Since 1977 a literature has grown describing examples of factitious illness by proxy (FIP).

The literature in English was searched using MEDLINE and supplemented by a manual search. Extracted data focused on terminology of a spectrum of behaviours, clinical features and psychopathology of perpetrators.

There has been difficulty with the use of terminology and classification of psychiatric disorders.

The spectrum of FIP is wide. Suggestions are made for the use of terminology and classification when FIP is identified.

A short self-report questionnaire was developed to assess dependence on benzodiazepines (BZDs), the Benzodiazepine Dependence Questionnaire (BDEPQ). The BDEPQ is the first scale to assess dependence on BZDs comprehensively, as all existing scales focus exclusively on withdrawal symptoms.

To evaluate its internal consistency and construct validity, 302 regular BZD users were recruited from media advertisements and assessed on a number of measures. The BDEPQ was compared with measures of depression, anxiety, sleep quality, BZD withdrawal symptoms and neuroticism to assess its construct validity. A 3–4 month follow-up was conducted to assess the ability of the BDEPQ to predict changes in BZD consumption and future BZD withdrawal.

The BDEPQ was found to have high internal consistency and to be relatively stable over the follow-up period. Three subscales were identified, each with good internal consistency and temporal stability. The BDEPQ was able to predict the severity of withdrawal symptoms.

The BDEPQ was found to be a reliable and valid self-report instrument for the assessment of BZD dependence in samples approximating the general population of people using BZDs.

Previous work suggests neurological disease commonly supervenes in cases of conversion disorder but has not identified clear predisposing factors. Patients' subsequent use of services has been neglected.

Clinical outcomes for 73 patients investigated for pseudoneurological symptoms at a neurological hospital 10 years earlier were compared with findings on presentation. Fifty-six patients complied with a structured interview concerning use of services.

Thirty patients had no relief from their original symptom at follow-up. They had been older, with more chronic symptoms, and different auxiliary psychiatric diagnoses. In 11 patients a clear neurological diagnosis was subsequently made for the original symptom. Provisional neurological diagnoses at presentation had been disproportionately common among these 11. Small numbers of patients with poor outcomes made most use of hospital and community services. High attenders met screening criteria for somatisation disorder at follow-up.

The prognosis for chronic symptoms remains poor, but subsequent rediagnosis of neurological disease is less frequent than commonly supposed. Somatisation disorder may develop if hospital contact does not lead to diagnosis of another disease.

The clinical and social outcomes were evaluated of “difficult to place” (DTP) patients discharged from hospital to alternative facilities.

In the course of a reprovision programme for a psychiatric hospital, 72 long-stay patients were considered to be too problematic to live within the usual range of community placements. Their clinical and social state was assessed shortly before the hospital closed. Severe, persistent behavioural problems were recorded for each subject at baseline. One year after being relocated, patients were reassessed.

Clinical and social measures were stable over time. The profile of severe behavioural problems changed over time, with one-third of the total problems subsiding and a similar number of new problems emerging. There was a significant reduction in physical aggression. One of the settings provided an environment as free of restrictions as the usual community homes.

The most difficult patients to reprovide for can be contained in a relatively non-restrictive care environment. There is some indication that aggressive behaviour can improve, raising the possibility that some DTP patients can move on to the usual community homes.

There is increasing awareness of the importance of psychopathological and behavioural changes in dementia and a need for an instrument to measure these features which achieves an appropriate compromise between brevity and breadth. We describe a newly developed 59-item instrument: the MOUSEPAD.

Reliability, sensitivity and validity were examined with 30 carers, each of whom was interviewed four times over six weeks.

For different symptom groups, kappa ranged from 0.43 to 0.93 for test–retest reliability, from 0.56 to 1.0 for inter-rater reliability, and from 0.43 to 0.67 for the validation study.

The scale may be useful as an outcome measure in drug trials, for correlating psychopathological and behavioural changes with post-mortem findings, and in epidemiological surveys.

The paper describes the development of an index of the relative need for psychiatric services for the purposes of distributing NHS funds in England.

