In some quarters schizophrenia has gained the reputation of a graveyard of research. Few findings stand the test of time, most of the pieces of this particular jigsaw seem to be missing, and it is not easy to make sense of those that are available. Even ‘hard’ scientific findings fail to be replicated, an example being the status of D2 receptors in drug-naive schizophrenics (Wong et al, 1986; Farde et al, 1987).

Although there have been many studies of violent behaviour, anger has been neglected as a subject of scientific and clinical investigation. Anger can be defined as an affective state experienced as the motivation to act in ways that warn, intimidate or attack those who are perceived as challenging or threatening. Anger is associated with sensitivity to the perception of challenges or heightened awareness of threats. Anger is likely to be closely associated with fear. Although anger is common in mental illnesses it is largely neglected, perhaps because of the social stigma attached to its expression.

Epidemiological research in schizophrenia is back in fashion and has taken an iconoclastic turn. Received truths about schizophrenia had a reassuring stability about them, rather like Euclidean geometry. In contrast to, and perhaps in reaction to, the frustrating nebulousness of the disorder itself, its distribution had the attributes of a universal constant: incidence and symptoms unchanging over time and across space–and between the sexes. Dissenting voices were few, but now are growing in number and volume. One sex difference, that of age at onset of schizophrenia, has been accepted since Kraepelin's time, although is still unexplained. But sex differences in incidence, course, and symptoms are now being mooted which hint at sex-dependent differences in aetiology. Much of the re-examination of this issue has sprung from the work of Jill Goldstein and colleagues at Harvard, Robin Murray, David Castle, and colleagues at the Institute of Psychiatry, as well as others, such as Mathias Angermeyer in Mannheim.

“In the practical decisions of life it will scarcely ever be possible to go through all the arguments in favour of or against one possible decision, and one will therefore always have to act on insufficient evidence” Werner Heisenberg (1962).

The development of selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (SSRIs) has added a new dimension to the pharmacotherapy of depression. Their lack of sedative and anticholinergic effects together with relative safety in overdose, has led some authors to suggest that the older tricyclic antidepressants (TCAs) should not now be considered a first-line treatment (Montgomery, 1988). However, since a report by Teicher et al (1990) of suicidal preoccupation associated with fluoxetine treatment, there has been both intense media interest and animated correspondence in clinical and scientific journals (O'Donnell, 1991).

Mental health services are of interest not only because of the large burden they impose, but also because they have been subject to more change than virtually any other type of health service over the past four decades. Although both the US and UK have taken to ‘deinstitutionalisation’ with enthusiasm, the US has so far proceeded somewhat further down that road than the UK. While both countries face similar problems, the NHS and Community Care Act 1990 may now lead to considerable further changes in the UK.

This annotation describes psychophysiological research that has examined the hypothesis that autonomic hyperarousal is a possible mediating factor between schizophrenic relapse and psychosocial influences such as expressed emotion (EE) and life events. We review several studies that have measured psychophysiological activity in schizophrenic patients while in the presence of their relatives. The findings from this area of research are compared with those of other psychophysiological studies of schizophrenia which have employed more traditional laboratory tasks such as the electrodermal response-habituation paradigm. Finally, some conclusions are drawn regarding the clinical implications of psychophysiological research, and areas for future investigation are suggested.

This review describes the history of PTSD in relation to military psychiatry, physiology, and crisis theory. It appears that the consequences of psychic trauma are often underestimated and mental health services often fail to provide adequate care. PTSD may be explained as an initially adequate reaction to danger, which becomes pathological if it does not disappear after the danger is gone. The authors argue in favour of better psychiatric intervention after traumatic events and better care for trauma victims.

Although delusion remains one of the basic problems in psychopathology, attempts to understand its pathogenesis have been dominated by unsubstantiated speculation. Previous psychodynamic formulations have recently given way to increasing interest in measurement, and testing of models derived from cognitive psychology. However, the formation, elaboration, and persistence of delusional beliefs may be an expression of the convergence of numerous causal influences, each exerting an effect at a different stage in the evolution of the belief. This review takes a structured overview of the literature, placing the numerous part theories and scant experimental findings within a general model of delusional development. It argues for a return to systematic research on symptoms rather than complex diagnostic formulations to facilitate better understanding of the development of delusional disorders and stimulate further interest in therapeutic intervention.

At least 1 in 600 adults wound themselves sufficiently to need hospital treatment. More men than women do it, although more women receive psychological treatment. Many have a history of sexual or physical abuse. Self-wounding differs from other self-harm in being aimed neither at mutilation nor at death. Self-wounding coerces others and relieves personal distress. Repeated self-wounding is one criterion of borderline personality disorder but we prefer to consider it an ‘addictive’ behaviour rather than an expression of a wider disorder. Psychological management may need to be augmented by drug or social treatment. Carers, including professional carers, usually need help to contain the turbulence that self-wounding produces.

