There is a difference of opinion among psychiatrists in this country about the place of psychodynamics in their subject. They appear to be divided roughly into two groups, the “cons” and the “pros”. This paper considers what the attitude of psychiatrists ought to be to psychodynamics, and it does this by selecting and examining the epistemological standing of one example of psychodynamic work. The example is contained in a book by Dr David Malan, entitled Individual Psychotherapy and the Science of Psychodynamics. The examination of this example brings out in what ways the two groups, the cons and the pros, are both wrong and right; and the way in which, therefore, the current difference of attitude is inappropriate, but understandably connected with the uneasy situation in which psychiatrists find themselves.

The literature on the simulation of psychosis is reviewed and six patients who were thought to be feigning a schizophrenic psychosis were studied. On follow-up, all but one of the patients became overtly schizophrenic. It is argued that the simulation of schizophrenia is a prodromal phase of the psychosis occuring in extremely deviant premorbid personalities.

In a prospective (controlled) trial, the result in 18 patients receiving eight, weekly half-hour sessions of brief problem-oriented dynamic psychotherapy was compared with the result in an equal number receiving eight weekly half-hour sessions of family practitioner therapy and in another 20 receiving no additional therapy. The subjects were drawn from patients at ten suburban family practices in Sydney. They had had psychological complaints for at least six months. No differences between the three treatment groups were found in the final outcome, either in a symptom severity and social dysfunction factor or in a physical disability and medication factor.

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.

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 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.

It has recently been found that tremor in patients on long-term lithium therapy has a lower frequency than that of normal physiological tremor and is likely to have an extrapyramidal component (Tyrer et al, 1981). Other extrapyramidal signs and symptoms have been found with chronic lithium therapy (Shopsin and Gershon, 1975; Baastrup et al, 1976; Branchey et al, 1976; Asnis et al, 1979). These extrapyramidal effects differ from the pseudoparkinsonism produced by antipsychotic drugs in that they do not respond to antiparkinsonian drug treatment (Schou, 1970; Tyrer et al, 1980).

This study compares the incidence of a variety of cutaneous conditions among 91 patients treated with lithium carbonate with the incidence of such conditions among 44 patients treated with other non-neuroleptic, maintenance medications. Data on cutaneous conditions and allergies were obtained using structured interviews, demographic data, medication histories and personal and family histories.

A significantly greater proportion of the lithium-treated patients than the comparison patients reported a cutaneous condition which may have been secondary to treatment in that it developed for the first time after the medication or appeared to have been exacerbated by the medication. Among the lithium-treated patients, females were found to be significantly more likely to report a secondary cutaneous condition. This effect was found across the whole range of cutaneous conditions. Male lithium-treated patients on the other hand reported approximately the same rate of secondary cutaneous conditions as both male and female comparison patients. Possible reasons for this sexual effect on incidence are discussed.

The literature on cutaneous conditions which have been associated with lithium therapy is also reviewed.

The 30-item General Health Questionnaire (GHQ) (Goldberg, 1972) was administered to 196 consecutive new dermatology out-patients and 40 consecutive admissions to dermatology beds. Thirty per cent of the outpatients and 60 per cent of the in-patients obtained high scores, while half the high scorers in each group scored high on the Wakefield Self-Assessment Depression Scale (Snaith et al, 1971). These findings suggest that dermatology out-patients have a higher prevalence of psychiatric disorder than the general population, and dermatology in-patients a higher prevalence than general medical in-patients.

High GHQ scores were associated with (a) diagnoses of acne, eczema, psoriasis or alopecia; with (b) extensive lesions on exposed parts of the body; and with (c) the use of high potency topical steroid. We indicate other areas that might be profitably explored in a full-scale study.

Twenty-three patients diagnosed as depressed and a matched group of normal subjects were interviewed on three occasions using standardised procedures. Their behaviour was quantified from video recordings. The results indicate that blink rate is increased in depression and falls to normal levels during treatment. The effect on blink rate was found to be independent of medication, but was related to the degree of improvement in the patients' condition. By contrast a sample of schizophrenic patients seen on one occasion showed a reduced blink rate which was probably a result of neuroleptic administration.

The reliability of the total scores on three rating scales (Melancholia Scale and the two Newcastle Scales) and the algorithms leading to the Feighner, Research Diagnostic Criteria, and the DSM-III subtypes of depression have been compared. The degree of inter-observer agreements for the various item-combinations was significantly higher than would be expected by chance. The average agreement for each assessment system ranged from 80 to 93 per cent. This 7 to 20 per cent lack of total agreement probably reflects the limitation of clinical assessments including the influence of halo effects.

Samuel Pepys's diary allows us an opportunity to see how a man of acknowledged ability and stability coped with the severe psychological trauma of being involved in the Great Fire of London in 1666. His self-monitoring provides an excellent record of the development of post-traumatic stress disorder and an account of his coping behaviour. Despite being one of the newest categories of mental disorder in the official nomenclature, posttraumatic stress disorder has obviously had a long existence.

