Forty-six patients, 9 male, 37 female, presenting to an ear, nose and throat department with a principal complaint of globus sensation were investigated by radiology, manometry, endoscopy and prolonged ambulatory pH monitoring to exclude a physical basis for their symptoms. Patients also underwent assessment by the Eysenck Personality Inventory (EPI) and General Health Questionnaire (GHQ). The only organic abnormalities detected were an abnormal degree of oesophageal acid exposure (seven patients) and oesophageal spasm (one patient). Female patients were neurotic introverts on EPI testing; males were stable ambiverts. High GHQ scores were present in 13 females (35%) and one male and there was a significant correlation between N scores (in the EPI) and GHQ scores. We propose that globus is a useful, single-symptom model for the study of conversion disorders.

It is incumbent on anyone who is honoured by an invitation to deliver the Maudsley Lecture to familiarise himself with the preceding lectures of the series. For me, the task has been unexpectedly instructive. Since its inception in 1919, the list of lecturers is impressive by virtue of not only their eminence, but also the heterogeneity and range of their selected topics. Taken as a group, the lectures emerge as a line of beacons which illuminate the direction, if not always the advances, of psychological medicine over the past three generations.

Bulimia nervosa is a disorder which has only recently been identified and described (Russell, 1979). It is a condition, found almost exclusively in young women, in which episodes of excessive uncontrolled eating are the central feature. Patients with bulimia nervosa usually present at normal weight because they compensate for the bulimic episodes in a variety of ways, such as by inducing vomiting, abusing purgatives and exercising extreme dietary restraint. In addition to these disturbed eating habits, patients with bulimia nervosa have attitudes to their shape and weight similar to those found in anorexia nervosa. They also present with a wide range of neurotic symptoms, particularly of a depressive nature (Russell, 1979; Fairburn & Cooper, 1984). It is generally accepted that these neurotic symptoms are usually a secondary reaction to the core eating disorder rather than of primary diagnostic significance (Fairburn et al, 1985; Cooper & Fairburn, 1986).

The study examined the mortality experiences of a population of mentally handicapped in-patients between 1983 and 1987. Demographic data and factors related to terminal illness and cause of death were considered. The findings suggested a continued trend towards increased longevity and indicated a number of groups at risk of early death.

Using clonidine, naltrexone, and diazepam, 60 withdrawals from heroin and other opioids involving 56 addicts were carried out with only one patient dropping out. In the last 23 cases, we used a modification of the standard technique, giving significantly higher doses of naltrexone and clonidine on the first day. This significantly reduced the average withdrawal time from 3.30 days to 2.32 days, despite lower clonidine dosage and significantly lower diazepam dosage on the second day. The speed, effectiveness, economy, and high acceptability of this withdrawal technique have implications for both private and state-funded treatment programmes.

Several scales are described for measuring aspects of eccentricity and social isolation; in particular, for assessing schizoid and schizotypal personality and for rating abnormal non-verbal expression. The latter is shown to be reliable, and the former to have a measure of validity. There was an association between schizoid personality traits and abnormalities of speech and non-verbal expression. However, abnormal non-verbal expression, but not schizoid personality traits or DSM–III schizotypal personality disorder, was particularly likely to occur in those subjects who had evidence of neurological deficit, and childhood symptoms indicative of developmental disorder. Abnormal non-verbal expression, but not personality disorder, was also associated with other characteristic features of Asperger's syndrome, such as unusual, 'special’ interests. It is suggested that Asperger's syndrome is a distinct syndrome from either schizoid or schizotypal personality disorder, but may be a risk factor for the development of schizoid personality disorder.

DSM-IIIR (American Psychiatric Association, 1987) has revised the Kraepelinian concept of paranoia, but has given it the name of delusional (paranoid) disorder. The description is of an encapsulated, monodelusional disorder with several subtypes as follows: Erotomanic, Grandiose, Jealous, Persecutory, Somatic, Unspecified.

A depression-screening instrument (DSI) was administered to all 25–34-year-old, British-born, married women registered with a health centre on a south-east London housing estate. A disproportionate number of high scorers lived in those dwellings with the highest disadvantagement score. The dwelling interiors of the high DSI scorers were significantly poorer in appearance compared with those of the low scorers. Significantly more of the high scorers (and of their husbands) described the estate as unpleasant, and bad for their children. They raised significantly more objections to other residents' (including children's) behaviour. Their complaints were only partly explicable in terms of their less favourable accommodation.

