The background to HIV infection, its mode of transmission, and its neurological and psychiatric complications are described. The management of AIDS-related psychiatric disorder and problems encountered among staff involved in the management of patients suffering from AIDS are considered. There is a need for appropriate educational programmes. Although the incidence of AIDS in the UK has been appreciably lower than in many other countries, there are no grounds for complacency; psychiatric disorder associated with HIV infection will be encountered much more frequently in the future. Psychiatric staff are urged to inform and prepare themselves in anticipation of this development.

This paper is concerned with steadily developing knowledge of the epidemiology of some psychiatric disorders in sub-Saharan Africa. The diversity of ‘Black Africa’ is noted, and preconceptions about African psychiatry briefly discussed. Problems of sociological versus clinical philosophies are also mentioned. Early estimates of prevalence of psychiatric disorder in black Africa were universally low, being based on hospital data. More recent studies, sampling diverse populations, suggest a burden of psychiatric morbidity in black Africa which is not dissimilar to that found in more developed countries, and some studies suggest that rates in Africa may even be higher than in developed countries.

An instrument for assessing and evaluating what relatives know about schizophrenia was evaluated as both a pre- and a post-test for an educational programme. The Knowledge About Schizophrenia Interview (KASI) places emphasis on the functional value of the reported knowledge rather than on the recall of information; it is quick, easy to administer, can be rated reliably, and has face-validity for the relative. The educational programme increased scores from pre-test to a post-test one week after the programme. Relatives with high criticism ratings on the Camberwell Family Interview had lower scores at both tests. Relatives of less chronic patients showed lower scores at pre-test and acquired significantly more information from the programme, while relatives of more chronic patients were less influenced by the information sessions.

For the past 20 years, benzodiazepines have been the most commonly prescribed psychotropic drugs. It is now difficult to imagine the excitement produced by this new class of compounds. Existing anti-anxiety drugs, mainly the barbiturates, were known to be dangerous in overdosage, tend to cause addiction, and have many side-effects. Previous compounds, including opium, alcohol, chloral, and bromides, were similarly burdened. The benzodiazepine era began almost 30 years ago, in style. “Four hours after being given chlordiazepoxide on New Year's day 1958, one of 12 chronically anxious but therapeutically recalcitrant patients previously studied by Tobin and N. D. C. Lewis telephoned that for the first time in many years he was totally free from symptoms” (Hordern, 1968). The early studies were all enthusiastic and confirmed the therapeutic potential of the drug (Tobin et al, 1960; Jenner et al, 1961). In the ‘tranquilliser decade’ of the 1970s, prescriptions of benzodiazepines increased at a rate that was perceived as alarming, ‘the relentless march of the psychotropic drug juggernaut’ (Trethowan, 1975). This concern was related more to the inappropriate use of these drugs for treating personal problems than to the demonstration of dangers with these compounds. The dangers, however, appeared to be remarkably few; the drugs were safe in overdose, had greater efficacy than the barbiturates (Lader et al, 1974), and had virtually no unwanted effects, apart from sedation when given in excessive dosage. It was therefore hardly surprising that they proved so popular with clinicians. As Priest (1980) commented when benzodiazepine prescription was at its peak: “it is a tremendous boon to the medical profession to have active weapons in the fight against misery that are not only effective but are relatively safe when abused by despairing and desperate patients”.

Despite swings between over-valuation and rejection of psychotherapy on the part of some psychiatrists, there remains a valid and necessary place for psychotherapy in psychiatry. The essential elements of that place are described.

The relationships between symptoms in 40 schizophrenic patients, selected for persistence of symptoms, were examined. The symptoms segregated into three syndromes: psychomotor poverty (poverty of speech, lack of spontaneous movement and various aspects of blunting of affect): disorganisation (inappropriate affect, poverty of content of speech, and disturbances of the form of thought): and reality distortion (particular types of delusions and hallucinations). Both the psychomotor poverty and disorganisation syndromes were associated with social and occupational impairment; in particular, the psychomotor poverty syndrome was associated with impairment of personal relationships, and the disorganisation syndrome with poor self-care and impersistence at work.

