The development of the British response to ‘the drugs problem’ since the 1960s does not lend itself readily to any optimistic interpretation. The initial wave of enthusiasm for clinics during the latter years of the 1960s soon faded. The clinic system was deprived of sufficient support, and many staff became disillusioned and burnt out. Treatment and responses gradually changed, not as the result of any clearly thought-out policy, but as the result of a vague drift of views.

It is suggested that schizophrenic thought disorder comprises four relatively independent components: delusion; intrinsic thinking disturbance; formal thought disorder; and deficient real-world knowledge – a new concept. Schizophrenic and neurotic control subjects were given tests of thinking, perception, appreciation of conversational discourse, and social and practical knowledge. Not all deluded schizophrenics had intrinsic thinking disturbance. Those that did tended to have overinclusive categorisation as the most apparent deficit. Formal thought disorder was associated with a poor performance on the test of conversational discourse. The most striking result was that 75% of schizophrenic patients were markedly deficient, relative to neurotic patients, on their knowledge of everyday social issues.

The prospective monitoring of two separate groups of chronically schizophrenic patients on regular depot maintenance therapy suggests that depression developing after an interval of 1 year from recovery from an acute relapse indicates a significant increase in the risk of a further relapse within 2 years, compared with depression within the first year, or no depression. Patients with such depression were more prone to relapses than other patients, despite regular medication within normal dose ranges. The results suggest that the aetiology of depression occurring in patients after 1 year in a stable mental state is different from that of depression within the first year, and in many patients, the former represents underlying schizophrenic activity prior to an early relapse.

Voluminous data on the familial distribution of schizophrenia in Iceland were evaluated in terms of a partly dominant genetic mechanism. The risks were found in most instances to be proportional to the probability of harbouring the proposed gene, but penetrance rates, which generally are around 25%, appear to be elevated when additional risk factors are present. This occurs in individuals with multiple ill relatives, in offspring of two schizophrenic people, or in monozygotic co-twins. Excessive risks also occur in families with unusually severe disease.

Twelve women, reporting rape to the police, were interviewed on three occasions over a 4-month period. Their psychological and behavioural experiences, during that time, were compared with those of 12 controls: women who were attending a Family Planning Clinic and without a history of such trauma, and small numbers of victims of non-sexual assault. All victims showed, initially, high levels of distress or some psychopathology but only the rape victims were reliable in attending follow-up appointments. In all but one case the acute, intense symptoms of distress resolved, but other substantial changes in lifestyle had taken place. The particular difficulties in counselling and research in this area were highlighted by this pilot work. Would-be counsellors should be cautious about taking on this kind of work unless considerable practical and emotional support is available to them.

Among custodially remanded male prisoners from Greater London and its surrounds, in 1979–1980, nearly 3% (63 men) were aged 55 or over, about one-third of these being over 65. More than 40% were detained on theft charges and few for more serious offences, although serious violence was not unknown and nearly one-fifth of those 65 or over were subsequently convicted of non-violent sexual assaults. Like their younger counterparts, less than one-fifth of those aged 55 or over appeared to be first-time offenders. About half of the men of 55 or over had active symptoms of psychiatric disorder on entering the prison and about half had some form of physical disorder, twice the rates for those under 55. Psychosis and alcoholism were the major psychiatric problems; 27% were alcoholics, to the extent of showing withdrawal symptoms on or soon after entering prison. Schizophrenia was less common than the younger age groups, but affective psychosis more so; 37% of the older men had a major functional psychosis. Two-thirds of the 55–64 age group and over three-quarters of the over 65s were without an address; most of both groups were personally isolated.

Physical illness at referral and subsequent mortality were studied in a group of elderly patients with depression, and compared with age/sex-matched controls. The depressed group was significantly less well at first interview, and had a significantly higher 4–year mortality. When the effect of physical illness was controlled, the depressed patients (particularly the men) still had a significantly higher 4–year mortality, suggesting that the greater mortality in the depressed group was not due to differences in physical health alone.

The results of stereotactic subcaudate tractotomy in nine patients with resistant bipolar affective disorder are presented in the form of a single case study with a summary of the other eight cases. Follow-up studies at 2–4 years showed substantial improvement in five patients and amelioration of symptoms in a further four patients, with a tendency for a greater improvement in the manic than in the depressive episodes. These preliminary results suggest that there is a place for this operation in the management of severe bipolar affective disorders which are not responding to any other treatment, although decisive recovery occurs less often than with unipolar depression.

The number of deaths in a large series of suicide attempters followed up after their attempts was 3.3 times greater than expected. Suicide or probable suicide occurred in 2.8% by the end of the eighth year of follow-up, the rate of suicidal deaths being 26.9 times the expected rate. The highest risk of suicide was during the first 3 years, especially in the first 6 months, following an attempt. Factors identified at the time of the attempts which were associated with suicide risk included: being male, advancing age (females only), psychiatric disorder (especially schizophrenia), long-term use of hypnotics, poor physical health, and repeat attempts. Recent disruption of a relationship with a partner and major rows rarely preceded the attempts of those who later killed themselves. Factors predicting long-term risk of suicide also predicted short-term risk. There were more than double the expected number of deaths from natural causes, the excess being greatest in females. Markedly high death rates were found for endocrine, circulatory and respiratory diseases, and accidents.

