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Separation anxiety continues to be implicated as an early risk factor to adult emotional disorder but recent research findings are somewhat contradictory. Inconsistencies in approaches to measuring memories of early separation anxiety may have contributed to this lack of clarity. We report the development of a brief self-report instrument, the Separation Anxiety Symptom Inventory (SASI), which was designed to overcome some of these deficiencies in measurement. The SASI was shown to have a coherent factorial structure, high internal consistency (Cronbach's Alpha > .80) and test-retest reliability over an average of 24 months (Intraclass Correlation Coefficient = .89), with serial scores not being affected by changes in contemporaneous anxiety levels. Some index of the validity of the measure was achieved by (a) comparing SASI scores of index twins with descriptors of their "insecure" behaviours in early life provided by corresponding co-twins; (b) comparing SASI scores with retrospective DSM III-R diagnoses of early anxiety disorders obtained by structured interviews; and (c) examining SASI scores in subjects with histories of school refusal. The SASI provides a useful standardised measure which will aid in the further testing of the separation anxiety hypothesis of adult emotional disorder.

Attachment theory has proposed that early separation anxiety is a risk factor for adult anxiety disorder, with the recent focus being particularly on panic disorder. The results of empirical studies examining this link are, however, contradictory, possibly because of inconsistencies across studies in measuring memories of early separation anxiety. In the present study, a psychometrically sound measure, the Separation Anxiety Symptom Inventory (SASI) was used to compare memories of such early symptoms in panic disorder (including those with mild phobic-avoidance), generalised anxiety disorder and control subjects. Anxiety patients as a group returned higher SASI scores (p < 0.001) with a non-significant trend for panic disorder patients to score higher than those with generalised anxiety. These results suggest that early separation anxiety may be a harbinger of adult anxiety and that risk of panic disorder may be higher in the most severely affected youngsters. As a risk factor, early separation anxiety does not however appear to be uniquely related to adult panic disorder.

When relationships are found between parents' and children's behaviors it is usually assumed the parents' behaviors produced those of the children. Forty-four young adult males and 36 young adult females reported the degree to which they showed various sex-linked behaviors and feelings of same versus opposite sex identity in childhood, and adolescence, and currently. These behaviors accounted for up to 57% of the variance of measures of the quality of relationships with parents. In men, opposite-sex-linked behaviors and identity correlated most strongly with current negative parental and particularly paternal relationships. They also correlated strongly with negative paternal relationships in childhood. Some sex-linked behaviors and sex identity items in men correlated positively with maternal overprotection in childhood and adolescence. Correlations between women's sex-linked behaviors and sexual identity items and their parental relationships were weaker but more consistently negative. As in men, opposite-sex-linked behaviors and identity in women correlated most strongly with current negative paternal relationships. The pattern of the associations and the finding that many opposite-sex-linked behaviors in subjects' childhood correlated most strongly with negative parental relationships in early adult life suggest that the parents' feelings could be partly a response to, rather than totally causal of, the subjects' sex-linked behaviors.

A selective review of the literature describing treatment of refugee survivors of torture and trauma revealed that approaches to psychotherapy used in treating South American patients differed from those used in treating Indochinese patients. South American patients were receptive to psychodynamic psychotherapeutic approaches that focused on detailed recollection of past trauma. Indochinese patients responded to a broader-based rehabilitation approach that could include psychotropic medication, supportive psychotherapy, and assistance in meeting practical needs. The authors suggest that many of the differences in treatment of the two groups may be attributed to cultural factors, with South American patients reflecting an affinity for the Western philosophical assumptions in which psychodynamic therapy is rooted and Indochinese patients reflecting a cultural background that values responsibility to the group, deference to authority, and restrained modes of emotional expression.

