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In autumn 1996, under the Presidency of Dr Robert Kendell, the College decided to mount a campaign to tackle the stigmatisation of people with mental illnesses. In 1997, a working party proposed goals, content, process and a 5-year governance. Other campaigns, both here and abroad, have either generically addressed ‘mental health problems' (e.g. Mind's ‘Respect’ Campaign) or targeted a specific mental illness, e.g. the World Psychiatric Association's anti-stigma campaign in respect of people with schizophrenia. Our working party decided that it might be timely to recognise the differences in public attitudes to the variety of mental illnesses. The campaign thus addressed six categories of mental illness: anxiety disorders, depressive disorders, schizophrenia, the dementias, eating disorders, and drug and alcohol misuse/addiction. Target populations were identified as doctors, children and adolescents, the workplace, the media and the general public. The working party had also secured funding and arranged for a survey, in July 1998, by the Office for National Statistics of opinions of the British public concerning people with these mental illnesses (Crisp et al, 2000). The Campaign started on 7 October 1998. Since that time, and drawing upon our survey findings within its initial literature review (Kelly, 1999) the Department of Health mounted its own anti-stigma campaign, ‘Mind Out for Mental Health’, which addressed a similar range of mental illnesses.

The College Anti-Stigma Campaign website ( ) came of age with the launch of a 4 week long display of 2000 advertisements on London Underground trains, starting 4th July 2002. [Figure 1][1] reveals the immediate impact on the website hit rate, with a five or six-fold

The multi-disciplinary team of Becker and colleagues elegantly present their findings addressing aspects of the impact on Fijian schoolgirls of exposure to Western television (Beckeret al, 2002, this issue). These findings support the notion that such exposure has generated disordered eating, underlying body dissatisfaction and intergenerational conflicts within the family that may, in part, be fuelling the process. Focusing on the expected escalation of such disordered eating in this population under these circumstances, their study was naturalistic in capitalising on the recent introduction of television to Fiji, with the first survey of these schoolgirls taking place within 1 month of its advent. The second survey was 3 years later in 1998. The authors point out that the traditional Fijian culture has ‘supported robust appetites and body shapes'.

Our 5-year long campaign to reduce the stigmatisations of and discriminations against people with mental illnesses, launched as an outline endeavour in October 1998, is now in its third year. This update is intended to reveal that since 1998 we have been constructively busy and are poised to go public’ in major ways. We are now therefore appealing to the membership at large to join in the tasks. To this end we have been busy generating a tool kit that you may wish to draw upon and a series of proposed projects, some of which are already underway and some of which you may be able to pick up on or adapt for local purposes, in addition to any of your own initiatives.

This time-honoured propensity has probably served humankind and its ancestors well in the service of species and related personal survival. Such biological mechanisms as those subserving immediate survival, the quest for food, reproduction and related territorial needs are presumably its foundation

A woman aged 80 years had suffered with anorexia nervosa in adolescence and the condition was rekindled after 50 years of remission. The remission was seen in the light of affective disorder and a chronic grief reaction.

It is a paradox that many areas of specialised and highly specialised practice in psychiatry are commonplace within medical practice in general. Problems of mother and baby psychia try, chronic pain, psychiatric aspects of brain injury and related rehabilitation, resistant affective disorder, personality disorder, disor ders of eating, sleeping and sexual dysfunction, all judged to have major psychopathological elements, are ubiquitous, many throughout the life-span. Certain treatment approaches such as behavioural and cognitive psychother apy and family psychotherapy fall into the same category. All of them have generated one or more National Health Service (NHS)services within the UK under the umbrella of psychia try. Some of them impinge on Health of the Nation concerns. Many of them also fall into the realm of human biology rather than neuropathology which is often a more mainstream interest within psychiatry. Yet many of them also significantly overlap with and sometimes un derlie mainstream psychiatric illnesses. The specialised services have a definite stand ing in our College. In contrast, the highly specialised services usually develop under the wing of academic clinical psychiatry and are fragile. A senior clinical academic retires and the service must be picked up by an NHS appointee if it is to survive. These days it must be obviously financially viable for it to stand a chance ofbeing considered it must earn its keep including around 30% for management costs. For those of us working in these apparent fringes, the evidence of the last few years has been depressing. Some highly specialised services have disappeared abruptly before serious consideration could be given to their merits in terms of wider clinical need, profes sional development and other teaching and research potential. If this haemorrhage is to be staunched, then certain steps had best be taken now. A nation-wide identification of existing highly specialised services

Eighteen psychiatric trainees from St George's Hospital were placed in three local general practices for periods of six months each. The aim was to broaden their postgraduate education by an experience of primary care and to test the feasibility of such a scheme. Their assessments of the placement were canvassed by postal questionnaire. All considered the experiment a success but there were a number of problems. Resistance among the trainees was much greater than expected. Some of the relationships in practice posed problems for them and the ongoing demands of their psychiatric training exceeded the practices' expectations. Supervision by the GP trainers was rated very highly and old knowledge returned rapidly.

