Battles have always been a feature of psychiatry, and the traditional hegemony of the hospital has been contested particularly often. Mosher (1983) has made one of the most recent major incursions into enemy territory on behalf of the community care guerillas, in a paper in the New England Journal of Medicine.

It is now generally agreed that the words ‘handicapped individual’ need to be considered as having a social rather than a medical or educational meaning. To arrive at such a conclusion, however, it is necessary briefly to consider the words ‘impairment’, ‘disability’ and ‘handicap’ (Figure 1).

Thirty five claimants with accident neurosis, in which there were gross perplexing somatic symptoms without demonstrable organic pathology were traced and followed-up in their homes, from one to seven years after compensation was received. Few claimants recovered and such recovery as did take place was unrelated to the time of compensation. Family processes leading to over-protection by relatives were examined and appeared to be vitally important in the prolongation of symptoms. The legal process and the delays involved caused great distress.

Nuclear magnetic resonance (NMR) imaging of hydrogen in body water and fat is proving valuable in clinical investigation of the brain. An introduction to the technique and to the biological significance of the images is presented here. The ‘multi-parameter’ nature of these images is stressed, and the individual parameters described. NMR imaging may well be of value in investigating the pathology of organic and functional psychoses.

Proton NMR imaging of the brain is rapidly becoming established as a useful investigative tool in medicine. This paper examines the usefulness of the NMR parameters—spin-lattice relaxation time (T1) and proton density (PD)—in differentiating groups of patients with senile dementia of Alzheimer type (SDAT) and multi-infarct dementia (MID) from each other, and from elderly controls. T1 values increase with severity of dementia. NMR parameters may also be of use in localising regions of brain damage.

The outcome in patients receiving long-term in-patient care for manic-depressive psychosis was compared with that in long-stay schizophrenic in-patients and discharged schizophrenic patients. The manic-depressive and schizophrenic in-patients differed in terms of positive and negative features and in the pattern of behaviour, but were equally cognitively impaired. The pattern of behaviour in both schizophrenic groups was the same. The results offer some support for the use of outcome as a validating criterion for the diagnosis of schizophrenia.

The incidence of serious psychiatric illness, as measured by first referral to hospital for specialist advice and treatment, has been investigated among 16,746 women taking part in the Oxford Family Planning Association contraceptive study. Of these women, 9,504 were recruited while using oral contraceptives, 4,144 while using a diaphragm and 3,098 while using an intrauterine device.

The results are reassuring with respect to oral contraceptive use. First referral rates per 1000 woman-years of observation in the oral contraceptive, diaphragm, and intrauterine device entry groups were 3.0, 2.6, and 2.8 respectively for non-psychotic psychiatric disorders and 0.46, 0.43, and 0.53 respectively for psychotic disorders.

Attempted suicide occurred only 40% as often amongst diaphragm users as amongst users of oral contraceptives or intrauterine devices; this finding presumably reflects the characteristics of women who choose the diaphragm as their birth control method.

The first three and a half years' operation of a psychiatric intensive care unit, based on the general hospital model, is described. This eight-bedded ward focusses on the treatment of the most acutely psychiatrically ill patients, and not on the forensic or custodial aspects of such units previously described. It has gained general acceptance within the setting of a state psychiatric hospital, and has received 1132 admissions since its inception. Demographic, clinical, and treatment data are presented and the advantages and disadvantages of the unit are discussed.

We propose a new scoring for Goldberg's (1972) General Health Questionnaire. We argue that the response ‘no more than usual’, to an item describing pathology, should be treated as an indicator of chronic illness rather than of good health, and we score these responses accordingly. We give evidence that this set of responses is associated with other measures of neurotic illness, and that the revised scoring provides a better prediction of caseness than the conventional scoring. The revised scoring is more strongly associated with trait neuroticism, and is more stable in repeated measurement. It is recommended in preference to the conventional scoring for most research and epidemiological purposes.

All X-rays requested by psychiatrists in-training during 1982 and performed by the Department of Radiology of a large mental hospital were analysed. Forty-five per cent of all requests were marked routine, and the majority of these were for chest X-rays; only 4% of these revealed significant abnormality and no patient under the age of 55 had a significant abnormality on routine chest X-ray. All routine skull X-rays were normal. One-third of the long-stay hospital population accounted for one-quarter of the overall workload of the department. It is recommended that: requests for routine skull X-rays be abandoned, and that routine chest X-rays for patients below the age of 55 be restricted to high-risk groups such as immigrants, those on steroids, etc. The financial implications of such a policy are discussed.

