Opinions vary on the relative importance of biological and learning processes in the aetiology of sexual expression and deviance. The structure of personality, consistency of fantasy patterns, and the familial nature of homosexuality hint at a biological an/age. Research with the HY-antigen complex and X chromosome, and the elucidation of the interactions of intrauterine testosterone and its products with the foetal brain and neurotransmitters, have given us new models to understand the programming of sexuality. However, gonadotrophin feedback is not relevant as an indicator of brain feminization in primates and man. Finally, the interaction of masculinization and defeminization provides us with a model for understanding homosexual behaviour.

Particular instances of sexual deviation can not be discussed sensibly without first considering certain general issues.

The first of these is the question of definition. The notion of what constitutes abnormal sexual behaviour has changed in the course of history and indeed its boundaries have expanded and contracted at different times. What emerges from the history of the concept is that it has been defined by the social and moral climate of the time and indeed sexual deviance can be seen, for the most part, as a social rather than a medical concept (Bancroft, 1974).

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.

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.

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.

The history of treatment approaches used to help individuals troubled by sexual deviation or variation is notable for the way it has reflected the changing attitudes of both society and medicine to such behaviour. In recent years the range of behavioural techniques has broadened considerably with the introduction of, for example, cognitive forms of treatment and a change in emphasis away from the suppression of deviant sexual behaviour and towards the positive development of desired behaviour. In addition, as with behaviour therapy in general, a more flexible approach to management has developed with much greater emphasis on designing treatment on the basis of each individual patient's needs. Furthermore, there has been a marked reduction in the number of requests received for help with deviant sexual interest. This reflects both the changes that are occurring in social attitudes to sexuality in general, and homosexuality in particular, which have reduced the pressures on individuals to abandon their personal styles of sexual behaviour, and the development of self-help groups and minority organisations.

In a continuing twin study of autism in Scandinavia and Finland, moderately mentally retarded triplets fulfilling Rutter's criteria for infantile autism were reported. Judging by physical appearance the triplets were identical. Behaviourally they were extremely similar though one was intellectually slightly better than the other two. All three showed the physical stigmata characteristic of the fragile–X syndrome, in spite of their overall appearance being non-conspicuous. The triplets had between 8 and 12 per cent of fragile–X positive cells and showed a distinct pattern of urinary excretion of substances yielding absorbency at 280 nM. Their mother and sister also had a high count of fragile–X positive cells.

The case histories are presented of three 17 year old identical male triplets with Asperger's syndrome. They show the impairments affecting social interaction, non-verbal communication and imagination, the motor clumsiness, and the circumscribed interests characteristic of that condition. They also have some features in their history and present behaviour more typical of childhood autism. Despite marked overall similarities, the three differ in the severity with which their problems are manifested. A relationship can be found between the amount of peri- and post-natal trauma, degree of intellectual impairment and number of autistic features. The findings support the hypothesis that autism and Asperger's syndrome are on the same continuum of pathology.

Fifteen patients with bilateral hemisphere brain injury secondary to thromboembolic stroke or trauma were evaluated for depression, cognitive impairment, and functional physical impairment. Analysis of CT scans and standardized mood scales revealed that patients with left anterior brain injury were significantly more depressed than patients without such injury. Depression severity was directly and significantly correlated with left lesion proximity to the frontal pole. Left lesion age, lesion temporal sequence, right lesion location, cognitive impairment, and functional physical impairment did not significantly correlate with depression. Depressive symptomatology previously shown to be associated with single left frontal lobe lesions appeared to dominate post-brain injury psychopathology regardless of location or temporal sequence of other brain lesions.

Retrospective review of 89 patients with pre-senile dementia followed by necropsy indicated significant differences between sub types of dementia. Patients with multi-infarct dementia (MID, 27 subjects) more often had cardiovascular abnormalities than patients with Alzheimer's disease (46 subjects). No patients with MID alone had a systolic blood pressure below 140 mm Hg, whereas 23 of 46 Alzheimer subjects and three of 16 patients with mixed features had such a systolic pressure.

The dexamethasone suppression test (DST) was performed on 21 patients with dementia of the Alzheimer type (DAT), 11 patients with multiinfarct dementia (Ml) and 14 healthy controls. Twelve of the DAT patients and eight of the Ml patients showed abnormal lack of suppression, compared with just one member of the control group. Abnormal DST was related to dementia as such and not to age or depression, or to levels of CSF monoamine metabolites. Basal serum prolactin concentrations were not increased.

The outcome of 78 patients with anorexia nervosa treated in a special clinic is described, using a standardized follow-up technique. The findings are compared with two previous studies which utilized an identical evaluation procedure. Certain predictors of poor outcome already identified by previous studies (long duration of illness before referral, previous personality problems, difficulties in relationship between family and patient) are confirmed. The findings suggest that early intervention may be an important component of effective treatment. The possible advantages of long term continuity of outpatient care are also discussed and the need for careful scrutiny of criteria for hospital admission emphasized.

It is concluded that chronic morbidity due to anorexia nervosa represents an important topic for further research. There is need for further identification of factors associated with chronicity, some of which may be secondary repercussions of the illness itself, and prospective evaluation of treatment programmes which focus on predictors of poor outcome.

Eight patients with bulimia nervosa were given methylamphetamine or placebo intravenously under double blind controlled conditions. In every patient, methylamphetamine reduced self-ratings of hunger and amount of food eaten as measured under laboratory conditions. This shows that the food intake of patients with bulimia nervosa can be modified by experimental drugs. The symptom of bulimia (rapid, excessive and distressing eating) which may be followed by self-induced vomiting or purgation was seen in four patients after receiving placebo but in none after receiving methylamphetamine. These findings suggest that the severe symptom of bulimia may be amenable to drug treatment. Further studies are needed to explore the mechanism by which methylamphetamine appears to prevent bulimia.

Goldstone and Sarbin proposed that auditory hallucinations occur because imagery in a non-preferred sensory mode is more easily misinterpreted as having an external origin. This led to the hypothesis that auditory hallucinators would show less preference for auditory than for visual imagery. Our results suggest that this is true. We also compared the vividness of internally-generated auditory imagery with that of visual imagery, independently of preference, to see whether vividness was impaired in the non-preferred mode in hallucinators. The evidence suggested that this was not the case, but we did find a significantly deficient capacity for creating vivid images of either kind in process patients (i.e. those with poor premorbid status) compared with reactive (good premorbid) patients, regardless of any history of hallucinations. The withdrawal of external attention which characterizes process patients might also be expected to impair their ability to confirm or disconfirm the external origin of an auditory stimulus. We predicted therefore that process hallucinators would be particularly incompetent in spatial location of sounds: our experimental results confirmed this to be the case.

Pemoline is a central nervous system stimulant, with pharmacological effects resembling amphetamine and methylphenidate in increasing central dopamine transmission (Fuxe et al, 1970; Sheel-Kurge, 1971).

As scientific technologies become more sophisticated, clinicians may come to think that they must devolve into passive recipients rather than contributors to the advances in basic knowledge. This perception and accompanying modesty towards the neurosciences, however, is an error. The intellectual trade between clinician and bench scientist has always been bi-directional and nowhere is this more clearly evident than in recent interactions between psychiatry and neuroscience.

Over the last 30 years the proportion of those over 65 in our population has increased by nearly 50 per cent. Over the same period alcohol consumption in general has risen by nearly 100 per cent, probably with an even greater increase in those suffering from alcohol-related problems. Nevertheless, many doctors still do not expect to find alcohol abuse in elderly people.