Psychopathic personality has always been a contentious concept, but it continues to be used in clinical practice and research. It also has its contemporary synonyms in the categories of antisocial personality disorder in DSM–III (American Psychiatric Association, 1980) and “personality disorder with predominantly asocial or sociopathic manifestations” in ICD–9 (World Health Organization, 1978), and some overlap between these and the legal category of psychopathic disorder identified in the English Mental Health Act 1983 is commonly assumed. Although the literal meaning of ‘psychopathic’ is nothing more specific than psychologically damaged, the term has long since been transmogrified to mean socially damaging, and as currently used, it implies a specific category of people inherently committed to antisocial behaviour as a consequence of personal abnormalities or deficiencies.

The most unequivocal demonstration of efficacy with putative or reference antidepressants is normally obtained from placebo-controlled studies; heavy reliance is therefore placed on such investigations, particularly in the early stages of development of any new therapeutic agent. However, many clinicians are understandably reluctant to allow some patients to be treated with placebo, which may lead to a sampling bias. It is equally understandable that doctors taking part in such studies are anxious about clinical deterioration or lack of response, and this in turn may result in a higher drop-out rate than would be seen in studies using reference antidepressants without a placebo treatment group. However, in spite of these and other drawbacks, it is still generally accepted that the efficacy of potential antidepressants is established in a more scientific and unequivocal way using placebo-controlled methodology. Fluoxetine has been the subject of a number of such investigations (Table I); their findings are reviewed in this paper.

Thirty-nine patients with DSM–III diagnoses of schizophrenia were examined for age disorientation, an inability to produce one's correct chronological age upon request. Six patients were age-disoriented and demented (as defined by Mini-Mental State evaluation), while two patients had delusions concerning their age, but were not demented. Age-disoriented, demented patients had very large cerebral ventricles and very low Mini-Mental State scores. This group differed on the cognitive and neuroanatomic variables from other demented, but not age-disoriented, patients, as well as from non-demented patients who were age-oriented. The age-disoriented patients appeared to be at an extreme end of the dementia spectrum in schizophrenia.

In the short term, both antidepressants and exposure therapy usually improve agoraphobia/panic (AP) and obsessive–compulsive (OC) disorders and are accepted by most patients; psychological methods omitting exposure are not consistently helpful. Antidepressants have a broad-spectrum rather than specific anti-agoraphobia/panic or anti-obsessive–compulsive action. For long-term efficacy, there is good evidence for the value of exposure, but none for drugs. Because of relapse on ceasing drugs, and their side-effects, medication is less useful as the first line of treatment for chronic agoraphobia/panic or obsessive-compulsive disorder than is the lastingly helpful approach of exposure. Antidepressants are worth trying when patients refuse or fail with exposure therapy, or are dysphoric.

In order to assess some psychometric properties of Marks & Mathews' (1979) short Fear Questionnaire, a Dutch translation of this form was administered to 143 phobic outpatients: 100 women and 43 men. There was a special interest in assessing validity by comparing the scores of agoraphobics, social phobics and simple phobics. The findings were that all scales have sufficient internal consistency, although the Total Phobia scale does not seem to add meaningful information to its subscales. Most scales are significantly related to neuroticism, and the Social Phobia subscale is strongly related to social anxiety. The Agoraphobia and Social Phobia subscales discriminate between categories of phobics in the expected way. For the Blood/Injury subscale the relevant comparisons could not be made. The data presented in this study can be used to develop FQ norms for phobic patients.

As a result of research in recent years, therapeutic possibilities for the treatment of depressive illnesses have been significantly expanded. Monoamine oxidase inhibitors and selective noradrenaline (e.g. oxaprotiline) or serotonin-reuptake inhibiting (e.g. fluoxetine, fluvoxamine) substances have been added to the classical tricyclic antidepressants, whose mode of action is primarily based upon combined noradrenaline and serotonin reuptake inhibition. Furthermore, the extent to which benzodiazepine derivatives or neuroleptics can be successfully used at low dosages for the treatment of depressive illness is currently being investigated.

