“In the practical decisions of life it will scarcely ever be possible to go through all the arguments in favour of or against one possible decision, and one will therefore always have to act on insufficient evidence” Werner Heisenberg (1962).

The development of selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (SSRIs) has added a new dimension to the pharmacotherapy of depression. Their lack of sedative and anticholinergic effects together with relative safety in overdose, has led some authors to suggest that the older tricyclic antidepressants (TCAs) should not now be considered a first-line treatment (Montgomery, 1988). However, since a report by Teicher et al (1990) of suicidal preoccupation associated with fluoxetine treatment, there has been both intense media interest and animated correspondence in clinical and scientific journals (O'Donnell, 1991).

This review describes the history of PTSD in relation to military psychiatry, physiology, and crisis theory. It appears that the consequences of psychic trauma are often underestimated and mental health services often fail to provide adequate care. PTSD may be explained as an initially adequate reaction to danger, which becomes pathological if it does not disappear after the danger is gone. The authors argue in favour of better psychiatric intervention after traumatic events and better care for trauma victims.

The prevention of suicide requires an understanding of protective as well as risk factors, and the recognition of high-risk groups. Factors which increase the risk in patient populations include previous parasuicide, recent relapse or discharge, features of mental state (depression, psychosis), social circumstances (isolation, unemployment), and demographic characteristics (male sex, young age). Protective factors are under-researched but are likely to lie in the nature of psychiatric care. Consequently, community care may affect suicide by altering the level of protection at critical periods in an episode of illness. The clinical prevention of suicide should therefore be a priority for community services, and the relationship between suicide and mental health care should be researched by a national process of monitoring.

This review focuses on ‘aches and pains' and conversion syndromes as a basis for the description of psychological factors and mechanisms of relevance for the somatisation of distress in childhood and which may contribute to medical help-seeking for children. The characteristic pattern of associated psychological factors includes child personality features; academic concerns; family health problems; and styles of family interaction. Further research is required to explore in more depth the nature of these factors, the mechanisms that mediate the development of severe handicapping problems, and effective interventions.

This study aimed to establish the prevalence of psychosocial problems in gay men with HIV infection, and to identify factors associated with psychological morbidity. The study was a cross-sectional controlled investigation, which included 24 HIV seropositive and 25 seronegative gay men. Outcome measures included current psychological status and psychiatric history; coping and health beliefs; and social and sexual functioning. Seropositive subjects had worse scores on the PSE total score, and greater sexual difficulties. There were also differences in health beliefs and coping. Psychological morbidity was associated with hopelessness, previous psychiatric illness, symptomatic HIV disease, and low self-esteem.

The burden of schizophrenia on rural and urban Nigerian families was studied using a standardised questionnaire. Rural families experienced more burden; however, the difference was significant only in respect of financial burden. Rural families of schizophrenics were shown to be more prone to minor psychiatric morbidity than urban families. Policies should be instigated to reduce such burden.

There is overwhelming evidence that the outcome for people with schizophrenia in Western industrialised countries is inferior to that of those living in the Third World. Extended family structures, greater opportunities for social reintegration, and more positive constructions of mental illness have been offered as possible explanations for this effect. The Asian community in the UK retains many of these features as well as strong links with native cultures of origin. The issue arises as to whether similar differences in outcome may be observed in the UK. An exploratory study was undertaken, examining the early progress of schizophrenia in a first-episode sample (n=137), and based on systematic examination of case-note data. A lower rate of relapse/readmission in the first 12 months after discharge was found in the Asian (16%) as compared with white (30%) and Afro-Caribbean (49%) patients. Available evidence suggested that speed of access to care, living with a family, and employment may account for this effect. Medication compliance may have contributed to differences in relapse between white and Afro-Caribbeans but was not a factor influencing the low rate among Asians. The limitations and strengths of case-note studies are discussed at length, and it is concluded that a prospective study is warranted and would be highly instructive.

Iron status and akathisia were assessed in 105 long-stay in-patients who fulfilled DSM–III–R criteria for schizophrenia, all but three of whom were receiving antipsychotic medication. Chronic akathisia was diagnosed in 23% and pseudoakathisia in 20%. No significant correlation was found between serum iron concentration and the severity of akathisia. There was no significant difference in serum iron concentration between patients with chronic akathisia and those without. However, serum iron and percentage saturation were significantly raised in patients with pseudoakathisia compared with patients with chronic akathisia, and tended to be higher than in patients with akathisia. These findings do not support an association between low serum iron and chronic akathisia.

Standard of living reflects the objective dimension of how well the basic needs of life are met, while quality of life is the patient's own subjective view of well-being and satisfaction with her/his life. Sixty-one schizophrenic out-patients completed self-report inventories and participated in interviews about quality of life and standard of living. When living standards were met by a well functioning social service system, patients' perceptions of their quality of life and their standard of living appeared to be independent. Subsequent analyses revealed that ‘inner experiences' was one quality-of-life domain frequently reported as unsatisfactory. Moreover, differences in quality of life were found across patients' age, education, and work status.

Staff-patient relationships in long-term settings were examined in 35 staff and 61 patients. Measures were also taken of the staff's general health, their coping style in relation to work events, and job satisfaction. A range of ratings of EE was evident in staff descriptions of patients under their care. Strain and criticism in the relationship were not associated with identified stressors in the workplace, or the general health of the carer. When patients were grouped according to high-EE and low-EE interviews, there were no significant differences in their symptoms. Criticism was associated with other patient characteristics, including aggressive and attention-seeking behaviour, underactivity, and limited social interaction. The findings have implications for staff training and for the maintenance of optimal staff-patient relationships in services supporting severely disabled patients.

