The onset of psychotic illness in the reproductive phase of life with a decrease in fecundity (and approximately constant incidence across populations) requires an evolutionary explanation. What is the survival value of the predisposing gene or genes?

Evolutionary theories, including the author's, are reviewed and critically compared.

Some theories (e.g. Huxley et al, 1964) postulate an advantage outside the nervous system: such theories fail to explain either the characteristic age distribution or constant incidence. More plausible are theories that relate the advantage to diversity of personality structure or social ability, or even to general intelligence, i.e. to the areas of function in which the phenomena of psychosis arise.

It is argued that psychosis arises as the boundary of a distribution of variation in cerebral structure generated in the course of hominid evolution. Language played a central role, with the critical changes taking place on the basis of a mutation that allowed the two cerebral hemispheres to develop with a degree of independence. Sexual selection (differing criteria in females and males in choosing a mate) acting on this genetic innovation has generated a dimension of competence in social interaction in relation to which there has been a progressive increase in cerebral size by delayed maturation (neoteny). A sexual dimorphism in cerebral asymmetry and the sex difference in age of onset of psychosis can be parsimoniously explained if a gene regulating the relative growth of the two hemispheres is X–Y homologous.

We evaluated integrated, multidisciplinary, community-based care for a cohort of people with treated long-term mental illness over two years in a field trial set in a semi-rural setting. The aim was to organise local psychiatric services on an extramural basis with general practitioner teams as the key element.

Trained research workers used a structured interview to collect standardised baseline and three-monthly socio-demographic, clinical, social, family adjustment and burden, and treatment measures from patients, informants, and key-workers. Analysis included descriptive statistics and, for longitudinal data, analysis of best-fitted straight lines.

We studied 34 patients (14 with schizophrenia, 11 with major affective disorders, and 9 with minor (non-major) affective disorders and anxiety disorders) who had a mean of 12 years continuous illness. At baseline, they were mainly characterised by research workers as mildly ill with fair social adaptive functioning, and by lay informants as having moderate target symptom severity and disturbance of social performance. Over two years, there were statistically significant, slight improvements in clinical global impressions ratings by research workers, and in informants ratings of target symptoms and social performance. Most patients continued to receive prescriptions for psychotropic drugs throughout follow-up, and they had a mean of 47 therapeutic contacts, mainly from nurses. Two patients were admitted to psychiatric hospital. There were few differences between patients in different diagnostic groups.

Integrated, multidisciplinary, community-based psychiatric care for people with treated long-term mental illness is feasible in a semi-rural setting: patients receiving pharmacotherapy and regular psychosocial treatments remained relatively stable on clinical and social measures over two years. The unique way in which the service was monitored, by making regular, systematic assessments of patients and carers, serves as an example for other services.

It was hypothesised that schizophrenic patients with tardive dyskinesia show an excess of neurodevelopmental disturbance, particularly minor physical anomalies, in association with cognitive dysfunction and abnormalities of cerebral structure.

Forty-seven out-patients with a DSM–III diagnosis of schizophrenia were examined for tardive dyskinesia using the Abnormal Involuntary Movement Scale; they were examined also for minor physical anomalies and neuropsychological test performance. Cortical atrophy, signal hyperintensities and lateral ventricular volume were determined on magnetic resonance imaging.

Patients with and without tardive dyskinesia could not be distinguished by age, gender distribution or a number of clinical measures; however, patients with tardive dyskinesia sorted fewer categories on the Wisconsin Card Sorting Test (P = 0.04). Cerebral structure in patients with and without tardive dyskinesia could not be distinguished on magnetic resonance imaging but those with dyskinesia, all of whom showed involvement of the orofacial region, showed more evident minor physical anomalies of the head relative to those of the periphery (P = 0.02).

Tardive orofacial dyskinesia in schizophrenia appears to be associated particularly with poorer frontal lobe function, while predominance of craniofacial dysmorphogenesis may constitute a vulnerability factor that is related to the early origins of the disease process.

Many patients complain less of their auditory hallucinations per se than of lack of control of the experiences. There is reason to believe that a non-distraction (exposure) approach could help patients gain more control over persistent auditory hallucinations and teach them that their experience is a form of thinking and has no external source. This study is a pilot test of that idea.

Five DSM–III–R schizophrenic outpatients with medication-resistant auditory hallucinations improved with a mean of 31 hour-long sessions over 3 months of therapist-guided exposure to their hallucinations and situations likely to evoke them.

Improvement was greatest in patients' anxiety and sense of control over their hallucinations, less in social use of leisure and hallucinating time.

These mildly encouraging pilot results warrant a controlled study of exposure for drug-resistant chronic auditory hallucinations and other psychotic experiences which are associated with anxious avoidance.

While neuropsychological deficits are recognised to occur in manic-depressive psychosis during episodes of depression and to reverse with clinical recovery, it is uncertain whether they can ever be seen outside episodes of illness.

Forty-five patients meeting DSM–III–R criteria for major depression or bipolar disorder were screened using tests of memory, executive function and overall intellectual function. All testing was carried out during remission of affective symptoms.

None of 24 young patients and 11 elderly patients scored in the impaired range on any of the tests. However, five of ten patients with chronic, severe affective disorder were impaired on one or more of the measures. On more detailed neuropsychological investigation, these five patients were found to show a variable pattern of impairment, ranging from memory and executive deficits in relative isolation, to widespread poor performance.

Enduring neuropsychological deficits may be a feature of chronic, severe manic-depressive illness.

Admission statistics for mania frequently show an increase in the summer. The present two-centre study was designed to test the hypothesis, in a representative sample of bipolar patients, that manic and depressive relapses show a seasonal pattern.

