Showing papers in "Psychological Medicine in 1979"

A scaled version of the General Health Questionnaire

Abstract: This study reports the factor structure of the symptoms comprising the General Health Questionnaire when it is completed in a primary care setting. A shorter, 28-item GHQ is proposed consisting of 4 subscales: somatic symptoms, anxiety and insomnia, social dysfunction and severe depression. Preliminary data concerning the validity of these scales are presented, and the performance of the whole 28-item questionnaire as a screening test is evaluated. The factor structure of the symptomatology is found to be very similar for 3 independent sets of data.

A scaled version of general health questionnaire

Abstract: This study reports the factor structure of the symptoms comprising the General Health Questionnaire when it is completed in a primary care setting. A shorter, 28-item GHQ is proposed consisting of 4 subscales: somatic symptoms, anxiety and insomnia, social dysfunction and severe depression. Preliminary data concerning the validity of these scales are presented, and the performance of the whole 28-item questionnaire as a screening test is evaluated. The factor structure of the symptomatology is found to be very similar for 3 independent sets of data.

The Eating Attitudes Test: an index of the symptoms of anorexia nervosa.

Abstract: Data on the development of a 40-item measure of the symptoms in anorexia nervosa are reported. The scale (EAT) is presented in a 6-point, forced choice, self-report format which is easily administered and scored. The EAT was validated using 2 groups of female anorexia nervosa patients (N = 32 and 33) and female control subjects (N = 34 and 59). Total EAT score was significantly correlated with criterion group membership (r = 0.87, P less than 0.001), suggesting a high level of concurrent validity. There was very little overlap in the frequency distributions of the 2 groups and only 7% of the normal controls scored as high as the lowest anorexic patient. Female obese and male subjects also scored significantly lower on the EAT than anorexics. Recovered anorexic patients scored in the normal range on the test, suggesting that the EAT is sensitive to clinical remission.

Bulimia nervosa: an ominous variant of anorexia nervosa.

Abstract: Thirty patients were selected for a prospective study according to two criteria: (i) an irresistible urge to overeat (bulimia nervosa), followed by self-induced vomiting or purging; (ii) a morbid fear of becoming fat. The majority of the patients had a previous history of true or cryptic anorexia nervosa. Self-induced vomiting and purging are secondary devices used by the patients to counteract the effects of overeating and prevent a gain in weight. These devices are dangerous for they are habit-forming and lead to potassium loss and other physical complications. In common with true anorexia nervosa, the patients were determined to keep their weight below a self-imposed threshold. Its level was set below the patient‘s healthy weight, defined as the weight reached before the onset of the eating disorder. In contrast with true anorexia nervosa, the patients tended to be heavier, more active sexually, and more likely to menstruate regularly and remain fertile. Depressive symptoms were often severe and distressing and led to a high risk of suicide.A theoretical model is described to emphasize the interdependence of the various symptoms and the role of self-perpetuating mechanisms in the maintenance of the disorder. The main aims of treatment are (i) to interrupt the vicious circle of overeating and self-induced vomiting (or purging), (ii) to persuade the patients to accept a higher weight. Prognosis appears less favourable than in uncomplicated anorexia nervosa.

Determinants of the ability of general practitioners to detect psychiatric illness

Abstract: This study of psychiatric illness among 4098 patients attending 91 general practitioners compares 2 methods of case identification: 'conspicuous morbidity' by the doctor's own assessments, and 'probable prevalence' by the patients' responses to the General Health Questionnaire (GHQ). In general, the latter gives somewhat higher estimates than the former, but there are wide variations in morbidity between practices. The ability of each general practitioner to detect psychiatric illness was measured by computing Spearman's correlation coefficient between his assessments and the GHQ scores of his patients. The mean correlation coefficient was + 0.36, but the range was very wide (0.09-0.60). The first part of the study deals with various demographic characteristics of the patients themselves which are associated with an increased likelihood of the doctor detecting a psychiatric illness; such factors include unemployment, female sex, and marriages which have ended by separation, divorce or death. The second part of the study examines characteristics of the doctors themselves in an attempt to account for the wide variation between them in their ability to detect psychiatric illness. A research psychiatrist made detailed observations on 2098 interviews carried out by 55 general practitioners. Each doctor's verbal and non-verbal styles were recorded minutely, and in addition various global ratings were made. The doctors completed personality inventories and supplied details of training and professional background. It was possible to account for 67% of the variance of correlation coefficient mainly in terms of 2 dimensions: 'interest and concern' and 'conservatism'. The way in which the doctor interviews his patients is shown to be important, but there are interactions between interview style and the doctor's personality.