The Morgan-Russell outcome assessment schedule is described and statistically analysed with reference to two independent series of patients suffering from anorexia nervosa. The value of check lists and simple scaling of data is emphasised as one way of improving the standards of routine case-note documentation in clinical psychiatric practice.

To clarify a controversy as to whether melatonin secretion is related to body weight, urinary sulphatoxymelatonin (aMT6s) excretion was estimated in 10 patients with anorexia nervosa before and after weight gain, and compared with 10 age-matched controls. There was no change in aMT6s excretion after weight gain, and no significant difference between the patients and control groups at either point. Significant increases in plasma LH, FSH, and estradiol were detected after weight gain in anorexic patients, independent of aMT6s excretion.

There is considerable disagreement on the classification of Asperger's syndrome and its relationship to autism. Unlike autism, Asperger's is not usually recognised before 30 months of age, and speech delay is not typical. However, if a child exhibits all the symptoms of autism apart from these two features, are these sufficient grounds for withholding a diagnosis of autism? This paper describes four boys and their father who, by presenting at various points on the autistic/Asperger spectrum, embody this dilemma for the diagnostician. The implications for research and clinical practice are discussed.

Ninety patients with the Gilles de la Tourette syndrome were studied. A high incidence of depression, hostility, and obsessionality was found. Depression was not related to administered medication, while aggression, hostility, and obsessionality were significantly associated with some important features of the syndrome, namely copro- and echo-phenomena and a family history of tics or the Gilles de la Tourette syndrome. Links between psychopathology and neurological and electroencephalographic abnormalities were minimal.

We compared the general distribution of diagnoses in 20 895 patients at the Maudsley Hospital with that of 504 patients born twins, including 117 twins where the co-twin had died before the age of 15. Significant differences in diagnostic distribution were found in the co-twin-dead compared with the co-twin-alive group; the former received diagnoses of schizophrenia, personality disorder, or substance abuse more often than the latter. While there were no overall differences between twins and non-twins, there were relatively more twins in the above three diagnostic groups. We suggest that the factors leading to the death of one twin are implicated in the later psychiatric morbidity of the survivor.

In a health centre, 3.6% of the registered patients were found to have received at least one prescription for psychotropic drugs in each quarter of a year. These patients were mainly elderly and female. Psychiatric interviews were held with randomly selected index patients, and with matched controls. Most index patients reported taking psychotropic drugs for several years, mainly anxiolytics, antidepressants and non-barbiturate hypnotics, and mainly in low dosage. Index patients had much higher levels of psychiatric morbidity, as shown by the Present State Examination, history of specialist psychiatric treatment, and previous drug overdoses. In index patients the main diagnoses were neurotic depression and phobic disorder. Index patients reported more problems with finances and with social isolation.

Research into the clinical features of dementia has concentrated almost exclusively on the cognitive impairment. Perhaps this is not surprising, since deteriorating cognitive function is the most prominent feature, and a necessary one from the point of view of diagnosis (American Psychiatric Association, 1980; McKhann et al, 1984). However, this emphasis on cognitive function has led to the neglect of the other major feature of the disorder; namely, the changes in behaviour which have long been recognised. For example, Bleuler (1924), describing a sub-group of people with senile dementia, wrote that “the patients are always engaged in an apparent activity”. Some of the behavioural changes in dementia are a major source of distress for the carers of these patients (Argyle et al, 1985; Rabins et al, 1982; Gilleard et al, 1982) and often it is the disturbed behaviour which results both in patients coming to medical attention and in them requiring institutional care (Sanford, 1975; Chenoweth& Spencer, 1986). Frequently encountered examples include aggressive behaviour and ‘wandering’. The disturbed behaviour can take many other forms, including changes in eating, the hoarding and moving of objects, marked sleep disturbance, alterations in sexual behaviour, and incessant trailing behind people.

A patient in whom a series of treatments of all sorts had failed was given two trials of psychotherapy over a prolonged period. Although the patient judged the trials of psychotherapy to be a failure, and therapy was terminated, he does seem to have matured, and his disturbed behaviour has ceased. The possible reasons for this are discussed.

Two cases of Kleine-Levin syndrome are described in which the onset of symptoms was temporally related to head injury. The possible aetiological role of trauma and an apparent response to treatment with lithium carbonate are discussed.

A man with Nelson's syndrome developed severe associated behavioural and psychiatric problems, which completely resolved following selective resection of his pituitary tumour. It is postulated that ACTH, β-endorphin, or related peptides may have caused these problems.

An unusual case of writer's cramp in a 12-year-old deaf girl is reported. Possible aetiological and contributing factors in her environment are discussed, with particular relevance to a hysterical conversion reaction.