We tested whether cortical and subcortical regional cerebral blood flow (rCBF) differs between patients with obsessive-compulsive disorder (OCD) and healthy controls. We then explored the relationship between rCBF and OCD mental state.

Thirty out-patients from the Maudsley Hospital with OCD as defined in DSM–III–R were scanned at rest using brain-dedicated, high-resolution, single photon emission tomography. RCBF was measured as uptake of 99mTc-HMPAO in 15 regions of interest and compared with rCBF data in 30 healthy people matched for age, sex and handedness. Symptom ratings were obtained using standard measures on the scanning day. Principal components factor analysis identified two distinct clinical dimensions: obsessive–compulsive (OC) and anxious–avoidant (AA). These were correlated with patients' rCBF measurements, using Spearman's rank correlation coefficient, and multiple regression coefficients calculated.

We found significant reductions in rCBF measurements of OCD patients compared with resting, healthy controls (F = 1.92, P = 0.04) in seven brain regions: the right and left superior frontal cortex, right inferior frontal cortex, left temporal cortex, left parietal cortex, right caudate nucleus and right thalamus. Regional differences were not secondary to generalised reduction in patients' brain perfusion. Reduced blood flow to the right inferior frontal cortex correlated significantly with illness severity (r = 0.37, P = 0.02). There was no relationship with age, age-of-onset, sex, handedness, depression or medication status. OC clinical dimension, concerning obsessions, compulsions and low mood, was significantly negatively correlated with left inferior frontal, medial frontal and right parietal rCBF. AA dimension, concerning anxiety and avoidance, was significantly positively associated with left and right superior frontal, right inferior frontal, medial frontal cortical, and right and left caudate and thalamic rCBF.

rCBF differs significantly between resting OCD patients and healthy controls, and separate clinical dimensions are associated with functionally distinct rCBF patterns.

Several studies have suggested a declining first-admission rate for schizophrenia. This study examines the care-based incidence of schizophrenia in a Dutch register area.

Data from Groningen psychiatric case register were used to compare first-admission rates for schizophrenia over 1976–90 with those of other functional psychoses, and to consider various potential biases.

Diagnostic habits probably affected time trends in incidence rates. Using a broader definition of schizophrenia, no evidence was found for a decrease in the incidence of schizophrenia. Although first admissions to intramural services showed a (non-significant) decrease, this effect seemed to be neutralised when all mental health services were taken into account.

Care-based studies of time trends in psychiatric disorders should embrace all mental health services. Furthermore, unless a diagnostic classification system with univocal criteria is used, bias caused by changing diagnostic habits cannot be ruled out.

We examined whether acute transient psychoses can be distinguished from schizophrenia and the affective disorders.

We studied 46 cases of nonaffective acute psychosis in the Chandigarh Acute Psychosis Study. With respect to separation from schizophrenia, we examined the distribution of duration of the episode. With respect to separation from affective disorders, we assessed the frequency of affective symptoms.

Duration was bimodal, suggesting the presence of two distinct conditions of short and long duration. Affective symptoms were minimal, suggesting that these were not atypical affective syndromes.

Acute transient psychoses conform neither with schizophrenia of brief duration nor with atypical affective psychosis, and thus require separate classification as proposed in the ICD–10.

This multicentre study compared a 16-week buspirone treatment with placebo in patients presenting with panic disorder with agoraphobia and also receiving cognitive behaviour therapy (CBT).

Double-blind testing was maintained until week 68, but not tested; 91 patients were included; 14 placebo-responders excluded; 77 patients randomised; 48 reached week 16 and 41 reached week 68.

At week 16, within-group analysis showed significant improvements in agoraphobia, panic attacks, and depression in both groups. Generalised anxiety improved only in CBT + buspirone. Between-group comparisons showed buspirone to have an effect on generalised anxiety and agoraphobia. Changes in degree of agoraphobia and depression were correlated in subjects on CBT + buspirone only. A significantly higher proportion of women, and of subjects showing high avoidance dropped out. Positive expectations regarding medication predicted success in both groups. At week 68, improvement was retained without significant buspirone effect.

Buspirone enhanced the effects of cognitive behaviour therapy on generalised anxiety and agoraphobia in the short term.

This study investigates the naturalistic course of panic disorder over four years and attempts to identify predictors for outcome.

423 DSM–III–R panic disorder patients who had taken part in an international multicentre drug trial were selected for follow-up; we were able to re-interview 367 (87%). For panic attacks, phobic avoidance and disabilities the same rating scales were administered as had been used for the clinical trials.