Within medicine, psychiatry is seen as a specialist subject, especially insofar as it deals with psychosis and other severe mental illness. Accordingly, it is often taught in medical schools alongside other so-called specialist subjects such as paediatrics and obstetrics and gynaecology. These are seen to contrast to generalist subjects such as medicine and surgery, but which them selves are usually taught within the framework of highly specialised firms concentrating on one or two organs or systems within the body. Within psychiatry there are specialist areas of practice. Some of these are recognised formally by our College and by the health service, e.g. child and adolescent psychiatry, psychiatry of addictive behaviour, psychiatry of learning dis ability, and forensic psychiatry. Others are less generally recognised and are more likely to be the consequence of idiosyncratic service or research developments, e.g. disorders of eating, sleeping and sexual function, neuropsychiatry, and puerperal disorders. This applies also to certain treatment approaches. For instance, milieu therapy and behavioural psychotherapy are less universally developed in psychiatric practice within the health service than is dynamic psychotherapy. Paradoxically it is some such categories of highly specialist practice which reflect more commonplace disorders within the general population. Psychiatric teaching to undergraduates often focuses on the major illnesses and their treat ment and management. All students clearly need to know how to identify the major psychoses and to know, in broad terms, about their long-term management, both in respect of compliance problems, and the importance of teamwork, management skills and working in the com munity alongside primary care systems. Psy chiatry provides a most useful and potentially well structured opportunity for medical students to experience working in the community. Medical students also especially need to know in a thorough way about the protean expressions of depression and how to assess suicide risk. However, other subject areas are equally impor tant for the medical student, and psychiatry is often turned to as a discipline that might be able to contribute to and take the lead in such teaching. One such area which psychiatrists themselves have a variety of views about their competence to spearhead in this way is 'communication skills'.

Some of the proposals in Achieving a Balance (DHSS, 1987) seem to have developed with little regard for postgraduate training in psychiatry. In psychiatry it has become common practice for SHO posts to be incorporated in training schemes with registrar posts, allowing several years of overall basic specialist training in preparation for obtaining the MRCPsych. This is in accord with the GMC Education Committee's position (GMC, 1987a) that specialist training can, on the ‘fast track’, follow on immediately from satisfactory completion of pre-registration posts (general clinical training) and full registration. Achieving a Balance states clearly that specialist training begins at registrar level and that any doctors in SHO posts should be receiving further general training. There are few guidelines concerning the necessary nature of such general training.

The theme of this book is the public's perception, often stigmatising, of mental illnesses and the impact this can have on compliance with pharmacological methods of treatment. This is considered in relation to strategies for tackling stigmatisation and related discrimination against medical

It is likely that our propensity to categorise people, and then to distance ourselves from and discriminate against certain groups, has time honoured instinctive (Gilbert, 2000) as well as more recent intra-psychic (Hughes, 2000) and sociocultural origins. One campaign working party with members drawn from such fields as cultural anthropology, sociology, behavioural psychology, psychoanalysis, human biology and psychiatry is currently attempting to shed light on this complex matter. The aim is to be helpful to the main thrusts of the Campaign to reduce prejudice and discrimination.

Records of ill people being stigmatised exist over the centuries, especially individuals with mental disorders and related mental health problems. Ingredients of such stigmatisation include a belief that such disorders are often self-inflicted and resistant to change. Also, the perceptions that those with them are dangerous and present major difficulties in social interaction (Hayward & Bright, 1997). Such stigmatisation then takes many behavioural forms, including abuse and social distancing. These same disorders are common and, overall, they comprise the largest group of health problems in the country today. For a century or more the public has been protected by the existence of mental hospitals. With their closure and the emphasis now on community care, public concern seems to be mounting and stigmatisation of those afflicted worsening.

