Background. High expressed emotion (EE) in families reliably predicts relapse in schizophrenia leading to the assumption that high EE stresses patients and is the cause of relapse. Attempts at validating the stressful properties of high EE using autonomic skin conductance measures have been inconclusive. Since memory loaded vigilance tasks are sensitive to stress, we used a memory loaded version of the Continuous Performance Test (CPT) to see if test performance would change in the presence and absence of high or low EE relatives. If high EE was stressful, performance should decline in their presence of high EE relatives. If low EE was protective against stress performance should improve in the presence of low EE relatives.

Methods. The CPT was administered to 41 schizophrenic and 51 normal control participants. CPT testing was conducted in the absence, then presence, then absence of high or low EE relatives.

Results. Control participants had significantly greater CPT scores than schizophrenic participants; there was no effect of the relative's presence or absence on CPT performance for either the high or low EE group. Schizophrenic participants from high EE homes demonstrated significantly better, rather than worse, CPT scores than those in low EE homes.

Conclusions. These findings fail to support the notion of high EE as stressor, but show that high EE and low EE patient groups perform a vigilance task significantly differently. We propose that patients from low EE groups may be underaroused relative to their high EE counterparts and that this underarousal leads to less than optimal performance on the CPT.

Background. Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new form of psychotherapy for post-traumatic stress disorder. We critically reviewed randomized controlled trials of EMDR.

Methods. A wide range of electronic databases and reference lists of articles obtained were searched and relevant experts were consulted. Studies were critically appraised according to established criteria.

Results. We found 16 published randomized controlled trials (RCTs) comparing EMDR with alternative psychotherapy treatments, variants of EMDR and with delayed treatment groups. Studies were generally small (mean number of patients = 35) and of variable methodological quality, with only five reporting blinding of outcome assessors to treatment allocation, and in some cases with high loss to follow-up.

In most cases EMDR was shown to be effective at reducing symptoms up to 3 months after treatment. In one case benefit was maintained up to 9 months and in another (uncontrolled) follow-up treatment effect was present at 15 months. Two studies suggest that EMDR is as effective as exposure therapies, three claim greater effectiveness in comparison to relaxation training, and three claim superiority over delayed treatment groups. Of the studies examining specific treatment components, two found that treatment with eyes moving was more effective than eyes fixed, while three studies found the two procedures to be of equal effectiveness.

Conclusion. The evidence in support of EMDR is of limited quality but results are encouraging for this inexpensive, simple therapy. Further research is warranted in larger samples with longer periods of follow-up.

Background. A variant of the ‘inner speech’ theory of auditory verbal hallucinations in schizophrenia suggests that there is an abnormality of the relationship between the ‘inner voice’ and ‘inner ear’, such that hallucinators are unable to distinguish inner ‘imagined’ speech from real external speech, and so misrecognize inner speech as alien.

Methods. Five experiments were carried out comparing 12 schizophrenic patients who were highly prone to hallucinate, with seven patients who were not, on a series of auditory imagery tasks that are differentially dependent on inner voice/inner ear partnership for successful performance: parsing meaningful letter/number strings; the verbal transformation effect; phoneme judgements; pitch judgements, and homophony and rhyme judgements.

Results. Contrary to our hypothesis, there was no evidence that the group with the propensity to hallucinate were impaired on tasks requiring normal inner ear/inner voice partnership.

Conclusions. Together with previous work indicating no impairment of the phonological loop in patients who hallucinate, these results suggest that inner speech and auditory verbal hallucinations are not connected in a simplistic or direct way. Indeed, a reappraisal of psychological models of hallucinations in general may be warranted.

Background. The high prevalence of depression in developing countries is not well understood. This study aimed to replicate the previous finding of a high prevalence of depression in Pakistan and assess in detail the associated social difficulties.

Method. A two-phase survey of a general population sample in a Pakistani village was performed. The first-phase screen used the Personal Health Questionnaire (PHQ) and the self-rating questionnaire (SRQ). A one in two sample of high scorers and a one in three sample of the low scorers were interviewed using the Psychiatric Assessment Schedule (PAS) and Life Events and Difficulties Schedule (LEDS).

