A possible neuropsychological basis for poor insight in psychosis has been proposed Consistent supporting evidence for this is lacking.

Seventy-four consecutive acutely psychotic in-patients who were recruited for a randomised controlled trial of compliance therapy were given a battery of neuropsychological tests, along with a comprehensive clinical assessment before and after the intervention.

Performance on neuropsychological tests improved during the patients' admission and treatment in hospital as did symptoms and levels of insight Cognitive function showed no relationship to insight and compliance initially, and very little after the intervention. Factors related to insight and compliance prior to discharge included: diagnosis, attitudes to medication, side-effects, being a detained patient and whether or not compliance therapy was given.

Clinical variables and attitudes to treatment appear to be more relevant to compliance and the development of insight in acute psychosis than neuropsychological impairment.

Hypochondriasis is a distressing disorder for which there is no adequate established treatment. This study evaluates the effect of cognitive–behavioural treatment of hypochondriasis, compared with a waiting list control.

Thirty-two patients were randomly assigned to either cognitive–behavioural therapy or a no treatment waiting list control. Cognitive–behavioural treatment consisted of 16 individual treatment sessions over a four-month period. The waiting list control lasted for four months and was followed by 16 sessions of cognitive–behavioural treatment. Assessments were made before allocation and after treatment or waiting list control. Patients who had cognitive–behavioural treatment were reassessed three months after completion of treatment.

Paired comparisons on post-treatment/wait scores indicated that the cognitive–behavioural group showed significantly greater improvements than the waiting list on all but one patient rating, all therapist ratings and all assessor ratings. After three months the benefits of therapy were maintained.

Cognitive–behavioural treatment is an effective therapy for hypochondriasis. Implications of the study are discussed.

A trial of CT in acute psychosis conducted by the authors has shown a significant impact on the rate and degree of recovery of positive symptoms, the focus of the intervention. This paper seeks to determine whether these effects generalise to other features of acute psychosis including dysphoria, insight and ‘low level’ psychotic thinking which were not directly targeted.

Measures of dysphoria, insight and psychotic thinking were taken over a six-month period following presentation for acute psychosis. Using survival analysis, time to recovery from psychosis using three definitions of increasing stringency was compared between the CT and control group.

CT was associated with a 25–50% reduction in recovery time depending on the definition used.

The impact of the CT intervention extended beyond positive symptoms to include insight, dysphoria and ‘low level’ psychotic thinking. Nevertheless this kind of ‘clinical’ recovery required a median of 20 weeks to complete. Implications for clinical models of acute care are discussed.

It has been reported that real ECT is more effective than simulated treatment among depressed patients with delusions and/or retardation, and that ECT is not effective among depressed patients who lack these features.

In two randomised, double-blind studies, 143 patients with major depression were subtyped regarding psychosis, retardation and agitation. In both studies, low dosage, right unilateral ECT was ineffective compared with other forms of ECT. This report examined whether the depressive subtypes differed in clinical response to the ineffective and effective forms of ECT.

The therapeutic advantage of effective forms of ECT was similar across the depression subtypes. Patients who lacked both psychosis and retardation showed this pattern.

The findings cast doubt on the utility of these depression subtypes in predicting ECT response. ECT is a viable treatment option for patients with major depression regardless of the presence or absence of psychosis, retardation and/or agitation.

OPCRIT (a suite of computer programs that allow data entry and generate diagnoses according to 12 operational diagnostic systems) is used in a wide range of psychiatric research including both European Science Foundation and NIMH research initiatives in the molecular genetics of mental disorders. We examined its concurrent validity in 100 subjects collected for linkage studies of Bipolar Disorder and Schizophrenia.

We compared diagnoses generated by OPCRIT from data rated by two trained clinicians with diagnoses made according to consensus, best-estimate, lifetime procedures by the same two raters according to DSM–III–R and RDC classifications.

Good to excellent agreement was achieved between OPCRIT diagnoses and those made by consensus best-estimate procedures.

OPCRIT provides a convenient, reliable, rapid and valid approach to polydiagnostic assessment that can be used as an adjunct to conventional (but time consuming) best-estimate consensus diagnostic procedures.

In the past psychiatric in-patients suffered increased cardiovascular and respiratory mortality. The present study investigated whether increased risks persist among patients in the community and are being addressed in general practice.

A survey of 101 long-term mentally ill adults in 16 general practices in the South Thames (West) Region.

Twenty-six patients were found to be obese (body mass index > 30 kg/m2), 53 were current smokers and 11 were hypertensive (mean systolic blood pressure > 160 mmHg or mean diastolic blood pressure > 100 mmHg, or both). Twenty-one reported daily cough and sputum, 24 shortness of breath, 11 wheezing and seven chest pain on exertion. These rates were significantly higher than population rates in a contemporary national survey. Nearly all the risk factors were recorded in the general practice records but few attempts to intervene were apparent.

Long-term mentally ill patients remain at increased risk of cardiovascular and respiratory problems in the community. Primary care teams should make special efforts to tackle risk factors among this group.

