The effectiveness of specialised work in any branch of medicine cannot depend alone on the personal and professional qualities of the entrant into the field. It demands extended and systematic training, not only in the clinical speciality itself, but also in those many disciplines that bear upon it. In the course of his or her studies, the trainee psychiatrist is expected to further his acquaintance with the relevant basic medical sciences (especially neuroscience), and with organic medicine (particularly neurology), and with the application of these to his field of study. His understanding of these and many other subjects, including genetics, biochemistry, sociology, epidemiology, and statistics, is indispensable to his professional development. Extended clinical experience will teach him something of the day-to-day applications of these studies to psychiatric practice in a wide variety of circumstances. He may also acquire knowledge of such specialised areas of work as mental retardation and forensic psychiatry. Although he will be aware of his many limitations, the well-trained consultant will draw, in his general clinical practice, upon these various fields of knowledge with a justifiable measure of confidence.

The publication of DSM-III introduced the diagnosis Post-Traumatic Stress Disorder (PTSD), thus providing, for the first time, a framework for studying the consequences of extremely stressful events. Previously, traumatic neuroses had attracted a wide variety of labels – as wide as the experiences that produced them. Competing explanations in psychological and biological terms have characterised the approach to these disorders, and social and legal issues have added to the confusion. In recent years, psychosocial issues have tended to dominate the literature in relation to PTSD. While acknowledging the importance of such phenomenological and psychosocial approaches, this paper seeks to redress the balance by focusing on a biological perspective.

Recent surveys indicate that the frequency of assaults on psychiatric staff by in-patients has increased substantially over the past decade. With patient assaultiveness becoming of greater concern, the need to predict, anticipate, and avoid confrontations with potentially assaultive patients has grown. Regrettably, the vast majority of studies examining the nature, correlates, and predictors of in-patient assaultiveness suffer from methodological problems that limit the validity of their findings.

Three groups of neuropsychiatric out-patients, homogeneous according to parameters of violent behaviour, were identified in a previous study using a cluster analysis procedure and compared in this study on psychometric variables. These groups were (a) a group manifesting frequent, impulsive violence (n = 35), (b) a non-violent group (n = 57), and (c) a group whose violent behaviour was much less frequent and severe than in the first group, and more provoked (n = 31). Impulsively violent patients showed language and visual-perceptual deficits, but no other neuropsychological or intellectual deficits. The MMPI F, K and Ma and MacAndrews Alcoholism scales and a perceptual organisation factor derived from the Holtzman Inkblot Test significantly discriminated groups. Results of this and the initial study have implications regarding psychological aspects of aggression and underlying biological mechanisms.

A survey of all admissions of patients under the age of 65 during the first 6 years of a District General Psychiatric Department without mental-hospital support is reported. Three high-uptake groups of in-patients were defined; the long-stay (12 months or more), the medium-stay (6–12 months), and the revolving-door group (more than three admissions in any period of 12 months). Identifying characteristics which distinguish between these groups were examined. During a 7-year period there was no accumulation of long-stay patients, and a striking lack of schizophrenic patients who remained in hospital for more than 6 months or who had more than three admissions in any twelve-month period. This was not accounted for by drift of the high-uptake groups out of contact with the service, but may be related both to the style of service provision and to the socially cohesive nature of the area under study. Local variation should be given due importance when community services are being developed.

A Republic of Ireland national survey of electroconvulsive therapy (ECT) showed wide inter-hospital variation in ECT rates. Psychiatric admission rates, professional attitudes, and patient turnover were found to predict these rates. No significant association was found between ECT rates and public/private care or other socio-economic factors. A limited examination of British admission data revealed a similar set of correlations, suggesting that the findings may apply in non-profit health-care systems outside the Republic of Ireland.

The clinic attendance of 100 consecutive referrals to child psychiatry is described. Only 47 cases ended in agreed discharge. Different factors were found to be associated with attrition at different stages in the treatment-uptake process. Of referrals offered an appointment, 16% failed to attend at all; this was significantly associated with parents being against referral. Of cases offered a subsequent appointment, 40% dropped out. Continued attendance was associated with a presenting problem of general anxiety and with consultation to the referrer. Dropping out was associated with parents who were separated.

The Geriatric Mental State Examination (GMS), a standardised psychiatric interview, and its computerised diagnostic system, AGECAT, have been applied to a large (1070) sample of subjects aged over 65 in Liverpool. In a split-half study of this sample, diagnostic scales within the GMS and a diagnostic index derived from them were tested for efficacy in cases of organic and early organic illness (mostly various stages of dementia) and depressive illness. Results demonstrated high levels of sensitivity and specificity, and positive predictive values were within the expected range when applied to these disorders, given their low prevalence in the community. The GMS, when used in this way, is a flexible and effective case-finding instrument.

Cognitive decline in a sample of 64 elderly people was assessed by a standardised informant interview dealing with changes in memory and intelligence which had taken place in the previous 10 years. Scores from the interview were found to correlate (r=0.74) with the Mini-Mental State Examination. Moreover, the informant interview was found to be less affected by pre-morbid ability than the MMSE. Direct assessment of decline by informants may be a solution to the problem of contamination by pre-morbid ability which affects traditional cognitive screening instruments.