Results. A total of 259 people were screened (96% response rate). The second stage yielded 55 cases, of whom 54 had depressive disorder, and 48 non-cases. The adjusted prevalence of depressive disorders was 44·4% (95% CI 35·3 to 53·6): 25·5% in males and 57·5% in females. Nearly all cases had lasted longer than 1 year. Comparison of the cases and non-cases indicated that cases were less well educated, had more children and experienced more marked, independent chronic difficulties. Multivariate analysis indicated that severe financial and housing difficulties, large number of children and low educational level were particularly closely associated with depression.

Conclusion. This study confirms the high prevalence of depressive disorders in Pakistan and suggests that this may be higher than other developing countries because of the high proportion of the population who experience social adversity.

Background. There is not yet consensus on the best diagnostic definition of mixed bipolar episodes. Many have suggested the DSM-III-R/-IV definition is too rigid. We propose alternative criteria using data from a large patient cohort.

Methods. We evaluated 237 manic in-patients using DSM-III-R criteria and the Scale for Manic States (SMS). A bimodally distributed factor of dysphoric mood has been reported from the SMS data. We used both the factor and the DSM-III-R classifications to identify candidate depressive symptoms and then developed three candidate depressive symptom sets. Using ROC analysis we determined the optimal threshold number of symptoms in each set and compared the three ROC solutions. The optimal solution was tested against the DSM-III-R classification for cross-validation.

Results. The optimal ROC solution was a set, derived from both the DSM-III-R and the SMS, and the optimal threshold for diagnosis was two or more symptoms. Applying this set iteratively to the DSM-III-R classification produced the identical ROC solution. The prevalence of mixed episodes in the cohort was 13·9% by DSM-III-R, 20·2% by the dysphoria factor and 27·4% by the new ROC solution.

Conclusions. A diagnostic set of six dysphoric symptoms (depressed mood, anhedonia, guilt, suicide, fatigue and anxiety), with a threshold of two symptoms, is proposed for a mixed episode. This new definition has a foundation in clinical data, in the proved diagnostic performance of the qualifying symptoms, and in ROC validation against two previous definitions that each have face validity.

Background. Previous studies have demonstrated impaired explicit and preserved implicit memory functions in schizophrenia. However, it is less clear whether schizophrenics can learn complex information (e.g. probabilistic stimulus–response associations) with or without access for conscious recollection. In this study we applied a classification learning task to assess explicit and implicit processes concurrently.

Methods. Two test procedures were administered to 40 schizophrenic subjects and 20 healthy volunteers: a probabilistic classification learning (PCL) task to evaluate implicit memory functions; and a category cue recognition test to investigate the explicit memory system. The PCL task included feedback guided category learning of geometrical shapes. These shapes were called category cues, predicting class membership with certain probabilities. The gradual increase of categorization performance during the feedback learning was a potentially implicit process, whereas the subsequent recognition of category cues required explicit memory functions.

Results. The schizophrenic patients improved their categorization performance to a similar extent to the controls, but they failed to recognize the category cues. Memory performances were independent of the positive and negative symptoms.

Conclusions. Patients with schizophrenia were able to establish representations of complex categories, but these remained unconscious. This is consistent with earlier reports, suggesting damaged explicit and spared implicit memory in schizophrenia.

Background. The Australian National Survey of Mental Health and Well-being was designed to detect and describe psychiatric morbidity, associated disability, service use and perceived need for care. The survey employed a single-phase interview methodology, delivering a field questionnaire to a clustered probability sample of 10641 Australians. Perceived need was sampled with an instrument designed for this survey, the Perceived Need for Care Questionnaire (PNCQ). This questionnaire gathers information about five categories of perceived need, assigning each to one of four levels of perceived need. Reliability and validity studies showed satisfactory performance of the instrument.

Methods. Perceived need for mental health care in the Australian population has been analysed using PNCQ data, relating this to diagnostic and service utilization data from the above survey.

