For the past 20 years, benzodiazepines have been the most commonly prescribed psychotropic drugs. It is now difficult to imagine the excitement produced by this new class of compounds. Existing anti-anxiety drugs, mainly the barbiturates, were known to be dangerous in overdosage, tend to cause addiction, and have many side-effects. Previous compounds, including opium, alcohol, chloral, and bromides, were similarly burdened. The benzodiazepine era began almost 30 years ago, in style. “Four hours after being given chlordiazepoxide on New Year's day 1958, one of 12 chronically anxious but therapeutically recalcitrant patients previously studied by Tobin and N. D. C. Lewis telephoned that for the first time in many years he was totally free from symptoms” (Hordern, 1968). The early studies were all enthusiastic and confirmed the therapeutic potential of the drug (Tobin et al, 1960; Jenner et al, 1961). In the ‘tranquilliser decade’ of the 1970s, prescriptions of benzodiazepines increased at a rate that was perceived as alarming, ‘the relentless march of the psychotropic drug juggernaut’ (Trethowan, 1975). This concern was related more to the inappropriate use of these drugs for treating personal problems than to the demonstration of dangers with these compounds. The dangers, however, appeared to be remarkably few; the drugs were safe in overdose, had greater efficacy than the barbiturates (Lader et al, 1974), and had virtually no unwanted effects, apart from sedation when given in excessive dosage. It was therefore hardly surprising that they proved so popular with clinicians. As Priest (1980) commented when benzodiazepine prescription was at its peak: “it is a tremendous boon to the medical profession to have active weapons in the fight against misery that are not only effective but are relatively safe when abused by despairing and desperate patients”.

Borderline personality has been, for many years, a discredited diagnostic concept. In 1979 a review of the literature concluded that its validity status was very uncertain. The authors have reviewed research conducted since then and discuss it in terms of the Robins & Guze (1970) criteria. In spite of existing unclear issues, the balance is tipping in favour of the validity of borderline personality, as diagnosed with new research criteria. This development is taking place in the context of a growing interest in the area of personality disorders.

In 1972 the author proposed that schizophrenia represents an aberration of central nervous processes that underlie cognitive and personality characteristics which can be observed in many healthy people. The present paper brings the evidence for that theory up to date and concludes that over the past 15 years it has received considerable empirical support. The way in which the theory confronts the question of whether or not schizophrenia is a disease is also clarified.

Volume measurements were carried out on 29 brains from institutionalised, chronic schizophrenic patients and 30 age and sex-matched controls using a stereological method. The volumes of the total fixated brain, the hemispheres, the cortex, and the central grey matter of the schizophrenic brains were significantly reduced while the volumes of the ventricles were significantly enlarged compared with the control group. The patients had been diagnosed by a psychiatrist on the basis of their case records as having either a Type I or Type II syndrome according to the symptoms they presented in the first years of their disease. The Type II patients were found to have significantly enlarged ventricles compared with the Type I patients.

The Copenhagen longitudinal high-risk study of offspring of 129 schizophrenic mothers commenced in 1962. At that time, the mothers were diagnosed according to contemporary Danish criteria. We have re-examined all of the hospital records of these mothers: 108 (84%) fulfil present-day DSM-III criteria for schizophrenia and 95 (74%) were diagnosed as paranoid schizophrenic according to ICD-8 criteria. In a follow-up at mean age 24, the offspring of the paranoid schizophrenic mothers were themselves found to be less frequently schizophrenic (5%) than were the offspring of non-paranoid schizophrenic mothers (29%).

A 21–27-year follow-up was conducted on 140 schizophrenic patients consecutively discharged from the Department of Neuropsychiatry, Gunma University Hospital, between 1958 and 1962, and 130 patients (93%) were successfully evaluated. Of these patients, 105 were still living, and the longitudinal courses could be fully observed in 98. With regard to the social outcome of the 105 patients, 47% were assessed as 'self-supportive’ whereas 31% were ‘hospitalised‘. As for psychopathological outcome, 31% were ‘recovered’, 46% were ‘improvead’, and 23% were ‘unimproved‘. In the studies of the longitudinal courses of the 98 patients, fluctuating courses of social adjustment were the most numerous in the early stages, whereas in the later stages many of the patients showed differentiation in one of two directions, namely the 'stable self-supportive’ state and the ‘chronic institutionalised’ state. However, this form of differentiation was not revealed in the distribution of psychopathological ‘end states'.