In October 1991 the then Secretary of State for Health, William Waldegrave, appointed Sir Bernard Tomlinson to act as adviser on health services in London. Early on it was agreed that Sir Bernard would also take account of the role of these services in teaching and research. Previous reports have focused on one or other aspect, e.g. the Todd Report (1966) and Flowers Working Party Report (1979) primarily considered teaching and research while the report of the London Health Planning Consortium (1979) mainly addressed provision of services. While the former two reports have been followed by extensive change in the organisation of medical academic activities in London, there has been much less change in health care delivery. For instance, primary care and community care are still seriously deficient in parts of London while high technology hospital based medical practice, sometimes providing a nationwide service, has survived and sometimes continued to develop in an entrepreneurial way. The problem is riven by academic and professional concerns of nationwide relevance and importance.

Medical practice can be reframed in terms of research and teaching, possessing and using the relevant knowledge, skills and attitudes. The doctor's curiosity and the diagnostic challenges of medical practice (and in particular of psychiatry) demand a capacity to think systematically, measure comprehensively and accurately and analyse the information obtained within the consultation as a preamble to management and treatment. The word ‘doctor’ means ‘teacher’ and the same communication skills are essential to both professions. Psychiatric practice is especially dependent upon them. They are also often essential for good clinical research.

Thirty out-patients with severe anorexia nervosa were randomly allocated to either 12 sessions of dietary advice or 12 sessions of combined individual and family psychotherapy. At one-year follow-up both groups showed significant overall improvement, and the dietary advice group showed significant weight gain. A similar mean weight gain for the psychotherapy patients did not reach statistical significance, but this group made significant improvements in sexual and social adjustment.

I took up my present appointment at St. George's Hospital Medical School in 1967 and found myself with friendly colleagues and a tradition of undergraduate teaching of psychiatry extending back to the immediate post-war period. This tradition had also been expressed in the textbook Psychological Medicine, written and revised over successive years by Guttman, Curran and Partridge, and in more recent years by Peter Storey, currently a senior colleague here. The book is hallmarked by its clarity of expression and the richness of its clinical observation, and has for long been a favourite with both undergraduates and postgraduates.

Ninety-six out of 137 consultant psychiatrists working for the majority of their time in the London area outside academic units returned questionnaires concerning attitudes to their work. Analysis of the 88 fully completed questionnaires suggested the existence of four relatively discrete but overlapping patterns of psychiatric practice in the Regions concerned, of which two largely excluded individual psychotherapy. These findings are discussed in relation to the education in psychotherapy of trainee psychiatrists working in mental hospitals.

SummaryTwenty-seven consecutive male patients suffering from anorexia nervosa were fol lowed-up 2–20 years after presentation; 20 had been treated with an in-patient refeeding/psychotherapy regime. The outcome of the series compared very closely with a similar group of female anorectics: 12 (44%) had a good outcome, stable weight restoration and normal sexual functioning; seven (26%) had an intermediate outcome, and eight (30%) poor (weight more than 15% below normal, and poor or no sexual activity). No patient had died. Good outcome in terms of weight was associated with good psychological and social functioning, while poor outcome was clearly associated with a longer duration of illness, previous treatment, and greater weight-loss during illness, although not with any specific dietary behaviour. Poor relationship with parents during childhood and the absence of normal adolescent sexual behaviour premorbidly were also strongly predictive of poor outcome.

SummaryFor the past fifteen years we have been studying aspects of relationships between sleep, activity, nutrition and mood. This paper comprises a brief statement of some of this research and our views to date.

The Middlesex Hospital Questionnaire (M.H.Q.) is a brief self-rating inventory with eight questions on each of six scales—\`anxiety' (Anx), \`phobic' (Pho), \`obsessional' (Obs), \`somatic' (Som), \`depression' (Dep) and \`hysteria' (Hys). In the present study the M.H.Q. was administered to a sample of 778 persons, mainly between 40 and 65 years, who were on the list of a general practice. The distributions of scores obtained on each of the six scales are displayed. The locations of the means and the spread of the results are considered suitable for a measure designed for the detection of high scorers. Positive correlations with age are shown with the scores on the \`depression', and even more with the \`somatic' scales. The majority of scales produce higher scores with females, but the sex difference itself varies noticeably with age, being greater in the 50-54 age group. `Hysteria' apart, the scales all show a positive correlation with each other, varying from 0.28 to 0.56.

Behaviour therapy is conducted in this department under combined general psychiatric and behaviour therapist supervision. Patients considered suitable for behaviour therapy are first assessed clinically at a phenomenological and psychodynamic level. On the basis of this assessment an appropriate symptom or number of symptoms are selected for treatment by behaviour therapy. The patient is thereafter observed by the original clinician and assessed at regular intervals. Meanwhile the behaviour therapist treats the specific symptom or symptoms.

