Handbook of Sleep Disorders (Neurological Disease and Therapy Series 6) ($198, 920 pp., 1990) is published by Marcel Dekker, New York. It is essentially an American book (with 24 out of 36 chapters originating from North America) with a distinctly American point of view. The book has been edited by Professor M. J. Thorpy, the Chairman of the Diagnostic Classification Steering Committee of the American Sleep Disorders Association. Professor Thorpy is also Director of the well known Sleep-Disorders Center, Montefiore Medical Center, New York.

In schizophrenia, where they find their fullest expression, delusions are an extraordinary phenomenon. They can take a bewildering variety of forms, persecutory, grandiose, hypochondriacal, referential, and so on. They can be fixed and immutable, or alternatively may shift and change to the point of what Bleuler termed a delusional chaos. Finally, their degree of implausibility starts from the inherently unlikely, ranges through the patently absurd and bizarre, and not infrequently comes to violate common sense at its most elementary in fantastic delusions.

Of 24 residents of a ten-bed, community-based hostel ward suffering chronic psychiatric illness, nine have been resettled in the community, with four more expected to follow them. Five residents have made Douglas House their home but another six have manifested behavioural disturbance necessitating return to hospital wards. We found community discharge to be associated with illnesses having good prognostic features, while organic illness militated against such placement. Indicators of a prior history of behavioural disturbance seem to predict difficulties in managing a patient in this environment.

The dexamethasone suppression test was carried out on 44 children to assess agreement with diagnosis of depression. No significant association was found between suppression of plasma cortisol and depression diagnosed clinically or by cluster analysis.

High mortality rates among schizophrenic patients from infectious diseases, particularly tuberculosis, pneumonia and gastro-enteritis, reported for periods up to the 1940s were shown not to be specific for schizophrenia, but were characteristic of the mental hospital population as a whole (Alstrom, 1942). Studies covering more recent times confirm the decline and virtual disappearance of mortality from tuberculosis (Baldwin, 1979), but an extensive literature continues to emphasise the relatively high mortality of the mentally ill, including those defined as schizophrenic (Innes & Millar, 1970; Tsuang & Woolson, 1977), and more recent record linkage studies (Herrman et al, 1983; Allebeck & Wistedt, 1986) have continued to show an excess of both natural and unnatural deaths. Long follow-up studies of reasonably large groups of well documented cases are relatively uncommon in this area and therefore the 532 cases in the Harrow study were carefully followed up from the point of view of the occurrence and cause of death.

Buspirone is an anxiolytic drug from the azapirone family of molecules. It differs chemically and pharmacologically from the benzodiazepines. Although its profile of efficacy is comparable with that of benzodiazepines, it produces less drowsiness, less psychomotor impairment, less alcohol potentiation, and has less potential for addiction or abuse. Buspirone also appears to have efficacy in major depressive disorders, in comparison with placebo, but its activity in panic disorders is less impressive. It may diminish alcohol dependence both in animals and in chronic alcoholics. Clinical studies in the elderly show no important difference from younger patients in safety and efficacy profile, pharmacokinetics, and dosage requirement. The drug appears to be well tolerated in primary care settings and to be free of adverse clinical interactions with many drugs that might be used concomitantly. However, because its pharmacology differs from that of conventional anxiolytics, patients need to be informed about both its gradual onset of action and absence of euphoria and immediate sedation.

The CIDI is a fully standardised, structured interview for the assessment of psychiatric disorders according to DSM–III–R and proposed ICD–10 criteria. The development of this interview has been the collaborative effort of researchers from 18 sites around the world. In a field trial to test the cross-cultural acceptability and reliability of the questions, there was found to be high acceptance and excellent reliability for the substance use questions, problems with the lengthy alcohol section, and difficulties translating relevant substance use concepts into different languages. There is therefore room for further improvement in the substance-related questions. There proved to be differences between ICD–10 and DSM–III–R regarding substance abuse and dependence disorders.

