The pineal gland, Descartes' seat of the soul, was variously considered until recently as a somewhat mysterious vestigial organ, or simply a good neuroradiological marker. The former point of view arose partly out of ignorance and the curious mythical associations related to its function as a ‘third eye’ in some lower vertebrates. The latter is due to the calcification which is present in most adult human pineal glands.

Areas of need exist where people with a mental handicap experience problems greater than, or differing from, the rest of the population. For example, there is a greater than average incidence of psychiatric disorder in mentally handicapped adults (Heaton-Ward, 1977) and children (Rutter et al, 1970; Gath & Gumley, 1986). Also, their families experience greater psychological distress and require support in their own right (Dupont, 1986; Shulman, 1988).

Present drug treatments for the more common types of dementia are largely palliative or symptomatic, but the promise of drugs to prevent the development of dementia does not seem unrealistic. Neuropharmacological strategies that aim to improve behavioural or cognitive symptoms in dementia are subdivided into drugs that modify central cholinergic, serotonergic, dopaminergic, GABAnergic, and peptidergic transmission. There are no clear clinical guidelines for the management of demented patients who are also hypertensive. The early identification of patients with incipient dementia, the detection of slight but theoretically important beneficial effects, the optimum method of drug administration, more soundly based treatment of behavioural symptoms, and the evaluation of drug combinations are all identified as areas requiring further research.

“Health is much more difficult to deal with than disease.” D. W. Winnicott

I

In a talk given in 1945 to the sixth form of St Paul's School, Donald Winnicott described his experience, as a schoolboy, of discovering Darwin's Origin of Species:

Gastrointestinal permeability was assessed by means of absorption of 51Cr-labelled EDTA in 24 patients with schizophrenia (12 in relapse and 12 in remission). The results were compared with those for patients with coeliac disease and those for normal controls. Significant differences between the schizophrenic patients and the normal controls were not established. The results for the schizophrenic patients in remission were no different from those for the patients in relapse, and there was no evidence from the study of an effect on gastrointestinal permeability of either anticholinergic or antidepressant medication. It is concluded that schizophrenia is, at least in the majority of cases, unrelated to coeliac disease.

In a prospective, longitudinal study of high-risk offspring of schizophrenic mothers, of several dimensions of pre-morbid behaviour ‘peculiarity’ predicted subsequent schizophrenia or schizotypy. Peculiarity/eccentricity may represent a subtle marker of the schizophrenic genotype. ‘Pre-schizophrenics', as compared with ‘pre-schizotypes', were characterised by affective dyscontrol, reflected in less introverted and more disturbed behaviour.

The two-syndrome concept of schizophrenia was investigated in a sample of 70 Nigerian schizophrenic patients. The positive and negative syndromes were studied in relation to demographic, historical, neurological and psychometric measures. The negative syndrome was associated with cognitive impairment, behavioural deterioration and left eye dominance, and also with poor pre-morbid educational achievement and longer length of current stay in hospital. The positive syndrome was unrelated to any of the independent variables. The two syndromes were not significantly related, supporting the view that they represent relatively independent dimensions of pathology. This provides further support for the validity of the Type I–Type II subtyping of schizophrenia in populations of patients from different cultural backgrounds, and suggests that the negative syndrome is related to the presence of neurodevelopmental deficits that possibly antedate the schizophrenic illness.

Psychotropic drug use was investigated using a two-stage survey of a random sample of persons aged 17 and over from a rural Spanish community. It was found that 6.9%, 11.8% and 25.1% of the population were consuming psychotropic, analgesic and somatic medicines respectively. Women presented a higher rate of psychotropic use than men (prevalence for women 10.7%, for men 2.6%). This female predominance was found to be significantly related to sociodemographic and medical factors. Psychotropic use was also associated with the physical health of the respondent. The coexistence of physical and mental illness generated an increase of consumption, whereas the absence of both types of illness was associated with a very low rate. The rates for physical and for mental illness alone were intermediate and were almost equal.

The total population of 15-year-olds in Göteborg, Sweden, were screened in 1985 for anorexia nervosa using brief questionnaires, growth charts and individual school nurse reports. An accumulated frequency of anorexia of 0.84% for girls up to and including 15 years of age was obtained, with 85% of the cases fulfilling DSM–III–R criteria. Boys were affected just over one-tenth as often as girls. The frequency of anorexia nervosa appeared to be much higher in private than in comprehensive schools. The peak age of onset seemed to be 14 years.

Data from a cross-sectional community survey of 2852 children were used to provide estimates of the prevalence of a ‘DSM–III-like’ major depressive syndrome in children aged 6 to 16. The severity of symptoms required to define a ‘case’ was varied to generate three levels of diagnostic certainty (DC). The overall estimates of prevalence made with high DC were 0.6% for pre-adolescents and 1.8% for adolescents. Corresponding rates determined with medium DC were 2.7% and 7.8%, whereas the figures for low DC were 17.5% and 43.9%. Utilisation of mental health and social services, comorbidity (combined disorders), poor school performance, problems in getting along with others and need for professional help all increased as diagnostic certainty increased. There was wide disagreement in data supplied by the different groups of respondents, i.e. parents, teachers and adolescents.

