Since 1977 a literature has grown describing examples of factitious illness by proxy (FIP).

The literature in English was searched using MEDLINE and supplemented by a manual search. Extracted data focused on terminology of a spectrum of behaviours, clinical features and psychopathology of perpetrators.

There has been difficulty with the use of terminology and classification of psychiatric disorders.

The spectrum of FIP is wide. Suggestions are made for the use of terminology and classification when FIP is identified.

The NHS is no longer a virtual monopoly provider of mental health residential care. This makes it difficult to assess the volume, range and adequacy of local provision.

Local data collectors used standard instruments to collect detailed information about 368 facilities (with 1951 residents) providing mental health residential care in eight districts. Because local definitions were inconsistent, facilities were reclassified on the basis of facility size and extent of day and night cover. The eight categories of accommodation are compared on levels of staffing, staff qualifications and the characteristics of their residents.

There was a nearly threefold variation between districts in the total number of residential places available per unit of population, and even greater variation in the number of places with 24-hour waking cover. Most residents have long-term, severe mental illness and severe impairment. Long-stay wards accommodate people who pose greater risk of violence than do the two types of non-hospital facility with 24-hour waking cover (P<0.001). The former also employ a much greater proportion of staff with formal care qualifications and, in particular, nursing qualifications than the latter (49% v. 15%, P < 0.001).

It is suggested that one consequence of the diversification in provision of mental health residential accommodation has been a relative reduction in the proportion of provision available to the most severely disabled. This might apply particularly to those who pose a risk of acting violently.

In this first investigation of motor function in schizophrenia using transcranial magnetic stimulation (TMS), the general hypothesis tested was that this methodology could be used to investigate the disruption of corticospinal inhibitory processes suggested by cognitive and psychophysiological paradigms.

Nine drug-free DSM–IV schizophrenic patients were compared with nine age- and sex-matched normal subjects. Electromyographic (EMG) recordings were made from the thenar muscles of the dominant hand during sustained, weak voluntary contraction. TMS over a particular threshold applied to the motor cortex would elicit a compound motor evoked potential (cMEP) followed by a period of suppression of EMG.

The latency of cMEPs following TMS was significantly shorter in the schizophrenic patients. The two groups did not differ significantly with respect to mean latency of suppression of EMG activity, or stimulus thresholds for either cMEPs or EMG suppression.

These findings could be the result of a relative lack of corticospinal inhibition of motor responses; a change in the site of TMS activation; or an abnormality of peripheral nervous function in schizophrenia. Drug effects were unlikely since seven of the patients were drug-naïve.

This study examines relations between regional cerebral blood flow (rCBF) and neuropsychological test results, age at onset and duration of disease in patients with frontotemporal-type dementia (FTD).

Sixteen patients with a diagnosis of probable FTD were examined using single photon emission computerised tomography (SPECT) with 99mTc-HMPAO as the tracer. The rCBF of 14 regions of interest relative to cerebellar blood flow was calculated. Psychological tests assessing language, verbal fluency, memory and visuospatial constructive ability were given.

Correlations were demonstrated between a global impairment score and relative blood flow in lateral frontal, medial frontal and left orbital frontal areas. Verbal fluency scores correlated with left lateral frontal medial frontal and left anterior inferior temporal blood flow. No relationships between decrease in CBF and age at onset or duration of disease, or between impaired cognitive function and age at onset or duration of disease, were found.

The present study demonstrates a close coupling between reduced rCBF and specific neuropsychological deficits in FTD.

Psychiatrists are sometimes asked to express an opinion about the competence and motivation of a mentally ill mother to be a consistent, adequate and safe parent of her recently born infant, There are no reliable methods for assessing mother–infant interaction and relationship in a psychiatric context.

The Bethlem Mother–infant Interaction Scale (BMIS) was developed by the staff of a specialised psychiatric mother and baby unit. Of the seven subscales, four measured different aspects of the mother's contribution to the dialogue with her baby, one measured her capacity to organise and maintain routine care, one attempted to rate the perception by staff of risk to the child, and the remaining subscale rated the baby's contribution to their interaction. In normal clinical practice the ratings were made consensually by nurses and they encompassed observations that had been made by them during the previous week.

