Torture, with its personal, cultural, political and psychosocial effects, is presented as a complex trauma. The efficacy of different treatment modalities for those survivors who need assistance is examined critically.

International literature searches using MEDLINE and Psych-Info, books and relevant book chapters were examined.

One hundred and twenty-five articles were selected for analysis; 30 of the most relevant are discussed.

Discrete approaches to treatment have been developed, but many have yet to be evaluated critically. Common therapeutic elements are outlined. It is recommended that an integrated, flexible, client-centred approach utilising several techniques is most likely to achieve best results. Wider socio-political aspects should be taken into account, and treatment must be consistent with cultural expectations. Future directions for research are outlined and the role of primary prevention is stressed.

This study was performed in order to evaluate the short-term efficacy and safety of fixed risperidone doses compared to haloperidol.

In a multi-national, parallel-group, double-blind study, patients with chronic schizophrenia (DSM–III–R) were randomly assigned to risperidone 1, 4, 8, 12 or 16 mg or haloperidol 10 mg daily for 8 weeks. Efficacy was assessed by the Positive and Negative Syndrome Scale for schizophrenia (PANSS) and clinical global impression (CGI), and safety primarily by the Extrapyramidal Symptom Rating Scale (ESRS).

One thousand three hundred and sixty-two patients were evaluated. The optimum risperidone doses were 4 mg and 8 mg, with response rates of 63.4% (56.8%; 69.7%) and 65.8% (59.2%; 71.9%) respectively. Response rate in haloperidol-treated patients was 58.7% (52.0%; 65.3%); the 95% confidence intervals (CI) of the differences between risperidone 4 mg or 8 mg and haloperidol were (–4.3%; 13.7%) and (–1.9%; 16.0%) respectively. There were no significant differences in CGI scores at endpoint between risperidone 4 mg, 8 mg, 12 mg and 16 mg and haloperidol (3.0, 3.0, 3.2, 3.1 and 3.1 respectively); the 95% CI of the differences between risperidone 4 mg or 8 mg and haloperidol were (–0.4; 0.1) and (–0.3; 0.2) respectively. Mean shifts to the maximum total ESRS scores versus baseline (mean (confidence interval)) were significantly greater in haloperidol-treated patients (5.1 (4.0; 6.2)) than in the risperidone 1, 4, 8 and 12 mg groups (1.1 (0.3; 1.9); 1.8 (0.9; 2.7); 2.7 (1.8; 3.6) and 3.2 (2.3; 4.1) respectively (P< 0.05)).

Risperidone is an effective antipsychotic for the treatment of chronic schizophrenia; doses of 4 and 8 mg seem to be optimal and have a lower incidence of side-effects than haloperidol.

This exploratory study seeks to generate new hypotheses about the relationship between obstetric complications and schizophrenia.

The British Perinatal Mortality Survey represents 98% of all births during one week in March 1958 in Great Britain. Present State Examination (PSE), Catego diagnoses of narrowly defined schizophrenia (n = 49), broadly defined schizophrenia (n = 79), affective psychosis (n = 44) and neurosis (n = 93) were derived from case notes for all cohort members. The remainder of the cohort, surviving the perinatal period, acted as controls (n = 16 812). Variables in the British Perinatal Mortality Survey were grouped into five categories: the physique/lifestyle of the mother (including demographic characteristics), her obstetric history, the current pregnancy, the delivery and the condition of the baby.

There were 7/17 significant differences in maternal physique/lifestyle and obstetric history between the births of schizophrenics and controls, compared to 4/40 comparisons of somatic variables relating to pregnancy, birth and the condition of the baby. This compares with 4/17 and 7/40 for affective psychotics and a total of 4/57 differences for all categories of variables when neurotics were contrasted with controls.

The purported increased risk of obstetric complications in schizophrenics may result from the physique/lifestyle of their mothers.

Abnormal cerebral anatomical lateralisation has been reported in schizophrenia and may implicate anomalous neurodevelopment in the aetiology of this disease. A popular recent hypothesis has predicted that such disturbances in normal lateralisation should be especially apparent in the morphology of the temporal lobes.

A temporal cortical region lying in the plane of the Sylvian fissure – known as the planum temporale – exhibits pronounced leftward asymmetry in normal right-handed males. We compared lateralisation of the planum temporale in schizophrenic and control males using MRI surface-rendering morphometry of the supratemporal cortex.

Contrary to the lateralisation hypothesis, normal patterns of leftward planum asymmetry were detected in both the schizophrenic and control groups. Schizophrenics and controls also exhibited a predicted symmetry in the bilateral areas of Heschl's gyrus, a supratemporal cortical structure immediately anterior to the planum.

These data do not support the notion that neurodevelopmental mechanisms of cerebral asymmetry are abnormal in schizophrenia.

It has been suggested that the dimensions of cerebral ventricles are a risk factor for poor outcome in psychotic illness.

A cohort of 140 patients with functional psychoses of recent onset who had undergone CT scanning, were followed up for an average of 46 months and assessed on six dimensions of course and outcome of illness.

