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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'.

We studied the long-term outcomes of intractable anorexia nervosa treated with leukotomy and specialized psychotherapy over 20 years ago.All traceable subjects were interviewed using the Eating Disorders Examination (EDE) and the Structured Clinical Interview for DSM-III-R (SCID). They also completed questionnaires. Detailed histories were taken.Four of five female subjects were traced. Their cases had been severe, with failure of previous intensive psychotherapy and now with high risk of death from terminal inanition. One patient had committed suicide, whereas the others enjoyed a reasonable quality of life. Persistent core psychopathology was evident, but patients had not succumbed to weight loss. All suffered depression and anxiety-related disorders, but endorsed their treatment, which had allowed sustained weight gain by release of appetitive behavior, provision of a license to change, and alleviation of phobic anxiety, allowing psychotherapeutic engagement.We argue that these outcomes are relatively favorable and would not have been possible without this latter engagement in specialist psychotherapy to address burgeoning panic at unavoidable weight gain.

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.

AIM: To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain. DESIGN: All patients were sent a postal questionnaire for symptom evaluation. SUBJECTS: All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904). RESULTS: 88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing. CONCLUSIONS: In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.

To determine incidence and prevalence of anorexia nervosa in a defined geographical area of south west London, UK, total population 519,900.Hospital and community health workers in the defined area were contacted initially by letter asking them to identify all cases (new or existing) of anorexia nervosa known to them in the period July 1991-June 1992, using DSM-III-R criteria. A semistructured interview was conducted with the respondents to confirm the diagnosis. The large database record of the senior authors' specialist anorexia nervosa service, including inpatient and outpatient service records, was concurrently screened for cases living in the defined area.The prevalence of anorexia nervosa was found by this method to be 20.2 cases per 100,000 population (0.02% total population). Prevalence in females aged 15-29 years was 115.4 cases per 100,000 (0.1% of young females). Similarly, the annual incidence of anorexia nervosa was found to be 2.7 cases per 100,000 total population. In females aged 15-29 years the incidence was 19.2 cases per 100,000.Such prevalence and incidence figures are probably significant underestimates since the disorder can often defy detection or correct diagnosis and, with our own methodology, some identified cases may not have been reported to the study. However, these results can be used as a start for resource planning and service development.

Ninety subjects with DSM-III-R anorexia nervosa were randomly allocated to four treatment options, one inpatient, two outpatient, and one comprising an assessment interview only. Twenty were thus offered a package of outpatient individual and family psychotherapy. At 2-year follow-up, 12 of the 20 were classed as well, or very nearly well, according to operationally defined criteria. Statistically significant improvements over time were obtained for weight, mean body mass index (BMI), and also for psychological, sexual, and socioeconomic adjustments. Weight and BMI changes were significantly better than for the assessment only group, some of whom had received extensive treatment elsewhere. The style of the outpatient therapy and compliance with it are described in some detail and prognostic indicators for the treated and untreated groups presented. Lower weights at presentation and vomiting were associated with poorer outcome, although age and length of history were not.

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.

Disgust with ‘fatness' and a consequent preoccupation with body weight, coupled with an inability to reduce it to or sustain it at the desired low level, characterizes the abnormal normal weight control syndrome. Individuals remain sexually active in a biological sense and often also socially. Indeed their sexual behaviour may be as impulse ridden as is their eating behaviour, which often comprises phases of massive bingeing coupled with vomiting and/or purgation. The syndrome is unlike frank anorexia nervosa in that the latter involves a regression to a position of phobic avoidance of normal body weight and consequent low body weight control with inhibition of both biological and social sexual activity. In abnormal normal weight control there is a strong and sometimes desperate hedonistic and extrovert element that will often not be denied so long as body weight does not get too low. Individuals nevertheless feel desperately ‘out of control’ and insecure beneath their bravura. The syndrome is much more common in females than in males. There is a clinical overlap with anorexia nervosa and obesity in many cases as the disorder evolves. Depression, stealing, drug dependence (including alcohol) and acute self-poisoning and self-mutilation are common complications. Clinic cases probably only represent the tip of the iceberg of a much more widespread morbidity within the general population. Like anorexia nervosa and for the same reasons the disorder is probably more common than it used to be.

A significant relationship between nocturnal enuresis and motility is demonstrated in a 35 year old male patient who had chronic nocturnal enuresis. After further treatment this relationship disappeared and the enuresis progressively diminished.

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.

