John Bowlby bemoaned the separation between the biological and psychological approaches in psychiatry, and hoped that attachment theory, which brings together psychoanalysis and the science of ethology, would help bridge the rift between them. Recent findings in developmental psychology have delineated features of parent–infant interaction, especially responsiveness, attunement, and modulation of affect, which lead to either secure or insecure attachment. Similar principles can be applied to the relationship between psychotherapist and patient - the provision of a secure base, the emergence of a shared narrative (‘autobiographical competence’), the processing of affect, coping with loss - these are common to most effective psychotherapies and provide the basis for a new interpersonal paradigm within psychotherapy. Attachment theory suggests they rest on a sound ethological and hence biological foundation.

Slater's work on the schizophrenia-like psychoses of epilepsy is re-examined in the light of subsequent developments in psychiatry and neurology. Simple causal links of the sort he postulated between epilepsies and psychoses appear increasingly tenuous, despite indications that some psychotic symptoms and some localised structural changes are linked. A resumption of the study of electrophysiological similarities between schizophrenia and limbic epilepsy may offer a useful alternative programme for research.

One hundred patients with cryptogenic epilepsy and normal intelligence and 100 age- and sex-matched controls were submitted to psychiatric interview using the Clinical Interview Schedule. Nineteen patients and 15 controls were identified as having psychiatric disorders. Anxiety and depression were the predominating diagnoses in both groups. Personality disorders were occasionally present in subjects with epilepsy. The study shows that patients with cryptogenic epilepsy and normal neuropsychological abilities should not be considered at any higher risk of psychiatric disturbance than a non-neurological patient population.

The effectiveness of ritanserin, a selective 5-HT2 and 5-HT1c antagonist, in reducing negative symptoms in schizophrenia was investigated in a double-blind, placebo-controlled trial. Trial treatment was added to a stable neuroleptic treatment in 33 schizophrenic patients with predominantly negative symptoms. Ritanserin reduced the negative symptoms, as measured with the SANS. The main reduction was for the items facial expression, global affective flattening, and relationships with friends and peers. Also a reduction in total BPRS score was found, which approached statistical significance. Significant reductions were observed for the BPRS items emotional withdrawal and depressive mood. Ritanserin or other drugs blocking 5-HT2 and/or 5-HT1c receptors could be important in reducing specific symptoms in schizophrenic patients.

Domestic and world opinion is gradually changing towards the idea of tolerating or even legalising active euthanasia. The implications of this are examined using Foulke's concept of the ‘levels' in group discussions. Psychiatrists have a unique experience in using the statutory mental health legislation, in addition to the ordinary law, to regulate medical care. A new ‘special defence’ is suggested, to be enacted by Parliament, intended to justify, but also designed to control, deliberate acts of medical euthanasia.

In a four-year follow-up study of 1042 elderly people (aged 65 years or older), randomly sampled from the community, levels of dementia were assessed using a two-phase case-finding procedure (screening followed by clinical interview) among survivors. Clinical information on those not reinterviewed was provided by death certificates, hospital case notes, or postal questionnaires. The weighted four-year cumulative incidence of dementia was 3.7% (95% confidence intervals: 2.4%-5.0%), with age-specific rates of 0.9%, 2.8%, 5.2%, 9.0%, and 8.7% for the age groups 65–69, 70–74, 75–79, 80–84, and 85–89 years respectively. While consistent with data from other British regions, it remains likely that these rates underestimate true incidence.

This paper describes the development of the PAS-ADD, a semistructured clinical interview for use specifically with patients with learning disabilities, based on items drawn from the PSE. The PAS-ADD includes a number of novel features including: parallel interviewing of patient and informant; a three-tier structure to provide a flexible interview appropriate to the patient's intellectual level; use of a memorable ‘anchor event’ in the patient's life to improve time focus; and simplified wording, improved organisation and lay out. Inter-rater reliability was investigated using an experimental design in which two raters viewed and re-rated videotaped PAS-ADD interviews which had been conducted by an experienced clinician. Reliability results compared favourably with those obtained in a major study of PSE reliability with a sample drawn from non-learning disabled individuals. Mean kappa for all items was 0.72. Other indexes of reliability were also good. In the current phase of development, the PAS-ADD is to be expanded to include further diagnostic categories, including schizophrenia and autism. The new version will be updated for use with ICD–10 criteria.

We present a prevalence study of psychiatric morbidity in people over 50 years of age with learning disability (LD), using a new semistructured clinical interview specifically for use with people who have LD (the ‘PAS-ADD’). Assessment involved parallel interviewing of subject and informant, these two sets of information being combined to reach a final diagnosis using ICD-9 and DSM-III-R criteria. Detection of dementia involved interviews with informants, plus investigation of loss of cognitive function over a three-year period. The experimental sample was a mixed community and institutional group (n = 105), including, as far as possible, all people in a single administrative district (Oldham) matching the age and ability criteria. Prevalence of psychiatric disorder excluding dementia was 11.4% (n = 12), most of which were depression and anxiety. Seventy-five per cent of these cases were unknown to mental health services. However, immediate care staff were usually aware of the symptoms, although often unaware of their clinical significance. Prevalence of dementia was also 11.4% (n = 12), with a combined case prevalence of 21.0% (n = 22). The PAS-ADD proved a flexible interview, effective in use with people of varying linguistic level and intellectual ability: 61.9% (n = 65) of the sample were able to be interviewed, fully adequate clinical interviews being obtained with a group of 38 people whose mean IQ was only 39. In the remaining 38.1% (n = 40), diagnosis relied exclusively on informant data. Overall, the combination of subject and informant data was essential for sensitive case detection.