The place of family therapy in adult clinical psychiatry remains unclear, despite considerable theoretical developments in the subject. In order to delineate the potential role of a family therapeutic approach, a study was conducted of the first 50 families treated in a newly established family-therapy clinic located in an adult psychiatric hospital.

The first national training scheme for attendants upon the insane began in 1891. The Medico-Psychological Association considered this initiative as essential if asylums were to have therapeutic credibility and recruit high-quality attendants. The initiative failed because poor pay and conditions of service were obstacles to recruitment and better standards of care. The Association then sought to integrate asylum and general nursing, leading to a double sense of betrayal on the part of the asylum nurses. They felt betrayed by the failure of the training scheme to improve their career structure and by the threat to their jobs posed by the proposed merger with general nurses. They responded by unionisation, so that two decades after the introduction of training, its only major effect had been to politicise nurses and engage them in disputes with their hospital superintendents and employing authorities. Training raised expectations in the attendants which neither the Association nor the institutions had intended to satisfy, and it was not seen by attendants as of benefit either to them or to patients.

Computerised tomography (CT) was used to assess the possible effects of substance abuse on brain morphology. Polydrug abusers had significantly wider third ventricles than normal controls, with a positive correlation between age and ventricle:brain ratio (VBR). Assuming no effect of age, estimated quantity of substance abuse was not significantly related to ventricular and sulcal measures, except that alcohol consumption correlated positively with VBR and severity of cocaine use correlated negatively with sulcal width. When age of the subjects was partialled out, alcohol use showed a tendency for association with VBR; however, severity of cocaine use did not remain a significant predictor of cortical sulcal width. The findings suggest that chronic use of alcohol, but not necessarily of other commonly abused substances, produces brain atrophy.

Seventy consecutive patients admitted to an alcohol unit were given a modified version of Yalom's therapeutic factor questionnaire at various points during the therapeutic programme. This programme consists of a two-week introductory programme, followed by a treatment programme, which includes psychodynamic groups, life-history reviews and intensive cognitive-therapy sessions. Internal agreement of ranking order of therapeutic factors was high among all patients and was independent of time spent in group therapy. Patients valued most an existential factor (which embraces concepts of personal responsibility and isolation), self-understanding and cohesiveness; they least valued guidance and identification. Therapists also completed the questionnaire: their ranking of therapeutic factors correlated highly with that of patients, but they ranked an existential factor much lower.

A cohort of first-generation Asian immigrants who received a diagnosis of a functional psychosis at the Bethlem Royal and Maudsley Hospitals were compared with an English-born control group. The Asians were found to have spent a lower total percentage of time in the two hospitals, had fewer in-patient admissions per year, and had a shorter average duration of stay in hospital than the matched controls.

Eight WHO research centres from Europe, North America and Asia took part in a WHO study aimed at assessing the reliability and consistency of sleep-EEG abnormalities in major depression. Each centre was asked to include in the study ten depressed patients aged 20–65 years meeting the Research Diagnostic Criteria for a major depressive disorder, and to match them by age and gender with ten controls. There were 67 patients and 66 controls included in the study. Compared with controls, depressed patients showed sleep-continuity disturbances such as increase in sleep-onset latency, and decrease in total sleep time and in sleep efficiency. Stages 2 and 3, as percentages of total sleep time, were reduced in depressed patients, REM latency was shortened and REM density increased. These findings confirm the presence of specific sleep-EEG abnormalities in major depression.

Fifty-six consecutively admitted elderly (65 and over) patients with depression were assessed on mental, physical and social states. They were followed up and assessed at home one year later. A group of 24 depressed in-patients aged under 65 years admitted to the same ward during the same period was also assessed. Outcome was different for the two groups, with 68% of the elderly ‘well’ at one year, against 50% of the younger group. The younger group were more likely to have ‘poor’ outcome (41 %) than the elderly (16%). However, there were more deaths than expected, particularly in the elderly. These findings differ from some previous studies, and indicate an excellent prognosis for depression in the elderly. Outcome in younger patients is less good.