Among his various approaches to an understanding of schizophrenic inheritance, whether dominant or recessive, Rüdin (1916) also compared the respective frequencies of one-sided and two-sided familial taint. Essen-Möller (1949) tried the idea on another sample, but neither of us arrived at a definite choice. Lateron Slater (1966) surprisingly demonstrated that unilaterality is typical not only of dominant but also of polygenic transmission. In the present paper we adjust Slater's computation and, in so doing, accentuate his result. We also find a similar preponderance of unilaterality on a recessive model, and offer an explanation for this. The findings substantially reduce the efficacy of laterality of taint as an indicator of mode of inheritance.

A complete, unselected series of 68 patients who were seen during their first episode of an undoubtedly schizophrenic illness, and followed up one year later (for 56 patients) is described clinically. Depressive symptoms were common at onset, and 22% of patients could have been considered cases of depression from these symptoms alone. At follow-up, depressive symptoms had reduced in prevalence and only 7% of subjects were depressed cases. Only two cases of depression at follow-up had not been cases at onset. These changes could not be attributed to the use of antidepressants or ECT. Depressive syndromes could be distinguished from akinesia and the negative syndromes. The findings indicate that depression cannot be attributed solely to the administration of neuroleptics.

Forty-three depressed patients in hospital were studied with weekly dexamethasone suppression tests (DSTs) and were followed as out-patients for at least three months after discharge. The detection rate of patients with LHPA axis dysfunction increased from 41% with a single DST to 59% with serial DSTs. There was a poor correlation between weekly post-dexamethasone cortisol levels and Hamilton depression rating scores. In patients with evidence of LHPA axis dysfunction, a DST at discharge discriminated effectively between a good and a poor outcome group; persistent non-suppression was strongly linked with a relapse of depression in the first three months after discharge. In general, our results support previous claims that the DST is a state marker for depressive illness.

DSM-III lifetime diagnoses were assessed in 52 patients with a lifetime history of anorexia nervosa or bulimia by means of a standardised diagnostic interview. It was found that 44.2% had a lifetime diagnosis of DSM-III major affective disorder, with abstaining anorectics having a lower rate of depression than those with bulimic symptoms. In the great majority of cases, the on set of affective disorder post-dated the onset of the eating disorder by at least one year. In patients whose eating disorder was in remission, the rate of depressive symptoms was lower than in those in the acute stage of their illness. These findings, combined with recent studies on biological changes in eating disorders, and psychological theories of depression, suggest that in most cases in which the two conditions are associated, the depression is secondary to the eating disorder.

Prior research suggests that psychotherapeutic techniques which differ in their contents are quite similar in their outcomes. Outcome data are reported from a study designed to maximise sensitivity to technique effects on outcome in a clinically realistic setting, and to permit detailed analysis of the relations between content, immediate impact, and outcome of therapy. Forty professional and managerial workers with depression or anxiety received eight sessions of Prescriptive (cognitive/behavioural) and eight sessions of Exploratory (relationship-oriented) therapy in a crossover design, with each client seeing the same therapist throughout. Outcome was assessed by standard interview and questionnaire methods. The results favoured Prescriptive therapy, although this difference was of moderate extent. The outcome was largely unaffected by the order in which the two methods were offered.

Psychoanalytical methodology has been described as causal explanation or hermeneutic understanding. This methodological dichotomy has been introduced into psychopathology by Karl Jaspers. Contemporary authors' contributions in the area are discussed. Although these authors accept a role for both methods, they agree with Jaspers that psychoanalysis should be subjected to the logical limitations of hermeneutic analysis. A logical framework for the interaction of explaining with understanding is presented and discussed in relation to psychiatric research.

A controlled modified cost-benefit evaluation of a hostel ward caring for new long-stay patients is described and results are presented for the first two years. In some respects the residents of the hostel ward had fewer psychotic impairments than those remaining on the wards of the district general hospital, mainly because the latter seem to continue to acquire such defects, while the former have remained relatively unchanged. The hostel ward residents also develop superior domestic skills, use more facilities in the community, and are more likely to be engaged in constructive activities than controls. These advantages were not purchased at a price, since the cost of providing this form of care for these patients has cost less than care provided by the district general hospital.

