The concept of schizophrenia has changed since it was first introduced by Kraepelin. To overlook or misunderstand this evolution will lead to confusion with adverse effects on the clinic and on research. Kraepelin's exclusively somatic approach to the study of the illness gave rise to a variety of attempts to provide a wider theoretical framework which will accommodate a subjective psychological approach. The first of these attempts was that by Bleuler and Jung, but it brought with it new difficulties. Jaspers' methodology was applied to the study of schizophrenia by Schneider, and it creates the theoretical space which will accommodate both the objective and subjective study of the illness and its victim as a person. An attempt is made here to outline a brief history of these ideas.

An evaluation of the prevalence of Schneiderian first-rank symptoms, and their diagnostic and prognostic value is described. 35.2 per cent of schizophrenic patients had first-rank symptoms. The presence of first-rank symptoms did not indicate either chronicity of illness or a poor outcome.

Platelet monoamine oxidase (MAO) activity was compared in four age and sex-matched groups: monozygotic (MZ) twins discordant for schizophrenia, normal MZ twins, normal dizygotic (DZ) twins and unrelated individuals. Among the twin groups, schizophrenic and normal, there was a remarkably consistent degree of genetic control amounting to 70–80 per cent of the variation in activity. The mean platelet MAO activity of the schizophrenic twins was significantly lower than that of controls, but not than that of their psychiatrically well, neuroleptic-free cotwins; indeed the correlation for the MZ twins discordant for schizophrenia was almost exactly the same as that for the normal MZs. Thus, lower platelet MAO activity in schizophrenia, where it is found, is genetically modulated and not the result of the illness or its treatment.

When mildly and severely mentally retarded people saw photographs showing expressions of basic emotions their overall performance was found to be correlated with intelligence. Certain specific patterns of confusion were determined, clinically the most significant being an inability to cope with high intensity emotions.

Of 156 discharged patients, the forty who succeeded in open employment had shown before they left hospital a combination of significantly less clinical disability, less abnormal behaviour, better work performance and better relationships with other people. We specify the approximate levels of these variables that were required to get and hold a job in the 1970s.

A new series of patients with personality disorders has provided an opportunity to extend to both sexes an earlier finding that personality disordered women tend to be mixed handed. Eighty-one subjects completed Annett's handedness questionnaire. The frequency of mixed hand preference in both sexes was similar to that found in the previous study, though deviations from consistent preference were small and dependent on the method used to classify handedness. The hysterical, antisocial and explosive personality types were particularly likely to have mixed handedness. These associations were reflected in small but significant trends among several psychometric variables.

Using radioimmunoassay techniques, serum levels of depot neuroleptics, fluphenazine and flupenthixol, were estimated in two groups of chronic schizophrenic patients with, and without, tardive dyskinesia. There were high correlations between drug dose and plasma concentration. There was no significant difference in dose-related serum levels of either drug between the groups.

The hypothesis that patients with tardive dyskinesia develop the syndrome because they do not metabolise neuroleptics as efficiently as those without the syndrome was not supported by the data.

In a prospective study the criteria and characteristics associated with the admission of acutely ill psychiatric patients to in-patient or day hospital care were examined. Over a four-month period, 54 patients were admitted to hospital and 43 to a day hospital. There were significantly more schizophrenics in the hospital. Day hospital patients were significantly younger, had shorter psychiatric histories, were considered less severely ill and had more insight into their illness. Hospital patients had poorer employment histories, and perceived their families as less supportive; admission had more often been requested by them or their families.

Using data from the Salford Psychiatric Case Register, point-prevalence patterns of service use in Salford County Borough are compared for 1968 and 1978 with respect to type of care, age and diagnosis. In a declining population, overall point-prevalence ratios increased from 9.52 to 13.44/1,000 adults, due almost entirely to two extensive new services — “injection-only” nurse contact with out-patients, and community psychiatric nurse domiciliary contact. Their development has apparently hardly affected use of other services. The increase was similar in most age-groups and in the predominating diagnostic groups (schizophrenia and depression). Prevalence ratios for long-stay patients barely changed in total, and increased for those accumulated in a ten-year period, but there was an upward shift in age. Day care increased, but its contribution remained relatively small. The diagnostic distribution of social work contact changed, as community psychiatric nurses (CPNs) assumed domiciliary care of people with schizophrenia.

In 23 young male adults with antisocial personality, mostly guilty of violent crimes, insulin measurements during the glucose tolerance test showed an enhanced insulin secretion only in those with unsocialized aggressive conduct disorder. The hypothesis that in antisocial personality there are at least two aetiologically different groups is supported.

This study was designed to replicate and extend earlier findings. Evoked potentials (EP) were recorded, using a task of varying complexity involving shape discrimination, with matched groups of obsessional and normal subjects. Results confirmed previous findings that obsessional patients are characterised by reduced amplitudes and decreased latencies of late EP components; divergencies between the groups were more marked for tasks of increased complexity.

Seventy severely depressed patients randomly assigned to receive 8 real or sham ECT were further subdivided on the basis of degree of recovery from depression afterwards. In comparison to a non-depressed control group the depressed patients were impaired on a wide range of tests of memory and concentration prior to treatment, but afterwards performance on most of the tests had improved. Real ECT induced impairments of concentration, short-term memory and learning, but significantly facilitated access to remote memories. At 6 month follow-up all differences between real and sham ECT groups had disappeared. On the majority of tests the previously depressed patients now performed at the same level as the control group. There was some evidence that a subgroup of treatment-resistant patients (poor outcome after real ECT) were significantly more likely to complain of memory problems 6 months later.

Two women who both experienced a psychotic illness after each of three consecutive pregnancies are described. Subjects who are at high risk for post-partum psychotic breakdown offer an almost unique opportunity for prospective tests of hypotheses about the aetiology of severe mental illness.

The phenomenon of post-treatment depression in schizophrenia has become the subject of considerable controversy regarding its causality (Ananth and Chadirian, 1980; McGlashan and Carpenter, 1976a). But as the recent commentary by Hirsch (1982) emphasizes, the most controversial issue is focused on whether this depression is neuroleptic-induced. Hirsch himself refutes neuroleptic-induction on the basis of various uncontrolled data which seem ostensibly incompatible with this causality. Results indicating that pretreatment depressions appear in a high proportion of recently hospitalized schizophrenics, occur in drug-free patients, and frequently remit or decrease following neuroleptic therapy are cited as evidence contradicting neuroleptic-induction. Hirsch therefore proposes an alternative view: that this post-treatment depression is an integral, “revealed” aspect of the schizophrenia syndrome which arises from the same pathophysiological process (cf. McGlashan and Carpenter, 1976b).

My association with the psychosurgical unit now carrying out over 80 per cent of these operations in Britain affords an unusual opportunity to assess the management of treatment-resistant affective disorders by a large number of psychiatrists from various parts of the country. The psychiatrists likely to refer patients for psychosurgery would be expected to be those more inclined to use psychotropic medication and physical treatments in general. Nonetheless, our experience is unequivocally of a widespread under-use of antidepressants. Most referral letters state that ‘… just about every antidepressant has been tried …’, but it is rare for the maximum dose of each drug used to be quoted. The letters suggest that with resistant illnesses the prescription of a series of drugs one after another at the usual doses is the therapeutic strategy, rather than giving one drug only in progressively increasing amounts to the limit of tolerance. Of course, the doses recommended by drug companies are understandably cautious and sometimes excessively so. For example, MIMS (November 1982) gives for “Anafranil” (Geigy); “More severe cases, 75 mg daily or more if necessary” and for “Surmontil” (M & B) “50–75 mg as single dose”.