict between ‘brain words' and ‘mind words'.

Although both lithium and triiodothyronine (T3) augmentation strategies may be rapid, safe, and effective ways of treating patients who fail to respond to tricyclics, little is known about the clinical or biochemical correlates of response. We examined clinical and endocrine variables which distinguished T3 and lithium responders from each other and from non-responders in a post-hoc analysis of two studies involving 51 subjects who had received these augmentation strategies under double-blind conditions. Lithium non-responders were more severely depressed and had more insomnia and weight loss than responders. T3 responders could be distinguished from lithium responders by greater weight loss. There were no reliable clinical differences between T3 responders and non-responders. Thyroid function tests did not differ between any of the treatment or response groups. Our findings suggest that clinical but not endocrine variables may distinguish responders to these two augmentation strategies.

In a two-year longitudinal study, a two-stage screening procedure was used to identify subjects in primary care with emotional disorder presenting with a recent onset of physical symptoms and a comparison sample of patients presenting with physical symptoms only. Somatisers (n = 44) were defined as subjects who had an emotional disorder but who presented with physical symptoms that could not be attributed to organic disease. The course and outcome of these conditions were compared with those of pure emotional disorder (n = 11), pure physical disorder (n = 90) and ‘mixed’ conditions (n = 39). The physical symptoms of somatisers were less likely to improve and lagged behind those of the other groups, and 16 of these acute somatisers went on to develop chronic somatoform disorders. Among somatisers, changes in physical symptom levels throughout the follow-up closely mirrored changes in emotional arousal. Emotionally disordered subjects reported more instances of parental lack of care, but somatisers were also more likely than other groups to report parental physical illness and to have had more physical illness themselves in childhood. A logistic regression suggests that adult somatisation is best modelled by parental lack of care followed by childhood illness.

The prognosis of depression in the elderly was investigated in a mixed-age sample of 242 consecutive referrals, with DSM-III defined unipolar major depressive episode, to a specialist unit for mood disorders. Subjects were followed up at about 1 and 3.8 years. There was no significant difference in outcome between younger (under 40 years), middle aged (40–59 years) and older (60 years or more) depressed patients. For the 61 elderly subjects with depression, prognosis improved with time, with 25% having a lasting recovery at the first and 41% at the second follow-up. Early onset, recurrence, and poor premorbid personality were associated with a worse prognosis. Three (5%) elderly depressives had committed suicide and seven (11%) had died from natural causes by the second follow-up. Despite some methodological limitations, our findings suggest a more optimistic outlook and the need for longer, more assertive treatment for elderly, depressed patients.

Single photon emission computerised tomography (SPECT) was used to measure regional brain uptake of technetium-99m hexamethyl-propyleneamine oxine (Tc99m-HMPAO) in elderly patients with Alzheimer's disease (AD), multi-infarct dementia (MID) and normals (n = 20 in each group). Different patterns of uptake were found between groups when cortical uptake was normalised to cerebellar uptake. Reductions occurred in all regions in AD, being most marked in temporal and posterior parietal areas. Significant correlations were found in AD between memory impairment and decreased temporal uptake bilaterally, and between duration of illness and reduced uptake in most brain regions. MID patients showed higher uptake in the anterior parietal region than did the other groups. A variable comparing anterior to posterior uptake significantly discriminated the two patient groups.

Patients with newly diagnosed schizophrenia (n = 27) or schizophreniform disorder (n = 22) and 24 healthy volunteers were investigated by CT scan, the investigators being blind to subject status. The patients had never received medication or had been treated only briefly with neuroleptics. The patients had significantly smaller brain volume and brain length than the controls. The patients had greater sulcal enlargement in the case of both Sylvian and interhemispheric fissures and surface sulci in the frontal and parietal regions. The sulcal enlargement was more pronounced in male patients and on the left hemisphere. The study revealed no enlargement of the lateral ventricles and only a trend towards enlargement of the third ventricle in the patients. The findings were not explained by substance abuse or level of education.