Endogenous opioid peptides and the control of pain

Abstract: In recent years it has become evident that peptides of relatively small molecular weight play an important role not only in the regulation of endocrine function but also in the control of certain pathways in the central nervous system. The discovery of peptides which mimic the actions of morphine is of particular interest since it may give an insight into the physiological modulation of responses to painful experiences. Two such pentapeptides, methionine-enkephalin (tyrosineglycine-glycine-phenylalanine-methionine) and leucine-enkephalin (tyrosine-glycine-glycine-phenylalanine-leucine) were identified in extracts of pig brains (Hughes et al. 1975) and of other species. It is of interest that the sequence of methionine-enkephalin is present in the pituitary peptide filipotropin as amino acid residues 61-65. Present evidence indicates that there are 2 independent peptidergic systems: one is characterized by the presence of the short-chain peptides, methionine-enkephalin and leucine-enkephalin, and is widespread throughout the central and peripheral nervous systems (Elde et al. 1976; Hughes et al. 1977; Simantov et al. 1977), whereas the other system contains the long-chain peptide, /?-endorphin (/Wipotropine^gj) and is centred around the hypothalamus-pituitary axis with extensions into the thalamus, midbrain, medulla and pons (Rossier et al. 19776). The investigation of the analgesic, or rather antinociceptive, properties of the opioid peptides is made difficult by the high sensitivity of the pentapeptides, the enkephalins, to the very rapid degrading actions of aminopeptidases and carboxypeptidases, whereas the long-chain peptides are resistant to these enzymes and have their activity more slowly reduced by an endopeptidase cleaving the molecule between amino acid residues 77 and 78. This property of the enkephalins makes the use of the ordinary antinociceptive tests unreliable, even if the peptides are administered directly into the cerebral ventricles. On the other hand, /?-endorphin is a very strong and long-lasting antinociceptive agent (Feldberg & Smyth, 1977), even after intravenous administration to mice but not to rats (Tseng etal. 1976; Rossier etal. 1977a). In this context it is of interest that the affinity of /?-endorphin to the receptor represented by [H]leucine-enkephalin or [H]methionine-enkephalin binding in brain homogenate is similar to that of methionine-enkephalin and leucine-enkephalin, whereas its affinity to the receptor represented by [H]naloxone or [H]naltrexone binding is considerably greater than that of methionine-enkephalin and particularly of leucine-enkephalin. In contrast to the opioid peptides, morphine has a much lower affinity to the binding site of [H]leucine-enkephalin than to that of [H]naloxone or [H]naltrexone (Lord et al. 1977). The evidence that methionine-enkephalin and possibly leucine-enkephalin play an important role in the control of the modulation of the transmission of noxious and painful stimuli is based on electro-physiological experiments, on the relationship between substance P and enkephalin in the central nervous system and the antagonism by naloxone of the analgesic effects of electrical stimulation of the pericentral grey in intractable pain and of those of electro-acupuncture. It has been shown (Duggan et al. 1977) that methionine-enkephalin and its amide have different effects on the responses of neurones of spinal laminae IV and V of spinal cats to noxious and innocuous skin stimuli. When administered in the substantia gelatinosa, the enkephalins predominantly reduce the responses to noxious stimuli with little effect on the responses to nonnociceptive stimuli. These observations are in good agreement with the immunohistochemical findings that methionine-enkephalin and substance P have a similar distribution in areas related to pain and analgesia (Hokfelt et al. 1977). Such areas are the periaqueductal grey, the marginal layer of the spinal trigeminal nucleus and the substantia gelatinosa of the dorsal horn of the spinal cord

Cure and care of neurosis. I. Cure.

