Various associations have been reported in the literature between severe mental disorders, particularly schizophrenia, and other diseases; the demonstrated association of two (or more) diseases would be of great theoretical and practical importance. If two (or more) diseases occur in the same individual significantly more often than would be expected by chance, the same aetiological factors may be involved, or one disease may be pathogenic to the other, or one condition may be a hitherto unrecognised manifestation of the other, or the patient — as a sequela of one disease — may be exposed to risk factors for the other. In addition to the scientific importance of such discoveries, knowledge of this kind may be useful for the furtherance of public-health programmes, for the organisation of services, and for the prevention of illness.

The frontal lobes are the most evolutionarily advanced organ of the body. Here lies the seat of the highest human functions of thought, intellect, creativity, self-control and social interaction (Milner & Petrides, 1984; Lishman, 1987; Russell & Roxanas, 1990; Kolb & Wishaw, 1990). As one recent reviewer notes (Reading, 1991), it is hard to avoid ‘sounding metaphysical’ when going through such a list. It seems that, in accordance with psychiatry's own late phylogenesis, the frontal lobes have only just been discovered.

To assess the efficacy of supervised disulfiram as an adjunct to out-patient treatment of alcoholics, a randomised, partially blind, six-month follow-up study was conducted in which 126 patients received 200 mg disulfiram or 100 mg vitamin C under the supervision of a nominated informant. In the opinion of the (blinded) independent assessor, patients on disulfiram increased average total abstinent days by 100 and patients on vitamin C by 69, thus enhancing by one-third this measure of treatment outcome. Mean weekly alcohol consumption was reduced by 162 units with disulfiram, compared with 105 units with vitamin C., and the disulfiram patients reduced their total six-month alcohol consumption by 2572 units compared with an average reduction of 1448 units in the vitamin C group. Serum gamma-GT showed a mean fall of 21 IU/I in patients on disulfiram but rose by a mean of 13 IU/I with vitamin C. Unwanted effects in the disulfiram group led to a dose reduction in seven patients and to treatment withdrawal in four (and in one vitamin C patient). Two-thirds of the disulfiram group asked to continue the treatment at the end of the study. There were no medically serious adverse reactions.

To examine the neuropsychiatric effects of infection with HIV, 220 drug users (27 HIV negative, 193 HIV positive) completed tests evaluating premorbid intelligence, memory, non-verbal performance, information processing speed, and mood. When these measures were compared cross-sectionally by the severity of HIV illness, symptomatic patients (in CDC stage IV) were impaired on Trails B, two-choice decision time, delayed recall of the Wechsler Logical Memory Test and most components of the Auditory Verbal Learning Test. These findings imply reduced capacity for concentration, speed of thought and memory. When 101 patients were retested a mean of 16 months after their initial assessment, performance on Trails A and B, Block Design and delayed recall of the Wechsler Logical Memory Test deteriorated more for patients at, or progressing within, CDC stage IV, than performance of patients at stage III. The results broadly correspond to the cross-sectional findings. However, there was a decline in all tests of memory function for the sample independent of clinical staging. This may be evidence of brain involvement before the appearance of other symptoms. Self-rated measures of mood did not change cross-sectionally, progressively, or interactively with time and stage of HIV illness, and cannot account for the changes in cognitive function observed. Change in drug use, similarly, does not account for the cognitive findings. Four (5%) of the retested subjects developed AIDS dementia complex, but most of the performance and memory impairments seen were subclinical despite the destructive neuropathology presumed to underlie intellectual decline in patients with HIV infection. An exploratory analysis of treatment with zidovudine in 65 patients with stage IV disease showed no demonstrable benefit for cognitive function.

The idea of a triggering effect in schizophrenia emphasises the role of life events as precipitating factors which act on an individual's specific predisposition towards the illness (Wing, 1978).

Although a polydiagnostic approach to the definition of psychotic disorder provides many advantages to the researcher, there are also disadvantages. A comparison between several different sets of operational criteria using the opcrit computer program on a consecutive series of 397 psychotic subjects is described. The results show that although current diagnostic procedures are generally reliable, such approaches can still only supplement skilled clinical judgement, and there remain many pitfalls for the unwary.

Levels of stress in carers of long-term schizophrenia sufferers attending a depot clinic were assessed. Nine out of 25 carers (36%) were identified as possible or definite cases on either the GHQ or the HAD. However, a substantial proportion of carers managed to cope with the difficulties without suffering psychologically.

