British Journal of Psychiatry

Almost since the beginnings of psychiatric practice, there has been a recognition that negative life experiences and stressful happenings may serve to precipitate mental disorders (Garmezy & Rutter, 1985). Nearly 200 years ago, Pinel wrote about the psychiatric risks associated with unexpected reverses or adverse circumstances, and it is reported that his initial question to newly admitted psychiatric patients was: “Have you suffered vexation, grief or reverse of fortune?” Nevertheless, although an appreciation that a variety of stressors may play a role in the genesis of psychiatric disorder has a long history, the systematic study of such effects is much more recent.

Three observations challenge Kraepelin's binary view of the functional psychoses: a bimodal distribution of the clinical features of manic-depressive illness and schizophrenia has not been demonstrated; affective illness appears to predispose to schizophrenia in later generations; and “schizoaffective’ illnesses cannot be separated in family studies from either of the prototypical psychoses. The alternative concept is that psychosis is a continuum extending from unipolar, through bipolar affective illness and schizoaffective psychosis, to typical schizophrenia, with increasing degrees of defect. According to this concept the genes predisposing to psychosis have a degree of stability that ensures that the form of the psychosis tends to remain the same within families, but there is also the possibility of change, implying that the genetic mechanisms themselves are variable. It is proposed that quantal changes in the “virogene’ are due to replications within the genome (e.g. the generation of tandem repeats of the element or a component of it); that such replications occur at a critical stage (e.g. gametogenesis, fertilisation, very early embryogenesis) in the course of reproduction; and that the “season of birth effect’ reflects the operation of the mechanism responsible for these replications.

The ability to shift cognitive set, which is probably subserved, at least in part, by the pre-frontal cortex, was determined for schizophrenic, bipolar (manic) and control subjects, using the Wisconsin Card Sorting Test (WCST). The schizophrenic and manic subjects both demonstrated poor performance on the WCST, suggesting that cognitive inflexibility and/or pre-frontal dysfunction, is not specific to schizophrenia (although laterality differences could exist). Moderate levels of poor performance in the non-psychiatric control group suggest the need for a review of the cut-off figures in the WCST currently used for predicting ‘brain damage’ and ‘focal frontal involvement‘, especially given the trend for the increasing use of cognitive assessment and rehabilitation in the major psychoses.

One thousand five hundred and seventy eight first degree relatives of schizophrenics, manics, depressives and controls were personally interviewed using the Iowa Structured Psychiatric Interview Form without knowledge of the probands' diagnoses. Our data, based on blind diagnostic assessment of the relatives, support the distinction between schizophrenia and affective disorders, although the distinction between schizophrenia and mania was not clear-cut. Our data could not support familial subtyping of paranoid and non-paranoid schizophrenia, and unipolar and bipolar affective disorders. Future studies attempting to develop research criteria for subtyping schizophrenia and affective disorders should utilize not only clinical and familial data but also biological markers and other non-familial variables.

Seventy agoraphobic out-patients were followed up prospectively for four years after treatment; the improvements manifested during treatment were found to be maintained and partly augmented. At the end of follow-up, 75 per cent of the patients had improved on the main phobia. No clear relationship was found between external control, social anxiety, depression and duration of the complaint at the beginning of treatment on the one hand and the results at follow-up on the other. The disorders remained phobic, no other neurotic symptoms having developed during the follow-up period.

Variables measured before or during psychological treatment may be used in several related ways: as an empirical guide to prognosis with any given treatment, as a means of studying possible treatment mechanisms, or as a method of identifying which stage or process in treatment is associated with therapeutic change. Using data from the same patients already described in a recently published study (Gelder et al., 1973), questions of relevance to each of these areas will be examined in turn.

Phenothiazine drugs were withdrawn from 17 chronic schizophrenic in-patients, with a control group of 14 patients remaining on active medication. The trial was conducted under double blind conditions over a period of 42 weeks with weekly assessment of the patients by ward nurses. Of the placebo group 35 per cent relapsed, relapse being related to the level of previous active medication.