Results. The survey findings indicate that an estimated 13·8% of the Australian population have perceived need for mental health care. Those who met interview criteria for a psychiatric diagnosis and also expressed perceived need make up 9·9% of the population. An estimated 11·0% of the population are cases of untreated prevalence, a minority (3·6% of the population) of whom expressed perceived need for mental health care. Among persons using services, those without a psychiatric diagnosis based on interview criteria (4·4% of the population), showed high levels of perceived met need.

Conclusions. The overall rate of perceived need found by this methodology lies between those found in the USA and Canada. The findings suggest that service use in the absence of diagnosis elicited by survey questionnaires may often represent successful intervention. In the survey, untreated prevalence was commonly not accompanied by perceived need for mental health care.

Background. This paper focuses on the long-term course of social disability in schizophrenia assessed at first onset, and after 1, 2 and 15 years in incidence cohorts in six European centres in Bulgaria, Germany, Ireland, The Netherlands, the Czech Republic and the United Kingdom. The study population comprises 349 patients comprising 75% of the original cohorts.

Methods. Social disability was assessed in a standardized way with the WHO Disability Assessment Schedule.

Results. Social disability in schizophrenia appears to be a persistent phenomenon. Its severity decreased overall in the period of follow-up, but this was not so in a small group traced to hospital or sheltered accommodation. Only 17% of subjects had no disability and 24% still suffered from severe disability. The great majority lived with their family, a partner, or alone. A deteriorating course was more frequent than late improvement. Gender, age, onset, duration of untreated psychosis or type of remission during the first 2 years did not predict the long-term outcome of disability. Severity of disability at the first three assessments of the illness contributed significantly to the explanation of its variance at 15 years.

Conclusion. Disability generally ameliorates, but less than expected or hoped. It needs continuing attention and care in this era of de-institutionalization.

Background. The pathophysiology of auditory hallucinations and delusions of control has been elucidated using functional imaging. Despite their clinical importance, there have been few similar attempts to investigate paranoid delusions. We have examined two components of social cognition (attentional and attributional biases) that contribute to the formation and maintenance of paranoid delusions, using functional magnetic resonance imaging (fMRI).

Method. Normal subjects performed tasks requiring attentional and attributional judgements. We investigated the neural response particularly associated with attention to threatening material relevant to self and with the ‘self-serving’ attributional bias.

Results. The determination of relevance to self of verbal statements of differing emotional valence involved left ventrolateral prefrontal cortex (left inferior frontal gyrus, BA 47), right caudate and right cingulate gyrus (BA 24). Attention to threatening material relevant to self differentially activated a more dorsal region of the left inferior frontal gyrus (BA 44). Internal attributions of events, where the self was viewed as an active intentional agent, involved left precentral gyrus (BA 6) and left middle temporal gyrus (BA 39). Attribution of events in a non ‘self-serving’ manner required activation of the left precentral gyrus (BA 6).

Conclusions. Anomalous activity or connectivity within these defined regions may account for the attentional or attributional biases subserving paranoid delusion formation. This provides a simple model for paranoid delusion formation that can be tested in patients.

Background. A combined family study and recovered study design was utilized to examine several hypothesized relationships between personality and bulimia nervosa (BN).

Methods. We studied 47 women with a lifetime history of DSM-III-R BN (31 currently ill and 16 recovered), 44 matched control women (CW) with no history of an eating disorder (ED), and their first-degree female relatives (N = 89 and N = 100, respectively), some of whom had current or previous EDs.

Results. BN probands' relatives with no ED history had significantly elevated levels of perfectionism, ineffectiveness, and interpersonal distrust compared to CW probands' relatives with no ED history. In contrast, diminished interoceptive awareness, heightened stress reactivity and perfectionistic doubting of actions were found among the previously eating disordered relatives of bulimic probands compared to their never ill relatives. Finally, a sense of alienation and emotional responsivity to the environment were elevated among currently ill compared to recovered bulimic probands.

Conclusions. The fact that perfectionism, ineffectiveness and interpersonal distrust are transmitted independently of an ED in relatives suggests that they may be of potential aetiological relevance for BN. In contrast, diminished interoceptive awareness, heightened stress reactivity and perfectionistic doubting of actions are more likely consequent to, or exacerbated by, previously having experienced the illness. Finally, a sense of alienation and emotional responsivity to the environment are more likely to be associated with currently having BN.

