Genital exhibitionism is a disorder without a satisfactory explanation; many views have been put forward as to its nature but although fragments of some of these theories appear to be relevant to the problems of some individuals, for others they are incongruent with the clinical data. At the present time we must conclude that the behavioural act does not signify a homogeneous population and that in every parameter so far studied, be it personality structure, attitude to women, erotic gratification from the act, other deviant behaviour or whatever, there is no single unifying characteristic which is always to be found. The intention in this paper is not to make a broad survey of the disorder for that has been undertaken within the last fifteen years by, inter alia, Evans (1970) and Rooth (1971, 1980); the purpose is to draw attention to some of the more recent studies in order to dispel stereotyped views and thereby to avoid the pitfalls in deriving the formulation of each individual case.

This paper explores the genesis of sadistic behaviour in men and its relationship to crime. Sixteen male special hospital patients, each with a diagnosis of psychopathic disorder, formed the basis of this descriptive study. In only three cases were the crimes explicable in terms of external circumstances and personality traits. The offences of the remaining 13 cases became comprehensible only when the offender's internal circumstances were explored: investigation revealed repetitive sadistic masturbatory fantasies which had spilled over into overt behaviour because the patients had felt impelled to seek and create increasingly dangerous in vivo ‘try-outs' of their fantasies. The paper discusses the crucial link between sadistic fantasy and behaviour.

Cerebral blood flow is known as an indicator of cerebral metabolism. Using the 133Xenon inhalation method, we studied the regional cerebral blood flow (r-CBF) in patients with different subtypes of depression and in remission. A left frontal hypervascularization and a right posterior hypovascularization were found in major depressives, compared to normal subjects, minor depressives, and normothymic bipolar patients. These results tend to confirm the existence of cerebral dysfunction in both hemispheres in major depression, as reported by other authors using different techniques.

Forty male patients with bipolar affective illness were examined for factors correlating with dangerous inpatient behaviour. It was found that 63 per cent of the variance for inpatient assaults could be accounted for by a combination of a history of severe childhood discipline, a manic state, the degree of psychosis and a record of violence prior to admission. Such information may be of use in the clinical prediction of violent acts by bipolar patients, as well as suggesting ways of preventing them.

Evidence from four case reports of heightened anxiety, irritability and emotional lability following withdrawal of lithium was confirmed by a questionnaire survey of 110 defaulters from a lithium clinic: 19 per cent of respondents retrospectively reported these temporary symptoms following withdrawal. The possible mechanisms of such a withdrawal effect are discussed, and a phased withdrawal is advocated in situations where continued clinical benefit from lithium is being evaluated. The questionnaire results also confirm anecdotal evidence that lithium reduces emotional responsiveness. The significance of these findings in terms of the current models of lithium's action is discussed.

A new problem-oriented cross-cultural method has been developed to identify the appropriate management of mental health problems in primary-care settings. It is designed to be used by multipurpose health workers in out-patient clinics in many developing countries. Presenting mental health problems in many cultural settings can be placed into one or more of eight behaviourly determined categories. After this initial categorization an algorithmic process is used to determine the sequence of observations which must be made in order to identify the appropriate management. The system allows for variations in available resources and local constraints. We outline the design principles of this algorithmic method and the rules for using it, and describe a training programme developed to teach people to adapt it and use it effectively. The evaluation studies that have been done in different developing countries confirm that the method is acceptable and efficient, and gives management decisions with a high degree of repeatability.

Three groups of 114 depressed patients admitted to hospital in Edinburgh, one in the year 1892, one in 1942–3 and one in 1981–2, were studied. The occurrence and content of depressive delusions were recorded. A significantly higher proportion of depressives had delusions in 1892 than in 1942–3, but there was no significant decline between 1942–3 and 1981–2. It is concluded that this decline in the proportion of depressives having delusions since 1892 probably does not reflect a genuine decline in the prevalence of depressive illness with delusions. The content of delusions differs between the years and between the sexes, and these differences are discussed.