Despite the simple and global nature of the ratings of the BMIS, moderate to high coefficients of inter-rater reliability were obtained for weekly ratings by nurses as well as for intra-rater reliability of ratings of videotaped interactions between mothers and their infants. Ratings of mothers and babies in day-to-day activity in the unit that were based on one hour's observation only were much less reliable. The internal consistency of the BMIS was high and comparisons with other methods used in non-clinical settings showed good criterion-related validity.

Using the BMIS facilitated attempts to reliably assess disturbances of mother–infant interaction and the scale was acceptable and clinically useful. The nurses' ratings of their perceptions of ‘risk’ to the infant, which are in some ways the most important, were the least reliable. Repeated weekly ratings gave a valuable impression of change or lack of it over time. The predictive validity of the scale has yet to be determined.

In view of the current changes in the National Health Service, it was considered an opportune time to review the literature on perinatal psychiatric illness.

A systematic review was undertaken of relevant articles on medline, ClinPsych and Excerpta Medica Psychiatry.

Sixty-eight articles were used in the review.

Developments in the field of perinatal psychiatry include a greater understanding of the nosology and aetiology of the conditions, the effect of maternal illness on the child as well as transcultural factors. The perspective of the individual sufferer has been somewhat ignored. New treatments with both pharmacotherapy and hormones are emerging, but perhaps the greatest current challenge is to adapt our management strategies to community care.

A short self-report questionnaire was developed to assess dependence on benzodiazepines (BZDs), the Benzodiazepine Dependence Questionnaire (BDEPQ). The BDEPQ is the first scale to assess dependence on BZDs comprehensively, as all existing scales focus exclusively on withdrawal symptoms.

To evaluate its internal consistency and construct validity, 302 regular BZD users were recruited from media advertisements and assessed on a number of measures. The BDEPQ was compared with measures of depression, anxiety, sleep quality, BZD withdrawal symptoms and neuroticism to assess its construct validity. A 3–4 month follow-up was conducted to assess the ability of the BDEPQ to predict changes in BZD consumption and future BZD withdrawal.

The BDEPQ was found to have high internal consistency and to be relatively stable over the follow-up period. Three subscales were identified, each with good internal consistency and temporal stability. The BDEPQ was able to predict the severity of withdrawal symptoms.

The BDEPQ was found to be a reliable and valid self-report instrument for the assessment of BZD dependence in samples approximating the general population of people using BZDs.

Auditory verbal hallucinations are thought to arise from the disordered monitoring of inner speech (thinking in words). We tested the hypothesis that a predisposition to verbal auditory hallucinations would be associated with an abnormal pattern of brain activation during tasks which involved the generation and monitoring of inner speech.

The neural correlates of tasks which engaged inner speech and auditory verbal imagery were examined using positron emission tomography in (a) schizophrenic patients with a strong predisposition to auditory verbal hallucinations (hallucinators), (b) schizophrenic patients with no history of hallucinations (nonhallucinators), and (c) normal controls.

There were few between-group differences in activation during the inner speech task. However, when imagining sentences spoken in another person's voice, which entails the monitoring of inner speech, hallucinators showed reduced activation in the left middle temporal gyrus and the rostral supplementary motor area, regions which were strongly activated by both normal subjects and nonhallucinators (P<0.001). Conversely, when nonhallucinators imagined speech, they differed from both hallucinators and controls in showing reduced activation in the right parietal operculum.

A predisposition to verbal hallucinations in schizophrenia is associated with a failure to activate areas implicated in the normal monitoring of inner speech, whereas the absence of a history of hallucinations may be linked to reduced activation in an area concerned with verbal prosody.

The determinants of self-esteem have been little studied in non-clinic samples. It has been suggested recently that child sexual abuse (CSA) may be a major determinant of low self-esteem in adulthood.