Background. Linguistic processing was explored in normally intelligent adults with either autism or Asperger's syndrome, to test if global coherence was impaired. Global coherence is the ability to establish causal connections and interrelate local chunks into higher-order chunks so that most linguistic elements are linked together thematically. Since individuals with autism are hypothesized to have weak central coherence then one would predict that the clinical groups would have difficulty integrating information globally so as to derive full meaning.

Methods. Two experiments were designed to test global coherence. Experiment 1 investigated whether individuals on the autism spectrum condition could arrange sentences coherently. Experiment 2 investigated whether they were less able to use context to make a global inference.

Results. The clinical groups were less able to arrange sentences coherently and use context to make a global inference.

Conclusions. The results suggest that individuals on the autism spectrum have impaired global coherence. Arranging sentences and making global inferences correlated highly, suggesting that central coherence may be a unitary force in these different tasks. Of the two clinical groups, the autism group had the greater deficit. The effect that such a deficit would have on one's daily life is discussed, along with possible explanations for the clinical groups' greater difficulty, and suggestions for future research.

Background. Cognitive theories of persecutory delusions in schizophrenia include increased attention to threat and reduced re-appraisal of information during decision-making.

Methods. We employed visual scan path measurements, an ‘on-line’ marker of attention, in schizophrenic patients with persecutory delusions (N = 19), negative symptom- and medication-matched patients with non-persecutory delusions (N = 8), and normal controls (N = 18). Stimuli comprised black-and-white photographs of social scenes rated as depicting either neutral, ambiguous or overtly threatening activity. Foreground areas containing salient information with regard to the overall scene were rated independently as either threatening or non-threatening in both the overtly threatening and ambiguous scenes; all foreground areas were rated as non-threatening in the neutral scene.

Results. For the ambiguous scene only, schizophrenics with persecutory delusions directed gaze to less threatening areas, and, for all three scenes, demonstrated reduced re-appraisal of information compared with both control groups. All subjects showed similar viewing strategies for the overtly threatening and neutral scenes.

Conclusions. These findings suggest abnormal information gathering and evaluation in schizophrenics, specifically related to the presence of persecutory delusions. In particular, the results point to biased processing of contextual information in an ambiguous setting in these patients, and perhaps perception of threat in inappropriate places.

Background. Few population studies have investigated the functional disabilities that accompany specific psychiatric diagnoses. This study assesses the nature and strength of current and residual impairments in various functional domains of life.

Methods. Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective study in the Dutch general population aged 18 to 64 (N = 7147). Psychiatric diagnoses were based on the Composite International Diagnostic Interview; functional disability was assessed on the basis of the Short-Form-36 and the number of disability days.

Results. Psychopathology was associated with increased disability in social, emotional and physical domains of life. Disability levels varied by psychiatric diagnosis, with mood disorders showing the poorest levels of functioning, especially for vitality and social functioning; alcohol-related disorders were associated with few disabilities. Co-morbidity strongly aggravated the disability. The effect of contextual factors on disability was limited, although somatic ill health, unemployment and adverse youth history increased the likelihood of functional disability. The findings indicate that psychopathology can also have residual debilitating effects.

Conclusions. Mental health care providers should be aware that the extent and the type of disability may vary with the different types of disorders and among different groups within the population. Since recovery from functional limitations may not be complete or may take more time than the remission of the psychiatric symptomatology, non-psychiatric follow-up care is needed. The high number of lost work days is relevant from an economic perspective. There is a need for illness-specific disability assessment instruments.

Background. GPs' attitudes towards depression vary, as do their abilities to detect and manage it effectively. Associations between attitudes and clinical behaviour have not yet been demonstrated directly. We tested two hypotheses: (1) that questionnaire measures of GPs' confidence in identifying depression predict their ability to identify depression in their patients; and (2) that GPs who prefer antidepressants prescribe more than those who prefer psychotherapy.