Borderline personality has been, for many years, a discredited diagnostic concept. In 1979 a review of the literature concluded that its validity status was very uncertain. The authors have reviewed research conducted since then and discuss it in terms of the Robins & Guze (1970) criteria. In spite of existing unclear issues, the balance is tipping in favour of the validity of borderline personality, as diagnosed with new research criteria. This development is taking place in the context of a growing interest in the area of personality disorders.

The dopamine hypothesis of schizophrenia implies that positive schizophrenic symptoms should be understandable by reference to brain structures receiving a dopamine innervation, or in terms of the functional role of dopamine itself. The basal ganglia, ventral striatum, septo-hippocampal system, and prefrontal cortex, sites of mesotelencephalic dopamine innervation, are examined and it is argued that their dysfunction could form the basis of particular schizophrenic symptom classes. The postulated involvement of dopamine in reinforcement processes might further assist such interpretations. This type of analysis can be extended to other categories of schizophrenic psychopathology.

The efficacy of ECT was investigated in a double-blind trial. Twenty-two patients with schizophrenia received trifluoperazine and were randomly allocated to receive eight real or eight simulated ECTs. In the first eight weeks, the group receiving real ECTs showed significantly more improvement as measured on the Brief Psychiatric Rating Scale. However, the groups showed no significant differences from the twelfth week onwards. The superiority of real ECT was not confirmed at the end of six months.

Abnormal auditory brain-stem responses (ABRs) were recorded in 10 out of 20 schizophrenic in-patients. The response abnormalities did not show any correlation to the degree of psychopathology, sub-group of schizophrenia, age, sex, or cerebral ventricular enlargement. Nor was there any correlation to previous neuroleptic treatment: a pathological ABR was recorded in 5 of the 8 patients who had never received such medication. A statistically significant relationship was found between ABR pathology and auditory hallucinations: 9 of the 11 patients who admitted having hallucinations exhibited brain-stem response abnormality, whereas ABR abnormality was recorded in only 1 of the 9 patients who denied having hallucinations. The data imply that brain-stem dysfunction is involved in the psychopathology of schizophrenia, and that interference with the auditory pathways in the brain-stem may induce auditory hallucinations in schizophrenic patients.

The Grammar of Psychotherapy is a method of teaching both communication skills and the elements of psychotherapy. Supervised training is supplemented by self-monitored tasks. The course is economical in terms of tutors' time, and is particularly suitable for trainees in general psychiatry.

Aspects of clinical psychiatric syndromes described in Africa which are discussed include the issue of schizophrenic disorders having a better prognosis in developing countries; controversy over this is by no means at an end. There is an increasing realisation as to the frequency of affective disorders in Africa; while somatisation is common, cherished beliefs, such as the absence of guilt, have not been confirmed by more recent research. Nor is suicide as infrequent as has been suggested. The relationship of background physiological abnormalities of cerebral functioning may be relevant to some of the clinical issues that are currently under discussion in African psychiatry.

Murray et al (1985) have proposed a method for using biological markers and information about family history to reduce the heterogeneity in a disease such as schizophrenia. They propose that families which are heavily loaded with illness are most likely to be segregating for a major locus and therefore should be used for studies of genetic marker or other biological traits that are thought to be related to a genetic etiology. They propose that patients without a family history (sporadics) of an illness should be investigated for hypothesised environmental components since they are the cases where environmental factors are most likely to play a large role. They give an example from their own data on Ventricular Brain Ratios (VBR) in a sample of schizophrenic twins (Reveley et al, 1984) where schizophrenic twins without any family history (FH-) of a major psychosis had significantly larger ventricles than did schizophrenic twins with a family history (FH+). They conclude that while there is a genetic determinant to ventricular size within the normal range, large ventricles reflect an environmental aetiology that is more important in sporadic cases than in those with a familial pattern to the illness. Subsequently, Reveley & Chitkara (1985) found that singleton schizophrenic patients who were FH-had a significantly larger VBR than did controls while FH+ patients had a mean midway between FH-patients and controls. While this is an attractive hypothesis for the structural brain changes seen in some schizophrenic patients, results of other studies are not consistent with these findings (Nasrallah et al, 1983; Schulsinger et al, 1984; Owens et al, 1985; DeLisi et al, 1986). For example, in our own data (DeLisi et al, 1986), ‘familial’ schizophrenics had larger ventricles than did controls and risk factors thought to be environmental (head injuries and birth complications) were found to be present in that sample.