Severe school attendance problems, which once commanded a great deal of attention in child and adolescent psychiatry, have fallen from favour and are increasingly viewed as varieties of social impairment which may accompany disorders such as anxiety disturbances in the case of school refusal and conduct disturbances in the case of truancy. It is argued that this relegation of school attendance difficulties may have gone too far. As presenting complaints, albeit sometimes masked by apparent physical illness, they still have much to recommend them as indicators of a wide variety of present and future problems: educational, social, family, legal, medical, and, last but not least, psychiatric. Prevalence, features, causative factors, outcome, and management are discussed. Particular attention is paid to DSM and ICD classification. Gaps in present knowledge are indicated.

As part of its concern with the environmental causes of disease, medical research tries to comprehend the nature of social processes and their implications for human health: an endeavour calling for sociological concepts and methods (Susser et al, 1985). Medical needs are mirrored within sociology, which has never been confined to study of the workings of society, but has always concerned itself also with their impact on individuals and on public health. The importance of cooperation between the two disciplines is thus indisputable. Nevertheless, interprofessional relationships have never been easy, and Pflanz's dictum, that “the history of the relationship between sociology and medicine is … mainly a history of unsuccessful encounters” (Pflanz, 1976), remains substantially true today. The difficulties have been ascribed to interdisciplinary tensions of the kind that arise when a relatively young academic profession seeks to assert its autonomy in a relationship with an older-established and more powerful one. Martin (1976), stressing the dangers that can result from mutually false expectations, invoked the analogy of a marriage in which:

When William Sargant died in 1988 at the age of 81, he had made his mark on British psychiatry. He had exerted considerable influence on US psychiatry as well. This was especially obvious during a time when physical treatments were hardly the fashion in US psychiatry. As The Times (1988) stated at the time of his death, he had made psychiatry more respectable by keeping it close to the medical model. He did a great deal to make depression intelligible to general practitioners and, therefore, to make it a legitimate, respectable illness.

An assessment schedule was used to determine the nature of insight in 91 mixed psychotic patients, and to examine its distribution and associations. While all the components of the schedule intercorrelated significantly, scores for compliance were only weakly related to those for ability to label psychotic phenomena as abnormal. Compliance and illness recognition were related to IQ. Total insight score was inversely correlated, moderately, with a global measure of psychopathology derived from the PSE, and was less in patients involuntarily committed. Age, sex, diagnosis, and the number of previous hospital admissions had little effect. The results support the notion that insight is not a unitary concept.

Many people with well defined borderline and schizotypal personality disorders may benefit considerably from small doses of neuroleptics. Depression that occurs with personality disorders, which is frequent, responds poorly to tricyclics but may respond better to neuroleptics, while the response to ECT is usually short lived. Selected borderline subjects may respond to MAOIs, particularly where there is a history of childhood hyperactivity. Carbamazepine and lithium may help some individuals with episodic behavioural dyscontrol and aggression, even in the absence of epileptic, affective or organic features. Drug treatments can be combined with psychotherapy, but further placebo-controlled trials are needed to clarify which drugs are most useful, and whether there are any useful clinical predictors of drug responsiveness.

This paper reviews the literature on the effects of liver disease on mental health, a topic which has been relatively neglected in the recent psychiatric literature. It discusses both the encephalopathy which may be associated with liver disease of almost any type and the psychological consequences of specific liver disorders. Also considered are the effects of liver disease on sexual function; the relationship between alcohol and hepatic disorder in causing mental disturbance; the effects of childhood liver disease; psychiatric aspects of liver transplantation; and the use of psychotropic drugs in patients with hepatic dysfunction.

The February 1992 issue of the British Journal of Psychiatry contained the summary report from the Second Phase of the Cross-National Collaborative Panic Study (CNCPS) on a clinical treatment trial of panic disorder. This manuscript was submitted in 1988 and took four years of response to critiques and revisions to generate a manuscript that was acceptable to the Editor of the British Journal of Psychiatry. In the same issue, Marks et al (1992) provided a ‘Comment’ which was critical of the study, calling it an “elephantine labour” which “resulted in the delivery of a mouse” and was highly critical of the statistical analyses and interpretation. Moreover, their ‘Comment’ was a springboard for discussing general issues in the treatment of panic disorder and the relative value of pharmacological versus psychological treatments. In our opinion, the Marks et al ‘Comment’ is inaccurate and misleading. At many points, they make reference to topics being missing that are actually addressed to our manuscript and they presented a statistical summary in Table 1 (p. 203) of our data which was inaccurate. In this Comment, we address each item criticised.

The prevention of suicide requires an understanding of protective as well as risk factors, and the recognition of high-risk groups. Factors which increase the risk in patient populations include previous parasuicide, recent relapse or discharge, features of mental state (depression, psychosis), social circumstances (isolation, unemployment), and demographic characteristics (male sex, young age). Protective factors are under-researched but are likely to lie in the nature of psychiatric care. Consequently, community care may affect suicide by altering the level of protection at critical periods in an episode of illness. The clinical prevention of suicide should therefore be a priority for community services, and the relationship between suicide and mental health care should be researched by a national process of monitoring.