I write as one who has grappled with improving the classification of the psychoses, but I believe that the strategy of developing a set of descriptive concepts, and using such preliminary groupings to search for the primary causes of the ‘diseases‘ defined (genes, brain damage, social and psychological stressors, etc.) is insufficiently ambitious. Psychiatry has been too reductionist in its attitude to both the causes and the treatment of symptoms (such as delusions), placing the entire emphasis on investigating and treating the ‘underlying disease‘, not the delusional process itself. Internal medicine has often been able to unfold the whole disease process from primary causes and preconditions through disordered physiology to symptoms. In psychiatry it is also important to understand the pathogenesis of symptoms, that is, to specify the stages in the transposition of stress and cerebral pathology into the phenomena of mental illness.

The Mystique of Dreams: A Search for Utopia Through Senoi Dream Theory (University of California Press, Berkeley, $9.95 (pb), 146 pp., 1990) is by G. William Domhoff, Professor of Psychology and Sociology at the University of California, Santa Cruz. The Dreaming Brain (Penguin, London, £6.99, 319 pp., 1990) is by J. Allan Hobson, Professor of Psychiatry at Harvard and an internationally recognised dream researcher. Dreamwork in Psychotherapy and Self Change (Norton, New York, £25, 372 pp., 1990) is by Alvin R. Mahrer who is Professor of Psychology at the University of Ottawa, and author of numerous books on psychotherapy and dreams. Dream, Phantasy and Art (Routledge, London, £30 (hb), £10.99 (pb), 120 pp., 1991) is by Hanna Segal, former Freud Professor of Psychoanalysis at University College, London, and a leading Kleinian psychoanalyst and writer. The Rhetoric of Dreams (Cornell University Press, Cornell, $22.50, 217 pp., 1988) is by Bert. O. States, Professor of Drama at the University of California, Santa Barbara.

As part of a study of the contribution of institution-alisation to the disabilities of schizophrenia (Johnstone et al, 1985), all patients fulfilling the St Louis criteria (Feighner et al, 1972) for schizophrenia and discharged from Shenley Hospital between 1 January 1970 and 1 January 1975 were followed up five to nine years later (Johnstone et al, 1981, 1984). Until Northwick Park Psychiatric Unit opened in 1975, psychiatric facilities for Harrow patients were all in Shenley Hospital. In the follow-up study the patients were examined in detail and an account of their social circumstances and functioning was obtained. It was considered that the study provided an opportunity to examine the success of community care in a group of schizophrenic patients who left hospital before very active policies of discharge for such patients had been developed. The results had both positive and negative aspects. For example, 18% of the patients examined had recovered to the extent that they had no significant symptoms and appeared to function satisfactorily, but more than 50% had definite psychotic features. No patients and few relatives sought a return to in-patient care, but severe emotional, social and financial difficulties were commonplace. Moreover, 27% of the sample had no contact with the medical or social services.

Modern comprehensive multidisciplinary mental-health services for children and adolescents have four origins: psychology from 1890, psychoanalysis from 1906, the child-guidance movement from 1920, and the children's departments of psychiatric teaching hospitals from 1930. Post-war changes in society and reform, especially the NHS Act 1946, contributed to rapid development of services and an increasingly wide range of sophisticated therapeutic interventions; professional and interdisciplinary associations and trans-Atlantic exchange were also influential. In the last three decades a succession of official inquiries, reports, legislation and reorganisations have had a damaging effect. Children and their services have been prey to causes célèbres, fashion and the exaggerated fads and foibles of the media and politicians; they have thrived best when society and their carers were tolerant, and loving, sought good qualities to augment, not evil to exorcise, and succeeded in balancing structure and control with flexibility and freedom to grow. Planners should review the past before acting.

Buspirone is a newer anxiolytic which differs chemically and pharmacologically from the benzodiazepines. The question as to whether buspirone can induce rebound, dependence, or abuse can be examined through a variety of clinical and control studies, as well as animal studies, together with meticulous follow-up of adverse reports. It is concluded that, on present evidence, the short-term use of buspirone is unlikely to be followed by rebound or long-term use through dependence; nor is abuse likely to be a problem.