Although converting-enzyme inhibition is of established value in the management of patients with severe chronic congestive heart failure, troublesome adverse reactions occur frequently during the course of treatment and may cause physicians to interrupt effective therapy. The three most common adverse reactions that are seen in patients with heart failure following treatment with captopril and enalapril (symptomatic hypotension, functional renal insufficiency, hyperkalaemia) are predictable consequences of interfering with the homeostatic functions of the renin-angiotensin system, which evolved millions of years ago to preserve life in sodium-depleted states. It is not surprising, therefore, that these untoward effects can be prevented or reversed by increasing the dietary intake of salt or reducing the dose of concomitantly administered diuretics; their occurrence rarely requires discontinuation of drug therapy. Recognition of this link between sodium balance and the adverse effects of converting-enzyme inhibition is important, because most patients with severe heart failure who experience such untoward reactions can nevertheless be expected to improve clinically during long-term therapy, if effective treatment is not interrupted.

Summary The communication skills basic to good medical practice are, for many of us, unnatural. The authors attempt to address aspects of the matter with particular reference to communication across ethnic boundaries.

Summary Seventeen anorexia nervosa patients were examined dentally and their dietary histories and eating habits studied. Analysis of the data confirmed earlier observations dental deterioration associated with anorexia nervosa. The deterioration included a pattern of enamel dissolution in cases of vomiting, regurgitation, and/or the consumption of large amounts of citrus fruits; and an altered caries response due to abnormal carbohydrate consumption. Despite the patient's probably insistent denial of 'anorectic' eating habits, the general practitioner should consider the existence of anorexia nervosa in the presence of such abnormal features, especially in young women. The relationship of these findings to larger populations with similar eating habits is discussed.

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.

Communication is a major aspect of medical practice in such areas as the consultation, counselling, team work, management duties, health education and teaching. Many communication skills essential to the clinical consultation are different from those used in everyday life. They require an understanding of the doctor/patient relationship and of the self as well as of others. They also require a subserving repertoire of specific behavioural skills. The present paper sets out to emphasize this pervasive importance of communication skills in medical practice and to suggest some educational goals and objectives for those skills of particular relevance to the consultation. It describes one attempt to pursue these within the author's own school despite the piecemeal nature of such teaching. In Britain great emphasis is placed on the importance of clinical skills and this is reflected in the priority given to them in the final professional examination, and yet their communication aspects are rarely well defined within the curriculum or directly assessed. The author advocates the teaching and assessment of communication skills as a continuous process throughout undergraduate and postgraduate medical education for clinical practice.

This paper reports observations following on a study of anorexia nervosa in 34 twins and one set of triplets, and within which approximately half the monozygotic (MZ) twins displayed concordance, compared with 7% of the dizygotic (DZ) twins. One additional case, involving childhood adoptions, is described, wherein neither genetic nor specifically assortative selection factors seem to have been at work. The findings suggest that genetic and environmental factors can interact to contribute to the development of this apparently culture-based and multifactorially derived condition. A number of possible genetic strands to the condition are proposed; probably not all of them are specifically necessary for its development. The same may apply to experiential influences. Elsewhere it has been argued that the one essential charactistic of anorexia nervosa is avoidance behavior and the factors permitting and facilitating it (Crisp, 1980). Experiential influences, in the form of psychological maturational challenges in adolescence impinging on constitutional propensities to the point of precipitating the disorder out, would seem often themselves to have been influenced by constitutional psychological characteristics and earlier childhood experiences. A further pooling and study of all known twin and adoptive cases might now advance our knowledge of this condition further.

The clinical characteristics of a consecutive series of 36 male anorectics were compared with those of a similar series of 100 female cases. Social class background and mean age of onset were found to be similar as were the majority of clinical features at presentation. Anorexia nervosa was associated with diminished differences between the sexes in terms of physical, experiential and behavioural characteristics directly related to the condition, and in terms of general psychoneurotic characteristics. The condition is one within which the individual is sadly reduced to an existence rooted in the experience, behaviour and impulses of starvation including the impulse to ingest and the consequent defences against this latter propensity and its implication of weight gain. Only the 'choice' of defence relates to premorbid 'personality' characteristics and thereby continues to characterize the individual. Overall the same background and presentation factors in both sexes predict similar outcomes, though a vomiting defence at presentation predicts good outcome for males and poor outcome for females. The condition is very rare in the male and such presentations may help to shed light on its overall nature.