A prospective multi-agency survey of problem drug use associated with illicit drugs and solvents in the city of Bristol in 1984–1985 found 759 problem drug users, giving a period prevalence rate of 0.4–0.8% of those aged 10–44 years. The group was a young one, with 92% under the age of 35. Over half had problems associated with opiates, mainly illicit heroin; 17% had problems associated with solvents, 9% with cannabis, 13% with stimulants, mainly illicit amphetamine, and 3% with hallucinogens. There was little indication of problematic use of barbiturates or cocaine. The problems associated with drugs and solvents were wide-ranging and not specific for individual drugs. Future community surveys would find it cost-effective to concentrate on the five best sources identified here, and to supplement these with indications of drug-taking among teenagers. The difficulties of using the definition of problem drug use for research and the value of case-register surveys for community drug monitoring are discussed.

Of 336 newly referred neurotic patients, 80 were not offered continuing psychiatric treatment. The factors associated with patients' not being offered continuing treatment were: short duration of illness; history of alcohol abuse and/or deliberate self-harm; age over 50 years; being widowed; and living more than 20 miles from the main hospital complex. The implications of these findings are discussed.

Therapeutic factors operative in in-patient and out-patient therapy groups were compared. These settings differ greatly, both in terms of the patient population they serve and the overall systems within which they operate. The study revealed significant differences between the therapeutic factors operative in these two settings, and suggested that clinicians should modify their techniques for running psychotherapy groups across settings, to take account of these findings.

Eighty-four chronic phobic patients were randomly assigned to self-exposure in vivo instructed by either a psychiatrist, a computer or a book; mean therapy time per patient was respectively 3.1, 3.2 and 0 hours. Seventy-one patients completed treatment. All three groups improved substantially and similarly to 6 months follow-up, with no significant difference between them; self-exposure treatment was effective even without therapist contact. Among the three groups, initial expectation of help and positive attitude to the psychiatrist were equally high and related to subsequent rating of help received. All three groups rated the psychiatrist as more tolerant, reliable, and understanding than the computer or book, but these attitudes did not relate to outcome, were initially similar among all three groups, and changed minimally at 6 months follow-up.

Illness phobia and hypochondriasis can be associated with severe disability and requests for reassurance. Exposure to illness cues and prevention of reassurance produced rapid improvement in both health anxiety and in social functioning. Our uncontrolled results warrant a controlled prospective trial with follow-up.

Eight chronic psychiatric in-patients with polydipsia, and polyuria, up to 22 litres per 24 hours, were studied by frequent timed body weight and urine volume measurements, and episodic plasma electrolyte estimations. During the day they all showed irregular water retention, with hyponatremia in proportion to the weight gain. During the night they always lost water and weight, returning to their individual lowest weights and to normal plasma sodium. Measurement of weight in chronic psychiatric patients can be used to identify patients with significant polydipsia, to monitor those with the disorder and permit targeted fluid restriction, and to assess the efficacy of treatment procedures such as medication.

Post-ictal psychoses have so far received little attention. The clinical details of 14 cases, diagnosed according to newly formulated criteria, were examined. Psychoses were usually precipitated by a run of seizures and occurred after a lucid interval. The seizures were partial complex with secondary generalisation in 11 cases. Catego analysis of the Present State Examination confirmed pleomorphic phenomenology. Follow-up details were available in all cases, for up to eight years. Psychoses tended to recur. Similarities with chronic epileptic psychosis are discussed, and a possible organic aetiology for post-ictal psychosis is proposed.

To determine whether tardive dyskinesia (TD) is a single abnormal movement syndrome or multiple syndromes involving different anatomical areas, we examined 228 out-patients diagnosed with TD at the Connecticut Mental Health Center in New Haven. Application of factor analysis to the seven anatomical severity scores of the Abnormal Involuntary Movement Scale yielded three statistically independent factors involving abnormal movements primarily of the jaw-tongue, face-lips, and extremities-trunk. Using logistic regression to predict the severity of these factors, we found that the severity of the orofacial scores was positively associated with age, schizoaffective or affective disorder, and living alone, while severity of non-orofacial movement was positively associated with current neuroleptic dose, non-use of psychiatric medication, and living alone. Our findings suggest that orofacial and non-orofacial dyskinetic movements may involve distinct clinical syndromes of TD, each having a different set of prognostic and, possibly, aetiological determinants.

Depressed patients were carefully matched in pairs with normal subjects for the variables which are known to influence the secretion of melatonin in humans. In contrast to the previous literature, nocturnal melatonin secretion was not lower in the depressed group than in the normal group, and there was no difference in the timing of secretion; indeed, the trend was for greater melatonin secretion in the depressed group. The results are discussed in relation to previous studies, none of which has been so carefully controlled for the relevant variables.

My title points to the basic paradox: if it is psychotherapy, can it be supportive? If it is supportive, can it be psychotherapy?

A case is described of a patient with Turner's mosaic (XO/XX) associated with anorexia nervosa. The cases described in the literature point towards the multifactorial aetiology of anorexia nervosa, emphasising factors other than the suppression of sexuality.