Psychiatry in severe and profound learning disability is essentially behavioural psychiatry. Some clinical and research observations of disorders of behaviour in this group are summarised in this study.

After inspection of the literature, I postulated a clinical syndrome of violence and self-injury in the severely learning disabled. A check-list of behavioural symptoms was developed and used in a community survey.

Behaviour, assessed by the check-list, supported the existence of organic behaviour disorder, as did small-scale psychophysiological testing.

Self-injury is strongly associated with violence, and with severe and profound learning disability. Pathophysiology of violence and self-injury may include high levels of psychophysiological arousal demonstrated by unstable EEGs. Reduction of arousal by antipsychotic medication is associated with clinical improvement in violent and self-injurious behaviours.

The Clinical Standards Advisory Group was asked by UK health ministers to advise on the standards of clinical care being achieved for people with schizophrenia. A subcommittee commissioned a review of standards, followed by research into how far these were reflected in contracts and met by providers.

No comprehensive but practical set of standards was found. A protocol of 143 items of good service practice was constructed, and applied by teams visiting services in 11 UK districts. The team appraisals were summarised in 20 key points, each scored 0 (absent) to 4 (excellent performance). Seven points were used to assess standards of commissioning and 13 for standards of service provision.

When placed into rank order, the mean key point scores for commissioners and providers in the same district tended to be very similar. Total district scores were then used to assign districts to one of three groups. Four performed reasonably well, five were moderate and two were poor.

One of the key elements associated with these differences was the local level of morale. After wide consultation, a revised protocol of 26 key points for direct rating was drawn up and has since been further tested.

Tricyclic (TCA) and monoamine oxidase inhibitor (MAOI) antidepressants are effective in the treatment of panic disorder. Two selective serotonin reuptake inhibitors (SSRIs) have also been licensed in the UK for this indication and studies with three other SSRIs have recently been completed. These provide further evidence for the role of serotonin in panic.

Review of clinical, animal and laboratory studies.

SSRIs have been shown to be effective in the treatment of panic disorder. The reported rates of improvement of 60–70% of patients taking SSRIs are similar to those seen withTCAs and greater than placebo. Other serotonergic agents do not appear to be effective. Animal work and human studies including measures of 5-HT in plasma, cerebrospinal fluid and platelets, challenge paradigms and tryptophan depletion show that the relationship between 5-HT and anxiety is complex.

Clinical trials have shown that of all the serotonergic agents only the SSRIs are effective in panic disorder. They are as beneficial as the TCAs and seem to be better tolerated which may be particularly significant in view of the chronic nature of the condition. Serotonin plays a role in panic disorder and serotonergic dysfunction, however the results and evidence do not fit one theory alone. It is also likely that different brain regions and 5-HTreceptors are involved in specific ways.

The growth in the USA of ‘recovered memory therapy’ for past sexual abuse has caused great public and professional concern. It became apparent that the polarisation of views and fierce controversy within the American psychiatric community was in danger of bringing psychotherapy into disrepute and it seemed important to examine objectively the scientific evidence before such polarisation developed in the UK.

A small working group reviewed their own experience, visited meetings and centres with expertise in this field, interviewed ‘retractors' and accused parents, and then began a comprehensive review of the literature.

There is a vast literature but little acceptable research. Opinions are expressed with great conviction but often unsupported by evidence.

The issue of false or recovered memories should not be allowed to confuse the recognition and treatment of sexually abused children. We concluded that when memories are ‘recovered’ after long periods of amnesia, particularly when extraordinary means were used to secure the recovery of memory, there is a high probability that the memories are false, i.e. of incidents that had not occurred. Some guidelines which should enable practitioners to avoid the pitfalls of memory recovery are offered.

An instrument was required to quantify and thus potentially measure progress towards a Health of the Nation target, set by the Department of Health, “to improve significantly the health and social functioning of mentally ill people”

A first draft was created in consultation with experts and on the basis of literature review. This version was improved during four stages of testing: two preliminary stages, a large field trial involving 2706 patients (rated by 492 clinicians) and tests of the final Health of the Nation Outcome Scales (HoNOS), which included an independent study (n=197) of reliability and relationship to other instruments.