A multidimensional measure of children's perception of control was administered to 56 adolescents before and after admission. Different sources of control (‘internal’, ‘powerful others' and ‘unknown’) were analysed by domain (sphere of behaviour) and outcome (‘success' or ‘failure’). There were changes across domain and outcome for all three sources of control with significant changes away from ‘powerful others' and ‘unknown’ control. The trend towards internality was also evident in significant changes in the adolescents' perceptions in the ‘general’ domain and for a ‘success' outcome. Changes towards ‘internal’ source of control were associated with higher cognitive ability, whereas changes away from ‘powerful others' were most marked in girls, and changes away from ‘unknown’ were greatest in the older adolescents. These preliminary observations may help us understand beneficial effects of in-patient care and plan strategies for sustained change in these patients.

In Oxford during the late 1970s and early 1980s a decline in rates of deliberate self-poisoning and self-injury in older female teenagers was followed by a steady increase between 1986 and 1989. Rates for male adolescents and young female adolescents remained relatively stable throughout 1976–89. Applying the Oxford rates to England and Wales suggests a total of 18 000–19 000 hospital-referred cases per year. While self-poisoning with minor tranquillisers and sedatives has declined, there has been a marked increase in paracetamol self-poisoning, such that by 1988–89 it was involved in 48.3% of overdoses. Relationship difficulties were the most frequent problems faced by these adolescents, especially the females, with unemployment and alcohol and drug problems also being common, especially in males, but psychiatric disorders relatively rare. Substantial proportions of the adolescents, especially the males, were not living with either relatives or friends, and had a history of violence or a criminal record. The annual rate of repetition of attempts, which was 8.9% overall, was higher in adolescents not admitted to the general hospital, and in females not referred to the hospital psychiatric service. Adolescent attempted suicide clearly continues to be a major health problem for which both effective preventive and therapeutic strategies are badly needed.

Although a polydiagnostic approach to the definition of psychotic disorder provides many advantages to the researcher, there are also disadvantages. A comparison between several different sets of operational criteria using the opcrit computer program on a consecutive series of 397 psychotic subjects is described. The results show that although current diagnostic procedures are generally reliable, such approaches can still only supplement skilled clinical judgement, and there remain many pitfalls for the unwary.

The aim of the present study was twofold: firstly, to determine cardiac vagal tone in subjects with generalised anxiety disorder directly, using an invasive pharmacological method; and secondly, to test whether the non-invasive method of measuring the amplitude of respiratory sinus arrhythmia (RSA) gives a reliable estimate of cardiac vagal tone in this form of anxiety disorder. Comparison of baseline physiological measures of anxious and control subjects revealed that cardiac vagal tone and heart rate were not different in the two groups of subjects, whereas length of the respiratory cycle and amplitude of respiratory sinus arrhythmia were reduced in the former group. Because of the higher respiratory rates of anxious subjects, the RSA method was found to underestimate cardiac vagal tone in generalised anxiety disorder.

A short paper of this title reported a study by Ansseau et al (1991). The present authors were invited to comment upon the study.

Autism is currently detected only at about three years of age. This study aimed to establish if detection of autism was possible at 18 months of age. We screened 41 18–month-old toddlers who were at high genetic risk for developing autism, and 50 randomly selected 18–month-olds, using a new instrument, the CHAT, administered by GPs or health visitors. More than 80% of the randomly selected 18–month-old toddlers passed on all items, and none failed on more than one of pretend play, protodeclarative pointing, joint-attention, social interest, and social play. Four children in the high-risk group failed on two or more of these five key types of behaviour. At follow-up at 30 months of age, the 87 children who had passed four or more of these key types of behaviour at 18 months of age had continued to develop normally. The four toddlers who had failed on two or more of these key types of behaviour at 18 months received a diagnosis of autism by 30 months.

Using a structured instrument, 325 elderly patients admitted to a general hospital for an acute medical problem were evaluated daily in order to detect symptoms of delirium. Patients were scored for ‘hyperactive’ or ‘hypoactive’ symptoms, and then the 125 patients with DSM–III delirium were rated as ‘hyperactive type’ (15%), ‘hypoactive type’ (19%), ‘mixed type’ (52%), or ‘neither’ (14%). There were no statistically significant differences between the groups with respect to age, sex, place of residence, or presence of dementia. These definitions of subtypes should be studied further.

Sex offenders suffering from psychotic illness formed an important small group of a regional secure unit's patients. Ten of the 11 such offenders had a diagnosis of schizophrenia. There was a complex relationship between their mental illness and offending.

We present a case of acute dystonia in an adolescent, with features that fit the description of the Pisa syndrome. The symptoms developed postoperatively, in a non-psychiatric setting, following administration of antiemetic medication, and the phenomenon was misdiagnosed as a conversion disorder. This case reinforces previous reports cautioning against misinterpretation of dystonic reactions as functional disorders, especially in children and adolescents.

A 13-year-old girl was referred because of sexual identity problems. There was no mental illness or neurological abnormalities. As her twin sister had no sexual identity problems, it appears that transsexualism is not transmitted by a simple genetic mechanism.