This issue contains one review article on multi-symptom conditions in Gulf War veterans with sets of papers examining various aspects of psychosis, depression, pervasive developmental disorders, and four individual articles examining a variety of topics.

Background. Gulf War veterans have a number of health complaints. We therefore decided to carry out a systematic review to identify and summarize the findings from studies that have assessed multi-symptom conditions in Gulf War veterans and in an unexposed comparison group.

Method. Studies published between January 1990 and May 2004 were identified by searching a large number of electronic databases. Reference lists and websites were also searched and key researchers were contacted. Studies were included if they compared the prevalence of chronic fatigue syndrome, multiple chemical sensitivity, CDC-defined chronic multi-symptom illness, fibromyalgia, or symptoms of either fatigue or numbness and tingling in Gulf War veterans and non-Gulf veterans. A total of 2401 abstracts were independently reviewed by two authors.

Results. Twenty-three publications fulfilled the inclusion criteria. Gulf deployment was most strongly associated with chronic fatigue syndrome (OR 3·8, 95% CI 2·2–6·7). Gulf War veterans were also approximately three and a half times more likely than non-Gulf veterans to report multiple chemical sensitivity or chronic multi-symptom illness as defined by CDC. The methodological quality of the studies varied but the later and larger studies were of a high methodological standard with robust sampling strategies, adequate response rates and good adjustment for confounders.

Conclusions. The results support the hypothesis that deployment to the Gulf War is associated with greater reporting of multi-symptom conditions.

Background. Traditional instruments that measure self-esteem may not relate directly to the schema construct as outlined in recent cognitive models. The Brief Core Schema Scales (BCSS) aim to provide a theoretically coherent self-report assessment of schemata concerning self and others in psychosis. The scales assess four dimensions of self and other evaluation: negative-self, positive-self, negative-other, positive-other.

Method. We analysed the psychometric properties of the BCSS using a sample of 754 students recruited by email and 252 people with psychosis recruited as part of a trial of cognitive therapy. We report the internal consistency, stability and the factor structure of the scale, and the association of the BCSS with measures of self-esteem and with symptoms of paranoia and grandiosity.

Results. The BCSS have good psychometric properties and have more independence from mood than the Rosenberg Self-Esteem Schedule. People with chronic psychosis reported extreme negative evaluations of both self and others on these scales, but their levels of self-esteem and positive evaluations of self and others were similar to the student sample.

Conclusions. Extreme negative evaluations of self and others appear to be characteristic of the appraisals of people with chronic psychosis, and are associated with symptoms of grandiosity and paranoia in the non-clinical population. The BCSS may provide a more useful measure of schemata about self and others than traditional measures of self-esteem.

Background. Assessing illness perceptions has been useful in a range of medical disorders. This study of people with a recent relapse of their psychosis examines the relationship between illness perception, their emotional responses and their attitudes to medication.

Method. One hundred patients diagnosed with a non-affective psychotic disorder were assessed within 3 months of relapse. Measures included insight, self-reported illness perceptions, medication adherence, depression, self-esteem and anxiety.

Results. Illness perceptions about psychosis explained 46, 36 and 34% of the variance in depression, anxiety and self-esteem respectively. However, self-reported medication adherence was more strongly associated with a measure of insight.

Conclusions. Negative illness perceptions in psychosis are clearly related to depression, anxiety and self-esteem. These in turn have been linked to symptom maintenance and recurrence. Clinical interventions that foster appraisals of recovery rather than of chronicity and severity may therefore improve emotional well-being in people with psychosis. It might be better to address adherence to medication through direct attempts at helping them understand their need for treatment.

Background. The aims of the study were to investigate whether (i) patients with lifetime presence of non-affective psychosis show an external-personal attribution bias for negative events, (ii) this attribution style can also be detected in first-degree relatives of patients with psychosis and subjects with subclinical psychotic experiences, and (iii) this attribution style is related to the presence of psychotic symptoms, in particular delusions.

Method. Participants were 23 patients with lifetime presence of non-affective psychosis, a high- risk group of 36 first-degree relatives of patients with non-affective psychosis, a high-risk group of 31 subjects with subclinical psychotic experiences and 46 normal controls. Attribution style was measured by the Internal, Personal and Situational Attribution Questionnaire. Positive symptoms were assessed with the Present State Examination (PSE) and the Scale for the Assessment of Positive Symptoms (SAPS).