Left and right sylvian fissure volumes and, to a lesser extent, third ventricular volume predicted negative symptoms and unemployment over the course of follow-up, the latter association being mediated by poor cognitive functioning. There was a significant linear trend in risk over the distribution of sylvian fissure volumes in the cohort, and associations were especially evident in schizophrenic patients. No associations were found with global severity of illness, duration of hospital stay, homelessness, or affective symptoms.

These findings support the notion that dimensions of the cerebral ventricles are a continuous risk factor for some measures of outcome in the functional psychoses.

Social mobility among patients with schizophrenia or major affective disorder was compared with that among the general population.

Mobility was studied retrospectively from 1970 to 1987. Socio-economic status (SES) was defined by occupation as in the population census (upper white-collar, lower white-collar, blue-collar, entrepreneur, farmer, unemployed). All patients aged 30–60 years at discharge (2901 men and 3620 women) in 1987–88 in Finland were included in the study. The SES structure of the general population was used for comparisons.

Among patients with schizophrenia there was a constant downward drift, commonly to unemployment. This risk was higher among men than women. In the youngest age group a marked decline from the parents' social status was observed. Among patients with major affective disorder the distribution of SES in 1970 was similar to that of the general population. By 1987, a downward drift was again observed, mainly to unemployment regardless of the initial SES group. The number of patients in occupational categories were usually 30–50% lower than expected.

Schizophrenic patients had a high risk of social drop-out. Among patients with major affective disorder the downward drift was much less.

Apart from ageing, the factors associated with vulnerability to the emergence of tardive dyskinesia are poorly defined.

Risk factors associated with the presence of a chronic choreic or dystonic disorder were assessed in a cross-sectional comparison of anamnestic and clinical data in a homogeneous group of 64 young psychotic patients (under 40 years of age) on chronic low to moderate doses of neuroleptics.

Dyskinetic subjects presented more indirect indicators of occult brain damage, such as a perinatal event or traumatic brain injuries in infancy and early childhood; neurological examination showed more anomalies in dyskinetic patients than in non-dyskinetics, with a higher prevalence of facial release reflexes.

These data may support the hypothesis that occult acquired brain damage is important in the genesis of this ‘drug-induced’ disorder.

We describe the development and psychometric investigation of the Beliefs About Voices Questionnaire (BAVQ), a self-report measure of how people understand and respond to their voices. The measure is unique in being driven by and gathering data essential to a cognitive formulation of voices.

Sixty subjects with chronic hallucinatory voices took part.

Psychometric properties of the scales were established, including test-retest reliability (mean = 0.89), internal reliability (mean Cronbach's α = 0.85), and construct validity using factor analysis and the criterion group method.

The BAVQ was found to be easy to complete and the scale may aid clinical assessment of voices, not least because of the possible value of cognitive therapy as a treatment approach.

In a study of patients with presenile dementia of Alzheimer type (PDAT), we aimed to investigate functional dependency in relation to the time since diagnosis and place of residence. Use of community and support services and the time between diagnosis and entry to permanent residential care were also studied.

Interviews with 109 cases of PDAT (diagnosed before age 65) and their carers.

The need for assistance in activities of daily living (ADL) was progressive with time from diagnosis. Five years after diagnosis, 57% of patients remained at home, 20% of whom required some assistance in each of six areas of ADL. The need for assistance in each ADL category was significantly greater for cases in permanent residential care than for those at home. There were no significant differences between the Mini-Mental State Examination (MMSE) scores of patients at home and those of patients in permanent care. Incontinence and the relationship of the carer to the patient were the strongest predictors of permanent residential care. Respite care had been offered in 63% of cases; 71% of these offers had been accepted.

Patients with PDAT who have a living relative are cared for at home for a considerable period of time despite severe cognitive impairment and loss of independence measured by ADL. The reports of carers suggest there is scope for improvement in supportive services to meet this community need.

Most studies which showed an excess mortality in psychiatric patients have been conducted on hospitalised samples.

This was a case register study. All South Verona patients with an ICD diagnosis who had psychiatric contacts with specialist services in 1982–1991 were included. Mortality was studied in relation to sex, age, diagnosis, pattern of care and interval from registration. Standardised Mortality Rates (SMRs) and Poisson regression analysis were calculated.

The overall SMR was 1.63 (95% CI = 1.5–1.8), which is the lowest value reported so far. Mortality was higher among men (SMR = 2.24; 95% CI = 1.9–2.6), among patients who were admitted to hospital (SMR = 2.23; 95% CI = 1.9–2.6), among younger age groups (SMR = 8.82; 95% CI = 4.9–14.6) and in the first year after registration (SMR = 2.32; 95% CI = 1.8–2.9). Higher mortality was found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87; 95% CI = 3.0–4.9). The SMR for suicide was 17.41. Using a Poisson regression model, diagnosis, pattern of care and interval from registration were all found to be significantly associated with mortality. When all these variables were entered together in the model, each maintained its predictive role.

