“Every one of the twenty-eight bones of the human skull has been inherited in an unbroken succession from the air-breathing fishes of the pre-Devonian seas.” (Gregory, 1967)

Personality disorders meeting DSM or ICD criteria represent the severe end of the broad spectrum of personality configurations involving maladaptive traits. The literature regarding long-term outcome of personality disorders is sparse. Most attention is devoted to formerly institutionalised patients with borderline, antisocial, or schizotypal disorders. Borderline patients at 10–25-year follow-up have a wide range of outcomes, from clinical recovery (50–60%) to suicide (3–9%). Certain factors (e.g. artistic talent) conduce to higher recovery rates, others (e.g. parental cruelty) to lower rates. Schizoid and schizotypal patients tend to remain isolated, and to lead marginal lives. The long-term outcome in antisocial persons is bleak if psychopathic traits are prominent. Personality traits and their corresponding disorders are egosyntonic, harden into habit, and are both slow to change and hard to modify. There is no one treatment of choice. Psychoanalysis and related methods work best within the anxious/inhibited group; cognitive/behavioural techniques are well suited to the disorders requiring limit setting and the amelioration of maladaptive habits.

Studies which examine patients with and without dementia during life and then examine brain tissue after death are extremely difficult to conduct. There are now several such studies published, representing a major contribution to the understanding of the pathologies of the dementias. These studies were not designed to represent population samples and, from an epidemiological viewpoint, they are flawed because none are population-based and none represent the full range of function observed during life. It is therefore important to examine the available studies for their contributions and biases.

More than 100 years after Freud's original endorsement of the drug, the use of cocaine is a problem for both users and for society, which struggles to organise effective responses to the epidemic of the last decade. During the 1980s the rapid spread of smokeable cocaine (including ‘crack’) was seen in the Americas (particularly the US). The initial simple predictions of an identical European epidemic were mistaken. The available data on the extent of cocaine use and of cocaine problems in the UK are examined. New forms of cocaine have been developed by black-market entrepreneurs (‘freebase’ and ‘crack’), and new technologies have emerged for their use; with these new technologies have come new effects and new problems. The general psychiatrist now needs a knowledge of directly and indirectly related psychopathology which has an increasing relevance to the diagnosis and management of the younger patient.

This annotation is concerned with how soon and at what rate antidepressant effects become apparent over a course of electroconvulsive therapy (ECT). The first question is of importance in the design and interpretation of biological studies of the mode of action of ECT. The second question is of practical interest to the treating psychiatrist when we ask how the speed of recovery is influenced by what the psychiatrist prescribes, that is, the number and frequency of treatments. These questions are little better answered now than 20 years ago. This may come as a surprise to many readers, who have been advised to use ECT when “seeking rapid improvement” in depressive disorders (ECT Sub-Committee of the Research Committee of the Royal College of Psychiatrists, 1989). This lack of progress is attributable to a dearth of appropriately designed ECT studies.

Deinstitutionalisation is at an advanced stage in the US, both in duration, and in reduction in state hospital beds. The new generation of chronically and severely mentally ill persons has posed the greatest problems. They no longer receive life-long hospital admission and thus permanent asylum from the demands of the world. Resistance to treatment and substance abuse are problems. Early proponents of deinstitutionalisation believed it would be cheaper, better, and give the mentally ill their freedom. In reality, good community care does not cost less. While a number of community programmes in the US have been impressive, they have served only a small proportion of the total population of severely mentally ill persons. More freedom has been of benefit for many, but has proved difficult for some patients. Some patients have been deinstitutionalised who cannot be effectively treated in the community. The homeless mentally ill epitomise all these problems.

I propose that psychiatry is an applied science and in addition something more. I believe the advances in its scientific content, over the last four decades, may have dazzled us into blindness, or at least made us inarticulate, about the dimension which does not fall within the boundaries of science. If that is true, the future of the subject is threatened by the neglect of one side of its foundations.

The title of this paper should not be taken to imply that the Mental Health Act tribunal system is not currently effective. There has been little serious criticism of the work of the tribunals, and they appear to have become accepted as a permanent aspect of the detention of patients. Some doctors appear to regard them as an irritation that distracts from the care of patients, and civil liberties pressure groups tend to question their real effectiveness. Careful, detailed studies have also tended to be critical, pointing out many defects that require attention. Peay (1989) has done some impressive research into the work of tribunals which must form the basis of any future reform. Cavidino (1989) has done a much wider study, but underpinned by a ‘theory’ which detracts from its value for tribunal members, and its treatment of tribunals is peripheral, and therefore superficial.

A historical review of Kahlbaum's Catatonia is presented. He attributed the condition to organic cerebral disease. It is now best considered as a neuropsychiatric syndrome due to a wide variety of organic disease processes, manifest in catelepsy in a setting of an abnormal mental state, most commonly an affective disorder. Chronic catatonic states were common sequelae of encephalitis lethargica; this disease has now disappeared in epidemic form with a resulting fall in the incidence of catatonia in psychiatric hospitals. Acute catatonia, due to medical and particularly pharmacogenic causes, continues to occur in current psychiatric practice.