Results. Relative to the controls, an externalizing bias was apparent in the patient group (β=0·20, p=0·03) but not in the two high-risk groups. There was a dose–response association between externalizing bias and the delusions subscale of the PSE (relative to lowest level: highest level of delusions: β=0·53, p=0·04; intermediate levels of delusions: β=0·23, p=0·35). No significant differences were found in personalizing bias between the four groups.

Conclusions. Patients with psychosis tend to use an externalizing bias in their explanations of negative social events, and this bias is associated with the presence of positive psychotic symptoms, in particular delusions. A deviant attribution style is not part of the vulnerability to psychosis.

Background. Adverse life events and social support may influence the outcome of major depressive disorder (MDD). We hypothesized that outcome would depend on the level of depressive symptoms present at the outset, with those in partial remission being particularly vulnerable.

Method. In the Vantaa Depression Study (VDS), patients with DSM-IV MDD were interviewed at baseline, and at 6 and 18 months. Life events were investigated with the Interview for Recent Life Events (IRLE) and social support with the Interview Measure of Social Relationships (IMSR) and the Perceived Social Support Scale – Revised (PSSS-R). The patients were divided into three subgroups at 6 months, those in full remission (n=68), partial remission (n=75) or major depressive episode (MDE) (n=50). The influence of social support and negative life events during the next 12 months on the level of depressive symptoms, measured by the Hamilton Rating Scale for Depression (HAMD), was investigated at endpoint.

Results. The severity of life events and perceived social support influenced the outcome of depression overall, even after adjusting for baseline level of depression and neuroticism. In the full remission subgroup, both severity of life events and subjective social support significantly predicted outcome. However, in the partial remission group, only the severity of events, and in the MDE group, the level of social support were significant predictors.

Conclusions. Adverse life events and/or poor perceived social support influence the medium-term outcome of all psychiatric patients with MDD. These factors appear to have the strongest predictive value in the subgroup of patients currently in full remission.

Background. Both generalized anxiety disorder (GAD) and stressful life events (SLEs) are established risk factors for major depressive disorder, but no studies exist that examine the interrelationship of their impact on depressive onsets. In this study, we sought to analyze the joint effects of prior history of GAD and recent SLEs on risk for major depressive episodes, comparing these in men and women.

Method. In a population-based sample of 8068 adult twins, Cox proportional hazard models were used to predict onsets of major depression from reported prior GAD and last-year SLEs rated on long-term contextual threat.

Results. For all levels of threat, prior GAD increases risk for depression, with a monotonic relationship between threat level and risk. While females without prior GAD consistently show higher depressive risk than males, this is no longer the case in subjects with prior GAD who have experienced SLEs. Rather, males appear to be more vulnerable to the depressogenic effects of both prior GAD and SLEs.

Conclusion. The effects of prior GAD and SLEs jointly increase the risk of depression in both sexes, but disproportionately so in males.

Background. We tested the hypothesis that depressive symptoms in healthy young adults would be associated with elevated levels of C-reactive proteins (CRP).

Method. We studied the association between depressive symptoms and CRP in 1201 young adults, as a part of the on-going population-based Cardiovascular Risk in Young Finns Study. Depressive symptoms were determined by responses to a revised version of Beck's Depression Inventory in 1992 and 2001. CRP and other known cardiac risk factors were measured in 2001.

Results. Higher depressive symptomatology in 1992 and in 2001 and their means score were related to higher CRP levels (B's range from 0·24 to 0·21, p<0·001). These relationships persisted after separate adjustments for various risk factors including sex, age, education, oral contraceptive use, dietary fat, physical activity, alcohol consumption, smoking status, LDL-cholesterol, HDL-cholesterol, systolic blood pressure and history of acute infectious disease. Adjustments for obesity and triglycerides levels, however, somewhat attenuated the relationship between depressive symptoms and CRP.

Conclusions. We concluded that higher levels of depressive symptoms are associated with higher levels of CRP, but this association may largely be attributable to obesity or triglycerides.

Background. Borderline personality disorder (BPD) is often co-morbid with major depression and may complicate its treatment. We were interested in differences in genetic and developmental risk factors between depressed patients with or without a co-morbid BPD.

Method. Out-patients with major depressive disorder were recruited for two treatment trials. Assessment of depressed patients included the assessment of personality disorders, developmental risk factors and DNA samples for genetic analyses.