The study is based on an empirical analysis of all psychiatric in-patient completed episodes in England in 1991/92. Any index of need should be independent of the effect of variations in health care supply on the use of psychiatric services. In order to disentangle the influences of supply from social and clinical determinants of utilisation, two stage least squares regression and multilevel modelling techniques were used.

The outcome was an index comprising six health and socio-economic variables. This is now being used by the NHS Executive to distribute about £2.2 billion of annual NHS expenditure for psychiatric services between English health authorities.

It is shown that the index is much more sensitive to needs and therefore more redistributive than the previous index of need used in the NHS.

It has been reported that real ECT is more effective than simulated treatment among depressed patients with delusions and/or retardation, and that ECT is not effective among depressed patients who lack these features.

In two randomised, double-blind studies, 143 patients with major depression were subtyped regarding psychosis, retardation and agitation. In both studies, low dosage, right unilateral ECT was ineffective compared with other forms of ECT. This report examined whether the depressive subtypes differed in clinical response to the ineffective and effective forms of ECT.

The therapeutic advantage of effective forms of ECT was similar across the depression subtypes. Patients who lacked both psychosis and retardation showed this pattern.

The findings cast doubt on the utility of these depression subtypes in predicting ECT response. ECT is a viable treatment option for patients with major depression regardless of the presence or absence of psychosis, retardation and/or agitation.

Failure to control impulsive behaviour has been postulated as an underlying mechanism common to substance use disorder, sociopathy and to a substantial subgroup of women with bulimia nervosa.

Three hundred and one women recruited to a general population study were selected either at random or because they had lifetime substance use disorder, affective disorder or symptoms of bulimia. A subsequent interview determined the existence of problems with impulsivity. Behaviour that is an integral part of a DSM–III axis 1 disorder was excluded from the impulsivity measure.

Similar rates of impulsivity were found in all three of these types of disorder, and this was little different from the rate found in the women selected randomly from the general population. However, among those with comorbid disorder there was more impulsivity, and the more comorbid disorders found, the higher the proportion with problems of impulsivity.

Because those in treatment facilities are more likely to have other comorbid disorders (Berkson's bias), findings derived from observations of women with bulimia who are in treatment may be compromised by selection bias and may have limited applicability to those with the disorder who are not in treatment.

Concerns have been expressed that staff burnout may make community mental health care difficult to sustain. This study compares stress and job satisfaction between community and hospital-based staff.

The GHQ-12, the Maslach Burnout Inventory and a job satisfaction measure were used to study 160 Inner London staff.

Community staff scored significantly higher on the GHQ-12 and the ‘emotional exhaustion’ component of the Maslach Burnout Inventory than hospital-based in-patient, day care or out-patient staff. Satisfaction did not vary significantly between settings.

These results may be explained in several ways. Community work may be inherently more stressful than hospital work, or may currently be stressful because of inadequate resources, training or supervision. The results may also reflect widespread recent changes in community services or the specific effects of working in a deprived area.

This paper considers the extent to which vulnerability to the outcome of major affective disorder is conferred through personality deviance. Results are based upon a 12 year longitudinal follow-up study of 80 patients with a primary depressive disorder, originally selected from a consecutive series seeking care at a hospital in Scotland.

The study included detailed clinical course assessments in association with the formal application of diagnostic criteria. Assessments on recovery from the index episode included measures of self-confidence and of neuroticism. Experience of selected severe loss events over the study period was also determined.

Limited self-confidence was strongly related, unlike neuroticism, to the subsequent first recurrence of affective disorder. Relationships between psychosocial, clinical and demographic factors and long-term outcome revealed psychosocial factors, in particular neuroticism and a lack of self-confidence, to have the greatest prognostic significance.

These results reveal the heightened risk over the long-term of a poor outcome for depressive disorder consequent upon measures of personality deviance and of exposure to adversity. While giving only limited support to narrowly defined psychosocial models of depression, they clarify the risk gradients involved and through this may provide a firmer basis than hitherto for relapse prevention.

