Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as ‘vital exhaustion’.

One of the targets of Durkheim's criticism, in his masterly book Le Suicide (1897), is the view upheld (according to him) by all 19th-century French alienists that suicide was, in all cases, a form of madness (henceforth, the ‘absolutist’ or ‘psychiatric’ hypothesis). Durkheim's view is important, particularly among sociologists, and lest they, and other readers, are led uncritically to accept his version of 19th-century French psychiatric views on suicide, it would seem important to put the historical record straight. The relevant literature is vast, and only representative writers are included in this paper. It is not the purpose of this paper to deal, in any way, with Durkheim's sociological views. (This is being done by Mohanna & Berrios (1990)).

Publications on the acquired immunodeficiency syndrome (AIDS) have reached such a pitch that leading medical journals have received letters of protest (Kubin, 1989), and some have been forced to defend themselves for the space they devote to the subject (Lock, 1989). While some consider that their problems have been ignored and that AIDS is attracting too much money and publicity (Adler, 1987), others believe AIDS research and clinical services are grossly underfunded (Rogers, 1989). Perhaps because modern medicine has rarely encountered such a completely ‘new’ disorder the fascination is great, no less in psychiatry than in other fields. An editorial in the Lancet (1989), just before the annual International Conference on AIDS, reminded us bluntly of the crucial questions: how many cases of HIV infection had been prevented in the year since the previous conference, and how many would be prevented before the next?

In the debates about the association between mental illness and the menopause, the psychiatric approach contradicts assertions by the gynaecological and psychoanalytic literature that the menopause has a negative effect on mental health. General population studies show that, if at all, psychiatric morbidity is more common in women in the five years before menopause. Sociocultural and family factors are more important in the aetiology of mental illness in menopausal women than physiological changes. Anxiety and depression in such women do not respond to oestrogen therapy, although some cases respond to antidepressants.

Over the past several years there has emerged a family of highly sophisticated but technically complex procedures for the visualisation of a range of cerebral functions in living man (Andreasen, 1988). The images they produce are so beguiling not just because of their potential to give new insights into the pathophysiology and treatment of major psychiatric disorders, but because they convey information through a quite fundamental modality: people are only convinced by what they can see. However, initial applications of such new technology have appeared just as likely to generate new questions and contradictions as to provide answers to current issues. This is readily illustrated by recent studies on the imaging of brain dopamine receptors in schizophrenic patients by positron emission tomography (PET) (see Waddington, 1989a).

Over the last ten years a new approach to psychiatric knowledge has developed under the influence of social anthropology. Its origins, assumptions, methods, achievements, and limitations are reviewed.

“All tragedy is the failure of communication”

(Wilson, 1956)

From time to time, general psychiatrists are asked to supervise offender patients who have been conditionally discharged into the community either by direction of the Home Secretary or by a Mental Health Review Tribunal (Mental Health Act 1983, sections 42(2) and 73(2)(4b)). In addition, they may be asked occasionally to provide psychiatric management for offenders released by the Home Secretary on life licence (Criminal Justice Act 1967, section 61). The effect of a conditional discharge following compulsory admission to hospital care by a court under a restriction order (Mental Health Act 1983, sections 37/41) is similar to that of a life licence.

The present state of knowledge of the possible relationship between depressive illness and multiple sclerosis is described. Problems of the research methodology are identified and suggestions made for useful areas of inquiry.

The manifold presentations of dystonia have been acknowledged as a spectrum of illness. Dystonia is primarily idiopathic or drug-induced; purely psychogenic causes would seem to be rare, although such an aetiology is commonly assumed. Response to medication in idiopathic cases is unpredictable, although anticholinergic medication and behavioural programmes are being evaluated.

Testing the null hypothesis has been the cornerstone of much statistical theory and practice over the last few decades. During this time it has encroached on most disciplines and become widespread in use within them. There are now few research papers in the scientific literature where the outcome of one or more hypothesis tests is not reported. With this ‘progress' there has undoubtedly been an improvement in the way in which data have been collected, analysed, and interpreted, and a move towards more objective evaluation of study results.