The lifetime geographical mobility of a group of 67 patients suffering from schizophrenia was investigated and related to the ecological structure of the city of Nottingham, where they first presented between 1978 and 1980. The study aimed to investigate the processes leading to a threefold rate of schizophrenia in the most socioeconomically deprived area of the city compared to the area of least deprivation. Results suggest that this skewed distribution begins early in the lives of the patients and is well established at least five years before initial contact with the psychiatric services.

Age-standardised rates were calculated for first admissions to hospital in Scotland with ICD-9 diagnoses of schizophrenia, affective psychoses, paranoid psychoses, reactive psychoses and depressive neuroses (ICD-9 295, 296, 297, 298 and 300.4) for the period 1969–88. First-admission rates for schizophrenia declined by an average of 3.3% per year in males and 4.4% per year in females over the period. The first-admission rate in males in 1988 was 8.4/100 000 (57% of 1969 rate) and in females was 4.8/100 000 (43% of 1969 rate). Rates for depressive neuroses, affective psychoses, reactive psychoses and combined psychoses also fell. Rates for mania rose, as did those for paranoid states in males. The decrease in first-admission rates is likely to reflect a true decrease in the incidence of schizophrenia over the period. The decline was unlikely to be accounted for by diagnostic change because there was no reciprocal increase in any other diagnosis sufficient to account for the change, and the rates for combined psychoses also decreased. There was evidence that rates for schizophrenia declined to a greater extent in younger age groups, especially in females. This could imply the presence of a birth cohort effect.

Recent reports that some influenza epidemics may be followed by a transient increase in the births of schizophrenic patients have led to the hypothesis that maternal viral infections contribute to the aetiology of schizophrenia. It is well known that respiratory viral infections are frequently brought into the home by young children. We tested the predictions that the risk of schizophrenia is decreased in first-born children, and increased in individuals who had siblings of a young age while in utero, using data from a Swedish family study. Our results are consistent with these predictions. In particular, having siblings three to four years older was associated with a significantly increased risk of schizophrenia, even after allowing for birth order, sibship size, and other potential confounders. If replicated, these results provide indirect support for the maternal viral infection hypothesis, although there are alternative explanations.

Remand prisoners diagnosed as psychotic by Holloway's psychiatrists were followed up to time of sentence. Most were referred to outside psychiatrists and then offered beds. Courts invariably enabled the beds to be used. Few women had committed serious offences, and most had been remanded because the courts thought they needed help. The study showed custodial remands to be an unsatisfactory way of seeking treatment for psychotic offenders. Alternatives need to be developed urgently. For psychotic people who continue to be remanded in custody, transfers rather than court orders should initially be used to effect admission.

Non-psychotic remand prisoners who were referred by Holloway's doctors to outside psychiatrists, or who were the subject of court reports, or who were diagnosed as mentally handicapped, were followed up to the time of sentence. Most of the referred women were minor offenders with diagnoses of mental handicap or personality disorder. They were usually refused beds on treatability criteria and then released with non-custodial sentences. Some were highly disturbed, and it seemed that the police who charged them, the courts who remanded them and the prison psychiatrists who referred them, all found it hard to accept that psychiatry had so little to offer these people. Local health and social services need to address the problems raised by this small group of women. Arsonists more often obtained beds than minor offenders, and were likely to be imprisoned when hospital places were not forthcoming.

One hundred and sixty-two women were evaluated for psychiatric morbidity in the second trimester of pregnancy and also six to eight weeks postnatally. A sizeable proportion of the women also had a second prenatal assessment in their third trimester and in the lying-in ward shortly after giving birth. Assessments were conducted with the 28-item GHQ. This was initially validated using a subsample of 106 women, taken from the original group, who were interviewed with the PAS. Thirty per cent of the women were ‘cases' at the first prenatal assessment, while only 14% were ‘cases' six to eight weeks postnatally. Thus, even though there was an overlap between prenatal and postnatal morbidity, there was also substantial difference between the groups that were symptomatic at both periods. This observation was reinforced by the low correlation between the mean GHQ scores at both periods. Both prenatal and postnatal morbidities were associated with recent adverse life events, with the latter more likely to be associated with marital and family events. This observation is in support of the view that neurotic problems, prenatally or postnatally, are caused mainly by psychosocial factors.