For these compounds to be used in an individualised manner, however, agreed diagnostic criteria must be taken into consideration, as well as other factors such as the severity and type of depressive syndrome (mild, marked, or severe, retarded or agitated). For example, the benzodiazepine derivative alprazolam has a therapeutic efficacy comparable to amitriptyline for the treatment of milder depressive syndromes, but is significantly less effective for a severe depressive disorder.

We undertook a study of fluoxetine, a selective serotonin-reuptake inhibitor (Wong et al, 1974, 1975), in a double-blind comparison with amitriptyline. We particularly wanted to know if the efficacy of fluoxetine was comparable to that of amitriptyline, and whether fluoxetine caused less adverse effects as a result of its selectivity, which remains unchanged even after its metabolisation to desmethyl fluoxetine (Fuller et al, 1978).

Schizophrenic in-patients with and without a family history were identified prospectively. The two groups did not differ with respect to clinical variables, ventricular enlargement, prevalence of cortical sulcal widening, or a history of obstetric complications, even when a variety of definitions of familiality were used.

Psychiatrists and general practitioners have found new ways of working together in the last ten years, but there have also been separate activities which could develop into rivalry. These opportunities and dangers are the central theme of this paper. Ways are considered in which the psychiatry of general practice differs from the experience of psychiatrists. Forms of help are suggested which general practitioners need from psychiatrists, whether in clinical practice or education.

The term ‘dysmorphophobia’ was first defined by Morselli (1886) who wrote of it as “a subjective feeling of ugliness or physical defect which the patient feels is noticeable to others, although his appearance is within normal limits”. A century later there is continuing debate as to its status as symptom, syndrome or discrete psychiatric illness. Misleadingly, it is not a phobia and there is no fear of physical abnormality per se – the ugliness of others is tolerated, although the patient may well be apprehensive regarding the response he anticipates his appearance will provoke in others. As a symptom the feeling may be expressed as a preoccupation with appearance, an obsession, overvalued idea or frank delusion. The accompanying self-consciousness may similarly range to full-blown delusions of reference. To some extent the failure of some authors, reporting on dysmorphophobic patients, to specify clearly the level at which the belief is held, has confounded clarification of the phenomenon.

We measured the growth hormone (GH) response to clonidine (an alpha-2-adrenergic agonist) and to apomorphine (a dopaminergic agonist) in 15 major endogenous and 15 minor depressive in-patients matched for gender and age. Results showed a significantly smaller GH response in the major depressives to both Clonidine (P<0.01) and apomorphine (P<0.001). No significant difference existed between the two groups with regard to changes in blood pressure and pulse rate during either test. While major depressives showed a trend toward smaller sedative side-effects than minor depressives after Clonidine, they showed significantly smaller sedative and gastro-intestinal side-effects after apomorphine. No significant correlation was present either in the major depressive or in the minor depressive group between the GH responses following Clonidine and apomorphine challenges. These results support the hypothesis of both noradrenergic and dopaminergic neurotransmitter disturbances in major depression, with individual variability with regard to those biochemical anomalies.

Sixty-two schizophrenic patients completed the Parental Bonding Instrument (PBI), a measure of perceived parental characteristics, rating their parents on care and protection. PBI ratings were related to a one-year course of illness. Patients who perceived their parents positively tended to experience a milder course of illness if they were in frequent contact with them, and a more severe course if they were not; the reverse was true for patients who perceived their parents negatively. PBI ratings were unrelated to the age at onset of illness. This suggests that patients' perceptions of parental attitudes influence the course of schizophrenia by a current stress effect. The PBI, used alone or in conjunction with other predictors, distinguished good- and poor-outcome cases and appears to be a potentially clinically valuable tool.

The dramatic clinical presentation of parasuicide tends to deflect attention from the repetitive pattern of this behaviour in many patients. In an epidemiological study of annual cohorts of parasuicides for 1972, 1977, and 1982 admitted to the Regional Poisoning Treatment Centre, Edinburgh, it was found that for certain subgroups of the population ‘repeaters' were actually commoner than ‘first-ever’ patients, and a number of risk factors were identified, of which social class was particularly important. The clinical characteristics of patients distinguished by their frequency of repetition were also described, with special attention to the stability of these differentiating features over time. It is suggested that the habitual repeater requires closer study, and that the factors which lead to initiation into a parasuicidal ‘career’ are not necessarily those which conduce to repetition.