This paper reports a test of the hypothesis that winter birth is a risk factor for childhood psychosis. All psychotic children (n = 208) admitted to a day-treatment facility in Paris from 1960 through to 1986 were compared with 1040 controls matched by sex and year of birth. Risk ratio estimates were computed for each month, and a significant increase was observed for boys born in December. This association was stronger in some years than in others. The fact that there were no excesses in contiguous months detracts from the persuasiveness of this association.

Variation in quarter of birth was examined in patients with a clinical diagnosis of AD. There was a significant excess of first-quarter births among AD patients as compared with the expected birth rates derived from an age-matched census sample. This finding was due entirely to the significant excess of first-quarter births in AD patients without a family history of dementia. No seasonal variation was found in the birth dates of other clinical groups.

We evaluated the dexamethasone suppression test (DST) as a predictor of response to drugs and placebo in 105 patients, in a large double-blind placebo-controlled out-patient trial to determine the efficacy of paroxetine HCI, a selective serotonin reuptake inhibitor, compared with that of imipramine HCI and placebo. The presence of a positive or negative DST did not predict response to either paroxetine or imipramine. However, a positive DST predicted a poorer response to placebo: only 3 out of 18 patients who showed DST non-suppression responded to placebo, as opposed to 11 out of 21 who exhibited DST suppression (P<0.05). A positive DST was associated with a 61% response to drugs and a 16% response to placebo. This finding suggests that the presence of a positive DST implies the need for active somatic treatment.

Elderly patients with early-onset and late-onset depressive illness presenting to psychiatrists for treatment were compared for social, demographic, and clinical measures. For most factors measured no statistically significant differences were found. In the early-onset cases, patients were significantly more severely depressed. There was some evidence for the hypotheses that family history is less important and biological factors more important in late-onset depression. It is suggested that the latter hypothesis should be tested by a range of the newer neuroanatomical and neurophysiological laboratory investigations. The findings indicate that neuroticism is an important underlying factor in both early-onset and late-onset depression in the elderly.

Platelet MAO activity and platelet serotonin uptake were determined in 20 agoraphobic and 16 neurotic depressive out-patients, and 19 healthy volunteers. Agoraphobic patients were characterised by significantly higher mean values of platelet MAO activity compared with the other two groups, while neurotic depressive patients exhibited significantly higher maximum platelet serotonin uptake velocity. These findings are compatible with an abnormality in the uptake and metabolism of serotonin.

Of a random sample of new attenders at a dermatology out-patient clinic, 40% were classified as suffering from a psychiatric disorder. There was no correlation between psychiatric morbidity and the severity or site of skin disease. Self-report measures of the behavioural impact of skin disease and attitudes to appearance were related to psychological morbidity. Except in subjects without visible skin pathology (5%) there was no evidence that psychiatric illness was an aetiological factor in the development of skin disease. Self-report measures were used to distinguish between those patients in whom psychiatric morbidity was closely related to skin disease (75%), and those in whom it may be coincidental (20%). Psychological care for the former group is most appropriately provided by physicians, who should be encouraged to improve their detection and management of psychiatric morbidity.

Of five patients with pervasive developmental disorders (PDDs), four developed psychotic illnesses in adult life. The other was treated with antipsychotic medication for many years following a mistaken diagnosis of schizophrenia.

Before a drug trial, researchers reasonably plan that participants will remain ignorant of which drug each patient is taking, reflected in the use of allegedly identical preparations. However, only rarely is this plan subjected to systematic scrutiny after the event, and our point of view is that this is unsatisfactory.

“A study was conducted to investigate a novel approach to the prophylaxis of schizophrenic relapse. The treatment strategy comprised brief intermittent courses of neuroleptic agents begun as soon as non-psychotic symptoms believed to be early signs of relapse appeared. Fifty four stable, remitted outpatients meeting the American Psychiatric Association's DSM–III criteria for schizophrenia were randomised double blind to receive brief intermittent treatment with either active or placebo depot neuroleptic injections. Only three patients given placebo injections and two controls were admitted to hospital during one year of follow up. Eight (30%) of the patients given placebo injections and only 2 (7%) of the controls, however, had a recurrence of schizophrenic symptoms. Patients given placebo injections experienced fewer extrapyramidal side effects and showed a trend towards a reduction in tardive dyskinesia. Dysphoric and neurotic symptoms were identified before eight out of 11 relapses, and these symptoms were more frequent in patients given placebo depot injections. These results suggest a viable but not necessarily better alternative to continuous oral or depot treatment for less ill, chronic, stabilised schizophrenics based on the early treatment of putative prodromal symptoms of relapse.”

The differential diagnosis of an athetoid arm movement in a 54-year-old lady with a psychiatric history of affective disorder was discussed. Further investigations after the conference yielded a firm diagnosis that unified both physical and mental symptoms.