The aim of this study was to establish the prevalence of current and past psychiatric morbidity in HIV seropositive asymptomatic subjects belonging to three transmission categories (gay men, intravenous drug users, and heterosexuals) compared with that found in HIV seronegative controls from the same groups. A cross-sectional, controlled study including 279 seropositive subjects belonging to groups II and III defined by the Center for Disease Control (94 gay men, 157 intravenous drug users, and 28 heterosexuals) and 159 seronegative subjects (38 gay men, 91 intravenous drug users, and 30 heterosexuals) is reported. Outcome measures included standardised, self-report questionnaires and a semistructured interview to assess current psychopathological status and past psychiatric history. In addition, a psychiatric diagnosis according to DSM-III-R criteria Axis I and II was made in the seropositive subjects. Results showed that these subjects differed very little from the controls and that overall levels of psychiatric disturbances in both groups were low and similar to those found in other life-threatening illnesses. Furthermore, intravenous drug users, regardless of HIV serological status, had the highest levels of psychological morbidity. Psychosocial distress was associated with previous and current lifestyle, independently of HIV status.

There is a perceived need for schools and casualty departments to receive appropriate information and guidelines in order to minimise the effect of PTSD. A recommended screening battery for PTSD was administered at the start of a two-session debriefing group and again three months later to a group of seven young survivors of a minibus accident. No studies using this screen other than those of shipping disasters have been reported to date. Screen scores were compared with those of survivors of the cruise ship Jupiter. No significant differences were found between minibus survivors when assessed at six months (before intervention), and Jupiter survivors, who when assessed at five months had already undergone debriefing. Post-debriefing assessment of minibus survivors demonstrated significant reductions on all measures.

“A higher than expected number of violent deaths and suicides in coronary prevention trials has provoked interest in the possibility that low serum cholesterol concentrations are associated in the general population with personality characteristics predisposing to aggressive and suicidal behaviour. We have investigated this possibility in the Edinburgh Artery Study. We measured serum lipid concentrations in blood samples taken from fasting subjects and assessed personality characteristics on the Bedford Foulds Personality Deviance Scales in a random sample of 1592 men and women aged 55–74 years, selected from age-sex registers of ten general practices in Edinburgh. Serum cholesterol concentration was not significantly associated with aggression in men, but it was associated in multivariate analysis (though not univariate analysis) with denigratory attitudes towards others among women. However, serum triglyceride concentration was related, especially in men, to hostile acts (r = 0.13, P < 0.001) and domineering attitude (r = 0.12, P < 0.001) independently of age, total and HDL cholesterol, cigarette smoking, and alcohol consumption. Subjects taking part in prevention trials have higher triglyceride concentrations than the general population and the relation between serum triglyceride concentration and aggression merits further investigation.”

Twenty-two schizophrenic patients (DSM-III-R criteria) with clinically significant akathisia were matched with 22 schizophrenic patients without akathisia on the following variables: age, sex, diagnosis, duration of illness, and current treatment. Both groups were assessed using a variety of clinical rating scales and several parameters of serum iron status. The akathisic patients showed greater severity of clinical psychopathology, particularly positive symptoms, and an excess of extrapyramidal side-effects. We were unable to confirm any association between low serum iron and neuroleptic-induced akathisia in our sample of community-based patients.

The incidence and nature of state-dependent pain were investigated in 43 consecutively presenting patients with recurrent autumn/winter episodes of major depression followed by spontaneous recovery in the spring. Twenty-two (51.2%) experienced state-dependent pain, which appears to be a common concomitant of wintertime depression.

The handedness in three randomly sampled groups of people with learning disabilities consisting of patients with Down's syndrome, epilepsy, and autism were studied using a validated instrument. All subjects were controlled for neurological and other medical disorders. A statistically significant increase in left-handedness and ambiguous handedness compared with the general population was found in all groups. There was no significant difference in the rate of left-handedness between the three groups.

A 42-year-old mentally handicapped woman presented with symptoms of affective disorder which resolved completely on excision of a colloid cyst of the third ventricle.

A first episode of mania is described in a previously healthy man who was partially sleep deprived for four nights. The sleep deprivation preceded the psychosis. During the psychotic episode he believed that he was the Messiah. This case is discussed in the light of reports exploring the relationship between psychosis and sleep deprivation.