Studies showing high rates of alcohol and drug misuse and deliberate self-harm in bulimia nervosa have led some authors to call for a distinct diagnostic subgroup, sometimes termed “multi-impulsive bulimia”. However, these studies have been uncontrolled and of clinic samples and may be subject to sampling bias.

One hundred and two women with DSM–III–R bulimia nervosa were compared with 204 normal controls and 102 controls with other psychiatric disorders, all recruited from the same community sample. Interview measures were used for diagnosis and for the assessment of alcohol and drug misuse and deliberate self-harm.

Bulimia nervosa cases did not differ from either of the control groups in terms of current alcohol consumption. Bulimia nervosa cases used more illicit drugs than either control group, but loss of control over drug use was very uncommon. Bulimia nervosa cases had a higher rate of deliberate self-harm than the controls. Only six (6%) bulimia nervosa cases had two or more of these behaviours concurrently.

Sampling bias is present in clinic-based studies of comorbidity in bulimia nervosa. Those with comorbid substance misuse and deliberate self-harm are probably heterogeneous in character, and their classification as a subgroup would therefore be premature.

Women take sick-leave more often than men, both in general and because of psychiatric disorders. The aim of the present study was to introduce the new dimension of sick-leave duration in the analysis of gender differences in minor psychiatric disorders.

A population-based register was used which included all sick-leave spells exceeding seven consecutive days, 1985–1987, in a Swedish county.

Sick-leave duration was longer for men. The greatest gender differences were found in the youngest and oldest age-groups. Women had higher incidence also in the longest spells. An increase in duration over the three years was found among women, leading to decreased gender differences.

Contrary to other studies on minor psychiatric disorders, small gender differences were found. It is suggested that sick-leave duration can be used as a quantitative measure of health-related working capacity.

Artificial Neural Network (ANN), as a potential powerful classifier, was explored to assist psychiatric diagnosis of the Composite International Diagnostic Interview (CIDI).

Both Back-Propagation (BP) and Kohonen networks were developed to fit psychiatric diagnosis and programmed (using 60 cases) to classify neurosis, schizophrenia and normal people. The programmed networks were cross-tested using another 222 cases. All subjects were randomly selected from two mental hospitals in Beijing.

Compared to ICD-10 diagnosis by psychiatrists, the overall kappa of BP network was 0.94 and that of Kohonen was 0.88 (both P < 0.01). In classifying patients who were difficult to diagnose, the kappa of BP was 0.69 (P < 0.01). ANN-assisted CIDI was compared with expert system assisted CIDI (kappa=0.72–0.76); ANN was more powerful than a traditional expert system.

ANN might be used to improve psychiatric diagnosis.

Hypnagogic and hypnopompic hallucinations are common in narcolepsy. However, the prevalence of these phenomena in the general population is uncertain.

A representative community sample of 4972 people in the UK, aged 15–100, was interviewed by telephone (79.6% of those contacted). Interviews were performed by lay interviewers using a computerised system that guided the interviewer through the interview process.

Thirty-seven per cent of the sample reported experiencing hypnagogic hallucinations and 12.5% reported hypnopompic hallucinations. Both types of hallucinations were significantly more common among subjects with symptoms of insomnia, excessive daytime sleepiness or mental disorders. According to this study, the prevalence of narcolepsy in the UK is 0.04%.

Hypnagogic and hypnopompic hallucinations were much more common than expected, with a prevalence that far exceeds that which can be explained by the association with narcolepsy. Hypnopompic hallucinations may be a better indicator of narcolepsy than hypnagogic hallucinations in subjects reporting excessive daytime sleepiness.

Failure to control impulsive behaviour has been postulated as an underlying mechanism common to substance use disorder, sociopathy and to a substantial subgroup of women with bulimia nervosa.

Three hundred and one women recruited to a general population study were selected either at random or because they had lifetime substance use disorder, affective disorder or symptoms of bulimia. A subsequent interview determined the existence of problems with impulsivity. Behaviour that is an integral part of a DSM–III axis 1 disorder was excluded from the impulsivity measure.

Similar rates of impulsivity were found in all three of these types of disorder, and this was little different from the rate found in the women selected randomly from the general population. However, among those with comorbid disorder there was more impulsivity, and the more comorbid disorders found, the higher the proportion with problems of impulsivity.

Because those in treatment facilities are more likely to have other comorbid disorders (Berkson's bias), findings derived from observations of women with bulimia who are in treatment may be compromised by selection bias and may have limited applicability to those with the disorder who are not in treatment.

Body dysmorphic disorder (BDD) consists of a preoccupation with an ‘imagined’ defect in appearance which causes significant distress or impairment in functioning. There has been little previous research into BDD. This study replicates a survey from the USA in a UK population and evaluates specific measures of BDD.

Cross-sectional interview survey of 50 patients who satisfied DSM–IV criteria for BDD as their primary disorder.

The average age at onset was late adolescence and a large proportion of patients were either single or divorced. Three-quarters of the sample were female. There was a high degree of comorbidity with the most common additional Axis I diagnosis being either a mood disorder (26%), social phobia (16%) or obsessive–compulsive disorder (6%). Twenty-four per cent had made a suicide attempt in the past. Personality disorders were present in 72% of patients, the most common being paranoid, avoidant and obsessive–compulsive.