Growing recognition that the world faces a modern epidemic of torture has stimulated widespread interest amongst mental health professionals in strategies for the treatment of survivors. In this article we outline the distinctive experiences of torture survivors who present for treatment in western countries. These survivors are usually refugees who, in addition to torture, have suffered a sequence of traumatic experiences and face ongoing linguistic, occupational, financial, educational and cultural obstacles in their country of resettlement. Their multiple needs call into question whether "working through" their trauma stories in psychotherapy will on its own ensure successful psychosocial rehabilitation. Drawing on our experience at a recently established service, we propose a broader therapeutic aim.

There is extensive evidence that subjects who identify as homosexual show opposite sex-linked behaviours. However no attempt has been made to investigate whether a similar association exists between such behaviours and the presence of homosexual feelings in the predominantly heterosexual. Eighty medical students completed an anonymous questionnaire reporting the ratio of their heterosexual to homosexual feelings and the presence of sex-linked behaviours in their earlier life and currently. As in previous studies correlations between opposite sex behaviours and subjects' degree of homosexual feelings were found in the male subjects. Correlations remained present, though mainly at a weaker level, in the predominantly heterosexual students. It is suggested this evidence of a dimensional relationship between opposite sex-linked behaviours in childhood and degree of homosexual feeling in adulthood renders irrational the classification of such behaviours as a gender identity disorder of childhood when homosexuality in adults is not regarded as a disorder.

A recent study visit to North America impressed on me the seriousness with which Australian psychiatry should consider the recent ideological shift in the USA to an extreme biological model of mental disorders. There is increasing evidence that proponents of this model are not simply promoting the value of biological research (with which few psychiatrists would quibble), but that the field is at risk of being overwhelmed by a reductionistic "biologism" which assumes an organic causation for all abnormal human behaviour.

Many immigrants to Australia are refugees, some of whom have experienced acute stress and trauma, including torture, prior to or during their escape from their home countries. In response to a growing recognition that the health care services may not be meeting the needs of these people the NSW Department of Health funded the establishment of a community-based rehabilitation service for traumatised refugees. This paper provides an overview of the recent history of the service, some of the organisational and staffing issues faced during its first year, some characteristics of the first 200 clients, principles of treatment, clinical, nosological and therapeutic issues and relationships with other agencies.

A substantial number of refugees arriving in Australia are the victims of torture and other forms of organised violence. In this article, the authors provide an overview of the broad range of physical and emotional disabilities that arise from these experiences, examine the special difficulties in identifying and assessing patients at the primary health care level, and offer an approach to counselling for survivors and their families.

The death of the well-known black leader, Steve Biko, in detention in South Africa in 1977 has continued to generate debate in the international medical literature. The three doctors who examined him during his terminal illness made a diagnosis of malingering in spite of overwhelming evidence suggesting that he had suffered extensive traumatic brain injury while in detention. The inquest into his death provided a rare insight into the manner in which state doctors function in relation to the police of a repressive regime. This article documents the relevant testimony from the inquest and explores the reasons for the doctor's mismanagement of Biko. It is suggested that failures in the doctors' judgement were a result of complex influences including the effects of their own social conditioning, the risk of habituation by state doctors to degrading prison conditions, the inroads that Apartheid has made into medical practice, the possibility of reprisal if state doctors oppose the wishes of the police, and, more speculatively, the possibility that the doctors' obedience and passivity were exploited by the Security Police who wished to absolve themselves from responsibility of Biko's injuries. Most importantly, it is argued that the repeated failure of the major medical organizations in South Africa to provide clear guidance and leadership to state-employed doctors increases the risk that individual doctors will continue to succumb to hierarchical pressures to condone acts of state-sanctioned violence against detainees.

We report a controlled study in which we searched for links between early family adversity and recent interpersonal stress in parasuicidal patients. Our subjects reported fewer adverse experiences in childhood than did the younger, predominantly female, patients investigated in previous studies. Nevertheless, 47% of our parasuicidal group, as compared to 19% of control subjects, reported a sequential pattern of relationship difficulties starting in childhood. The pattern of early exposure to neglectful and overprotective parenting followed by recent conflict or separations in adulthood was found to discriminate most clearly between the parasuicidal and control groups. We suggest that factors such as low self-esteem, a sense of helplessness in the face of adversity and an abiding insecurity in intimate relationships may variously account for this heightened vulnerability. We conclude that a history of adverse relationships beginning in childhood should alert primary care-givers to the risk of suicidal behaviour in patients who are exposed to distressing separations or interpersonal conflict.