The impact of a 16% increase between censuses in the population aged 65 and over, on a psychogeriatric department whose bed complement remained static between 1974 and 1984, has been studied. Demand for service, as measured by new referrals, rose by 150%, while admissions fell by 14%. The increase in new referrals was uniform across the diagnostic spectrum, but the fall in admissions was not. Functional admissions fell in all age-groups except that of women of 85 and over, while organic-case admissions other than for cases of dementia virtually collapsed. Overall admissions for dementia rose to the predicted level, but the distribution of the increase was irregular and unexpected. Admissions of males and females aged 65–74 and females of 85 and over fell relatively and absolutely, while those of women aged 75–84 and men of 85 and over were little changed. Only admissions of men aged 75–84 alone increased in real terms.

A survey of 54 firesetters who had been in hospital or prison was conducted. The results confirmed earlier findings on several aspects, such as male predominance, unstable childhood and proclivity to self-injurious behaviour. Revenge emerged as the commonest motive overall and an association with alcohol was found. Only 11% of the fire-raising episodes, whether among hospital or prison groups, were truly trivial. Arsonists in prison and hospital had many features in common and generally were quite psychologically disturbed, which contrasted with those who set fires for profit. A poor outcome was found, with continuing self-harm and a high suicide rate. Our findings suggest that arson recidivism arises in at least 35% of arsonists.

Using PET, we investigated the potency in six patients of therapeutic doses of neuroleptic drugs for preventing specific binding of trace doses of intravenously administered 76Br labelled bromospiperone to corpus striatum in vivo. Measured receptor occupancy showed a clear-cut dose-dependent saturation curve with increasing daily oral dose of neuroleptics, indicating the validity and reliability of the method when used as an in vivo radioreceptor assay. Following drug withdrawal in eight patients, recovery to normal or supranormal receptor availability occurred in a matter of days. The results demonstrate an approach that may help resolve controversies about, and design better strategies for, neuroleptic treatment schedules.

Since recent reports suggest structural brain abnormalities in autistic patients, we analysed magnetic resonance imaging (MAI) scans of autistic children. Planimetric measurements were done on midsagittal MRI scans, produced with a 0.5 T superconducting magnet. Scans of 13 ‘high-level’ austic subjects were compared with 35 control MRI scans, read as anatomically normal by a neuroradiologist. Corpus callosal, fourth ventricular, cerebellar, cerebral, and cranial areas were measured. The fourth ventricle was found to be significantly larger in the autistic group. No other areas in the midsagittal scans differed statistically between groups. Results suggest that structures defining the fourth ventricle are anatomically altered in autistic patients.

Using the newly revised DSM-III-R criteria for substance-abuse diagnoses, we examined dependence syndrome elements among 83 psychiatric patients. The sample included 14 with no history of substance abuse. The remainder abused alcohol (52), sedatives (31), hallucinogens (12), stimulants (33), cannabis (44), cocaine (52), or opiates (47). Many patients (52) had abused more than one type of drug. Ten items assessing the proposed dependence symptoms for each type of drug were factor-analysed. The dependence syndrome items formed a single factor for opiates, cocaine, and alcohol, but not for other drugs. When the items were combined into cumulative scales, they had excellent internal consistency. Furthermore, they formed good approximations of unidimensional Guttman scales on which higher scores indicated greater syndrome severity. The items associated with higher scores differed across drugs, with opiates having the most striking differences from the other substances. Medical-psychosocial consequences were relatively independent of the dependence syndrome, although alcohol and cocaine dependence had some association with other problem areas. These findings support the utility of a common dependence syndrome concept for drugs of abuse as well as alcohol, and provide empirical support for the current revision of the DSM-III diagnostic criteria.

Conversive hallucinations are rare in the psychiatric literature. The authors present a case which demonstrates the psychogenesis and phenomenology of conversive hallucinations in a young female patient.

An elderly patient with bipolar manic-depressive psychosis, stabilised satisfactorily on lithium carbonate, developed acute symptoms of lithium toxicity shortly after commencing mefenamic acid. Vulnerability factors for the interaction may have included age, history of cardiac failure, and impaired glomerular function. It is hypothesised that the interaction may have been mediated by inhibition of prostaglandin activity.