In 1972 the author proposed that schizophrenia represents an aberration of central nervous processes that underlie cognitive and personality characteristics which can be observed in many healthy people. The present paper brings the evidence for that theory up to date and concludes that over the past 15 years it has received considerable empirical support. The way in which the theory confronts the question of whether or not schizophrenia is a disease is also clarified.

To illustrate the contribution anthropology can make to cross-cultural and international research in psychiatry, four questions have been put to the cross-cultural research literature and discussed from an anthropological point of view: ‘To what extent do psychiatric disorders differ in different societies?’ ‘Does the tacit model of pathogenicity/pathoplasticity exaggerate the biological aspects of cross-cultural findings and blur their cultural dimensions?’ ‘What is the place of translation in cross-cultural studies?’ and ‘Does the standard format for conducting cross-cultural studies in psychiatry create a category fallacy?’ Anthropology contributes to each of these concerns an insistence that the problem of cross-cultural validity be given the same attention as the question of reliability, that the concept of culture be operationalised as a research variable, and that cultural analysis be applied to psychiatry's own taxonomies and methods rather than just to indigenous illness beliefs of native populations.

The Quality Extinction Test was used to detect lateralised abnormalities of hemispheric functions in schizophrenic patients. Course of illness significantly affected the distribution of tactile extinctions, chronic patients showing more left-side extinctions than sub-chronic ones. Age significantly affected the number of left extinctions, and sex the number of right extinctions. The importance of clinical and epidemiological characteristics of the patients in determining the quality and degree of hemispheric dysfunction in schizophrenia was confirmed.

A bilingual rater was trained in English in a technique of assessing relatives emotional attitudes to patients, and was then required to rate material in Hindi without any further experience. This strategy revealed that the rating of critical comments, hostility and positive remarks could be transferred from English to Hindi without distortion. There were problems with the remaining two scales, over-involvement and warmth, but these were due to technical issues connected with rating and not to cross-cultural distortion.

This paper describes the development of three self-monitoring forms to enable students to make constructive use of audiotapes of their interviews with patients. Each interactogram is described in detail, with examples where necessary.

The rationale and limitations of discriminating between cases of schizophrenia with and without a family history are reviewed. It is concluded from the evidence available that, by identifying subgroups of greater aetiological homogeneity, the strategy can be a useful starting point for research into likely causes.

Neuroleptics are structurally a heterogenous group of compounds which possess antipsychotic activity. They increase dopamine metabolites by blocking dopamine receptors and enhancing presynaptic turnover. This forms the cornerstone of the dopamine hypothesis of neuroleptic action, which is supported by wide-ranging behavioural, physiological and biochemical studies. It is, however, clear that neuroleptics are far less specific for the dopamine receptor than was previously considered. They influence a range of neuronal activities, including calcium-activated potassium conductance, which governs the rate of action potential generation by many neurones. Recent physiological studies indicate that all commonly used neuroleptics alter calcium-activated potassium conductance in central neurones, in concentrations similar to those achieved clinically. An adaptive increase in calcium-activated potassium conductance mechanisms in key sensory processing neurones would render the psychotic patient less susceptible to bombardment by environmental stimuli. This action may explain in part the therapeutic effect of neuroleptics.