The resulting 12-item instrument is simple to use, covers clinical problems and social functioning with reasonable adequacy, has been generally acceptable to clinicians who have used it, is sensitive to change or the lack of it, showed good reliability in independent trials and compared reasonably well with equivalent items in the Brief Psychiatric Rating Scales and Role Functioning Scales.

The key test for HoNOS is that clinicians should want to use it for their own purposes. In general, it has passed that test. A further possibility, that HoNOS data collected routinely as part of a minimum data set, for example for the Care Programme Approach, could also be useful in anonymised and aggregated form for public health purposes, is therefore testable but has not yet been tested.

Schizoid personality and poor social adjustment have been thought of as common antecedents of schizophrenia but the existing literature is inconclusive. We have carried out a large cohort study with improved methodology.

The premorbid personality and adjustment of 50 054 Swedish men were assessed on entry into the army at the age of 18. Individuals who developed schizophrenia or another psychosis after 15-year follow-up were identified. Odds ratios for variables independently associated with the later development of schizophrenia were calculated, adjusting for potential confounders.

Four variables reflecting early problems with interpersonal relationships were strongly associated with later schizophrenia and, to a lesser extent, non-schizophrenic psychoses, but also occurred commonly in the cohort as a whole. These associations with schizophrenia persisted after early-onset cases were excluded, though their predictive value was low (3.0%, 95% CI 1.5–4.5).

Some aspects of premorbid personality and adjustment may act as risk factors for schizophrenia. The results appear to be most consistent with a multi-factorial aetiology for schizophrenia and offer tentative support for a psychological disturbance mediating genetic and environmental effects on the causal pathway to the illness.

The aim was to compare the efficacy of intensive clinical case management (ICM) with standard community care in the management of ‘hard to treat’ patients with a severe mental illness.

A randomised controlled trial was carried out in East Lambeth, a deprived area of inner London. Seventy people with psychosis designated as ‘hard to treat’ by referring teams were included; 35 were randomised to ICM (case load eight patients per worker), and 35 to standard care, which offered follow-up by a community psychiatric nursing service (30 patients per worker). Outcome measures were admissions and hospital bed utilisation; contact with services; symptomatology; social behaviour; social functioning; quality of life; patients' satisfaction with care at 9 and 18 months.

There were no differences in patients' symptoms, social behaviour or social functioning. Quality of life was significantly improved in patients receiving ICM at 9 months. Satisfaction with care was significantly greater among case-managed patients. All ICM patients remained in contact with services throughout the study, while six control patients were refusing all contact with services at 18 months.

ICM failed to improve the clinical outcome of ‘hard to treat’ patients. The service was successful in maintaining contact with patients, was greatly appreciated and had a positive effect on their perceived quality of life.

The aim was to measure the criminal convictions received by people who leave special hospital and to test previously identified correlates of conviction.

A cohort study design was used and the subjects were all 425 patients discharged from the special hospitals in 1982 and 1983. The outcome measure was a criminal conviction received within 10.5 years of discharge.

Five and a half years after discharge 26% of ex-patients had been convicted of any offence, 9% of a violent offence, 5% of a sex offence and 10% of any serious offence. Ten and a half years after discharge 34% of patients had been convicted of any offence, 15% of a violent offence, 7.5% of a sex offence and 15% of any serious offence. When other variables are controlled for, gender and destination on discharge do not predict conviction. Age, a legal category of psychopathic disorder and prior criminal record do predict, but the effect is small.

The rate of conviction of patients leaving special hospital has fallen over the past 20 years; this is the case for crime in general and for serious crimes in particular. The change in rates of conviction over time for patients of different legal categories, previously thought to be different, is the same. The low predictive power of the variables examined here suggests that actuarial methods are of limited value in predicting offending in this group.

Less syntactically complex speech in patients with schizophrenia has been thought to represent a premorbid dysfunction, of possible prognostic value and indicative of a neurodevelopmental origin for schizophrenia.

Narratives written at age 11 by children who then developed psychiatric disorders in adult life (using PSE CATEGO diagnoses), especially schizophrenia, were compared with matched controls on syntactic complexity syntactic maturity, grammatical deviance and spelling ability.

Children who later developed either schizophrenia, affective psychosis or a neurotic type of disorder in adulthood did not differ from normal controls on any of the measures of syntactic production, grammatical errors or spelling.

it is probable that previous reports of reduced syntactic complexity in schizophrenic speech are a consequence of being in a psychotic state and do not represent a premorbid deficit.