Abstract: Behavioural psychotherapy has long historical roots. Recently it has led to effective treatment for selected neuroses, including phobic, obsessive-compulsive and sexual disorders. Potent therapy has become a tool of experimental psychopathology which advances theory and practice. A pervasive principle is exposure of the patient to those stimuli which evoke his discomfort until this subsides. Level of arousal during exposure does not affect outcome. Theoretical issues are reviewed which decide when exposure will be sensitizing or habituating. Both psychoanalytical and conditioning models of neurosis are out of date, and models derived more directly from clinical experiment are becoming possible. The aetiology of phobias and rituals can be seen as failed extinction rather than enhanced acquisition. Relevant phylogenetic and biological factors are discussed. At the other extreme, well-documented faith-healing indicates huge gaps in our knowledge of psychotherapy.

Schizophrenia and physical disease.

Abstract: In the 2000 years since Hippocrates noted that fever sometimes alleviated psychotic behaviour an extensive speculative, theoretical and observational literature has accumulated about the relation between physical illness and psychosis. Yet, in 1977, Lipper & Werman concluded that 'prospective, well controlled investigations on the relationship between schizophrenia and physical illness remain to be performed'. The proportion of methodologically sound observational studies, mainly of mortality, certainly is small. There is fairly general agreement that, compared with the community population as a whole, the relative risk of death in schizophrenia is increased, probably about twofold, and is slightly higher in females than in males. Most studies agree also that the excess risk of death declines as age increases and as length of hospital stay increases. The largest excess mortality tends to occur in the first year after referral or hospital admission, raising the possibility of selective referral of physically ill patients (Malzberg, 1953; Innes & Millar, 1970). Thus, unless 0degaard's (1952) dictum is accepted, that nearly all schizophrenics, at least until recent times, eventually found their way into hospital, there must be doubt about the validity of apparently raised relative risks from specific causes of death. Babigian & Odoroff (1969) found that the chronically ill, the aged and alcoholics contributed most of the excess deaths. Suicide and other traumata are the commonest causes of death in most recent studies. Reduced relative risks always call in question the thoroughness of ascertainment among the case population. Special caution must therefore be exercised in reviewing the evidence for positive or negative associations of particular diseases with schizophrenia, in addition to the usual uncertainties surrounding the psychotic diagnosis itself. Virtually all the research so far reported antedates the standardization developed for the WHO International Pilot Study, though the earlier studies at least avoided much of the risk of bias resulting from drug therapy in the last 25 years. The choice of method is critical to robust determination of disease linkages with schizophrenia. Most studies that have not relied simply on proportionate mortality (the proportion of deaths from the specified disease in schizophrenics compared with the proportion in a control population) have compared sexand age-specific death rates among schizophrenics with general population rates. The small number of morbidity studies, particularly of cancer, have generally used some variant of this technique also. Schizophrenia is not a very common condition, with an annual incidence which may be as low as 1 per 1000 (Baldwin, 1971; Cooper, 1978) and, although sound in principle, the difficulty of assembling large enough numbers of cases has restricted most such studies to generalities, such as the relative risk of any cancer among all schizophrenics, whereas to be of value in testing aetiological hypotheses it would be highly desirable, if not essential, to ascertain statistical associations between specific diseases and various subtypes of schizophrenia in individuals. A more difficult and more expensive method, but one which would eliminate much of the uncertainty, would be to compare outcomes of cohorts of cases and matched controls with respect to incidence of supposedly associated diseases (Baldwin, 1977). The controls would have to provide for the possibility that diseases linked with schizophrenia might also be linked with other psychoses or even be characteristic of psychiatric disorder generally. A good example of this type of design is the Iowa City follow-up study of discharged psychiatric patients (Tsuang & Woolson, 1977).