Results. In each study there was a significant association between the 9-repeat allele of the dopamine transporter (DAT1) and BPD, with odds ratios (OR) >3 and p[les ]0·02. This association remained significant when developmental risk factors for BPD (childhood abuse and neglect and borderline temperament) were also included in the analyses. The OR was even larger in the depressed patients aged [ges ]35 years (OR 9·31, p=0·005).

Conclusion. This replicated association in depressed patients between the 9-repeat allele of DAT1 and BPD may provide clues to understanding the neurobiology of BPD. The finding that the association is larger in the older depressed patients, suggests that the 9-repeat allele may be associated with a poorer prognosis BPD, rather than a young adult limited variant of BPD.

Background. The relative contribution of psychosocial and clinical risk factors to suicide among Chinese populations is an important issue. In Hong Kong, this issue requires vigorous examination in light of a 50% increase in suicide rate between 1997 and 2003.

Method. Using a case-control psychological autopsy method, 150 suicide deceased were compared with 150 living controls matched by age and gender. Semi-structured interviews were conducted with the next-of-kin of the subjects. Data were collected on a wide range of potential risk and protective factors, including demographic, life event, clinical and psychological variables. The relative contribution of these factors towards suicide was examined in a multiple logistic regression model.

Results. Six factors were found to significantly and independently contribute to suicide: unemployment, indebtedness, being single, social support, psychiatric illness, and history of past attempts.

Conclusions. Both psychosocial and clinical factors are important in suicides in Hong Kong. They seem to have mediated suicide risk independently. In addition, socio-economic adversities seem to have played a relatively important role in the increasing suicide rate in Hong Kong.

Background. Autism is a neurodevelopmental disorder associated with slight increases in brain volume. There has been some suggestion that medial temporal lobe structures may be preferentially involved in this disorder, although results have not always been consistent. Here, we investigate amygdala and hippocampus volumes in medication-naive subjects with high-functioning autism.

Method. Whole-brain magnetic resonance imaging scans were acquired from 42 patients and 42 closely matched, healthy control subjects.

Results. Amygdala volume did not differ significantly between patients and controls. A significant increase in hippocampal volume was proportional to an increase in overall brain volume.

Conclusions. These results argue against preferential involvement of medial temporal lobe structures in autism, at least in high-functioning medication-naive individuals.

Background. Emotional Stroop tasks have shown attention biases of clinical populations towards stimuli related to their condition. Asperger Syndrome (AS) is a neuropsychiatric condition with social and communication deficits, repetitive behaviours and narrow interests. Social deficits are particularly striking, including difficulties in understanding others.

Method. We investigated colour-naming latencies of adults with and without AS to name colours of pictures containing angry facial expressions, neutral expressions or non-social objects. We tested three hypotheses: whether (1) controls show longer colour-naming latencies for angry versus neutral facial expressions with male actors, (2) people with AS show differential latencies across picture types, and (3) differential response latencies persist when photographs contain females.

Results. Controls had longer latencies to pictures of male faces with angry compared to neutral expressions. The AS group did not show longer latencies to angry versus neutral expressions in male faces, instead showing slower latencies to pictures containing any facial expression compared to objects. When pictures contained females, controls no longer showed longer latencies for angry versus neutral expressions. However, the AS group still showed longer latencies to all facial picture types, compared to objects, providing further evidence that faces produce interference effects for this clinical group.

Conclusions. The pictorial emotional Stroop paradigm reveals normal attention biases towards threatening emotional faces. The AS group showed Stroop interference effects to all facial stimuli regardless of expression or sex, suggesting that faces cause disproportionate interference in AS.

Background. Patients with borderline personality disorder (BPD) frequently report unresolved life events but it is still poorly understood, how these experiences are represented in the brain. Using functional magnetic resonance imaging (fMRI), the present study aimed at investigating the neural correlates of the recall of unresolved life events in patients with BPD and healthy controls.

Method. Twenty female BPD patients and 21 healthy control subjects underwent fMRI. During measurement subjects recalled unresolved and resolved negative life events. Individual cue words were used to stimulate autobiographical memory. After scanning, subjects rated their emotional states during the recall of both types of memories.