We examined the functional and structural cerebral changes in chronic alcoholics, analysing their association with personality features and alcohol drinking habits.

Forty patients with alcohol dependency, including 15 with antisocial personality disorder (ASP) as defined in DSM–III–R and 10 age and sex matched healthy controls were studied after termination of withdrawal symptoms, using high resolution single photon emission tomography (SPECT), cranial computerised tomography (CT) and brainstem auditory evoked potentials (BAEP).

We found significant reductions in regional cerebral blood flow (rCBF) measurements of alcoholic patients. Low flow in frontal regions encountered in 67.5% of the patients was associated with the duration of alcohol consumption, while no such relation existed with the amount of daily intake. Patients with ASP exhibited more marked frontal hypoperfusion. Significant brain atrophy detected by CT was present in 40% of the patients and did not correlate with frontal hypoperfusion.

Patients with ASP are more sensitive to toxic effects of alcohol. Alternatively chronic alcoholism leads to frontal lobe dysfunction recognised as ASP in the clinical setting.

There is evidence that people with a history of sexual abuse may have an increased risk of developing alcohol and drug problems.

A self-completion sexual abuse questionnaire was designed and administered to a sample of attenders at three London alcohol services. Drinking behaviour was assessed using the Severity of Alcohol Dependence Questionnaire and the Alcohol Problems Questionnaire, and additional data were derived from case notes.

Fifty-four per cent of women and 24% of men identified themselves as victims of sexual abuse or assault. For the majority this had started before the age of 16 and involved non-relatives. Subjects with a history of sexual abuse were younger, reached drinking milestones earlier, were more likely to have a family history of alcohol misuse and had more alcohol-related problems than non-abused subjects. Sexual abuse, age and alcohol dependence predicted level of problems in a regression analysis.

The high rates of sexual abuse and its association with indications of increased morbidity suggest it is an important issue for the management of alcohol problems. More use could be made of self-completion questionnaires for the investigation of sexual abuse.

Little is known about the long-term outcome of schizophrenia that has its onset during childhood and early adolescence (early-onset schizophrenia, or EO-SZ). Whether or not EO-SZ is an aetiologically separate form of schizophrenia (SZ) is unresolved.

The study was a 14.8-year follow-up, using methods such as systematic sampling, evaluation of possible non-respondent bias, consensus best-estimate diagnoses (DSM–III–R) made independently in childhood and adulthood, measures of positive and negative dimensions, of non-psychotic behaviour disturbances (NPBD) and of developmental problems before the appearance of SZ.

There was high stability of EO-SZ (n=40) diagnoses (mean onset at 14.0 years) until adulthood (mean age at follow-up 28.8 years) but a lower stability of positive and negative schizophrenic dimensions. There was a poor outcome of EO-SZ, a strong over-representation of males but few gender differences, and no effect of age of onset on clinical features and outcome.

EO-SZ taken as a whole shows no qualitative differences to adult-onset SZ. However, a distinction through the onset of preschizophrenic developmental problems or NPBD might be a way to investigate heterogeneity within EO-SZ.

The aim of this study was to verify the presence and stability across life of the positive/negative distinction in early-onset schizophrenia (EO-SZ) through a longitudinal factor analysis of the schizophrenic dimensions, and to identify the factors predicting several indices of long-term outcome for EO-SZ.

Forty children consecutively referred for DSM–III–R schizophrenia (SZ) in a specific catchment area comprised the sample.

Across a 14.8-year follow-up, longitudinal factor analysis identified two separate factors corresponding to the positive and negative symptom dimensions. We also observed that: the GAS rated over the last three years of adult illness and the severity of negative symptoms during the stabilised interepisode intervals in adulthood were the indices of adult outcome that were most easily predicted; and the best childhood predictors of adult outcome were premorbid functioning and severity of positive and negative symptoms during acute episodes.

The presence of premorbid non-psychotic behaviour disturbances (NPBD) and premorbid developmental problems was not related to severity of outcome, in contrast to the former variables.