Methods. Forty GPs in Liverpool and Manchester completed the Depression Attitude Questionnaire (DAQ) and were asked for prescribing (PACT) information. Attender surveys using the General Health Questionnaire (GHQ-12), in combination with GP ratings of patients' psychological status, generated indices for GPs' case identification, bias and accuracy. We tested associations between these indices and the four DAQ components, in particular GPs' confidence in diagnosis, across a total of 1436 patients. We also compared the DAQ component on attitudes to treatment with relevant PACT data.

Results. The DAQ assessment of GPs' ability to identify cases of depression bore no relationship to their observed ability, as measured by accuracy, bias, or identification indices. However, there were significant associations between observed diagnostic ability and: preference for psychotherapy; ease in managing depression; and, belief in successful treatment. PACT data were available for 26 (65%) GPs. There was an association between preference for antidepressants and prescription of SSRIs (rs 0·3981, P < 0·044), but not for overall antidepressant or tricyclic prescribing, or for dose of dothiepin.

Conclusions. The DAQ measure of ease of identification is not valid when compared to actual clinical practice. The ability of GPs to identify depression may not be an independent variable, but may rather reflect other beliefs, attitudes and skills. This has considerable implications for educational interventions in primary care.

Background. Cognitive deficits in schizophrenia have recently been ascribed to impaired representation and use of cognitive context. Context is defined as relevant information held temporarily in mind to mediate appropriate but often non-habitual responses.

Methods. Parallel studies in a variety of cognitive domains were designed in order to explore the generality of any schizophrenic deficit in context use. In all of the tasks (a Stroop task, a Continuous Performance Task and a cued spatial location task), we examined how performance was affected by the time for which contextual information must be held in mind, and by whether context or task demands were consistent or varying between trials. It was predicted that manipulation of these variables would produce tests especially sensitive to schizophrenic attentional problems.

Results. Predictions were partially confirmed. Although increasing contextual demands failed in most cases to produce disproportionate slowing of performance in patients, error data were largely in line with predictions. At the same time, the data did not suggest a simple unitary context deficit. Instead, different aspects of context – the time over which contextual information must be held in mind and the consistency of context – were differentially important in different tasks.

Conclusions. The cognitive impairments of schizophrenic patients cannot be simply characterized as a generalized context deficit. A more differentiated, if not task specific, picture of schizophrenic deficits is suggested.

Background. There is substantial evidence that the genetic liability to autism confers a risk for a range of more subtle social and communication impairments, as well as stereotyped and repetitive behaviours. Recent research suggests that increased expression of particular personality traits may be a manifestation of the liability to autism.

Methods. To investigate this we examined the personality traits of the adult relatives of 99 autistic and 36 Down's syndrome probands, using the informant version of the Modified Personality Assessment Schedule.

Results. There was significantly increased expression of the traits anxious, impulsive, aloof, shy, over-sensitive, irritable and eccentric among the autism relatives with evidence of different profiles for male and female relatives and for parents and adult children. Factor analysis revealed three broad groups of traits, two of which (‘withdrawn’ and ‘difficult’) appeared to reflect impairments in social functioning and a third group of anxiety related traits (‘tense’). Each of these factors differed in their pattern of associations with the factor we termed ‘withdrawn’ showing a similar pattern of association to that found for other autism related conditions. The ‘tense’ factor appeared in part to be related to the burden of caring for an autistic child.

Conclusions. This study confirms the finding that particular personality traits may aggregate in the family members of autistic individuals and furthermore that some of these traits may be a manifestation of the liability to autism.

Background. A high risk of schizophrenia has been found among Caribbean immigrants in the Netherlands and Great Britain. One hypothesis to explain these findings is that patients with a diagnosis of schizophrenia or patients with symptoms of psychosis not specifically diagnosed, emigrate more than the general population. Such selection might account for high rates of Surinamese patients with a diagnosis of schizophrenia in Netherlands psychiatric hospitals. We examined this hypothesis.

Methods. The files of patients with schizophrenia or patients suffering from unspecified psychosis were selected from the archives of the National Psychiatric Hospital in Surinam. These patients were traced to investigate patterns of emigration. Data from the Central Bureau for Statistics in the Netherlands and from the Central Population Bureau in Surinam provided the percentage of the general Surinamese population that emigrated to the Netherlands. The difference between the two percentages was evaluated using the chi-squared test. Using the same method the percentage of remigration from the Netherlands among Surinamese patients was compared with the percentage of remigration among the general Surinamese population.

