Notwithstanding that (excluding the dementias) they form the core of serious psychiatric illness the 'functional psychoses' lack a satisfactory label. The adjective 'functional' implies that, by contrast with the 'organic' dementias, there are no identifable changes in the brain. Seventeen years of neuroradiological research, backed up by post-mortem studies, have established beyond reasonable doubt that in schizophrenia at least such changes (a modest mean increase in ventricular size, a possible reduction in brain size and loss of asymmetry) are present but their meaning and the relationship to symptomatology is obscure.This modest gain in understanding has done little to illuminate nosology. The failure of the research community to establish whether schizophrenic, affective, schizo-affective and delusional psychoses (the subject matter of this volume) are distinct or overlapping disease entities (and if, in part, the latter -what overlaps with what?) represents the major unresolved crisis in psychiatric research. As this book makes abundantly clear there are an embarrassingly large number of ways of defining schizophrenia (or affective or schizo-affective psychoses) and, although this book does not document the evidence, they define quite different populations of patients. The Diagnostic Q Statistical Manual (DSM 111-R) criteria for example are considerably more restrictive than the criteria of Bleuler. There has been a welcome trend, well illustrated in this volume, towards the application of operational criteria. This helps us to agree on what (for a given purpose) we are going to call schizophrenia. but it docs not tell us whether what we are calling schizophrenia has any meaning in terms of predicting outcome or response to treatment. There is also the problem of labelling whatever illnesses have been excluded from the definition.The authors have provided a useful compendium of the different diagnostic systems that are now in use together with a brief commentary on the origins and application of each. What they have not done is to provide a critique of the validity (or otherwise) of the different systems, or to address the problem of whether there really are separable disease entities. Their own solution (the 'polydiagnostic approach') is to use an array of different criteria. This sounds cumbersome and evades the categorical question. A quite different approach (which I favour) is to accept that the categories are arbitrary, and to deal with continua which are defined by the frequency of occurrence of different psychopathological features (e.g. Schneiderian first rank symptoms, affective flattening, elation). One can then ask questions such as how age of onset and sex relate to form of psychosis, and what are the predictors of early relapse and response to neuroleptic medication without being too concerned about whether this is a case of true schizophrenia (according to x's criteria) or schizo-affective disorder. But for an account of which criteria are actually being used to reach diagnoses and what they...

Post-traumatic stress disorder (PTSD) has been described as the characteristic sequel to extreme events in life such as war and especially torture. This limitation to a single approach in regard to diagnosis and treatment has been criticised as being a too narrow concept to describe the effects following extreme events in life, especially as most studies so far were limited to PTSD and a small range of symptoms or disorders. The study presents data on psychiatric disorders in a group of exiled survivors of torture presenting to an out-patient department for psychiatry. A DSM-III-R-based psychiatric interview, including the general assessment of functioning scale (GAF), an open list of symptoms and the Vienna diagnostic criteria in regard to depression were used to evaluate a broader range of possible sequels. The most frequent present diagnosis in 44 patients seen over a period of 3 years was PTSD (n = 40), but criteria for a present diagnosis of other disorders were fulfilled in 34 patients, even years after torture, mainly major depression or dysthymia (n = 26). Criteria for functional psychosis were fulfilled in 4 patients. Many patients reported symptoms not assessed by DSM-III-R criteria, including feelings of shame and guilt, and ruminations on existential fears. The impairment as indicated by the GAF (mean 59.1) correlated best with the presence of the endogenomorphic-depressive axial syndrome, but not with duration of imprisonment, age or other factors. Research on sequels to extreme trauma should not be restricted to a simple diagnosis of PTSD, but should continue to look for a broader conceptualisation, including neglected categories like the axial syndrome, as PTSD is common, but might not be the only factor of importance for research and treatment. ICD-10 might offer a more adequate interpretation of sequels.

The purpose of the present study is to investigate the relationship between dysphoric states (episodes in which irritable mood is prominent and relatively persistent) and manic-depressive illness. A further purpose is to clarify the probable causal influence of chemotherapy and the social consequences concerning dysphoria. The observations carried out on 14 patients are illustrated by 2 case reports. A strong tie seems to exist between dysphoric state and manic-depressive illness, especially with respect to typical biorhythmic disturbances. Although the origin of such states is generally unknown, there are indications that neuroleptics and lithium may play a major role. Social consequences are on the whole minor, if the disturbances in mood and drive occur acutely and markedly. On the other hand, mild to moderate mood changes (especially when unaccompanied by drive changes) may lead to severe social impairment. The reason for this may be that the latter-mentioned states are misinterpreted by the entourage as personality traits rather than as expressions of an illness.

No abstract

In addition to genetic findings and treatment response, the course prognosis is also meant to be a possible validating criterion for diagnosis and diagnostic systems. In our study we used the polydiagnostic approach (i.e. the simultaneous application of various criteria for diagnosing a given disorder to one and the same population) to test the ability of several diagnostic systems to create homogeneous groups regarding the course (episodic/chronic). We applied Schneider’s FRS, ICD-9, DSM-III, Spitzer’s RDC and the Vienna Research Criteria to 90 patients with the diagnosis of delusional syndrome (aside from any nosological classification), who underwent 6–9 years of follow-up. At the index examination, schizophrenia was most frequently diagnosed with Schneider’s FRS, which apparently encompasses a very heterogeneous group of patients regarding psychopathology and course. Diagnostic systems which allowed the diagnosis of affective disorders despite the presence of mood-incongruent delusional symptomatology (DSM-III, RDC, Vienna Criteria) or offered the diagnosis of schizoaffective disorder (DSM-III, RDC) succeeded in separating subgroups with an episodic course on a statistically significant level. In ICD-9 this significance appeared only after exclusion of the schizoaffective cases from the group of schizophrenias. Our data thus uphold the old rule of thumb that affective symptomatology apparently has a very high prognostic value regarding the course of the illness and is in this respect superior to productive symptomatology (such as delusions and hallucinations), still taken to be pathognomonic for schizophrenia by some of the diagnostic criteria under study. This aspect warrants further investigation and should be taken into account in the development and improvement of diagnostic manuals (e.g. ICD-10, DSM-IV).