While 61 % of all patients experienced at least occasional panic attacks at follow-up, few suffered from serious phobic avoidance (16.7%) or serious disabilities (work 7.9%; family 8.7%; social 13.9%). Panic attack frequency at baseline, original trial medication and continuous use of psychotropic medication during follow-up are not related to outcome, whereas longer duration of illness and more severe phobic avoidance at baseline are unfavourable.

The course of panic disorder is not uniform. Since long duration of illness and severe phobic avoidance at baseline are predictors for an unfavourable outcome, more rigorous efforts should be undertaken to detect and treat panic disorder at an early stage.

This study tested whether adding imagined exposure to live exposure would increase the concordance between behavioural and subjective improvement in obsessive–compulsive disorder (OCD).

46 OCD out-patients were randomly allocated to 9 weekly sessions of either combined live + imagined exposure/ritual prevention (Exi, n = 23), or only live exposure/ritual prevention (Ex, n = 23). Patients were asked to do 90 min of daily self-exposure at home (corresponding to Exi or Ex). Measures were: (A) behavioural; (B) subjective; (C) clinical global impression (CGI).

After 9 weeks of treatment, improvement was greater on behavioural than subjective measures (similar for the Exi and Ex groups). At 20 weeks (3-month follow-up) each group had improved slightly more on subjective measures and slightly less on behavioural ones. Two subjective measures improved less during Exi than Ex, but this difference disappeared at follow-up. The greater difference between behavioural and subjective improvement scores in Exi than in Ex did not relate to clinical outcome at the end of treatment or follow-up.

Compared to live exposure alone, combined imagined plus live exposure did not enhance behavioural/subjective concordance.

To assess quarterly fluctuations in schizophrenia births in a southern hemisphere data set, and to compare the quarterly birth distributions of patients born in the northern and southern hemisphere.

The month and place of birth of patients with schizophrenia (n = 9348) were extracted from a mental health register.

The quarterly birth distribution of patients with schizophrenia differed significantly from the estimated general population distribution in SH-born patients. The quarterly distribution of patient births differed significantly when the two hemispheres were compared.

These data support the hypothesis that there is a risk for schizophrenia that is related to the time of birth, and which fluctuates across the year.

This study looks at the outcome of infants exposed to dothiepin in breast milk in an attempt to guide clinicians on the risk-benefit ratio of breast-feeding when on antidepressants.

Thirty women, who had had HDRS scores > 15 within the first five years postpartum from the same women's hospital, were assessed with their children 3–5 years postpartum; half had breast-fed while on dothiepin (study group). Thirty-six non-depressed women were also assessed. Rating scales assessed depression, anxiety, self-esteem, personality, social support, marital relationship, child behaviour and temperament. The children were assessed by the McCarthy Scale.

Comparisons of the two depressed groups showed no significant differences on any measures except marital conflict and child behaviour, which were the most disturbed in the study group (P < 0.001). Overall cognitive scores for the children did not differ between the groups. Higher levels of dothiepin and northiaden were associated with higher cognitive scores on subscales (P = 0.02).

We are cautiously optimistic about the lack of any negative associations between cognitive development and exposure to dothiepin via breast milk.

Age-associated memory impairment (AAMI) describes a non-disease ageing-related decline in memory. Pharmacological treatment trials have been reported and DSM–IV has introduced a term for the disorder. No prevalence study with the original criteria has previously been published.

An age-stratified sample was taken of 50–95-year-olds registered with a local health centre. Diagnosis of AAMI was made by questionnaire, cognitive testing, and medical and psychiatric assessment.

Prevalence rates for the total population and for the over-50s were estimated to be 5.8% and 18.5%, respectively. These rates are dramatically affected by minor alterations to individual criteria.

It appears AAMI is less common than previous estimates suggested, although the diagnostic criteria do not satisfactorily define people with an age-related decline in memory. Complaint of memory decline is more strongly correlated with measures of affect and personality than with measures of current memory test performance or estimates of memory decline.

This systematic review of the association between schizophrenia and obstetric complications (OCs) was performed to assess the degree of heterogeneity between studies and to quantify the increased risk of schizophrenia in exposed subjects.

Twenty case-control, one prospective cohort and two historical cohort studies were identified using a medline search supplemented by a manual search and direct communication with other researchers. Individual odds ratios were calculated for each study and a pooled estimate produced. The effect of methodological variation between studies was further assessed by partitioning studies according to study characteristics.

Overall, there was no significant heterogeneity of effect between studies, and the pooled odds ratio for the exposure to OCs on subsequent development of schizophrenia was 2.0 (95% CI 1.6–2.4). However, partitioning according to study design revealed significant heterogeneity (z = –2.60, P < 0.01) between the pooled estimate from the case-control studies and that from the historical cohort studies. There was a gap on the funnel plot in the region of small studies finding no effect.