The purpose of this paper is to review the association between genetic syndromes and self-injurious behaviour.

The information available from the literature on the subject of self-injurious behaviours and genetic syndromes was collated and presented with a critical appraisal.

Self-injurious behaviours are associated with some genetic syndromes. However, the causal relationship between the genetic syndromes and the self-injurious behaviour remains far from clear.

Although self-injurious behaviour has been shown to be the part of a broader phenotype in many genetic disorders, the specificity and sensitivity of these behaviours in this context remain unclear.

We reviewed evidence from prospective studies to test whether individuals can develop amnesia for traumatic experiences, a process variously termed ‘repression’, dissociative amnesia’ or ‘psychogenic amnesia’.

Using specified criteria, we selected and analysed studies which prospectively assessed memory in victims of documented traumatic experiences.

In studies in which people were asked directly about a past traumatic experience, they consistently reported memories. Non-reporting occurred only in studies where subjects were not asked directly about the experience. This latter design leaves open the well-documented possibility that subjects simply did not disclose events that they actually remembered. Some prospective studies were also limited by incomplete documentation of trauma and failure to rule out other more ordinary causes of amnesia.

Prospective data as yet fail to demonstrate that individuals can develop dissociative amnesia for traumatic events.

Many sedative and antipsychotic agents have been used in the management of severe self-injury associated with learning disabilities. Their efficacy has been questioned. Recent research has identified some biological abnormalities associated with severe self-injury and allowed a more rational selection of treatment.

Review of published literature, including trials, previous reviews and case reports.

There is evidence for the efficacy of opiate antagonists in the management of severe self-injury, and recent research has identified potential methods of predicting treatment response. Dopamine D1 antagonists and some agents affecting serotonin turnover may also be of benefit.

More rational psychopharmacological treatments for severe self-injurious behaviour may become available. Such treatments are difficult to evaluate for methodological and ethical reasons. They usually involve the clinical use of compounds for unlicensed indications, rather than trials of agents developed specifically to treat severe self-injurious behaviour. Combining psychopharmacological and psychological interventions may provide additional benefits.

A relationship exists between mental disorder and offending behaviours but the nature and extent of the association remains in doubt.

Those convicted in the higher courts of Victoria between 1993 and 1995 had their pyschiatric history explored by case linkage to a register listing virtually all contacts with the public psychiatric services.

Prior psychiatric contact was found in 25% of offenders, but the personality disorder and substance misuse accounted for much of this relationship. Schizophrenia and affective disorders were also over-represented, particularly those with coexisting substance misuse.

The increased offending in schizophrenia and affective illness is modest and may often be mediated by coexisting substance misuse. The risk of a serious crime being committed by someone with a major mental illness is small and does not justify subjecting them, as a group, to either increased institutional containment or greater coercion.

In recent years, studies of the risk of recurrence in affective disorder in relation to the number of prior episodes have given contradictory results.

Survival analysis was used to calculate the rate of recurrence after successive episodes in a case register study including all hospital admissions with primary affective disorder in Denmark during 1971–1993. A total of 20 350 first-admission patients were discharged with a diagnosis of affective disorder, depressive or manic/cyclic type.

The rate of recurrence increased with the number of previous episodes in both unipolar and bipolar disorder. Initially, the two types of disorders followed markedly different courses, but later in the course of the illness the rate of recurrence was the same for the two disorders.

The course of severe unipolar and bipolar disorder seems to be progressive in nature despite the effect of treatment.

‘Cloze procedure assesses the predictability of text by deleting words at set intervals and having a panel of raters fill the blanks. Two refinements to the procedure are described: ‘modified Cloze and ’ ‘reverse Cloze’, the latter examining the subject's ability to interpret a partial transcript.

Samples of speech were obtained from patients with schizophrenia, manic-depression and orthopaedic disorders using a standard prompt, and the output analysed using modified Cloze. In addition, subjects completed a reverse Cloze passage.

Both modified Cloze and reverse Cloze discriminated the performance of patient groups, with patients with schizophrenia performing worst.

These techniques extend earlier findings suggesting reduced predictability in psychotic speech, particularly for patients with schizophrenia. The reverse Cloze procedure suggests a ‘mirror-image’ deficit and is a potential objective index of psychopathology that is much simpler to apply than traditional Cloze.