The data presented are those from a two-year prospective study of 69 patients identified in the Nottingham field centre of the WHO Study of Determinants of Outcome of Severe Mental Disorders. Premorbid personality, childhood adjustment and adolescent adjustment were assessed at the patients' first presentation to psychiatric services with a psychotic illness. Ratings were made blind to diagnosis. Premorbid explosive and paranoid traits were commoner in patients with schizophrenia than in patients with other non-organic psychoses, and these traits were associated with later onset of schizophrenia. Premorbid schizoid traits were significantly commoner in patients with schizophrenia compared to patients with other psychoses, but only in those patients for whom a parent was the informant. Schizoid traits were no commoner in men with schizophrenia than in women, and were not associated with earlier age of onset. The findings suggest that premorbid personality, in men and women, may shape the expression of symptoms produced during an illness episode.

Accidents may often have been far more traumatic psychologically and emotionally than appears to be the case at first sight. Attention is drawn to such “Cryptotrauma” and illustrated with three clinical vignettes. Emphasis is placed on the need for painstaking analysis of the accident in all its details. Without such careful investigation “Post traumatic stress disorders” can easily be overlooked, since patients tend not to offer the information spontaneously.

Video-based and in vivo (face-to-face) contact have been shown to be effective ways to change stigmatising attitudes and behaviours. The two approaches reflect the strengths and weakness of sometimes conflicting priorities in anti-stigma programmes: broad audience v. grassroots control. Regardless of perspective, anti-stigma interventions have the greatest impact when contact is targeted, local, credible and continuous.

Stupor is an unusual but striking phenomenon, generally recognized but difficult to define in precise clinical terms. A large literature exists on the diverse conditions in which it may occur, but there is little information on differentiating one cause from another, or on the prevalence of these causes. This insufficiency extends to the phenomenology of stupor, where descriptive criteria are not always adequate for separating stupor from allied states. Such difficulties are reflected in a current text book by Merskey and Tonge (1965). The authors only recognize stupor if there is total akinesis, where it is assumed that the diagnosis is schizophrenia. Depressive stupor is not recognized as an entity.

Several surveys of mental illness in husband-wife pairs have all concluded that sick couples occur in the general population with a frequency significantly in excess of the number to be expected by chance (Penrose, 1944; Gregory, 1959; Kreitman, 1962; Ryle and Hamilton, 1962; Pond et al., 1963; Nielsen, 1964). The statistical methods employed in such investigations have been criticized by Hall et al. (1971), but these authors' arguments appear to suggest that the relative excess of conjoint illness has, if anything, been under-estimated.

A recent challenge in schizophrenia has been the management of patients who have failed to respond not only to standard therapeutic regimes but also to trials of atypical neuroleptics such as clozapine and risperidone. This article focuses on the further psychological and pharmacological management of such patients.

It is debatable whether the notion of dangerousness now has any utilitarian value for psychiatry. The presence or absence of dangerousness is very much in the eye of the beholder. It is an all or nothing term – you either have it or you do not! While there is usually little disagreement about the few very violent individuals “who, for 24 hours a day, and in any situation, are likely to cause harm to others” (Chiswick, 1995), most patients are not in this category and “little bit dangerous” is unlikely to be of much comfort to clinical staff. It is unhelpful to deny that dangerousness is any more than an adjective which has been elevated into a pseudoscientific construct whose definitions (Scott, 1977; Walker, 1978; Home Office & DHSS, 1975) amount to little more than “past harm predicts future behaviour”.

Much of the evidence that religion provides a protective factor against completed suicide comes from cross-sectional studies. This issue of the Journal includes a report of a new prospective study. An understanding of the relationship between spirituality, religion and suicide is important in assessing and caring for those at risk.

The analysis of schizophrenic persons' attempts at coping with their disease has developed into a fertile research area over the last few years. Results are expected that may lead to a better understanding of specific psychopathological phenomena, and hopes are raised for improvements in specific therapeutic programmes (cf. Böker & Brenner, 1983; Wiedl & Schöttner, 1989a). Previous studies have shown that schizophrenics use many different strategies to cope with their disease. Sometimes conflicting results deal with the frequency of specific ways of coping, their orientation to specific symptoms or strains, their relationship to the course of the disease and the nosological classification of the patients, and finally, with their suitability or usefulness (cf. Wiedl & Schöttner, 1989b). Altogether, these investigations have contributed to correcting the image of the schizophrenic as a person who is passive and helpless against his/her illness, and have expanded the scope of knowledge in psychiatry and clinical psychology (cf. Strauss, 1989a,b).

The prominence of risk in UK social and criminal justice policy creates opportunities, challenges and dangers for forensic psychiatry. The future standing of the specialty will depend not only on the practical utility of its responses to those opportunities and challenges, but also the ethical integrity of those responses.

