The records of all 53 clients who referred themselves to a community mental health centre in the first three years of its existence were studied retrospectively. These showed increasing and generally appropriate use of direct access for the relief of serious, often long-standing emotional distress. Self-referrals were much more often men than women, and some clients would probably not have been reached in any other way. The service seemed to reduce the local GPs' burden, at least subjectively. However, no-one presented with acute psychiatric disturbance or immediately impending breakdown. Any prevention achieved seems likely to be long-term rather than short-term.

Psychoanalytical and family therapies are contrasted: psychotherapeutic change involves a change of frame. The new frame in family therapy is the system; for analytical therapy it is the unconscious, but there are striking formal similarities between them. To achieve this change, there are two basic modes of therapy, reflective and directive, each containing elements of both. An essential ingredient in therapy is an uncoupling of action from effect, which occurs in play; psychotherapy can be seen as a special type of play. In family therapy, the therapist may useful playful paradox: ‘therapeutic double binds'. Transference, the vehicle of psychoanalytical therapy, is a metaphorical relationship that is also essentially playful—serious but not real. Some guidelines for considering the relative indications and contraindications of family and individual psychotherapy are offered.

In a double-blind cross-over trial, 20 chronic schizophrenic patients were treated with sulpiride and haloperidol in two 12-week periods. The final median dose of sulpiride was 2000 mg/day (range 800–3200) and of haloperidol 12 mg/day (range 6–24). Sulpiride had an antipsychotic effect and therapeutic profile not significantly different from that of haloperidol. In spite of the high doses of sulpiride, extrapyramidal side-effects were seen less frequently during the first four weeks of the sulpiride period than during the corresponding haloperidol period (P < 0.05), whereas autonomic side-effects were equally rare for both drugs. A positive correlation was found between daily dose and plasma concentration of both sulpiride (P < 0.001) and haloperidol (P < 0.05), but no correlation could be established between clinical effects and plasma levels of either neuroleptic.

In a group of 23 hospital patients aged over 50 with Down's syndrome, psychological testing indicated that significant intellectual deterioration, which was un-related to chronological age, sex, length of hospitalisation, or earlier mental age, had occurred in nine. Clinically, there was no evidence in any patient of active physical illness, focal neurological signs, or dementia, but significant associations were found between intellectual deterioration and decreased visual acuity, hearing loss, and macrocytosis.

Body image perception was measured in 50 women with bulima nervosa and 19 age and weight matched female controls, using a visual size estimation apparatus. Both groups overestimated body widths, but not the width of a neutral object, and whilst there was a trend for bulimics to overestimate more than controls this did not reach significance. The part of the body most overestimated corresponded to the part most disliked in only a third of both groups. The bulimics without a previous history of anorexia nervosa overestimated body width more than those with such a history; this may be related to the fact that the former had a significantly greater weight index. Bulimics who were within 5% of mean-matched population weight overestimated body width less than the others, this difference reaching significance when compared with the heavier groups; a similar, but non-significant, trend was demonstrated in controls. This may be linked to a greater dissatisfaction with body size. Duration of illness, frequency of bingeing and self-induced vomiting were not shown significantly to alter body size estimation. The bulimics who completed a 10-session outpatient treatment programme subsequently demonstrated a significant decrease in overestimation of waist and hip width.

The article describes the outcome of a comparative study of home care, by a trained nurse, versus hospital out-patient supervision in the management of chronic psychiatric patients in Bangalore, India. Twenty-five patients, with a mean duration of illness of nine years, were started on the home care programme while a matched control group of 25 similar patients continued the regular out-patient contact offered by the hospital. Comparative assessments were carried out on the groups at the time of intake and again after two years. The results indicate that hospital admission was less often needed among the home care group.

A variety of psychiatric symptoms have been described in relation to Wilson's disease, an inherited disorder of copper metabolism. At least four symptom clusters can be identitifed: affective, behavioural/personality, schizophrenia-like, and cognitive; the first two groups appear to be the commonest. Four cases (three newly reported) are described, and current approaches to the psychiatric management of Wilson's disease discussed.

First admission rates from 1969–78 for Scottish psychiatric units were calculated for discharge diagnoses of affective psychosis for each five-year age-group from 15 years to over 74 years. There were clear-cut linear increases in rates of depressive psychoses, mania, and all affective psychoses, consistent with a relatively steady increase in the rate of first-onset affective psychoses with increasing age. These findings are discussed in terms of social, psychological, and biological hypotheses of the causes of affective disorder. It is argued that no single factor could produce the observed linear increases with age and that the data appear more consistent with an integrative aetiological model of affective disorder.

Twenty patients with dementia were assessed by two raters, using the Standardised Psychiatric Interview of Goldberg et al (1970). Inter-rater reliability was good or fair for many items, but test–retest reliability and validity were less good. A single interview does not appear to provide a full picture of psychiatric (excluding cognitive) symptoms in demented patients.

Rehabilitation and support services in psychiatric hospitals and general hospital psychiatric units serving two-thirds of the population of Scotland were reviewed. Although there are wide between-hospital differences, especially between rural and urban areas, the National Health Service in Scotland is making considerable efforts to provide staffing, accommodation, occupational activities, and support services for the long term mentally ill. Services provided by local authorities, with the exception of group homes, are seriously deficient. The total number of services provided by an individual hospital correlated highly with an assessment of its adequacy in providing such services in relation to other hospitals. A simple count of services may therefore be used to assess adequacy. There was also a correlation between the range of a hospital's services and numbers of misplaced new chronic in-patients.