Behavioural changes in temporal lobe epilepsy.

Abstract: About 30 years ago pioneering studies, particularly by English investigators, began to alert clinicians to the existence of the behavioural changes of temporal lobe epilepsy. Yet despite this long history, disputes continue about the status of this syndrome. A major cause, although not the exclusive one, of these disagreements is that the phrase 'behavioural change in temporal lobe epilepsy' evokes differing associations. I shall present here briefly the view of one group and contrast these with some other conceptions. According to this view a characteristic syndrome of behavioural change (Waxman & Geschwind, 1975; Bear & Fedio, 1977) occurs with higher frequency in temporal lobe epilepsy (and possibly in other cases with a spike focus in limbic structures) than in other neurological conditions. It is also more frequent in this condition than in other forms of epilepsy. The study of Bear & Fedio (1977) brings evidence that it occurs in a very high percentage of temporal epileptics. It is commonly observed on first encounter and is therefore not primarily the result of drug therapy. It is also rare in other forms of epilepsy treated with the same drugs. Since it may precede the first recognized seizure and is rare in other neurological conditions, it is unlikely to be the result of stress of illness. Although some patients suffer from behavioural changes which occur during or after seizures, in most patients the characteristic syndrome is interictal, i.e. present constantly, without obvious relationship to individual seizures. The syndrome includes the following features: increased concern with philosophical, moral or religious issues, often in striking contrast to the patient's educational background, an increased rate of religious conversions (or strongly justified, rather than casual, lack of religious feeling), hypergraphia (a tendency to highly detailed writing often of a religious or philosophical nature), hyposexuality (diminished sex drive sometimes associated with changes in sexual taste), and irritability of varying degree. Of particular interest was the finding in the Bear & Fedio study of differences between those with left and right spike foci. The same personality picture can be seen in patients without temporal lobe foci but its high frequency in this type of epilepsy is remarkable. Furthermore, in an as yet unpublished study, Bear and his associates have found that these features were very much more frequent in temporal epileptics than in other cases of epilepsy. Let me now underline certain features of this description. I have deliberately spoken of the behavioural or personality syndrome of temporal epilepsy, not of behaviour disorder. Many patients with the syndrome have neither been hospitalized nor in trouble with the police, and may make good adjustments, yet show the characteristic personality. Some patients with this constellation do, of course, have adjustment difficulties which bring them to medical attention. I have not been speaking of psychoses with temporal lobe foci. A small number of patients with this syndrome are psychotic, although even in these cases one usually observes the same fundamental personality pattern. Nor have I used the term schizophreniform. While some patients with idiopathic behaviour disturbances who would be labelled as schizoid or schizophrenic may possess some of the attributes of this syndrome, the majority of the patients with temporal epilepsy lack some of the cardinal features of schizophrenia, e.g. flatness of affect or blocking are unusual, even among those who are psychotic. Indeed, the use of terms borrowed from the standard psychiatric nomenclature may serve only to obscure the characteristic features of this condition.

Schizo-affective psychosis: definitions and incidence.

Abstract: Eight definitions of schizo-affective psychosis have been compared in a sample of psychotic first admissions. Their mutual concordance is very low (mean 0·19) showing that there is very poor agreement about the meaning of the term ‘schizo-affective’ at present. Ten patients (4·5 % of admissions and 8 % of psychotic admissions within the age group studied) satisfied 3 definitions, a figure which demonstrates the numerical importance of this group of unclassified mental disorders.

The contextual threat of life events: the concept and its reliability

Abstract: The reliability of Brown's contextual measure of threat is assessed and found to be highly satisfactory. Previously inexperienced raters achieve highly reliable ratings after only brief training. The implications for the concept of the threat of life events are discussed.

Comparative reliability of categorical and analogue rating scales in the assessment of psychiatric symptomatology.