The psychosocial circumstances associated with low self-esteem in two random samples of women, one reporting CSA, the other not were compared, with particular emphasis on characteristics of family of origin. A two-phase (postal-then-interview) random community study assessed self-esteem and related variables.

Psychosocial variables predicting low self-esteem were the same in the two groups. They included being a follower or a loner, having an overcontrolling mother, being poorly qualified, giving a history of depressive disorder and displaying current psychiatric disorder. In addition, the subject's CSA status led to low self-esteem but only when it was of the most intrusive type. The CSA women had a substantially lower mean total self-esteem score. However, not all aspects of self-esteem were diminished equally; 12/30 items differed between the two groups, and two of the five generated self-esteem factors, which we named Pessimism and Fatalism, which differed between the control group and the whole CSA group. There were no differences for Likeability and Determination.

Predictors of low self-esteem for women include childhood temperament, a poor relationship with the mother, low qualification attainment, psychiatric morbidity, both previous and current, and, only when it is the most intrusive, CSA.

Previous work suggests neurological disease commonly supervenes in cases of conversion disorder but has not identified clear predisposing factors. Patients' subsequent use of services has been neglected.

Clinical outcomes for 73 patients investigated for pseudoneurological symptoms at a neurological hospital 10 years earlier were compared with findings on presentation. Fifty-six patients complied with a structured interview concerning use of services.

Thirty patients had no relief from their original symptom at follow-up. They had been older, with more chronic symptoms, and different auxiliary psychiatric diagnoses. In 11 patients a clear neurological diagnosis was subsequently made for the original symptom. Provisional neurological diagnoses at presentation had been disproportionately common among these 11. Small numbers of patients with poor outcomes made most use of hospital and community services. High attenders met screening criteria for somatisation disorder at follow-up.

The prognosis for chronic symptoms remains poor, but subsequent rediagnosis of neurological disease is less frequent than commonly supposed. Somatisation disorder may develop if hospital contact does not lead to diagnosis of another disease.

The Bethlem Scale was designed as a validated measure of mother–infant adjustment in mother–baby units.

A multi-centre trial was conducted to investigate aspects of the reliability, validity and clinical usefulness of the Bethlem Mother–infant Interaction Scale within five in-patient psychiatric mother–baby units.

This revealed good inter-rater, test-retest and inter-item reliability. Correlations of the scale items with psychiatrist's ratings and changes in scoring over time suggest reasonable validity, despite some design problems with individual items.

Mother–infant interaction scales may have an important role in improving the quality of care for mothers and their babies in the psychiatric setting. The development of a more extensive scale, the Monash Mother–infant Interaction Scale, is discussed.

The proliferation of psychotherapies has been balanced by an equal and opposite tendency towards integration. Integrative approaches are particularly relevant to psychotherapy in psychiatric settings.

Medline and manual literature searches yielded over 250 articles on psychotherapy integration, which are reviewed in the light of the authors' experience in a district psychotherapy service.

Psychotherapy integration is an umbrella term covering a wide range of meanings: rapprochement between different theoretical positions; convergence of ideas and techniques; eclectic selection from many different methods; and integration proper in specifically integrative therapies. Many effective psychotherapeutic treatments for psychiatric disorders are integrative, including those for depression, schizophrenia, bulimia nervosa and borderline personality disorder.

Integration at the level of practice is common and desirable. At the level of theory, clarification and creative conflict are essential. Different therapeutic approaches should work closely together but retain their separate identities.

The longer term prognosis of depressed patients treated with ECT is relatively unknown. We describe seven-year mortality and readmission risks for the Nottingham ECT series.

Cases were defined and subtyped using the Present State Examination (PSE). Follow-up was naturalistic. Death and readmission were ascertained using the Nottingham case register.

The risk of death was doubled (SMR=1.99, 95% CI = 1.34–2.84, P < 0.001). The seven-year cumulative probability of remaining without readmission was 0.27 (95% CI 0.19–0.35), being 0.79 (0.71–0.87) at 16 weeks (relapse) and 0.34 (0.24–0.44) thereafter (recurrence readmissions). Multiple regression analysis showed that delusions predicted relapse, while endogenous subtype, absence of psychomotor retardation, and previous history predicted recurrence readmissions.