Two cohorts of bipolar I patients, one in London, England (n = 86), the other in Dunedin, New Zealand (n = 58), were tracked retrospectively during 1985–88 and prospectively during 1989–91, with the onset of all relapses being carefully dated.

In the London cohort there were 221 episodes of mania and 76 of depression; in the Dunedin cohort there were 201 of mania and 61 of depression. No consistent seasonal pattern of mania was detected in either centre. There was an autumn preponderance of depressive episodes in both centres.

Relapse of bipolar depression, but not of mania, appears to be determined in part by seasonal factors.

Clinicians see many more nonagenarian patients now and there is a need for epidemiological data relating to this group. The aim of the present study was to investigate the prevalence of depressive symptoms and syndromes in this age group.

The DSM–IV and the ICD–10 criteria for depression were used and correlated with physical health, disability in daily life, gender, use of drugs, social circumstances and cognitive dysfunction. Data were derived from 329 persons aged 90 and over, registered in a parish of Stockholm, who had been extensively examined by physicians and nurses.

The prevalence of Major Depressive Episode as defined in DSM–IV was 7.9%; and of mild, moderate and severe Depressive Episode (combined); as defined in ICD–10 9.1%. No gender difference was found. Disability in daily life and the use of psychotropic drugs were found to correlate with depressive symptoms and syndromes.

This randomised controlled study tested whether adding imagined to live exposure plus ritual prevention would enhance gains in obsessive-compulsive disorder (OCD).

Out-patients with OCD were randomly allocated to either have nine sessions of daily live self-exposure and ritual prevention to external cues alone (Ex) (n = 23) or to have, in addition to Ex, daily self-exposure to the imagined internal cues of the consequences of not ritualising (group Exi) (n = 23). All patients had the same sessional exposure time of 1 h 30 min (Exi 1 h live, 30 min imagined; Ex 1 h 30 min live), and had to practise either Exi or Ex daily for the same duration and to keep diaries of that self-exposure homework throughout treatment. Patients were followed up to week 32. Outcome measures were YBOCS for rituals and obsessions, compulsion checklist, target rituals and obsession, general anxiety, depression (Beck, Hamilton), work and social disability, clinical global impression (CGI).

At weeks 4, 9, 20 and 32 the two groups improved similarly with no significant difference between them, neither for washers nor for checkers. Imagined exposure was more difficult to do than live exposure and there were more drop-outs.

Daily imagined exposure to internal cues did not enhance exposure to external cues. Perhaps longer imagined exposure would have been more enhancing.

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.

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.

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.

This study examines whether cognitive dysfunction in chronic fatigue may be accounted for by depression and anxiety or is due to brain pathology evident on magnetic resonance imaging (MRI).

Twenty-six subjects with chronic fatigue, with and without coexisting depression, and 18 age-matched normal controls were recruited from primary care following a presumed viral illness six months previously. Comparison was made with 13 psychiatric controls with depressive illness on standardised cognitive tests. MRI determined the presence of cerebral white-matter lesions.

No substantial differences in performance were shown between subjects with chronic fatigue, most of whom met the criteria for chronic fatigue syndrome, and controls. Subjective cognitive dysfunction increased with psychopathology. White-matter lesions were found in a minority from all groups. Improvement in fatigue and depression coincided with improved performance on cognitive measures.

Subjective complaints of cognitive impairment are a prominent feature of chronic fatigue, but objective cognitive and MRI abnormalities are not. Such complaints probably reflect psychopathology rather than a post-viral process.

The detailed effects of mercury poisoning on cognitive function, brain anatomy and regional brain function are largely unknown. We report the case of a 38-year-old man who was exposed to toxic levels of inorganic mercury.

Four years after exposure, the patient was assessed using magnetic resonance imaging (MRI), single-photon emission computerised tomography (SPECT) and detailed neuropsychological evaluation.

The patient developed a myriad of physical and psychiatric complaints, including stomatitis, muscle spasm, tremor, skin rash and the psychiatric syndrome known as ‘erythism’ (Mad Hatter's disease). Neuropsychological evaluation revealed marked and significant deficits of attention concentration, particularly when under time pressure. The MRI scan was unremarkable; however, SPECT revealed hypermetabolism of the posterior cingulate cortex.

Mercury poisoning appeared to result in a dysregulation of posterior cingulate cortex, which was associated with attention/concentration deficits and marked anxiety/agitation.

Hedonic tone and its absence, anhedonia, are important in psychopathological research, but instruments for their assessment are lengthy and probably culturally biased.

A new scale was constructed from the responses of a large sample of the general population to a request to list six situations which afforded pleasure. The most frequent items were reviewed and those likely to be affected by cultural setting, age, or sex were removed. A pilot study led to an abbreviated scale of 14 items, covering four domains of pleasure response. This questionnaire was subjected to psychometric evaluation in new samples from the general population and psychiatric patients.

The scale was found to have a score range that would distinguish a ‘normal’ from an ‘abnormal’ response. Validity and reliability were found to be satisfactory.

The new scale, the Snaith-Hamilton Pleasure Scale (SHAPS), is an instrument which may be recommended for psychopathological research.

Infection with the human immunodeficiency virus (HIV) is associated with substantial psychiatric morbidity. This paper summarises the main forms of psychological intervention currently used, and reviews research evidence for their efficacy.

Publications on the mental health aspects of HIV infection and psychological interventions were identified through the main HIV journals and general psychiatric and psychological periodicals, with the assistance of AIDS Abstracts.

Publications concerned psychological interventions at the time of HIV testing, interventions for infected people at different stages of disease, and risk-reduction interventions. While many publications were identified describing uncontrolled investigations, only a few studies had involved systematic evaluative research.

There is a need for systematic evaluation of psychological interventions for HIV infection, in terms of both efficacy and cost.