Although the result indicates that subjects exposed to OCs are twice as likely to develop schizophrenia, the analysis suggests that the observed association could be inflated by both selection and publication biases.

This study compared the efficacy and tolerability of paroxetine with placebo in the treatment of panic disorder.

After three weeks of placebo, patients received 12 weeks of treatment with paroxetine (20, 40, or 60 mg) or placebo, and finally two weeks of placebo. Dosages were adjusted according to efficacy and tolerability. Standardised cognitive therapy was given to all patients. The primary measure of outcome was reduction in the number of panic attacks.

Analysis of the results showed statistically significant differences in favour of paroxetine between the two treatment groups in two out of the three primary measures of outcome, i.e. 50% reduction in total number of panic attacks and number of panic attacks reduced to one or zero over the study period. For the third measure of outcome, the mean change in the total number of attacks from baseline, there was a positive trend in favour of paroxetine. The results of the primary measures of outcome were strongly supported by the results of the secondary efficacy measures of outcome. In addition, paroxetine, at all doses, was very well tolerated.

Paroxetine plus cognitive therapy was significantly more effective than placebo plus cognitive therapy in the treatment of panic disorder.

Analysing data from the Epidemiologic Catchment Area (ECA) study, Weissman and colleagues reported that panic disorder was strongly associated with suicide attempt. However, they did not control optimally for comorbid disorders known to increase suicide risk.

Reanalysing the ECA data, we controlled for comorbid disorders in the aggregate rather than one at a time when we estimated the association between panic disorder and suicide attempt.

Panic disorder was not associated with an increased risk of suicide attempt.

Comorbid conditions strongly influence whether people with panic disorder are at especial risk of suicide attempt.

Psychiatric case registers (PCRs) are particularly useful for studying patterns of care over time. Methods of ‘survival analysis’ have rarely been used for assessing such data.

A longitudinal study was conducted over 10 years (1 January 1982 to 31 December 1991) on 1423 first-ever psychiatric patients, using the PCR of South Verona, Italy. The product-limit method, the log-rank test, the Cox regression model and the Poisson regression analysis were used to analyse episodes of care and relapses.

The duration of the episodes of care increased consistently from the first to the fifth episode. The probability of opening a new episode of care after the first one increased consistently from the second to the sixth episode. The only variable significantly associated with the length of the first episode of care was diagnosis (highest probability of having longer episodes for schizophrenic patients), while the length of the breaks following the first episode of care was associated with diagnosis, sex and occupational status (highest probability of opening a second episode of care for schizophrenic subjects and those with alcohol and personality disorders, for males, and for unemployed patients). The probability of opening a new episode of care decreased with time since last contact and increased with number of previous contacts.

The community psychiatric service in South Verona is fulfilling its original aim, that is, to give priority to the continuity of care for patients with chronic and severe mental illnesses. Survival analyses proved to be useful methods for assessing episodes of care.

The Royal Air Force Wroughton Post-Traumatic Stress Disorder (PTSD) Rehabilitation Programme is described. It comprised a 12-day structured in-patient ‘course’ of group psychotherapy and day-case group follow-up sessions over a one-year period. Psychological debriefing was the main therapeutic technique employed.

This is a ‘before and after’ open outcome study. A comprehensive assessment protocol confirmed the presence and severity of PTSD and measured co-morbid psychopathological status, occupational and social function longitudinally.

A highly significant global response to treatment is demonstrated in the 34 subjects included in the study, with 85.3% not fulfilling the DSM–III–R criteria for PTSD at one year after treatment.

Further controlled studies assessing the value of psychological debriefing techniques in the treatment of established PTSD are required.

We examined whether expressed emotion (EE) influenced the course of schizophrenia in Japan.

We conducted a cohort study. Of 73 subjects with schizophrenia meeting the diagnostic criteria of ICD–9 or DSM–III–R, 52 participated in the study. The Camberwell Family Interview was conducted to evaluate EE. The subjects had been followed up for nine months and psychiatrists who were blind to the EE status evaluated their symptoms with the Brief Psychiatric Rating Scale.

The relapse rate in the high-EE group was 58% and that in the low-EE group 21 % (P < 0.01). Nine-month relapse risk ratio was 2.72 (95% CI 1.24 to 5.97).

In Japan, as elsewhere, EE is a good predictor of schizophrenic relapse.

The long-term course of seasonal affective disorder has not been well studied.

Using the Structured Clinical Interview for DSM–III–R, we interviewed 75% of a sample of 124 subjects diagnosed from five to eight years previously as fulfilling DSM–III–R criteria for recurrent major affective disorder, seasonal pattern.