Computed cranial tomography was performed on 48 patients with Senile Dementia of the Alzheimer Type (SDAT) who have since been followed up in a continuing prospective study. At six-months follow-up, ten patients had died; these did not differ significantly from the survivors either in mean age or duration of dementia, although the latter tended to have been shorter in the deceased. Despite having shorter histories, the deceased had performed worse on initial testing with several cognitive measures, and this was significant for the mental test score; this suggests some patients may have a more rapidly progressive form of SDAT. In a comparison between the CT scan of the deceased and survivors, the deceased were found to have significantly lower mean attenuation densities in the parietal, occipital, and left thalamic regions. The hypothesis that low attenuation density in the parietal regions of the CT scan in SDAT is associated with a more rapid demise is supported for the present period of follow-up.

Clinical reports have suggested that antidepressant medication may contribute to the sexual dysfunction experienced by some depressed patients. A double-blind trial in a non-psychiatric male population compared amitriptyline (tricyclic), mianserin (tetracyclic) and placebo for their effects on nocturnal sexual arousal. In a three-way crossover design active drug or placebo were taken for two weeks preceding measurement of the frequency, amplitude and duration of nocturnal penile tumescence and synchronous sleep indices. Both active compounds significantly decreased the amplitude and the total duration of nocturnal erections. The effects on sleep indices were as previously reported. Few differences were found between the tricyclic and tetracyclic drugs. Some implications of these findings are considered.

The dexamethasone suppression test (DST) was used in an in-patient crisis unit to determine whether the test could identify suicidal patients who might benefit from tricyclic antidepressants. DST results, DSM-III diagnoses, and measures of symptom levels were obtained for 72 patients admitted for a 3–5 day period; 31 were non-suppressors. Abnormal DST results were not related to DSM-III diagnosis or to scores on measures of depression and symptom levels. Only three patients met DSM-III criteria for major depression with melancholia; 26 patients had a diagnosis of alcohol or substance abuse. The poor specificity of the DST in this patient population suggests that its routine use in such patients could be highly misleading.

Seven cases of nightmare were treated by simple rehearsal of the nightmare and/or rehearsal with an altered ending, followed by earlier introduction of the ending. One-year follow-up of five patients showed complete relief from nightmares in the four patients who achieved early introduction of a ‘masterful’ ending, and marked improvement in the patient who could only imagine a neutral ending. All but one of the patients also presented with neurotic symptoms (anxiety, phobias, depression and compulsion/obsession). These were treated by rational discussion and the formulation of positive ‘threat-eliminating’ statements to be repeated as homework and in times of stress.

We compared the psychiatric manifestations of 56 CATEGO S schizophrenic in-patients from three ethnic groups (white, coloured and black). A marked similarity among the groups on both schizophrenic and non-schizophrenic symptoms was found, as well as a high prevalence of depressive and anxiety symptoms. Differences occurred on the syndromes of (1) olfactory hallucinations and (2) subcultural delusions and hallucinations. Black patients had both syndromes more frequently than either white or coloured patients.

In a successful attempt at extending the construct validity of the Dutch version of the Maudsley Marital Questionnaire (MMQ), its sub-scales were correlated with the Marital Deprivation Scale, the Sexuality Experiencing Scale, the Marital Communication Inventory, and the Hopkins Symptom Checklist.

This is a 13-month follow-up study of 105 two to 17 year-old children bereaved of one parent, with 85 controls. Data were gathered on physical and mental health in the children and surviving parents, the child's sex and age and the bereaved parent's sex and psychopathology being included as risk factors. Dysphoria, falling school performance and withdrawn behaviour were significantly increased in bereaved children of both sexes at all ages, while temper tantrums, bed wetting and the depressive syndrome only increased in the age and sex categories normally associated with these conditions. A global index of psychopathology was increased compared with controls on most subgroups of bereaved children (P < 0.0001), the highest scores for both sexes being associated with having a mentally ill (usually depressed) widowed mother. The results are discussed and suggestions made for future research.

Four sets of commonly used ‘operational definitions' of psychiatric disorders were applied to clinical information, obtained on the basis of semi-structured interviews with samples of hospital in-patients, out-patients, and general population. The agreement among them in defining ‘cases' and in assigning specific diagnostic categories was examined. There was considerable variation among the diagnostic systems in distinguishing between ‘cases' and ‘non-cases' and in identifying sub-groups of cases as having specific diagnoses. Comparison of operationally defined syndrome categories with diagnoses assigned by clinicians also showed much disagreement.

The mid-life period is regarded as a period of profound physical and psychosocial change for women. Psychological disturbance at this time has been associated with discrete life events. The influence of other psychosocial variables on psychological disturbance is examined in a general population sample. Five psychosocial variables are shown to have a relationship with psychological disturbance, either in conjunction with or independently of life events. The implications of these findings for the understanding of psychological disturbance at this time are discussed.

Although it is widely believed that behaviour modification is successful in an institutional setting, the lasting efficacy of such programmes for adolescents with acting-out and conduct problems has long been questioned. A follow-up enquiry was carried out at one and two years on adolescent patients who had been through an institutional behaviour modification programme. The results were compared with those obtained for a similar group of patients who were accepted for the programme but not admitted; significantly more of the treatment group than the comparison group had improved in terms of behavioural outcome measures, and their level of independent living was greater.