In Great Britain 1–2 million people may be homeless. Most homeless people are men, but about 10–25% are women, of whom about half are accompanied by children. Significant mental illness is present in 30–50% of the homeless: functional psychoses predominate; acute distress and personality dysfunction are also prevalent. Co-morbidity of mental illness and substance abuse occurs in 20%, and physical morbidity rates exceed those of domiciled populations. The homeless mentally ill also have many social needs. Pathways to homelessness are complex; deinstitutionalisation may be only one possible cause of the increase in the number of homeless people. There is much recent research estimating the extent of mental illness and the characteristics of selected subgroups of accessible homeless people. The evaluation of potential service solutions has received less attention. This review outlines the research, highlights current views on the definition and classification of homeless populations, and offers some guidelines on avenues which need to be explored.

Psychiatry is becoming increasingly confident about defining the benefits to be expected from each treatment (World Health Organization, 1991). The World Health Organization has published a list of essential drug treatments, but neither it nor any national regulatory body has ever examined non-drug treatments. This article examines the utility of the psychotherapies as treatments for persons with psychiatric disorders, and within a health service, whether supported by private insurance or by public taxation. It is not about the utility of psychotherapy paid for by an individual, for what people do with their own money is their own business. However, when deciding how to apportion a limited health budget, one should choose treatments that are more effective, safer, and cheaper than competing alternatives. Precisely how effectiveness, safety, and cost efficiency should be traded off against each other is a moot point, but there is agreement that treatments that are ineffective, harmful, and costly should not be used.

Complex segregation analyses were performed on families ascertained through 40 unselected consecutive patients with Tourette's syndrome to examine the hypothesis that its transmission is consistent with genetic inheritance. Analyses were done using several diagnostic classifications. All results were consistent with an autosomal dominant gene with high penetrance. The penetrances ranged from 0.882 to 1.000 for males and 0.452 to 0.980 for females, depending upon the specific classification scheme incorporated into the analyses.

In July 1983 the Regional Medical Officer of the North East Thames Regional Health Authority (NETRHA) appeared on television to announce the closure of Claybury Hospital and much of Friern Hospital over a ten-year period.

When NETRHA announced its decision, the policy to be pursued was innovative because it involved psychiatric hospitals serving inner-city populations, and because there was apparently no intention to achieve its aim by decanting patients into other psychiatric hospitals, as had been done with the closures of St Wulstan's and Banstead Hospitals. Although the run-down of psychiatric hospitals had been occurring at a steady rate in the United States and in England and Wales since the early 1950s, there had been few attempts to evaluate the policy, and none had been in any sense comprehensive (this supplement, paper 7). Clinicians and research workers in the field of social psychiatry were well aware of the need for large-scale evaluative studies, since protagonists and opponents of the policy of deinstitutionalisation were locked in a polemical argument which was pursued with increasing stridency through lack of reliable information.

The introduction of clozapine to current psychiatric practice is considered against a background of potential problems of resource allocation posed by the development of a number of ‘budget-busting’ drugs. It would appear that clinicians may increasingly have to operate within a climate in which the rights of individual patients to expensive treatments will seem to be pitted against the abilities of their communities to afford such treatments. Both clinicians and pharmaceutical companies have roles in the development of such conflicts.

Until recently, it was considered that Down's syndrome precluded a diagnosis of mania, or gave rise to an atypical presentation. There have been seven case reports of mania in people with Down's syndrome and all these cases are reviewed. The clinical features of mania are noted to be similar to those previously described in individuals with learning disabilities due to other causes. However, all reported cases are male and none has a family history of affective disorder. In two of the seven men reported, the illness followed a rapid cycling pattern. Hypothyroidism and monoamine biochemistry in people with Down's syndrome are discussed in the context of these atypical features.

d-Fenfluramine is a 5-HT agonist which decreases food intake and excessive carbohydrate intake in humans. A placebo-controlled trial of d-fenfluramine (45 mg/day) was conducted in 43 patients with bulimia nervosa. The patients entered an eight-week trial of medication during which they also received cognitive-behavioural therapy. Treatment response was assessed using food diaries to record eating behaviour, and self-rating questionnaires to measure psychopathology. The drug trial, and a follow-up assessment after a further eight weeks, were completed by 39 patients. Abnormal eating behaviour and psychopathology improved significantly in both the d-fenfluramine and placebo groups during the treatment trial. The study failed to show that the addition of d-fenfluramine affords an advantage over brief psychotherapy alone. Although d-fenfluramine is effective in suppressing the overeating, excessive snacking, and excessive carbohydrate consumption which are frequently found in overweight or obese patients, this study suggests that the drug is not an effective treatment for bulimia nervosa.

The homeless mentally disordered defendant facing minor charges poses considerable problems regarding appropriate disposal. Psychiatric assessment may be required in order to facilitate the court's decision, but this is often available only after remand in custody. A psychiatric assessment service based at two inner-London magistrates' courts is described. Over 18 months, 201 defendants were referred. They were predominantly male, single, and of no fixed abode, suffering from serious psychiatric disorder; these defendants had often received previous in-patient treatment, frequently as detained patients. They typically were recidivists charged with minor offences. Following initial assessment, 25% were admitted to hospital, 50% were released, and 25% returned to custody. The Crown Prosecution Service discontinued 29% of cases. For those admitted directly to hospital, the mean (s.d.) time from arrest to hospital admission was 5.8 (6.8) days, significantly quicker than with prison-based assessments.

Empirical research concerning the relationship between life event stressors and schizophrenia is critically reviewed. In accordance with the view that patients suffering from schizophrenia are vulnerable to stress, there is evidence of a relationship between stressors and variation in severity of symptoms over time. There is less indication that schizophrenic patients have had higher levels of stressors than the general population or than patients suffering from other psychiatric disorders. These findings are consistent with vulnerability-stress models of the development of schizophrenia.