The hypothesis that panic disorder is a separate biological disease has attracted a great deal of controversy in recent years. One of the cornerstones of this theory is that panic attacks arise spontaneously, suggesting that the illness is generated by an autonomous physiological process. A number of cases are reported that illustrate Beck's theory that cognitive factors are central to the genesis of acute anxiety. Evidence for a developmental/cognitive theory of anxiety is discussed, and it is concluded that a purely biological model for panic disorder is inadequate.

The direct and indirect costs associated with schizophrenia in Australia were calculated using the incidence approach and compared with similar costings of myocardial infarction in Australia and the United States. In Australia schizophrenia affects one-twelfth as many people as does myocardial infarction, yet costs half as much. This is because the stream of costs associated with each case of schizophrenia is six times the stream of costs associated with myocardial infarction. To illustrate the utility of this costing approach, the information was used to estimate the cost-benefit ratio likely to follow the introduction of social intervention strategies. The information also showed that Australian support for research in schizophrenia is inadequate when compared with that for myocardial infarction and quite out of proportion to the cost of schizophrenia to the community.

In recent years, large numbers of South African children have been the target of state-sanctioned abuse, including imprisonment in adult gaols. In spite of the restrictions on the gathering and dissemination of information in South Africa, reports from diverse sources have provided evidence that detainees as young as 11 years of age are subjected to unsanitary and crowded prison conditions, near-starvation diets, intimidation and torture. The immediate and potential long-term effects of this political abuse of children should be of great concern to the medical community.

We selectively review recent research findings in the field of psychoimmunology which test the hypotheses that immunological dysfunction may be aetiologically related to mental illnesses such as schizophrenia, and that certain morbid affective states such as depression and other forms of psychosocial distress may be the cause of immunosuppression and through this mechanism affect the outcome of illnesses such as cancer. Our examination of research implicating immunological or infective mechanisms in the aetiology of schizophrenia indicates that most studies have been unable to control for major methodological difficulties but the compatibility of these theories with the dopamine hypothesis suggests that further research attention is warranted. More clearly, there is growing evidence demonstrating a link between depression, other states of psychological distress and immunosuppression, but the clinical significance of these findings remains uncertain. The complex relationship between stress and the outcome of illnesses such as cancer is discussed and the possible implications of these findings for clinical psychiatry are suggested.

It is commonly believed that patients with agoraphobia have suffered more frequently from aberrant family experiences in childhood. Some authors have described an excess of parental deprivation and others have incriminated parental overprotectiveness. Recent studies have failed to confirm these impressions but, instead, find that agoraphobic patients recall deficits in parental warmth and care during their early years. This report of a Sydney case-control study adds support to the view that parental overprotectiveness in isolation is unlikely to place the child at greater risk of developing agoraphobia in the future. Only when the child experiences a sense of parental neglect and lack of care, either alone or in combination with overprotection, does the risk of agoraphobia in adulthood appear to be increased.

New mental health legislation was enacted in New South Wales in 1983 and, although the reformed Act remains unproclaimed, some of the new procedures have already been introduced into psychiatric hospitals. The spirit of the Act is clearly aimed at protecting the rights of the mentally ill, who are often unable to act as their own advocates. To ensure this protection, it is now routine for solicitors to represent detained patients in their pleas for release. In this report we describe three recent cases that illustrate the difficulties that arise when solicitors and psychiatrists contest the legitimacy of detention orders. The atmosphere of judicial hearings is becoming increasingly adversarial and the public disclosure of sensitive information can provoke unnecessary distress in patients and their families. In the zeal to preserve civil rights, the special needs of psychiatric patients can be obscured, sacrificing the patients' rights to confidentiality, privacy and appropriate treatment. While the involuntary detention of patients is a matter of the utmost seriousness, current procedures, which seem to be modelled on those of the criminal legal system, are proving to be inappropriate to the needs of psychiatric patients.