Abstract: The reliability of 26 items from the ninth edition of the Present State Examination (PSE) was assessed using both the conventional categorical scales and separately constructed analogue scales. Reliability was also calculated when the analogue responses were rescaled down to 2, 3 and 4 categories. The levels of inter-rater agreement obtained were comparable to those achieved in previous studies of PSE reliability, although as expected the levels of agreement on audiotapes were greater than those for independent interviews performed on the same day. These levels were not significantly affected by any of the changes in scale format, but there were apparent differences in reliability depending on the statistics used. In selecting or constructing a psychiatric rating scale, the question of reliability should not influence the choice of a categorical or continuous scale, or the number of scored points in the scale.

Psychiatric symptoms in self-poisoning patients

Abstract: Self-poisoning patients admitted to hospital were studied for persistence of psychiatric symptoms over a 3-month period and evaluated at 3 points in time with the General Health Questionnaire and the Present State Examination. Symptoms were identified which had a high or low prevalence at 3-month follow-up. GHQ and PSE scores correlated at 0.8. The implications of the study are discussed, particularly the earlier need for out-patient help in those who had a moderate or high number of symptoms at initial interview.

Skin conductance responsivity during acute episodes of schizophrenia as a predictor of symptomatic improvement.

Abstract: Skin conductance responses to a series of tones were measured in 41 patients during an acute episode of schizophrenia before they received treatment and after 4 weeks of treatment with either α-flupenthixol, β-fiupenthixol or placebo. Patients who did not habituate to the tones prior to treatment tended to show no symptomatic improvement during the course of treatment. Patients who habituated and also showed an acute onset of their current symptoms (‘Feighner negative’ patients) showed a marked improvement even without active medication. Skin conductance responsivity did not change with improvement in symptoms alone, but decreased in patients on active medication (α-flupenthixol).Non-habituation of skin conductance and insidious onset (i.e. fulfilment of the Feighner criteria) were found to be independent predictors of poor outcome. Taken together, these criteria may define a group of patients with particularly poor prognosis.

Corticosteroid and growth hormone responses to methylamphetamine in depressive illness.

Abstract: It is suggested that, if depressed patients have deficient noradrenergic function at central α-adrenergic receptors, then they will also have impaired corticosteroid responses to methylamphetamine but unaltered growth hormone responses This prediction has been confirmed when the responses of a group of patients with endogenous depression were compared with the responses of a group of patients with other functional psychoses, a group of patients with reactive depression, and a group of patients with other psychiatric diagnoses These findings support the hypothesis that there is a functional deficiency of noradrenaline at some central α-adrenergic receptors

Psychiatric diagnosis in self-poisoning patients.

Abstract: The Present State Examination was administered to 539 patients who attended a casualty department after an act of self-poisoning during the course of a year. Computer analysis by means of the Catego program showed that 30% of the patients had insufficient symptoms to be considered as psychiatric ‘cases’. Fewer than 4% had symptoms of functional psychosis. About 60% of the patients were classed as depressed: on several indices this group was less severely ill than a group of depressives receiving psychiatric treatment. It is suggested that psychiatric treatment is essential for only a small proportion of self-poisoning patients. The effectiveness of psychiatric treatment for the large group of patients with depressive disorders of minor severity and probably short duration has still to be evaluated.

The stability of perceptual disturbances in anorexia nervosa.

Abstract: Patients with anorexia nervosa have previously been shown to display disturbances in visual self-perception and interoception. In the present investigation we wished to determine the stability of these disturbances and the effects of weight gain on them. We studied 29 females, 16 patients with primary anorexia nervosa and 13 controls, who had also been studied one year previously. Each subject took part in investigations of body image, using a distorting photograph technique, and interoception, using a satiety aversion to sucrose test. We found that some anorexic subjects tend to overestimate body size and have an absence of aversion to repeated sucrose tastes. Moreover, these disturbances were stable over the year and were not affected by weight change.

Altered platelet monoamine oxidase activity in affective disorders.