An hypothesis that migraine is the experience of a protective vascular response to cerebral information overload has been explored to a limited extent by examining the association between laterality of the attack and verbal and spatial performances under standard symptom-free conditions. The study was restricted to individuals with unilateral symptoms always presenting on the same side. It emerged that those with classical migraine do not always have prodromata referable to the same side as the pain. Indeed, in the present study, prodromata were almost exclusively referable to the left (dominant) cerebral hemisphere. A subgroup of those with speech disturbances as a feature of the prodromal symptoms was also found to have relatively impaired language abilities on routine testing. It is this finding that lends some support to the hypothesis. The findings also invite the refining proposition that information overload, as defined in the hypothesis, is almost always borne by the dominant (verbal) hemisphere in our species. Such overload might concurrently or sequentially also overtax a suggested limited right hemisphere language capacity, in terms of the hypothesis, accounting for the right-sided pain sometimes presenting in these cases. Otherwise, pain appears to be predominantly left-sided or midline. Perhaps the frequency of this particular syndrome is an indictment of the limitations of language as a basis for communication, as well as reflecting the possibility that most of our stressful transactions and their cerebral processing use a verbal substrate. The results also reveal the need for agreement on rules for classification of laterality in migraine.

Twenty-seven male anorexics have been followed up over 2–20 yr (mean 8 yr) and their outcome assessed. This has been compared with outcome in female patients with similar pictures at presentation ( Burns and Crisp , 1984). Features of the family and personal history and clinical aspects of the disease at presentation were compared with outcome and a number found to be significantly associated with it. Poor relationship with parents during childhood and the absence of normal adolescent sexual behavior and fantasy premorbidly were strongly predictive of a poor outcome. Long duration of illness, previous treatment and greater weight loss during illness were also associated with poor outcome, although no specific dietary behaviour was predictive. The remarkable similarity in outcome pattern between the male and female prompts re-evaluation of some theories of the nature of the role of sexual conflicts in anorexia nervosa.

Rate of weight gain, together with metabolic rate before and after a glucose meal, were studied in a group of 15 female anorexia nervosa patients as their weight was being restored to normal levels. The previously obese anoretic patients gained weight more rapidly, on the same food intake, than those who were of normal weight before their illness began. The increase in metabolic rate (as treatment progressed) was less in the previously obese patients, who also showed a tendency for the metabolic rate to increase less after a glucose meal than the patients with no history of obesity. The thermic effect of glucose was greater in patients with anorexia nervosa than in a comparable control group of six female students.

Psychiatry has expanded rapidly as a medical discipline in the last two decades but has not always been able to recruit sufficient young doctors of ability to its ranks. In view of recent governmental and professional reports on future medical practice we set up a study group comprising members from academic, NHS, sub-specialty, community and in-training psychiatry to examine the present tasks, attractions and constraints within a career in psychiatry and propose possible improvements for further consideration. In marrying these views to foreseeable developments we are sensitive to the requirement to take into account both the needs of the community and the job satisfaction of the future psychiatrist. To this end we indicate briefly our views concerning the attractions that a career in psychiatry currently has for the good graduate and ways in which the provision of interest and stimulation, educationally and professionally, can be increased so as to attract psychiatrists of high calibre both to general adult psychiatry and to areas of the specialist services which are at present unpopular. Finally, we propose a pattern of psychiatric services which we believe will embody both a useful and an attractive specialized job and interesting educational goal for future medical practitioners.

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.

Ophthalmic outpatients without physical signs have been shown, as a group, to be significantly more anxious and depressed than a control group. They also have a higher incidence of somatic complaints of a kind commonly made by patients with psychiatric 'disorder'. There was a higher incidence of past psychiatric history in the proband group, and they also gave a greater subjective assessment of recent conscious life stress.

Cases of 180 anorectics were studied by means of a retrospective analysis of hospital notes. Of these 98 were “nonvegetarian” and 82 were “vegetarian.” The two groups were examined for differences in clinical and social backgrounds. Vegetarian anorectics were more likely to be abstainers, hyperactive, vegans, and to consume large quantities of noncalorific fluid and also showed greater fear of “fatness” than nonvegetarian anorectics. The mothers of vegetarian anorectics were more likely to be weight conscious and the fathers fearful of illness than their counterparts. As families they were also significantly more overprotective and enmeshed. Vegetarianism was especially a feature of anorectics of Asian origin.

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.

Anorexia nervosa has been viewed here as a defensive biologically regressed posture pivoting around the events of puberty and reflecting primary gain. There is rarely any secondary gain - on the contrary life is miserable though still usually possible. The disorder is rooted in psychobiological mechanisms within the individual and in individual and family psychopathology concerning the meaning of body weight and fatness, evoked by the proband's adolescence and its maturational challenges. There are many identifiable 'risk factors' that can influence the evolution of the condition. Treatment requires a combined behavioural and psychotherapeutic approach involving special medical and nursing and psychotherapeutic skills.

Summary The Eysenck Personality Inventory, the Middlesex Hospital questionnaire, and forearm blood-flow were used to measure aspects of psychological status in forty-one patients with the irritable bowel syndrome, who were compared in this respect with twenty-five matched psychoneurotic subjects and with a general population. The results show a positive association between psychoneurotic disorder and the irritable bowel syndrome.