In-patients with psychotic symptoms and cannabis-positive urine analysis were assessed by PSE within one week of admission and again at one and six months. Concurrently admitted psychotic patients with drug-free urine analysis were controls. At one week the two groups differed significantly on only five PSE items: changed perception, thought insertion, non-verbal auditory hallucinations, delusions of control, and delusions of grandiose ability. One item (delayed sleep) differed at one month, and none at six months. The symptom cluster at one week is consistent with acute cannabis intoxication. Subjects and controls were mostly single, poorly educated, unemployed people with histories of psychotic disorders, and given major tranquillisers on admission. Compared with controls, subjects were younger, less likely to have psychiatric histories, more often male, Afro-Caribbeans with a history of convictions and compulsory admissions. The commonest diagnosis was schizophrenia. Use of the label ‘cannabis-induced psychosis’ may obscure a diagnosis of paranoid schizophrenia. A short-lived psychotic episode does occur in clear consciousness after cannabis intoxication, but chronic cannabis-induced psychosis was not found.

Claims have been made that maternal infection with influenza during pregnancy is a cause of schizophrenia in the child. These assertions are based upon some apparently significant associations between the timing of influenza epidemics in the general population and birth rates of people who later suffered from schizophrenia. Such associations have not been present in studies of the 1919 and 1957 epidemics, with sample sizes larger than those on which the claims were made. More decisively, in an investigation of the subsequent psychiatric admissions of people born a few months after the 1957 epidemic, it was found that the children of 945 mothers who actually suffered from influenza during the second trimester of pregnancy were at no greater risk of developing schizophrenia than children of mothers who were not infected. In contrast to the predictions of the influenza hypothesis of 26.5 extra cases by broad diagnostic criteria and 15.8 cases by narrow criteria, the numbers observed in children of mothers exposed to influenza in the second trimester were 3 and 1 cases respectively, close to the expected rate. It is concluded that prenatal influenza and schizophrenia are unrelated.

In a clinical series of 40 bulimic women, a reported history of unwanted sexual experience was associated with more frequent bingeing and (to a lesser extent) vomiting. These symptoms were more marked when the abuse was intrafamilial, involved force, or occurred before the victim was 14 years old. Further research is required to establish the causal links between the phenomena of sexual abuse and bulimic symptoms.

Gilles de la Tourette's syndrome (GTS) is a relatively rare neuropsychiatric disorder characterised by multiple motor tics accompanied by vocalisations. It usually starts in early childhood and is more common in males than females. Obsessional compulsive disorder (OCD) is an integral part of GTS (Robertson, 1989). GTS is also associated with coprolalia, copropraxia, and other echophenomena, as well as attention-deficit disorder, self-injury, and other behaviour problems (Robertson et al, 1988; Robertson, 1989). Family pedigree studies have demonstrated that most GTS cases in the community are mild and do not receive medical attention (Kurlan et al, 1987; Robertson & Gourdie, 1990).

A vulnerability/stress framework for schizophrenia is one means by which the strong evidence for genetic and other biological factors in schizophrenia can be combined in a useful way with persistent evidence that stressful environments may play a role in precipitating psychotic episodes (Gottesman & Shields, 1972; Zubin & Spring, 1977; Nuechterlein & Dawson, 1984; Nuechterlein, 1987; Ciompi, 1989). Within a large longitudinal study of the early course of schizophrenia, we have been attempting to examine several possible ways in which both psychobiological vulnerability factors in the patient (Dawson & Nuechterlein, 1987; Nuechterlein et al, 1991) and external environmental stressors (Ventura et al, 1989) individually and jointly influence the course of schizophrenia. At the Second International Symposium on Schizophrenia in Bern, we focused on two promising mediating factors in schizophrenia — those involving persistent information-processing abnormalities and stress-triggered autonomic arousal (Nuechterlein et al, 1989). We focus here on recent analyses that relate to current controversies in the literature on interpersonal attitudes that are typically called expressed emotion (EE) — socio-environmental attributes that have been statistically associated with psychotic relapse in schizophrenia.