We report the treatment of a family in which both spouses developed panic disorder, and their son, school phobia, soon after the death of a close relative. The interactional style observed within this family suggested that interpersonal factors were important in the generation of anxiety in each member. Detailed case histories such as the one we report underscore the importance of a systemic perspective when assessing individuals who present with anxiety disorders.

The importance of differentiating depressive pseudodementia from true dementia seems to be well recognized by psychiatrists, yet there seems less recognition that other functional psychoses in the elderly can present with symptoms of cognitive impairment. In this report, we describe two patients--one suffering from late onset schizophrenia and one from a manic illness--who were diagnosed as suffering from dementia in the early stages of their illnesses. We discuss some of the difficulties in making diagnoses in these cases which include an historical tendency for clinicians, including psychiatrists, to assume an organic aetiology for first presentation psychoses in old age. Although the concept of pseudodementia has been criticised in recent years, we conclude that it retains its clinical utility in that it orientates the clinician to the importance of recognizing treatable functional psychoses in the elderly.

A study of 106 pairs of monozygotic (MZ) and 94 pairs of dizygotic (DZ) twins tested the hypothesis that part of the previously described genetic influence on blood lipid levels can be ascribed to closer similarities among MZ than among DZ twin pairs in environmental factors that affect lipid levels. Participants were adult twin volunteers (age 17-66; 64 male and 136 female pairs) who were selected from the NH & MRC Twin Registry or were respondents to advertisements. They completed a 4-day weighed food diary from which mean nutrient intake was derived. Information on lifestyle and demographic variables was obtained by questionnaire and a nonfasting blood sample was taken for measures of total, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol and the HDL2 and HDL3 subfractions. Height and weight were measured, and body mass index (BMI) was calculated (kg/m2). Estimates of the heritability of sex-adjusted lipid levels were 0.72 for total cholesterol, 0.79 for HDL cholesterol, 0.69 for HDL2, 0.20 for HDL3, 1.06 for LDL cholesterol, and 0.44 for sex-adjusted BMI. In all cases except for HDL3, genetic variance was statistically significant. After adjusting for the effects of environmental variables in three different ways, the estimates of heritability were somewhat lower for total cholesterol, HDL2, and BMI, and those for HDL cholesterol (borderline) and LDL cholesterol (definitely) remained statistically significant but were decreased. A genetic influence on HDL3 was not found. Adjusted heritability estimates obtained from one method of analysis were 0.35 for total cholesterol, 0.49 for HDL, 0.04 for HDL2, -0.34 for HDL3, 0.66 for LDL, and 0.32 for BMI. These results suggest that the assumptions made in the classical twin study approach are not appropriate when examining genetic effects on lipid levels or BMI, or indeed on any biological variable that may be affected by environmental factors that tend to be more similar in MZ twins than in DZ twins. In these circumstances, more complex models may be needed to differentiate between genetic and environmental influences.

Little attention has been paid to the situations which provoke the initial attack of anxiety in agoraphobia. According to the behaviour completion hypothesis many normal subjects experience increased tension in such situations when there is a delay in the completion of a behaviour. One hundred and eight medical students completed a questionnaire designed to investigate this hypothesis. They reported experiencing increased tension or anxiety significantly more frequently in situations provoking agoraphobia when the situations contained a component of delay, as compared to such situations without this component, or to situations not commonly provoking agoraphobia. It is proposed that tension, anxiety and panic form a continuum of increasing levels of arousal, but are associated with different cognitions. It is further proposed that the arousal level of agoraphobics is sensitized, so that delay which provokes mild increases of arousal in the healthy, provokes high arousal in agoraphobics. This finding supports the hypothesis that delay in behaviour completion is a mechanism in the generation of tension and anxiety.