Early-onset affective disorder is associated with obstetric complications and a high familial risk of psychiatric illness, in particular psychosis. In a matched case-control study, we investigated 47 adult in-patients with major depressive disorder or bipolar 1 disorder, who had earlier in life presented to a child psychiatry department. Cases were matched on sex, social class and ethnic group with 47 controls, who were admitted to hospital for affective disorders in adult life but had no psychiatric contact before the age of 21. We found that both psychiatric disorder in first-degree relatives and a history of obstetric complications were associated with early onset. Childhood symptoms did not predict the type of adult affective disorder.

Reports of childhood sexual experiences with adults were collected from 120 women attending general-practice surgeries and 115 women psychiatric patients. The method of study, research team and county of residence were the same for the two groups. The psychiatric patients tended to report rates of events higher than the general-practice attenders by a factor of 2–3. The results suggest an association between such experiences and later psychiatric patienthood and are compatible with a causal role for them in some cases.

Sixty-nine mentally ill patients in treatment in an intensive community support system in Boulder, Colorado, were evaluated using the same measures of quality of life and psychopathology as were used in assessing mentally ill patients in hospital and community facilities in Manchester. Psychopathology was greater in the Boulder samples, but quality-of-life scores were no worse for the American patients. The relationship of these findings to systems of care and availability of psychiatric hospital beds is discussed.

Somatising patients present with a variety of psychosocial dysfunctions. Using the Dysfunctional Analysis Questionnaire and the Global Assessment of Functioning scale, we studied the nature and severity of psychosocial dysfunction in a group of somatising patients. Dysfunction was less marked in the cognitive area than in social, vocational, personal and familial areas. Patients with depressive disorders showed more dysfunction than those with somatoform disorders in all psychosocial areas except cognitive.

The evidence for abstinence phenomena after discontinuation of lithium is weak and ambiguous. Early manic and depressive recurrences after lithium discontinuation may suggest rebound, but studies carried out with appropriate methodology have failed to confirm its reality. Discontinuation of prophylactic lithium treatment of recurrent manic-depressive illness, whether abrupt or gradual, involves risk of relapse, but the existence of a special lithium withdrawal syndrome remains unproven.

We followed up a sample of psychiatric patients (diagnoses predominantly schizophrenia and depression) who had participated in in-patient studies of their CSF over the past 15 years. The status of 73 former patients was confirmed, of whom 12 had died. Seven of these patients died at age ⩽40, largely of suicide, homicide, or accidental causes. These seven patients had significantly lower CSF 5-HIAA and HVA than living control patients. There were significant direct correlations between age at death and both CSF 5-HIAA and HVA in the deceased patients. The results offer support for CSF monoamine metabolites relating to early death in a diagnostically diverse sample of psychiatric patients.

The epidemiological evidence that the offspring of women exposed to influenza in pregnancy are at increased risk of schizophrenia is conflicting. In an attempt to clarify the issue we explored the relationship between the monthly incidence of influenza (and measles) in the general population and the distribution of birth dates of three large series of schizophrenic patients - 16 960 Scottish patients born in 1932–60; 22 021 English patients born in 1921–60; and 18 723 Danish patients born in 1911–65. Exposure to the 1957 epidemic of A2 influenza in midpregnancy was associated with an increased incidence of schizophrenia, at least in females, in all three data sets. We also confirmed the previous report of a statistically significant long-term relationship between patients' birth dates and outbreaks of influenza in the English series, with time lags of - 2 and - 3 months (the sixth and seventh months of pregnancy). Despite several other negative studies by ourselves and others we conclude that these relationships are probably both genuine and causal; and that maternal influenza during the middle third of intrauterine development, or something closely associated with it, is implicated in the aetiology of some cases of schizophrenia.

It has been suggested that schizophrenia is a disappearing disease. The evidence for this assertion is reviewed, and also for a parallel theory advanced in recent years that the disorder may be undergoing a benign metamorphosis in its course and outcome. It is concluded that the evidence is presently unconvincing given the methodological problems inherent in most follow-up studies; changes have taken place in clinicians' assumptions, in treatments, and in the quality of follow-up studies, rather than in the disorder itself. Nevertheless, possible time trends in the incidence and outcome of schizophrenia call for further scientific investigation.

“I have three specific aims: firstly, to review some of the concepts supporting contemporary American (USA) Psychiatry; secondly, to explain the origins, strengths and frailties of these particular foundations; and thirdly, to provide examples of activity in the Department of Psychiatry at Johns Hopkins School of Medicine that intends to both revise and restructure these foundations in ways that enhance teaching, practice, and research.”