In a study of plasma amino acids in psychiatric patients, serine to cysteine (S/C) ratio was higher (S/C = 1.57±0.28) in 57 psychotics compared to 27 nonpsychotics (S/C = 1.06±0.23). This difference was highly significant at P <0.001. Psychotic patients were given a psychosis score (p score) of 1–4, The S/C ratios of individual patients were significantly correlated to their p scores (r = 0.65, P <0.001). S/C ratios were not related to diagnosis, age, sex, food intake and medications. When the initial S/C ratio and p scores of 22 patients were compared to their S/C ratio and p score at the time when they were improved and ready to be discharged, there was a concomitant fall both in S/C ratios and p scores suggesting the high S/C ratios may be indicative of a state rather than a trait characteristic. Our findings lead us to the conclusion that S/C ratios may provide a marker for the presence of psychosis and an index of its severity.

The demonstration that an endocrine disorder can precipitate a specific mental illness would be an important step towards the development of much needed animal models of affective disorder. To this end we have sought and found evidence for a causal connection between Cushings syndrome and the apprearance of a depressive illness (Kelly et al, 1980 and 1983). Whether or not hyperthyroidism can cause a manic depressive illness is at present uncertain. Reported values for the incidence of depression in hyperthyroidism vary from 1–20 per cent (Bursten, 1961; Clower et al, 1969; Dunlap and Moersch, 1935; Johnson, 1928; Katzenelbogen and Luton, 1935; Kleinschmidt et al, 1956; Lidz and Whitehorn, 1949) and these are similar to estimates of the incidence of depression in a general population (Watts et al, 1964; Shepherd et al, 1966; Crombie, 1974; Brown and Harris, 1978). Similarly estimates of the incidence of hyperthyroidism in depressed patients are around 1 per cent (Bursten, 1961; Bluestone, 1957; Martin, 1963) which is also similar to the incidence of hyperthyroidism in the general population (Tunbridge et al, 1975). Finally in a population of patients with recurrent manic depressive illness, the eight observed episodes of hyperthyroidism striking during normal health were not apparently followed by any mental disturbance (Checkley, 1978). We now report upon a patient in whom two episodes of mania coincided with two episodes of hyperthyroidism and discuss the possibility that the two illnesses were related to each other.

Psychological deterioration, defect state and psychological deficit are all terms introduced this century to replace Kraepelin's idea of dementia praecox. They all express the notion that schizophrenics have some global impairment in psychological functioning, which is different from the presenile dementias or recognised causes of cerebral dysfunction. At the beginning of the century it was generally regarded as organic in nature. In the 1960s the social revolution in psychiatry encouraged the view that the deterioration was psychosocial, the effect of institutionalisation. There has been a recent trend to revive the organic formulation.

The five articles which follow examine the idea from different points of view. They were commissioned because correspondence to the editor indicated that the issue was topical and controversial. It is hoped that they may be the first of a series of multi-author contributions on topical issues.

Manfred Bleuler presents his view that deterioration is not a progressive condition, but one of several outcomes, and even then liable to remission. Luc Ciompi discusses the relationship between organic and psychosocial factors in its cause, and concludes that it is the result of an interaction between the two. Tim Crow gives a clear account of the organic model. David Abrahamson draws attention to some methodological issues, which have led to a false clinical impression, and wrongly overemphasised the extent of deterioration. Digby Tantam analyses the complex effect of drug treatment.

Naylor's recent hypothesis that vanadium ‘poisoning’ could be a factor in the severity of manic-depressive illness drew attention to the normal and even essential presence of vanadium in the diet, and in human living tissues. The whole brain may contain only about 45 micrograms of vanadium (Underwood, 1977; 1979), as against 500 micrograms of manganese, 130 μgm selenium, and less than 20 μgm molybdenum—others of the 12 or so essential metals required in traces. We might take copper as the principle trace metal—an important component of over 50 enzymes, including monoamine oxidase and dopamine β-hydroxylase—with a total in the whole man of about 100 mg. In contrast, metals like potassium (140 gm), magnesium (35 gm), iron and zinc (3–4 gm) are not present in traces but in gram quantities. Lithium, present naturally in the body in extremely minute amounts, is raised in therapy to occupy a borderline position in the scale, rather more than copper, less than zinc.

Regular, long term haemodialysis is a standard treatment of patients in chronic renal failure. Its psychiatric implications have been dealt with in a number of studies, most of which concentrate on purely psychological or social aspects, for example patients' perception of and response to illness (Pritchard, 1974), the relevance to outcome of basic personality (Kaplan De-Nour and Czaczkes, 1976), or the impact on the family of dialysis carried out at home (Farmer et al, 1979). There are two distinct psychiatric syndromes of importance which can be clinically recognized.

In 1966, Sir Aubrey Lewis retired from the Maudsley Hospital. To mark the occasion, the postgraduate students at the Bethlem Royal and Maudsley Hospitals published a selection of his writings, which appeared in 1967. But the flow of papers from his pen continued unabated until his death in 1975. Michael Shepherd was thus enabled to bring out a further volume in 1979, containing some of these later papers'.