The overall mortality of psychiatric patients treated in a community-based system of care was higher than expected, but lower than the mortality reported in other psychiatric settings. The highest mortality risk was found in the first year after registration.

The study tested the hypothesis that subjects with Parkinson's disease (PD) have more autonomic complaints and more attenuation of autonomic reflexes than controls, and that both clusters of variables are related to the presence of anxiety and depression.

Thirty-two subjects and 32 healthy controls matched by age and sex were prospectively compared on psychiatric, cognitive and autonomic tests.

‘Autonomic’ symptoms: were more frequent in PD patients than in healthy controls; were not related to age or changes in autonomic reflexes; were significantly associated with depression and anxiety (medication was not relevant to the association); and did not correlate with motor symptoms.

The diagnosis of anxiety and depression in some PD subjects is likely to be a behavioural phenocopy caused by autonomic failure. This explains why antidepressant medication is often unhelpful in PD subjects diagnosed as depressed.

Chronic fatigue syndrome (CFS) is a poorly understood condition, apparently related to both psychiatric disturbance and infectious illness. Little progress has been made in identifying aetiology, owing to a lack of epidemiological studies using case-definition criteria.

A community postal survey of a random sample of over 1000 patients registered at a local health centre comprised a fatigue questionnaire and the 12-item General Health Questionnaire (GHQ).

Total fatigue scores were modestly higher in women than men. Fatigue was most frequently attributed to psychosocial factors. Fatigue and GHQ scores were strongly correlated. Two men and two women satisfied British criteria for CFS, a prevalence of 0.56% (95% CI 0.16–1.47%); three were probable psychiatric cases.

Previously reported sociodemographic associations of CFS may reflect medical referral patterns. A strong association exists with psychological morbidity, but relabelling CFS as a psychiatric disorder is not justified.

This study examines the hypothesis that more recently ill patients with chronic fatigue syndrome (CFS) might have different characteristics from more chronic patients in tertiary referral centres.

Sixty-four patients who fulfilled strict diagnostic criteria for CFS had detailed medical, viral, immunological and psychiatric assessment. Patients were advised to remain within their energy limits. Patient and doctor monitored progress using a scoring system.

Using the Schedule for Affective Disorders and Schizophrenia, patients were placed into four groups: group A (no psychiatric disorder, 35 patients), group B (psychiatric disorder before onset of CFS, 7 patients), group C (coincident psychiatric disorder and CFS, 11 patients), and group D (psychiatric disorder after onset of CFS, 11 patients). There were no viral or immunological differences between the groups. Patients in groups B, C and D had more severe illness than those in group A (P< 0.05), but patients in group A had more muscle pain (P< 0.05) than patients in group C. Counselling resulted in 52 patients becoming better; nine remained the same and three became worse.

A lower incidence of psychiatric disorder may characterise patients who are more recently ill, as may the type of associated emotional disorder and better outcome.

Contracting in psychiatric services from the NHS into prisons has been advocated to improve the care of the mentally disordered in custody. The Belmarsh Scheme is such a service.

A prospective study investigating the characteristics of a six-month cohort of remand prisoners requiring transfer to hospital and evaluating the service's effectiveness.

Fifty-three (4.3%; 95% CL 3.2% to 5.6%) of the 1229 new remands required transfer to hospital; all were accepted. The transfer group contained a higher proportion of black men (51%) than all other remands (30%) (difference 21%; 95% CL 8% to 35%, P = 0.002). Transfer times were lower than those reported for a neighbouring prison.

The Belmarsh Scheme secured in-patient psychiatric care rapidly for all those identified as needing it.

Studies of mental health problems of homeless people have used diagnosis as the sole measure of these problems. In this study, the feasibility and reliability of measuring social disablement in the psychiatric assessment of homeless people was investigated.

A random sample of 101 homeless men living in four long-stay hostels was assessed for their social disablement by the Social Behaviour Schedule (SBS). The prevalence of SBS problems in these men and the interobserver reliability were assessed.

The results show that the SBS is a reliable screening instrument which is relatively easy to use. The most frequent SBS problems were ‘Other problems’, ‘Hostility’ and ‘Depression’. Less than 10% of the hostel sample had disablement items similar to those of patients in long-stay wards.

The SBS is a useful and reliable tool in the psychiatric assessment of men in hostels for the homeless.

Some authors have argued that hostels for homeless people are increasingly taking over the role of psychiatric long-stay wards, and that this creates a problem. We set out to test this hypothesis.

The social disablement of a random sample of 101 homeless men, described in Part 1, was compared with that of a sample of 66 psychiatric patients from a long-stay ward.

The study sample rated significantly lower for social disablement than the long-stay ward sample. Thirteen subjects of the hostel sample had psychotic social behaviour problems. These had no history of being long-stay psychiatric patients.

The hostel sample differ significantly in their social disablement from the chronic psychiatric patients. There is a small proportion of severely disturbed residents who might have been over-represented in previous non-random surveys.