Crimes relating to sexual behaviour account for only 1 per cent of all indictable crimes but for half a century sex offenders have been the subject of a disproportionate amount of psychiatric interest and enquiry. The belief, that there is a link between specific mental malfunction and sex offending, as distinct from other forms of offending appears to have wide acceptance. In 1972 the Royal College of Psychiatrists appeared sufficiently confident of this view to ask candidates aspiring to membership of the College to “Give an account of the psychopathology of rape”. Like incest and buggery, rape is an act, a deed, an item of behaviour. To speak of the aetiology, treatment and prognosis of such acts is to misapply terminology and to confuse criminal behaviour with mental disorder. The problem is not simply one of semantic niceties for the sloppy use of medical language in this controversial area can lead jurists and policy-makers to carry expectations that lack any firm psychiatric basis. This contribution will attempt to review some legal and psychiatric aspects of the more serious crimes.

Three hundred male Irish alcoholics were selected from 508 consecutive alcoholic admissions to hospital. Using well defined diagnostic criteria, they were divided into three subgroups (1) primary alcoholics, (2) alcoholics with secondary affective disorder and (3) those with primary affective disorder and secondary alcoholism. Although the three groups reported differences in past history and family history of affective disorder and in time spent in hospital for both alcoholism and affective disorder, there was little to distinguish them in behaviour associated with alcoholism or in family history of alcoholism. The implications of these findings and their significance for the relationship of affective disorder and alcoholism are discussed.

Review of 19 uncontrolled studies of antidepressants in phobic and in obsessive-compulsive disorders suggests that such drugs do not act reliably in the absence of symptoms of anxiety-depression (dysphoria). In dysphoric patients the drugs have a broad-spectrum effect not only reducing phobias and rituals but also anxiety-depression, panic, anger, and hostility, all of which are highly intercorrelated, but none yet demonstrated to be the core disturbance. Phobics, but not obsessive-compulsives, have an unusually high dropout rate from treatment when drugs or placebo are given. When antidepressants are stopped, even after 6–8 months, relapse is likely. The drugs do not reduce the liability of many phobics and obsessive-compulsives to have dysphoric episodes over the years. Exposure treatments are more lastingly effective for phobias and for rituals, but do not reduce the liability to later dysphoric episodes.

Eighteen agoraphobic patients were randomly assigned to 12 week treatment with imipramine (I) or imipramine and programmed in-vivo exposure practice (l+BT) to investigate the contribution of behavioural instructions to the clinical effects of pharmacotherapy. Significantly greater improvement on phobic measures was found in the l+BT group compared to the I group. Differences were less marked on measures of panic and anxiety. The results suggest that imipramine possesses an antiphobic effect which can be substantially enhanced with programmed practice. Controlled large-scale investigations of the pharmacological and instructional effects of the pharmacotherapy of agoraphobia are needed for a definitive evaluation of the specific antiphobic effect of antidepressant drugs.

All ‘new chronics' (N = 571), defined as patients aged 18–64 years in hospital more than one but less than six years, were identified in 14 psychiatric hospitals serving 56 per cent of the Scottish population. The bed occupancy was 20/100,000 of the general population (range between hospitals 12–29/100,000). First admissions (5.8 beds/100,000) were clearly distinguished from re-admissions. Although for the whole group schizophrenia was the most common diagnosis the majority of first admissions had organic brain disease. First admissions were more disabled and most were well placed in hospital. Thirty-eight per cent of all patients did not need inpatient care; 20 per cent could have been accommodated in staffed hostels. Widespread differences, especially in numbers, found between hospitals may have been due in part to different attitudes among staff towards the prospect of patients' discharge.