Abstract: Platelet MAO activity was found to be elevated in primary depressive illness, and the severity to correlate positively with MAO activity. The reactive depression subgroup's mean platelet MAO activity was not significantly different from that of the controls. The endogenous group's unipolar and bipolar subgroups had significantly different platelet MAO activity, respectively high and low. The differences in MAO activity between unipolar and bipolar patients appeared to persist in the well state, but not after lithium carbonate therapy. These differences in MAO activity were apparent with the substrate tyramine but not with benzylamine. Altered MAO activity in patients with affective disorders may be determined through genetic mechanisms.

The effect of sex, marriage and age at first admission on the hospitalization of schizophrenics during 2 years following discharge.

Abstract: Two hundred and eighty-two schizophrenics discharged from St John's Hospital, Stone, were followed-up. The reliability of the diagnosis was measured by the extent of agreement among the hospital clinicians. The number of readmissions and the time spent in hospital were ascertained and correlated with the sex, civil state and age at first admission of the subjects. It was found that a higher proportion of males than of females was readmitted; that the proportion of single persons among male schizophrenics is higher than among comparable age groups in the general population; that single males are more frequently admitted than single females; that the peak age of first admission for males is 10 years earlier than for females and that men whose age at first admission is below the median are more frequently readmitted than those whose age at first admission is above it. Women are more frequently married than men at the onset of schizophrenia, giving rise to the suggestion that marriage has a protective effect in schizophrenia. This hypothesis was not supported by our findings. The bearing of these findings on the course, genetics and marital handicap of schizophrenia is discussed.

Emotional disturbance following childbirth: clinical findings and urinary excretion of cyclic AMP (adenosine 3'5'cyclic monophosphate).

Abstract: Emotional disturbance was assessed in a group of women in the first few days following childbirth and again 2 months and 1 year following childbirth; the clinical features are described. Variables such as social class, age and parity were not related to the level of emotional disturbance, but a history of marital problems, sexual difficulties, poor relationships with immediate family or disrupted family relationships in childhood were so related. Twenty-four hour urinary excretion of cyclic AMP (adenosine 3'5' cyclic monophosphate) was estimated in the same group of women on 2 occasions in the week following childbirth and again 2-3 months later in approximately one third of the original sample. Excretion of cyclic AMP in the few days following delivery was elevated compared with excretion 2-3 months later, and there was a significant rise in urinary excretion of cyclic AMP between the 1st and 2nd urine collections. Those women showing most emotional disturbance on the 3rd day after delivery and women indicating most mood change in the direction of becoming elated had the highest levels of cyclic AMP in the 2nd urine collection.

Attitudes of families to some aspects of Huntington's chorea.

Abstract: One hundred and fifty-three complete questionnaires received from families with a history of Huntington's chorea were analysed to discover their attitudes towards the disease. Of special interest were: (a) how and when they were first informed about their illness; (b) what effects the knowledge of the hereditary aspects of the disease had on them and on their children; and (c) their reaction to a possible future predictive test.

Patterns and issues in multiaxial psychiatric diagnosis.

Abstract: The multiaxial diagnostic model, consisting in the systematic formulation of a patient's condition according to separate clinical variables or aspects, is receiving increasing attention in several parts of the world. This innovative model promises to improve diagnostic reliability and validity and involves many methodological challenges. This paper reviews patterns and issues in the conceptualization of axial content, number and organization of axes, dimensional versus categorical scaling, and evaluation and further development of multiaxial systems.

Body image disturbance in anorexia nervosa during the acute and recuperative phase

Abstract: Perception of body size, subjective experience of body image distortions and differentiation of body concept in the human figure drawing were assessed in adolescent anorexia nervosa patients and controls shortly after hospital admission, and again 6 months later during the recuperative phase. Size estimation was not found to be a distinguishing variable, as both groups exhibited overestimation tendencies of comparable magnitude at both time periods. By contrast, experiences denoting estrangement from the body, insensitivity to body sensations, and weakness of body boundaries were more prevalent in anorexics, and persisted at high levels after frank symptoms of weight and eating disorder had subsided. Anorexics were also shown to depict the human figure with less differentiation relative to controls. Within the anorexic sample the presence of vomiting was linked to greater subjective experience of body image distortion, and such phenomena appear to be a more enduring feature in this subgroup. Overall, the results were viewed as lending support to the argument that defects in body image formation render the anorexic vulnerable to their manifest pathology, which is itself activated by maturational conflicts unique to adolescence.