Index ECT treatment predicted high longer-term mortality and readmission risks. PSE/CATEGO-based subtyping identified patients most vulnerable to relapse and recurrence.

The clinical and social outcomes were evaluated of “difficult to place” (DTP) patients discharged from hospital to alternative facilities.

In the course of a reprovision programme for a psychiatric hospital, 72 long-stay patients were considered to be too problematic to live within the usual range of community placements. Their clinical and social state was assessed shortly before the hospital closed. Severe, persistent behavioural problems were recorded for each subject at baseline. One year after being relocated, patients were reassessed.

Clinical and social measures were stable over time. The profile of severe behavioural problems changed over time, with one-third of the total problems subsiding and a similar number of new problems emerging. There was a significant reduction in physical aggression. One of the settings provided an environment as free of restrictions as the usual community homes.

The most difficult patients to reprovide for can be contained in a relatively non-restrictive care environment. There is some indication that aggressive behaviour can improve, raising the possibility that some DTP patients can move on to the usual community homes.

An epidemiological study of anorexia nervosa and bulimia nervosa in primary care was performed using the General Practice Research Database (GPRD).

The GPRD was screened between 1988 and 1994 for newly diagnosed cases of anorexia nervosa and bulimia nervosa. The validity of the computer diagnosis was established by obtaining clinical details from a random sample of the general practitioners (GPs).

Incidence rates for detection of cases by GPs in 1993 was 4.2 per 100 000 population for anorexia nervosa and 12.2 per 100 000 for bulimia nervosa The relative risks of females to males was 40:1 for anorexia nervosa and 47:1 for bulimia nervosa A threefold increase in the recording of bulimia nervosa was found from 1988 to 1993. Eighty per cent of anorexia nervosa cases and 60% of bulimia nervosa cases were referred to secondary care.

There is a continuing expansion of service need for bulimia nervosa The majority of cases of eating disorders are referred to secondary services. There is scope for more effective management of bulimia nervosa in primary care.

Unipolar and bipolar patients with a chronic illness pattern were investigated to determine whether they experienced a higher number of life events prior to the onset of recurrent affective episodes.

The study participants consisted of 27 recovered bipolar patients, 24 recovered unipolar patients and 26 healthy control subjects. Life events and psychiatric status were assessed by bimonthly interviews over the period of one year using the Inventory for Recent Life Events and the Research Diagnostic Criteria.

In both unipolar and bipolar patients, analyses revealed no significant differences in the number of life events experienced, irrespective of whether the patients had presented with a depressive episode of at least minor intensity during the study (all P > 0.1). Specifically, an increase in marital problems was observed in bipolar patients prior to the onset of recurrent hypomanic and manic episodes (P=0.06).

The causal association between life events and the onset of depression, shown to be relevant in non-chronically depressed subjects, does not apply in chronic affective disorders. In addition, our results suggest that marital events have an impact on the onset of recurrent hypomanic and manic episodes.

Eye movement desensitisation and reprocessing (EMDR) has attracted controversy and has led to publications covering a wide range of psychological problems treated by EMDR, in particular, post-traumatic stress disorder (PTSD). There is growing clinical evidence of the effectiveness of EMDR, but a lack of a convincing theoretical basis to explain its rapid effect.

This paper argues that a combination of Pavlovian and Darwinian theory provide a theoretical explanation for the therapeutic effectiveness of EMDR.

We suggest that the investigatory component of the orienting reflex is an evolutionary development enabling organisms to assess their environment for both opportunities and threats. We propose that EMDR is rapidly effective because it is a clinical method of Pavlovian conditioning by which the positive visceral element of the investigatory reflex can be paired with clinically-induced noxious memories to remove their negative affect.

Compared with established forms of treatment for PTSD, EMDR is rapid, with resulting clinical and economic benefits. Our suggested theoretical basis for EMDR has implications for further explanatory research and for developments in EMDR treatment.