We have no introspective knowledge of the effects of preconscious processing on our perceptions. We are, therefore, not aware that our expectancies may have prejudiced our perceptions. Expectancies tend to foster perceptions with which they are consonant. Therefore false expectations, driven by false beliefs, may result in misperceptions which reinforce those false beliefs. This morbid cycle is central to the delusional misidentification syndromes. This cycle, with positive feedback, is intrinsically unstable, which helps to explain brief episodes of delusional misidentification. Good sensory data, strong links between sense data and memory, and good judgement will all help to prevent misperceptions. The less these constraints are disrupted, the stronger will be the psychological forces needed to generate a delusional misidentification. It is likely that suspiciousness generates particularly assertive effects on preconscious processing of perceptions. Abnormalities of perceptual processing in patients with schizophrenia explain their proclivity to delusional misidentification.

Research on symptoms may often be more fruitful than research on syndromes because: (a) the validities of psychiatric diagnoses remain questionable; (b) interview assessments of a large number of symptoms are inadequate; (c) the diagnostic approach results in problems of misclassification and confounding; (d) the dimensional/categorical issue may be more readily resolved with research using a symptom approach; (e) useful animal models of symptoms are more likely to be developed than useful animal models of syndromes; and (f) symptoms may be better phenotypes than syndromes in genetic research.

Post-traumatic stress disorder (PTSD) is a recently introduced diagnosis. The disorder is quite common, yet often unrecognised, and leads to significant morbidity or mortality. Effective treatment often entails use of psychotropic medication. Only recently has this become apparent, and awareness of the role of drug therapy in PTSD remains limited. A number of studies have indicated efficacy for antidepressant, mood-stabilising, anticonvulsant and antianxiety medications. This review describes the role of pharmacotherapy, by examining issues of diagnosis and recognition of PTSD, the theoretical basis for drug use, goals of drug treatment, dose ranges, and clinical application of psychotropic drugs.

The range of interventions available for the treatment of erectile failure has increased in the past ten years. A significant development is intracavernosal injection of vasoactive drugs, but this treatment is far from ideal. Other, less invasive, pharmacological interventions are being investigated; as yet, none of these appear effective enough to have any significant clinical impact. External vacuum devices are a viable option for some patients, and penile prostheses have become increasingly sophisticated, although research examining their benefits has not. The range of available treatment methods and the growing complexity of the assessment for erectile problems demands an eclecticism of approach which can best be provided by multidisciplinary clinics specialising in sexual dysfunctions.

Unprecedented numbers of cases of MPD have been diagnosed, mainly in North America, since 1957. Widespread publicity for the concept makes it uncertain whether any case can now arise without being promoted by suggestion or prior preparation. In order to determine if there is any evidence that MPD was ever a spontaneous phenomenon, a series of cases of MPD from the earlier literature has been examined, with particular attention given to alternative diagnoses which could account for the phenomena reported and to the way in which the first alternate personality emerged. The earlier cases involved amnesia, striking fluctuations in mood, and sometimes cerebral organic disorder. The secondary personalities frequently appeared with hypnosis. Several amnesic patients were trained with new identities. Others showed overt iatrogenesis. No report fully excluded the possibility of artificial production. This indicates that the concept has been elaborated from the study of consciousness and its relation to the idea of the self. The diagnosis of MPD represents a misdirection of effort which hinders the resolution of serious psychological problems in the lives of patients.

In DSM–III–R, pica, with anorexia nervosa, bulimia nervosa and rumination disorder of infancy, is accorded the status of a separate eating disorder. However, in the Draft of ICD–10, only anorexia nervosa and bulimia nervosa are listed under eating disorders. Pica in children, and feeding disorder in infancy and childhood, are incorporated with enuresis, encopresis, and feeding, movement and speech disorders in a separate “heterogeneous group of disorders”. Extensive research on the history and terminology of eating disorders from the 16th to the 20th century suggests that, historically, pica was regarded as a symptom of other disorders rather than a separate entity. This paper aimed to locate and assess chronologically significant definitions and accounts of pica, to provide a fuller clinical description of a condition which, despite its current relevance, has received little detailed historical examination, and to give some consideration to the multiple aetiological theories which have been put forward. The historical findings are related to the descriptive criteria for pica in DSM–III–R and Draft ICD–10.

This paper describes the results obtained by combining data from the Northwick Park and Leicester randomised controlled trials of ECT. Patients who suffered from depression in which retardation and delusions were features and who received real ECT had a significantly improved outcome at the end of four weeks of treatment (as measured by improvement in the HRSD) in comparison with those who received simulated ECT. However, this treatment effect was not detectable at six-month follow-up. Patients who were neither retarded nor deluded did not benefit significantly from real as opposed to simulated ECT.

In-patients suffering from major depressive disorder (endogenous subtype) were randomly allocated to treatment by either traditional ECT with constant-voltage modified sine-wave stimuli (n = 17) or modern, constant-current brief-pulse ECT (n = 14). All treatments were bilateral and monitored by simultaneous recording by EEG. The severity of depressive illness was assessed the day before treatment, after three treatments, and seven days after the last treatment. The improvement and final depression rating scores, the likelihood of recovery, and the average number of treatments received were virtually identical in the two groups. We concluded that the policy of bilateral suprathreshold modern ECT monitored by EEG is as efficacious as traditional ECT.