Depression and cancer: a follow-up study.

Abstract: Thirty-nine male and 90 female patients aged 40 and over, who had been given a primary diagnosis of depression, were followed up for 2 1/3-4 years. During this period 9 male and 9 female patients died. Five male patients and 1 female died from cancer that had not been diagnosed at the time of their psychiatric admissions. The male cancer deaths are significantly higher than expected. The possible relationships of malignant neoplasm to affective disorder are discussed.

Factors affecting the prescribing of psychotropic drugs in general practice consultations.

Abstract: The characteristics of patients and information-gathering processes in general practice consultations producing prescriptions for antibiotics and psychotropic drugs are discussed. The contribution of patients presenting symptoms and the exploration of these by the general practitioner in the prescribing of psychotropic drugs, is compred with that of diagnosis.

Interactions in contingency tables: a brief discussion of alternative definitions.

Abstract: The purpose of this note is to indicate how the disagreement between Tennant & Bebbington and Brown & Harris has arisen. The difference between the 2 pairs of authors is due, at least in part, to their use of different models for the analysis of the data in question. There can be no final answer as to which model is correct - the data are simply open to more than one interpretation. Nevertheless, it is interesting that the use of a multiplicative model, seemingly ignored by Brown & Harris, leads to a simple description of the data in which the 'vulnerability factor' and the 'provoking agent' may be considered to act independently on the response. Consequently, in stating that their data contain an interaction so obvious that it can be detected by 'visual inspection', Brown & Harris may have been somewhat rash.

Amenorrhoea, body weight and serum hormone concentrations, with particular reference to prolactin and thyroid hormones in anorexia nervosa.

Abstract: Twenty women with anorexia nervosa were investigated at varying stages during weight gain. Basal prolactin and TSH and prolactin responses to TRH were normal and unrelated to body weight. LH, FSH and 17 beta oestradiol were low in emaciated patients and rose with weight gain. There was no correlation between serum gonadotrophin and prolactin concentrations. T3 and T4 concentrations were low but T3 rose with weight gain during refeeding over 4-6 weeks, whereas T4 remained low. A positive correlation was found between the TSH response to TRH and body weight. The abnormalities in the hypothalamic-pituitary-thyroid axis were similar to those seen in a variety of chronic illnesses and appear to be unrelated to the amenorrhoea. The failure of restoration of normal function at least after short-term refeeding requires further investigation. It was concluded that the amenorrhoea in anorexia nervosa is not associated with changes in prolactin secretion but is determined primarily by changes in the hypothalamic-pituitary-gonadal axis. These changes are induced largely by nutritional factors but psychological factors may also be involved.

Variations in referral pattern to the psychiatric services by general practitioners.

Abstract: Referral rates to psychiatric services in North-East Scotland by 147 individual urban and rural general practitioners were calculated. Among city doctors, the greater the number of years since qualification the more patients were referred. Single-handed city doctors also had very high referral rates. Subsequent interviews were conducted with 76 general practitioners. Topics covered included reasons for referral to psychiatric services. Psychotics, severely depressed patients, alcoholics and violent patients were the most frequently referred groups.

Tranylcypromine ('Parnate') overdose: measurement of tranylcypromine concentrations and MAO inhibitory activity and identification of amphetamines in plasma.

Abstract: A case of tranylcypromine overdose is reported. Tranylcypromine, amphetamine methamphetamine and phenylethylamine were detected in the plasma by gas chromatography and their identity confirmed by mass spectrometry. The data suggested that the amphetamines were metabolic products of tranylcypromine. Platelet monoamine oxidase activity was more than 95% inhibited during the 72 h after the overdose despite complete clinical recovery by that time. The possible role of amphetamines and phenylethylamine in causing the clinical manifestations of tranylcypromine overdose is discussed.