Assessment of drug-induced movement disorders was carried out regularly on 104 psychiatric patients requiring antipsychotic medication on admission to hospital. The data relevant to motor restlessness were subjected to a principal components' analysis. According to their component scores, patients were then classified into two main groups: an akathisia group and an illness-related-movement group, the former group showing the clinical and pharmacological characteristics expected of akathisia. Clinical features which distinguished between the two groups, and between grades of akathisia severity, were identified, so an objective, phenomenological description of the akathisia syndrome was possible. Our observations suggested two distinct types of acute akathisia; one related to severe parkinsonism and one not. The implications of these findings are discussed.

A strong correlation was obtained between white blood cell (WBC) lithium concentrations and the severity of observed side effects in a group of 40 patients receiving prophylactic lithium therapy. However, there was no significant correlation between these levels and the specific side effect of hand tremor, although WBC concentrations were higher in patients with greater tremor. These results contrasted with those for plasma and red blood cell (RBC) lithium concentrations, which showed no relationship to side effects. This suggests that WBC lithium concentrations may be a more sensitive index of side effects than conventional plasma estimations.

The psychotherapy of sexual deviation involves difficult theoretical, social, moral, ethical and therapeutic issues, as well as the psychotherapist's personal value system. These basic issues must be elaborated.

Two thousand three hundred and ninety consecutive visits to a walk-in psychiatric emergency service were studied to examine issues relevant to service provision. Only a third of patients were from the catchment area. Psychotic patients and those admitted or kept overnight (guests) were more frequent after hours and among non-medical referrals, especially family and police referrals; but suicidal patients often came from other hospitals. At index visit a third of patients were offered follow-up, but attendance was poor. Factors influencing attendance were examined. Keeping overnight avoided unnecessary admissions. There was little evidence that patients abused the service.

The findings suggest that a psychiatric emergency service should be available to all referrals 24 hours a day.

In a prospective study of a community sample, we examined changes in social relationships accompanying the onset and remission of neurotic symptoms. For those who developed symptoms in the course of 12 months, no decrease was found in the availability or reported adequacy of either close or diffuse ties, compared to those who remained symptom-free. For those having a remission, an increase in the adequacy of social relationships and a decrease in rows was observed only in those who improved later on, at the 12-month interview. But with either the onset or remission of symptoms, the availability of relationships remained unchanged. These observations cannot establish the direction of causality, but suggest that neurotic symptoms are more associated with the perception of social relationships than with the structure of personal networks.

Thirty-two agoraphobic patients were randomly allocated to four groups and treated by repeated exposure to cine-films at twice weekly intervals for three weeks. Three of the groups saw the same cine-film, comprising a range of agoraphobic scenes, and a control group saw a potter working on his wheel. The three groups seeing the phobic cine-film included one who viewed it at an illumination level below the visual threshold (subliminal group), one seeing it under normal conditions (supraliminal group) and one which underwent graduated exposure from subliminal to supraliminal viewing levels as the study proceeded (faded group). The faded group showed significantly greater improvement than the control and supraliminal groups and this improvement was maintained over twelve weeks.

A double blind, placebo controlled trial was carried out to examine the contribution of propranolol as an adjunct to neuroleptic medication in the treatment of chronic schizophrenic patients whose florid symptoms had not remitted with neuroleptic medication alone. Propranolol was shown to have a more beneficial effect than placebo, but the results were much less dramatic than those which have been described in previous studies. Recent work has shown that there may be a pharmacokinetic interaction between propranolol and neuroleptics, and this should be considered as one possible explanation of our findings.

Family data from schizophrenic and control probands were analyzed using a descriptive analysis and multiple threshold models to determine whether a given group of diagnoses made in accordance with ICD–9 was aetiologically related to schizophrenia. The proportion of relatives receiving any psychiatric diagnosis, other than schizophrenia and affective disorder, was essentially the same between the two study groups. Furthermore, the data did not fit the multiple threshold model tested. Thus, the hypothesis that schizophrenia and a spectrum of disorders defined according to ICD–9 have a common familial aetiology was not accepted.