BDD patients had a high associated comorbidity and previous suicide attempts. BDD is a chronic handicapping disorder and patients are not being adequately identified or treated by health professionals.

The clinical validity of melancholia has been argued on the basis of its capacity to predict response to electroconvulsive therapy (ECT). We have argued that a sign-based (CORE) rating system of psychomotor disturbance can identify patients with melancholia. Therefore, the clinical validity of the CORE system was tested here in terms of its capacity to predict response to ECT.

The response of 81 patients with primary affective disorders to an individualised course of ECT was investigated. CORE scores and other clinical predictors were evaluated in terms of their capacity to predict effect size changes in symptoms and disability.

CORE scores predicted ECT response, as did the presence of psychotic features. The combination of marked psychomotor change (high CORE scores) and psychotic features predicted the best response to ECT.

This study supports the clinical validity of the CORE system for diagnosing melancholia.

The aim was to assess the effect of a flexible dose of paroxetine, compared with clomipramine and placebo, in obsessive-compulsive disorder (OCD).

In a multinational randomised study, 406 subjects with OCD of at least six months duration received double-blind mediation for up to 12 weeks. Doses were adjusted according to therapeutic effect and side-effects. Primary efficacy measures were the Yale–Brown Obsessive–Compulsive Scale and the National Institute of Mental Health Obsessive–Compulsive Scale. Secondary efficacy measures were the Montgomery–åsberg Depression Rating Scale, Symptom Check-List (90), Clinical Global Impression, and Patients' Global Evaluation.

Paroxetine was significantly more effective than placebo, and of comparable efficacy to clomipramine. Paroxetine had significantly superior tolerability to clomipramine on three measures: CGI efficacy index, anticholinergic adverse events, and adverse events leading to withdrawal.

Paroxetine is as effective as clomipramine in the treatment of OCD. The comparable efficacy and better tolerability of paroxetine suggest that it would be an appropriate treatment for OCD.

It has been proposed that schizophrenia is associated with underactivity of brain glutamatergic neurotransmission, especially at the level of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptor. Glycine potentiates NMDA receptor-mediated neurotransmission, indicating that it may serve as an effective therapeutic agent in the treatment of schizophrenia.

Eleven treatment-resistant patients with chronic schizophrenia completed a double-blind placebo-controlled, six-week, randomly assigned, crossover treatment trial of 0.8 g/kg body weight/day of glycine, added to their prior antipsychotic treatment.

Glycine was well tolerated, resulted in significantly increased serum glycine levels and induced a mean 36 (7%) reduction in negative symptoms (P < 0.0001). Significant improvments were also induced in depressive and cognitive symptoms. The greatest reduction in negative symptoms was registered in the patients who had the lowest baseline serum glycine levels.

These results extend previous findings and suggest an additional approach to the pharmacotherapy of negative symptoms and cognitive deficits in schizophrenia.

Identifying predictors of treatment outcome can suggest ways to improve treatment delivery and understanding of its mechanism of action.

Predictors of treatment outcome were sought among 46 out-patients with obsessive–compulsive disorder who completed a nine-week randomised controlled trial of two forms of exposure therapy with ritual prevention.

In both exposure conditions the best predictor of good outcome at the end of treatment (week 9) and of follow-up (week 32) was early compliance in doing exposure homework within a week of starting treatment. A weaker predictor of good outcome at follow-up was within-session reduction in anxiety from weeks 0 to 4.

The strongest and most consistent predictor of better outcome to weeks 9 and 32 was compliance with exposure and ritual prevention in the first week of treatment.

Deliberate self-harm (DSH) is common in adolescents in the United Kingdom and suicide has greatly increased in frequency in older male adolescents. There is, however, very little information about DSH in older children and young adolescents.

Analysis of data collected by the Oxford Monitoring System for Attempted Suicide between 1976 and 1993 for all cases of DSH in under 16-year-olds referred to the general hospital in Oxford.

Seven hundred and fifty-five individuals were involved in 854 episodes of DSH. There were very few cases under 12 years of age but after that the behaviour increased greatly in frequency with each year of age, especially in girls. Eighty-five per cent were girls, the sex ratio being 5.7 girls to each boy. Most cases involved self-poisoning. During the final six years of the study period paracetamol was involved in 54.7% of overdoses, compared with 19.5% in 1976–1981. A minority of individuals had had previous psychiatric treatment. The most frequent problems were relationship difficulties with parents, followed by difficulties with friends, school and social isolation. Among those who reported previous episodes of DSH, in the majority of cases these had not come to medical attention. Repetition of self-harm occurred in 9.4% of cases within a year of an episode and 19.3% during the overall study period. There was some indication that repetition was most common in youngsters discharged from the Accident and Emergency Department without a psychiatric assessment.

DSH in under 16-year-olds is not uncommon and there is evidence that it occurs far more frequently in the community than is reflected in general hospital figures. The problem of paracetamol self-poisoning in this age group needs to be addressed. A psychiatric assessment should be performed in all cases coming to the general hospital.