Results. Surinamese patients with schizophrenia or unspecified psychosis did not emigrate more frequently to the Netherlands compared with the general Surinamese population. They did remigrate significantly more frequently.

Conclusion. High migration rates do not explain the high hospital admission rates for schizophrenia among Surinamese in the Netherlands.

Background. The study examined the role of parental death and chronic depression with severe episodes in affecting risk of breast cancer. This avenue of research is in accord with oncology findings, which suggests that causative factors of breast cancer occur and develop over a period of 20 years or longer.

Methods. Participants consisted of 1213 women in the Baltimore Epidemiologic Catchment Area study surveyed in 1980 and followed through 1994–1995. They were assessed for depressive and anxious disorders, paternal death in childhood and relatively recent adverse life events prior to cancer hospitalization.

Results. In the course of the study, 29 women were hospitalized for breast cancer and 10 died of breast cancer. The psychosocial variables that predicted increased risk of breast cancer were maternal death in childhood (OR = 2·56, P < 0·001) and chronic depression with severe episodes (OR = 14·0, P < 0·001). Neither relatively recent life events nor other depressive and anxiety disorders were associated with increased risk. Maternal death and chronic depression with severe episodes were reported to have occurred at least 20 years prior to breast cancer hospitalization.

Conclusions. Maternal death and chronic and severe depression occurred at least 20 years prior to breast cancer hospitalization and could have been involved in the causation or facilitation of cancer development. The authors suggest that meta-analysis of other prospective studies are needed to create larger groups of individuals with these stresses to confidently establish these variables as risk factors.

Background. Many studies have demonstrated co-morbidity of alcohol abuse/dependence with mood and anxiety disorders but relatively little is known about anxiety and depression across the full continua of alcohol consumption and problems associated with drinking.

Methods. Participants from a general population sample (N = 2725) aged 18–80 years completed the Alcohol Use Disorders Identification Test (AUDIT) and four measures of negative affect (two depression and two anxiety symptom scales) included in a self-completion questionnaire.

Results. High consumption, AUDIT total score, and AUDIT problems score were associated with high negative affect scores in participants under 60 years old (ORs in the range 1·80–2·83). Graphical and statistical analyses using continuous measures of alcohol use/problems and negative affect identified non-linear relationships where abstainers and occasional drinkers, as well as heavy and problem drinkers, were at risk of high anxiety and depression levels. This pattern, however, was not found in those aged [ges ] 60 years. The U-shaped relationship was not an artefact of abstainers being typical of the general population in their distribution of negative affect.

Conclusions. Studies of co-morbidity should acknowledge the possibility of non-linear associations and employ both continuous and discrete measures. Abstainers, as well as heavy drinkers, are at increased risk of symptoms of depression and anxiety disorders. Psychosocial factors may play a role in the U-shaped relationship between alcohol consumption and mortality.

Background. Higher rates of suicidal behaviour have been reported among staff in mental health care than in the general population. However, no studies of these two groups have been carried out simultaneously, using the same methods. This study aims to investigate whether they differ in terms of age- and sex-standardized prevalence of suicidal behaviour.

Methods. Identical questions about suicidal behaviour were addressed in the same year to a random sample of the general population and to mental health-care staff in Stockholm. Life weariness among the latter was also investigated.

Results. Age- and sex-standardized past year prevalences of suicidal thoughts and suicide attempts were found to be similar among mental health-care staff and the general population. Lifetime prevalence of both suicidal thoughts and suicide attempts was significantly higher among mental health-care staff than among the general population. Psychologists/social workers have a higher probability of: lifetime thoughts of life is not worth living; death wishes; and, suicidal thoughts, than nurses/assistant nurses.

Conclusions. Reports on lifetime prevalence of suicidal behaviour may be biased in populations that are not reminded of these problems in everyday life. Data on past year prevalence of suicidal behaviour show clearly the similarity between the general population and the mental health-care staff.