Results. When contrasting unresolved and resolved life events, patients showed significant bilateral activation of frontotemporal areas including the insula, amygdala, and the anterior cingulate cortex, the left posterior cingulate cortex, right occipital cortex, the bilateral cerebellum and the midbrain. In healthy subjects, no differential brain activation was related to these conditions. The 2×2 factorial analysis (ΔBPD−Δcontrols) revealed similar results with bilateral activation of the frontal cortex including parts of the insula and of the orbitofrontal cortex, temporal activation including the amygdala, activation of the right occipital cortex, and parts of the cerebellum. Patients but not controls reported higher levels of anxiety and helplessness during the unresolved versus resolved memory condition.

Conclusions. The activation of both, the amygdala and prefrontal areas, might reflect an increased effortful but insufficient attempt to control intensive emotions during the recall of unresolved life events in patients with BPD.

Background. Although included in the current edition of the DSM, there does not seem to be consensus among mental health professionals regarding the diagnostic status and scientific validity of dissociative identity disorder (DID). This study was aimed at the detection of simulation of inter-identity amnesia in DID.

Method. A sample of 22 DID patients was included, together with a matched control sample of subjects instructed to simulate inter-identity amnesia, a guessor group that had no knowledge of the stimulus material and a normal control group. A multiple-choice recognition test was included. The rate of incorrect answers was determined. Moreover, the specific simulation strategy used was examined by providing subjects with a range of choices that varied in extent of disagreement with the correct answer and determining whether plausible or implausible answer alternatives were selected.

Results. On the recognition test DID patients selected incorrect answers above chance like simulators. Patients thus seem to use their knowledge of the correct answer in determining their given answer. They were not characterized by a well-thought-out simulating behaviour style, as indicated by the differences in selection of specific answer alternatives found between patients and simulators.

Conclusions. DID patients were found not to be characterized by an actual memory retrieval inability, in contrast to their subjective reports. Instead, it is suggested that DID may more accurately be considered a disorder characterized by meta-memory problems, holding incorrect beliefs about their own memory functioning.

Background. The majority of people providing informal care for people with amyotrophic lateral sclerosis (ALS) are spouses. This prospective study set out to examine changes in and predictors of psychological distress in spouse carers of people with ALS.

Method. Fifty spouse carers of people with ALS underwent an initial interview and at least 21 underwent two further interviews, at median intervals of approximately 5–6 months. They rated the functional impact of their partner's ALS on everyday activities and everyday cognitive, emotional and behavioural changes that might have occurred in the person with ALS. They also rated their own social support and marital relationship, and completed measures of mood, burden and strain. The ALS Severity Scale was also completed for their partner with ALS.

Results. Over time, carers' psychological distress (a global measure combining mood, burden and strain) increased significantly. Initially carers' psychological distress was best predicted by the psychosocial impact of their spouse/partners' ALS, the extent to which their partner demonstrated emotional lability and how many other people were considered as dependents of the carer. Subsequently, carer distress was best predicted by an initial measure of negative social support and by their initial satisfaction with their social relationships.

Conclusions. Despite the significant physical impairment associated with ALS, psychosocial factors appear important in determining short- and longer-term psychological well-being in carers of people with ALS and may help clinicians to predict which carers are likely to experience psychological difficulties as part of their caring role.

Background. Body dysmorphic disorder (BDD) is a highly distressing and impairing disorder characterized by a preoccupation with imagined or slight physical defects in appearance. Well designed studies on its prevalence and on base rates for diagnostic criteria are rare. Therefore this study aimed to reveal prevalence rates of BDD in the general population and to examine clinical features associated with BDD.

Method. Of 4152 selected participants 2552, aged 14–99 years, participated in this German nationwide survey. Participants were carefully selected to ensure that the sample was representative; they were visited by a study assistant who provided instructions and help if needed. Participation rate was 62·3%. DSM-IV criteria for BDD, as well as subthreshold features (e.g. individuals who consider some part(s) of their body as ugly or disfigured, but do not fulfill all BDD criteria) were examined. We also assessed suicidal ideation associated with the belief of having an ugly body part, as well as the desire for cosmetic surgery. Furthermore, somatization symptoms were assessed.

Results. The prevalence of current BDD was 1·7% (CI 1·2–2·1%). Individuals with BDD reported higher rates of suicidal ideation (19% v. 3%) and suicide attempts due to appearance concerns (7% v. 1%) than individuals who did not meet criteria for BDD. Somatization scores were also increased in individuals with BDD, relative to those without. BDD was associated with lower financial income, lower rates of living with a partner, and higher rates of unemployment.

Conclusions. Our study shows that self-reported BDD is relatively common and associated with significant morbidity.