Erythrocyte catechol-O-methyl transferase (COMT) activity was studied in 65 patients with depressive illness and anxiety states. A hypothesis that measurement of this enzyme might have some value as an aid to diagnosis and as an index of clinical recovery has not been confirmed. In patients with endogenous depression, agitated subjects had COMT levels significantly higher than normal (P < ·01) and retarded subjects had levels significantly lower than normal (P < ·02). These observations are congruent with some reports of high and low urinary MHPG excretion in patients with depression. Further data correlating COMT assays with catecholamine metabolites in depressed patients may reveal homogeneous biochemical subgroups which could serve as a guide to rational therapy.

The relationship of depression with affect deficit in schizophrenic patients continues to challenge both the clinician and the researcher. Often there is considerable difficulty in differentiating these two affect states in a reliable and valid fashion. On the observational level, depressed affect often appears somewhat restricted, having lost the full range of the euthymic state. On a subjective level, schizophrenic patients often complain of anhedonia, a defect in pleasure capacity which is shared by patients who are depressed. On the prognostic level, there is a large body of literature that links depressive features in acute schizophrenics to favourable subsequent course (Astrup & Noreik, 1966; Vaillant, 1964). We were, therefore, interested in investigating the relationship of depression with impaired affect and with positive/negative symptoms in young acute schizophrenic patients. We used a systematic multidimensional study of affect impairment among 37 young acute schizophrenic patients in a prospective, longitudinal approach over a 2-year span. In addition to a detailed assessment of the affect profile, including depression, both at baseline and on follow-up, we rated patients clinically for a positive and negative syndrome as well as general psychopathology, and we conducted premorbid and outcome measurements.

Recent clinical investigations have shown that long term treatment with the tricyclic antidepressants desipramine and amitriptyline reduces the sensitivity of the alpha-2 adrenergic autoreceptor. In order to determine whether the tetracyclic antidepressant mianserin also has this action, the effect of clonidine, an alpha-2 adrenergic receptor agonist, on plasma levels of the norepinephrine metabolite 3-methoxy-4-hydroxyphenlethyleneglycol (MHPG), blood pressure, and patient-rated sedation were measured in fifteen depressed patients before and during mianserin treatment. Postsynaptic alpha-2 adrenergic receptor function was assessed by measuring the growth hormone response to clonidine before and during treatment. Mianserin had little or no effect on the ability of clonidine to lower plasma MHPG and blood pressure, and to increase sedation and growth hormone secretion. The findings of this investigation indicates that long term mianserin treatment does not produce significant subsensitivity of the alpha-2 adrenergic receptor and suggests that a reduction in alpha-2 adrenergic autoreceptor sensitivity is not a necessary action for all effective antidepressant treatments.

Of 49 schizophrenic patients followed up 12 months after their first admission to hospital, only about 45% had experienced no relapse and had no schizophrenic symptoms; a poorer outcome was more often found in Feighner positive than Feighner negative schizophrenic patients. The patients' overall level of unemployment had more than doubled to 51%. In patients whose acute episodes responded to treatment, pimozide taken once weekly as maintenance therapy was as effective as intramuscular flupenthixol decanoate, but tardive dyskinesia appeared in two patients receiving weekly pimozide; the repeat psychometric assessment at 12 months found modest improvements, i.e. no evidence of intellectual decline, in Matrices, Block Design, and Digit Copying tests. Forty per cent of relatives still showed significant psychological distress, which correlated with patients' schizophrenic symptoms, and the relatives' social functioning remained poorer than that of a normal community sample.

The fugue has received little recognition in the literature in recent years. Stengel (1941, 1943) defines the fugue state as consisting of “transitory abnormal behaviour characterized by aimless wandering, and more or less marked alteration of consciousness, usually, but not necessarily, followed by amnesia”, According to Henderson and Gillespie (1944) the patient in a true fugue suddenly leaves his previous activity and goes on a journey which has no apparent relation to what he has just been doing, and for which he has complete amnesia afterwards. William McDougall (1926) states: “Fugue is the name given to those instances in which a person suddenly disappears from his accustomed haunts and re-appears at some distant place, astonished and puzzled to find himself there, and unable to give any account of himself in the period between his disappearance and his re-appearance.” In a footnote McDougall adds: “This word is sometimes used in a wider sense to include wandering of a seemingly aimless kind for which the subject (generally a psychopath) can assign no adequate reason or motive, but of which, nevertheless, he can give some description.” In our cases the criteria for a fugue have been sudden onset of wandering with clouding of consciousness and a more or less complete amnesia for the event.

Over the past 3 years we have collected 37 cases, either from the hospital records or from cases personally seen by us. Interesting features have emerged which, as far as we can ascertain, have not previously been described. A control group matched for sex, age and clinical diagnosis has been studied to exclude fortuitous associations. In the 37 cases of fugue under review, 31 are men and only 6 women. This incidence in favour of males is in accordance with the findings of other workers who have dealt with mixed groups, but differs from Stengel (1941), who picked his cases mainly from the female wards of Bristol Mental Hospital.