This study describes a group treatment of bulimia using an adaptation of Fairburn's (1981) cognitive behavioural approach. Thirteen bulimic women with a self-reported average of 24 self-induced vomiting episodes per week were treated in two groups; each group met once a week for 16 weeks. The primary outcome measure was the number of self-reported vomiting episodes; pre- and post-treatment measures of eating attitudes, depression, assertiveness, and global level of psychological distress were also evaluated. Vomiting frequency decreased to an average 2.2 times per week (a 91% improvement) with seven patients abstinent by the end of treatment. Significant pre- to post-treatment changes were also demonstrated on measures of depression, eating attitudes, and assertiveness. Six-month follow-up data on 11 patients indicate a mean vomiting frequency of 3.8 per week; six patients maintained their progress. Although Fairburn had greater success using an individual cognitive behavioural approach, the results of the present study are promising for the development of a cost-effective treatment.

A point-prevalence study in South-west Scotland found that 0.77 per 1,000 of the total population were receiving lithium. Almost one quarter had done so for more than ten years. At the time of lithium commencement, only 68% had always been diagnosed as having an affective illness; 59% of the patients were also receiving antidepressants, major tranquillisers, or both. Though this might be due in part to unnecessary administration of supplementary drugs, 19% of non-inpatients had moderate depressive symptoms, significant depressive illness, or manic symptoms. Lithium side-effects were prominent: 30% of the sample complained of weight gain, thirst or excessive micturition; 42% had noticed hair changes; and 7% had diminished thyroid activity, but most patients believed they had benefited considerably from lithium therapy.

In a longitudinal study in South-west Scotland of patients suffering mainly from affective illness, the introduction of lithium as prophylactic therapy was associated with a significant reduction in the number and length of hospital in-patient admissions, as well as in the number of courses and total number of electro-convulsive treatments. However, there was no significant reduction in the length of time patients received either antidepressants or major tranquillisers. A rating of individual patients suggested that a bare majority (52%) had improved considerably following the introduction of lithium.

A review in South-West Scotland of all patients prescribed lithium for the first time during the years 1972–82 showed that on average, 12 per 100,000 of the general population start this drug each year. By the end of the period, lithium had been stopped in 58% of patients; the most common reason for discontinuation was the development of side-effects, of which tremor was the most frequent. In only 15% was lithium stopped as it was considered no longer necessary; 44% of patients discontinued lithium within one year of starting it.

Behavioural changes have often been noted in patients with epilepsy. This study investigated the converse phenomenon—the occurrence of transient sensory, cognitive and affective changes resembling those described by epileptics, in affectively ill patients. Forty-four patients with affective illness, 37 with complex partial seizures, and 30 hypertensive controls were interviewed to determine the lifetime occurrence of these phenomena. Such symptoms occurred frequently in association with episodes of affective illness and epilepsy, but were rare in controls. Visual, auditory, olfactory and epigastric symptoms, illusions, jumbled thoughts and amnesia were common to both epilepsy and affective illness. Greater numbers of symptoms were associated with better response to lithium and tricyclic antidepressants. Transient sensory, cognitive, and affective phenomena may be more common in affective illness and other psychiatric conditions than is generally recognised, and may be clues to the underlying pathophysiology of these conditions.

The consistency of de Clérambault's syndrome and its relationship to other diagnostic labels is examined in terms of operational criteria derived from the original description of the syndrome. Five new cases of erotic delusions are examined, and 53 cases reported in the recent literature are reviewed; none of these completely satisfies the diagnostic criteria, while the majority of patients actually suffered from another disorder, most commonly schizophrenia. The justification for the retention of the syndrome as a nosological entity is discussed, and it is argued that the term should be seen as principally of historical interest.

Ekbom et al (1972) described dystonic syndromes that appeared as a side-effect to treatment with the butyrophenone group of neuroleptic drugs. These symptoms consisted of tonic flexion of the trunk to one side, accompanied by its slight rotation, in the absence of other concomitant dystonic symptoms. They called this the ‘Pisa syndrome’. A literature survey of neuroleptic-included extrapyramidal side-effects gave little reference to this syndrome (Sovner & DiMascio, 1978; Berger & Rexworth, 1980), but two cases that fit the description of this side-effect are presented here.

In 1952 Eysenck threw down the gauntlet, when he claimed that psychoanalytical forms of psychotherapy were no more effective than spontaneous remission. As we trudge through the fourth decade of this debate, its quality remains as divisive and acrimonious as ever. Professor Michael Shepherd (1979, 1980) has latterly taken on Eysenck's mantle, averring that psychotherapy is not only ineffective but may actually harm patients. In an editorial in the British Medical Journal (1984), he launched yet a further attack, arguing on this occasion that the psychotherapist is little more than a ‘placebologist’ exerting his effects through nonspecific means. Why bother with highly trained therapists when an inert pill will produce the same result?