“The role of stressful life events in the onset of Graves' disease (toxic diffuse goitre) is controversial. However, the numerous early clinical reports that supported such an association were not adequately controlled and specificity of the diagnosis could be questioned. Later studies have not shown a causal relation, but these studies were small, did not have proper controls, or epidemiological methods were inappropriate. To assess possible associations between life events, heredity, social support, and Graves' disease, we have done a population-based case-control study in a defined area with about 1 million inhabitants. Over 2 years, 208 (95%) of 219 eligible patients with newly-diagnosed Graves' disease and 372 (80%) of all selected matched controls answered an identical mailed questionnaire about marital status, occupation, drinking and smoking habits, physical activity, familial occurrence of thyroid disease, life events, social support, and personality. Compared with controls, patients claimed to have had more negative life events in the 12 months preceding the diagnosis, and negative life-event scores were also significantly higher (odds ratio 6.3, 95% confidence interval 2 · 7–14 · 7, for the category with the highest negative score). Individuals who had relatives with thyroid disease (especially first-degree and second-degree relatives) were more likely to have Graves' disease (3 · 6, 2 · 2–5 · 9). Slightly more patients than controls were divorced (1 · 8, 1 · 0–3 · 3) and reported a less frequent intake of alcohol (0 · 4, 0 · 2–0 · 8). When results were adjusted for possible confounding factors in multivariate analyses, risk estimates were almost unchanged. These findings indicate that negative life events and hereditary factors may be risk factors for Graves' disease.”

Neurosyphilis continues to present in atypical forms, leading to erroneous diagnoses by physicians and psychiatrists. This patient, with a previous history of psychosis, presented in a catatonic state with rhabdomyolysis and renal failure. A subsequent breakdown was thought to be schizophrenic until unusual features led to a reassessment and discovery of neurosyphilis which was treated with penicillin and resulted in a remarkable clinical recovery.

The aim of the present study was twofold: firstly, to determine cardiac vagal tone in subjects with generalised anxiety disorder directly, using an invasive pharmacological method; and secondly, to test whether the non-invasive method of measuring the amplitude of respiratory sinus arrhythmia (RSA) gives a reliable estimate of cardiac vagal tone in this form of anxiety disorder. Comparison of baseline physiological measures of anxious and control subjects revealed that cardiac vagal tone and heart rate were not different in the two groups of subjects, whereas length of the respiratory cycle and amplitude of respiratory sinus arrhythmia were reduced in the former group. Because of the higher respiratory rates of anxious subjects, the RSA method was found to underestimate cardiac vagal tone in generalised anxiety disorder.

“The birth dates of schizophrenic inpatients in eight health regions in England and Wales were reviewed for any effect of the 1957 A2 influenza epidemic. 5 months after the peak infection prevalence, the number of births of individuals who later developed schizophrenia was 88% higher than the average number of such births in the corresponding periods of the 2 previous and the next 2 years. This finding is in accordance with a study from Helsinki and with clinical and neuropathological evidence of aberrant fetal brain development in the pathogenesis of schizophrenia.”

The effects of ECT on plasma insulin and glucose were assessed in 20 depressed patients, during the first, third and fifth session of ECT. After each administration of ECT there was a significant rise in blood glucose and plasma insulin levels, both of which peaked at 15 minutes. Insulin responses tended to attenuate over the course of ECT, whereas the glucose responses were similar for all three treatments. ECT was effective in all patients, although two months after the last treatment nine patients had partially relapsed (Hamilton score > 15). Those who relapsed had a more attenuated insulin response at the fifth treatment than those who had remained well, which suggests that insulin response to ECT may be predictive of clinical outcome.

Relapse is a central problem in the treatment of addictive behaviour, and a specific problem in the out-patient treatment of the opiate withdrawal syndrome. This study investigated factors associated with relapse among 42 opiate addicts receiving out-patient detoxification treatment at a London drug-dependence clinic. All subjects completed a questionnaire about their social, psychological, and environmental circumstances in the week before interview, and were interviewed within the first two weeks of the programme. Forty per cent had lapsed to illicit heroin abuse within the previous week. Interpersonal factors and drug-related cues were associated with lapse to opiate use. Most subjects encountered a range of high-risk situations, such as regularly meeting other drug users and being offered drugs, and persistent negative mood states.

Numerous studies have examined whether certain specific attributes of intrafamilial attitudes and relationships are related to the onset and course of schizophrenia. A frequent underlying assumption of this research has been that these attributes interact with a biological predisposition to the disorder, raising or lowering the probability of its expression or of recurrences, once the initial onset has appeared. Previous work within a longitudinal study of disturbed adolescents indicated that a number of qualities in parents were associated with an increased risk for schizophrenia spectrum disorder, particularly deviant communication and negative affective attitudes and interaction behaviour (Goldstein, 1987). In assessing the quality of communication, the construct and operational definition of communication deviance (CD) as elucidated by Wynne et al (1976) were used. With regard to affective attitudes, the operational definition of high expressed emotion (EE), developed by Brown et al (1972) and by Vaughn & Leff (1976), was used, while affective interactive behaviour was coded using the affective style system of Doane et al (1981).

A short paper of this title reported a study by Ansseau et al (1991). The present authors were invited to comment upon the study.