Attempts to draw a line of genetic demarcation between schizophrenic and affective illnesses have failed. It must be assumed that these diseases are genetically related. A post-mortem study has demonstrated that enlargement of the temporal horn of the lateral ventricle in schizophrenia but not in Alzheimer-type dementia is selective to the left side of the brain. This suggests that the gene for psychosis is the ‘cerebral dominance gene‘, the factor that determines the asymmetrical development of the human brain. That the psychosis gene is located in the pseudoautosomal region of the sex chromosomes is consistent with observations that sibling pairs with schizophrenia are more often than would be expected of the same sex and share alleles of a polymorphic marker at the short-arm telomeres of the X and Y chromosomes above chance expectation. That the cerebral dominance gene also is pseudoautosomal is suggested by the pattern of verbal and performance deficits associated with sex-chromosome aneuploidies. The psychoses may thus represent aberrations of a late evolutionary development underlying the recent and rapid increase in brain weight in the transition from Australopithecus through Homo habilis and Homo erectus to Homo sapiens.

Reductions in emergency psychiatric presentations to hospital occurred during and after the finals of the World Cup football competitions, an effect evident in women as well as men, and more marked among the mentally ill than those who were not. Increases in the numbers of schizophrenic and neurotic men presenting before, and alcoholic men during, the competitions can be attributed to the football. The generalised reductions during and after could reflect an indirect effect upon help-seeking, although actual relapse rates of mental illnesses might be affected. These changes could arise from enhancement of national identity and cohesion.

Using data from the first community-based, epidemiological survey of Puerto Rico, this paper examines the current prevalence of use of spiritist healers by Puerto Ricans, the role of spiritism in the provision of mental health services, and the association between spiritism and psychiatric disorders and symptoms. Those who visit spiritists were found to be more likely to work outside the home, to have a low family income, to have sought help for emotional problems from mental health professionals, and to have mild symptoms of depression.

Behaviour therapy and benzodiazepines are directed towards common problems and are often used in combination. At present we know little about the beneficial or adverse interactions of these two treatments. This paper reviews the available literature and suggests that there are important theoretical and clinical issues to be resolved.

Some of the major effects of alcohol, and alcoholism, on the brain are reviewed, with reappraisal of evidence drawn from brain imaging, neuropathology, clinical psychology, and laboratory experimental work. A hypothesis is developed which may help to account for the wide variability encountered in individual susceptibility to alcoholic brain damage and its varied manifestations. Therapeutic implications are considered.

The concept of insight into psychosis has received scant attention in the psychiatric literature. Drawing on sources such as phenomenology, clinical research and experimental psychology, it is proposed that insight is not an ‘all-or-none’ phenomenon but is composed of three distinct, overlapping dimensions, namely, the recognition that one has a mental illness, compliance with treatment, and the ability to relabel unusual mental events (delusions and hallucinations) as pathological. A scheme is proposed to standardise the assessment of insight to assist further research.

Schizophrenia is clinically heterogeneous but it is not known whether this is due to the existence of discrete subtypes. For the purpose of explication, ‘indicators' of schizophrenia are divided into three levels: phenomenology, pathophysiology, and aetiology. Five heterogeneity models and a number of quantitative approaches are described. It is imperative to apply rigorous methods of study to the comparison of unitary models and competing heterogeneity models of schizophrenia.

Eleven people were killed and 60 injured in the Enniskillen bombing of November 1987. Survivors were psychologically appraised six months and one year later. At six months 50% had developed post-traumatic stress disorder (PTSD). This group comprised more females than males. However, all victims had high scores on the GHQ. We found no correlation between psychological injury (as measured by the GHQ) and physical injury (as measured by the ISS), calling into question previous assertions.

A prospective inquiry of a largely working-class sample of women with children considers the effect of employment on risk of developing clinical depression. The hypothesis was that there would be a direct protective effect arising from employment once quality of other support was taken into account. In fact full-time working mothers were at high risk. This appeared to be explained by either prior work strain or a severe event involving ‘deviant’ behaviour on the part of husband/boyfriend or child. Neither factor was relevant for part-time workers. The severe events appeared to be particularly depressogenic for full-time workers because they represented either failure in the motherhood role or a sense of entrapment in an unrewarding work/domestic situation. However, those in part-time work had a low rate of onset compared with non-workers, and the difference appears to be related to non-working women feeling less secure about their marriages.