The conduct of this survey has brought home to us the great diversity which exists in the amount, content and methods of teaching psychiatry in U.K. medical schools today. No two schools are quite alike in the type of staff facilities, in the allocation of teaching time in the several years of the course, or in the persons available to act as teachers. After two trial runs, we evolved a schedule of inquiry which has enabled us to compare schools in a number of respects in which reasonably reliable and quantifiable data were available. This report necessarily concentrates upon those aspects in which the various schools can be compared with each other: it does not do justice to the full detail of all the teaching given in any one school. In particular, we have deliberately confined our attention to teaching which is given to all students, whether they take advantage of it or not. Except for some observations on organized periods of elective study, we have not dealt with the extra opportunities which arc available in a number of schools for students who go out of their way to seek additional experience in psychiatry. Our schedule of inquiry was discussed by one of us personally with the psychiatrist responsible for teaching in every school except one—a London part-time teacher who remained obdurately “too busy” to comply with this request. It was found necessary, in the majority of cases, to supplement our interview and the schedule return by further inquiries; in a few particulars, and in respect of certain schools, we are still left in some uncertainty as to the accuracy of the information given to us. This report is submitted, however, as the best approximation possible within the limitations of our survey.

A treatment regime for anorexia nervosa is described. It combines the administration of chlorpromazine and controlled dietary intake with psychotherapy to the patient. The immediate and follow-up (an average period of 1½ years) clinical status of twenty-one patients, treated in this way, is presented. Treatment is often a long-term matter and the pitfall of regarding the patient as "cured" because there has been an immediate substantial weight gain as a result of treatment is evident. Thus, while nineteen patients initially regained a normal body weight, only nine are regarded as having so far achieved a normal pattern of eating behaviour and an adequate heterosexual and social adjustment with prospects of freedom from further illness.

EEG recordings were performed on 32 patients with classical anorexia nervosa before the onset of treatment. A control group matched for age and sex was examined under identical conditions. The recordings were examined blind. A significantly greater number of patients displayed generalized abnormality of the EEG background activity and had unstable responses to hyperventilation. Four patients had bilaterally synchronous fast atypical spike and wave discharges. One control subject, the identical twin of a patient, showed concordance with her sister in this respect. There were significant associations between the prevalence of abnormality of the background rhythms, instability of the hyperventilation response, and the duration of illness and presence of electrolyte depletion. Those patients with stable overbreathing responses tended to have higher blood sugar and lower plasma insulin levels. Severe hypothermia in 2 cases was accompanied by marked slowing of the dominant frequency. The patients with spike and wave discharges had a clinical history of epilepsy, either spontaneous or iatrogenic.

In the practice of our department at the Middlesex Hospital, the need has been felt for a means of rapid quantification of common symptoms and traits relevant to the conventional diagnostic categories of psychoneurotic illness. Until now, none of the available British scales have fulfilled this requirement. The most widely used is the Maudsley Personality Inventory (Eysenck, 1959) with its subsequent modifications. This, however, although scientifically based, is limited to the assessment of broad categories such as “neuroticism” and “extraversion” which appear to go only a small way towards describing the wide variability of psychoneurotic disturbances. Foulds and his co-workers (Foulds, 1965) have for a number of years developed personality scales in which clinical sophistication and a rigorous methodology are combined. Their Symptom-Sign Inventory, however, consists of eighty questions which have to be presented orally. Furthermore, although the inventory covers psychotic disturbances, it is necessary to use an additional questionnaire, the Hysteroid-Obsessoid Questionnaire (Caine & Hawkins, 1963) to complete the spectrum of psychoneurotic illness. Moreover, the concept of psychiatric illness developed by these workers is individual rather than conventional in a number of respects. The Tavistock Self-Assessment Inventory (Sandler, 1954) is too long for the present purposes (876 items in six booklets). The Taylor Manifest Anxiety Scale (Taylor, 1953) is short and convenient, but it measures one dimension only. As many doctors, including psychiatrists, find it useful to think in terms of orthodox clinical categories for diagnostic, therapeutic, prognostic and research purposes, it was decided to design and attempt to validate a self-rating scale adapted to these categories, taking the patient 5–10 minutes to complete and capable of being rapidly scored by the doctor or an assistant.

SummaryA case is described of anorexia nervosa arising in a mentally-handicapped 35-year old person with Down's syndrome. The late onset is accounted for on the grounds that adolescent challenges had only recently arisen in this instance. Removal of the patient from the provocative situation, coupled with some effective psychotherapeutic ‘grief work’ with the family, was associated with restoration of normal body weight and menstrual function, following the patient's acceptance of the usual re-feeding treatment programme.