In the follow-up period, 38% of the sample continued to fulfil DSM–III–R criteria for seasonal illness; 28% had recurrent major depressive disorder, but no longer displayed a seasonal pattern; 18% were completely well with no further depression; 6% had subsyndromal symptoms; and 5%, although not meeting DSM–III–R criteria for seasonal illness, were still displaying constant periodicity. A short duration of index episode and a high frequency of illness predicted a continuing seasonal course of illness.

Diagnostic criteria for seasonal affective disorder need to be further refined, possibly restrictively, if they are to be used to predict the future course of seasonal illness.

A history of sexual abuse has been widely reported in patients with eating disorders. However, the association does not appear to be specific, because a high rate of such abuse has also been found in other psychiatric patients.

A standardised interview method was used to elicit details of sexual abuse in a psychiatrically normal control group and samples of patients with anorexia nervosa, bulimia nervosa, or depression.

An equally high rate of abuse was found in all three clinical samples. Among the patients with anorexia nervosa the presence of bulimic episodes was not found to be associated with reports of abuse; and among the patients with bulimia nervosa there was no relationship between abuse and a history of anorexia nervosa. Among the patients with eating disorders, borderline personality disorder, assessed by means of self-report questionnaire, was not found to be related to reports of abuse, although there was an association between abuse and both indices of impulsive behaviour and the overall level of personality disturbance.

Childhood sexual abuse appears to be a vulnerability factor for psychiatric disorder in general and not eating disorders in particular. The way in which abuse interacts with other aetiological factors to produce different psychopathological trajectories remains to be elucidated.

Depression in later life is often thought to differ from that at other times of adulthood. The evidence for this is controversial but is important to any proposed organic model of depression in the elderly. Here, early- and late-onset depressions in later life are compared.

Fifty-seven depressed patients with a mean age of 74 were studied, 21 with an early onset (aged 59 or less) and 36 with a late onset. All were suffering from major depression according to DSM–III–R. The measures at entry included severity and symptoms, cognitive function, antecedent life events, physical health and vascular risk factors and/or vascular disease. We also recorded any family history of mood disorders, as well as the course of illness.

The anxiety item scores of the Hamilton Depression Rating Scale were significantly higher in those with an early onset, but otherwise symptoms differed little. Heritability was greater in the early-onset group. There was a striking association of vascular disease and/or risk with late-onset patients.

Vascular disease is associated with late-onset depression. This is consistent with the hypothesis that depression in later life is a more ‘biological’ disorder.

Our aim was to describe the medium-term course (2–3 years) in a series of victims who had experienced severe trauma.

We selected a consecutive series of 31 trauma victims and applied a structured clinical schedule (CAPS-2) to their psychiatric evaluations prepared for the court on two separate occasions approximately one year apart.

Post-traumatic stress disorder and depression were the commonest diagnoses, occurring in 39% and 16% of the victims respectively when they were first assessed. Most had improved between the assessments and this was especially the case for the re-experiencing of the trauma and over-arousal, but less so for avoidance; 20% of subjects showed no improvement, often being handicapped by secondary psychiatric illness.

Traumatised victims generally showed recovery in the 2–3 years after the trauma, but this was slow and was not universal.

Different definitions of chronic fatigue syndrome (CFS) have different psychiatric exclusion criteria and this affects the type and frequency of associated psychiatric morbidity found. The operational criteria for neuraesthenia in ICD–10 vary in this and other respects from the Centers for Disease Control and Prevention (CDC) criteria for CFS. Neuraesthenia and associated psychiatric morbidity in CDC-defined CFS are evaluated.

CFS subjects and controls were interviewed with the Schedule for the Clinical Assessment of Neuropsychiatry (SCAN). The computerised scoring program for SCAN (CATEG05) facilitates the assignment of operational definitions according to DSM–III–R and ICD–10. Subjects were re-interviewed with SCAN an average of 11 months later. No specific treatments or interventions were given during this period.

The majority of subjects fulfilled ICD–10 operational criteria for neuraesthenia and had two and a half times the rate of psychiatric morbidity as the healthy comparison group according to the CATEG05 Index of Definition (ID). Approximately 80% of subjects fulfilled both DSM–III–R and ICD–10 criteria for sleep disorders. There was a significant fall in the number of subjects fulfilling criteria for depression and anxiety disorders and a significant increase in the number of subjects with no diagnosis for DSM–III–R criteria over time. There were no significant changes over time for any diagnosis according to ICD–10 criteria or for overall levels of psychopathology as reflected in CATEG05 ID levels.

The ICD–10 ‘neuraesthenia’ definition identifies almost all subjects with CDC-defined CFS. Fifty per cent of CFS subjects also had depressive or anxiety disorders, some categories of which remit spontaneously over time.