The time course of clinical improvement was studied in 41 schizophrenic and schizoaffective acute in-patients treated for 28 days with 10, 20 or 30 mg/day of oral fluphenazine hydrochloride in a double-blind, randomised study. Significant improvement was seen in the four BPRS factors: thinking disturbance, hostile-suspiciousness, withdrawal–retardation and anxious depression. The first two of these factors were improved by day 5. Significant improvement was seen up to day 22 for three of the four factors, but without significant improvement during the last week (although scores continued to drop). The half of the sample showing greater overall improvement did not improve faster than the sample as a whole. These more improved subjects did not differ significantly from the less improved subjects in the thinking disturbance factor until day 15, suggesting that at least a two-week neuroleptic trial would be necessary to begin to differentiate more and less responsive patients. The longer-term course of improvement cannot be determined from these data. The withdrawal–retardation and anxious depression factors showed their greatest improvement later than the ‘positive’ symptom factors, suggesting that the former may improve as a result of change in the latter.

The prolactin response to intravenous clomipramine, a 5-HT uptake inhibitor, was significantly attenuated in 12 patients with major depression. In contrast, in a further 12 depressed patients, the PRL responses to thyrotropin-releasing hormone, which acts directly on the pituitary to release PRL, were not reduced. These findings suggest that the reduction in 5-HT-mediated PRL release seen in depressed patients is due to an impairment of brain 5-HT function rather than a pituitary abnormality.

Patients with a serious mental illness requiring admission were randomised to home care or standard hospital care. Over the initial 18 months, 60 patients entered each group and were studied for a mean of 10 months. Home care reduced hospital use by 80%, with patients being admitted for a mean of 14 days, compared with 72 days for the standard group, but this bed-saving made no difference in direct treatment costs. Home care offers individualised treatment, and many patients require continuing support with the emphasis on areas such as finances and housing.

When the factor structure and psychometric qualities of the Level of Expressed Emotion scale, an instrument intended to assess patient's perceptions of expressed emotion, were evaluated, three moderately intercorrelated factors emerged, with good internal consistency; these were lack of emotional support, intrusiveness/control, and irritability. This did not quite correspond to the a priori scales described in the original version. As in the original LEE, the three factors add to a total score intended to measure ‘perceived expressed emotion’.

Although the excess of schizophrenic births in the winter and early spring has been replicated and some non-conclusive work supports the same seasonal birth trend in patients with major affective disorders, the aetiopathogenetic foundations of this phenomenon remain uncertain. The primary role of perinatal seasonal factors that predispose to the development of schizophrenia via induction of brain damage has been invoked, as has a tendency for patients to conceive during the spring and early summer. In order to test these two hypotheses, cerebral ventricular size and cortical atrophy in 206 schizophrenics and 107 patients with major affective disorders were assessed by CT and analysed in relation to month of birth. Compared with schizophrenics born during the remainder of the year, those born between December and April, particularly in cases lacking a family history of schizophrenia, showed increased chances for ventricular enlargement, but not for cortical atrophy. No association between season of birth and central or cortical atrophy was found for patients with major affective disorders. This suggests that the brain-damaging effect played by perinatal seasonal factors has both a disease and an anatomical specificity.

A retrospective analysis of the clinical records of 53 schizophrenic in-patients who committed suicide, and the same number of matched control subjects, was carried out using a larger set of demographic, psychosocial and clinical variables. Univariate analysis of the data indicated an early disturbed psychosocial adjustment, more severe mental illness, unsatisfactory social situation, and more frequent suicidal behaviour in the suicide group. Suicide in schizophrenic in-patients thus appears to be closely connected with a particularly incapacitating form of the illness and its deleterious psychosocial consequences.

The notion of a subclinical preschizophrenic condition already present in childhood is given further support by the findings of this follow-back study, which also brings into sharper focus the childhood profile of the likely adult schizophrenic.

Four men with HIV infection who were referred to liaison psychiatry for assessment of eating disorders are described. In all four cases the eating disorder had implications for the clinical management of their HIV infection. Investigations of weight loss, dietary intervention, and compliance may all be affected by the presence of an eating disorder. The development of HIV disease may exacerbate the symptoms of an eating disorder.

Forty-six homosexual men and women who were twins took part in a study of their sexuality and that of their co-twin. Discordance for sexual orientation in the monozygotic pairs confirmed that genetic factors are insufficient explanation of the development of sexual orientation. There was a high level of shared knowledge of sexual orientation between members of twin pairs, and a relatively high likelihood of sexual relations occurring with same sex co-twins at some time, particularly in monozygotic pairs. The implications of these results for the study of the origins of sexual orientation and for twin research are discussed.

Three men presented to a single regional secure psychiatric unit over a twelve-month period, after taking their youngest child hostage in their own homes because of a threatened separation from the family. In each case the episode had escalated because of hostility to police involvement in what for them was a typical domestic upheaval. All cases ended without injury. In each man, substance abuse, a family history of domestic violence and fears of rejection were prominent, and the recent birth of a child may have been an added precipitant. There may be a common family structure which predisposes to such situations. Psychiatric intervention was deemed appropriate, with some evidence of benefit for the two men who engaged in treatment.

Three cases of stress-induced hallucinations in young soldiers are described. The hallucinatory experience was not accompanied by gross psychopathology. The phenomenology and psychopathological implications of hallucinations following exposure to environmental stress are discussed.

The misidentification of a familiar person or of oneself may occur as a complication of dementia. Seven patients experienced alterations of the sense of familiarity for a familiar object or place, for the misidentified person in a novel role, for personal characteristics, or for unfamiliar events as familiar. Five of these had persecutory delusions. These cases suggest that person misidentification in dementia begins with an altered sense of familiarity for a familiar person from a mismatch of new perceptions with past memories. They are sustained by paranoid elaboration or confabulatory rationalisation of a double.