Out-patient services in Britain for psychiatric patients have expanded enormously under the National Health Service. Well over half a million patients are seen at clinics annually. Concomitant with this increase the out-patient department has changed in function. No longer is it principally concerned with providing follow up and support for discharged mental hospital in-patients; instead, because of the greatly increased demand for psychiatric care for less severe disorders and under the influence of the movement for community care it now should play a part not at all subservient to the in-patient department. The clinic, properly run, should be an arena of treatment in its own right.

In 1937 an excellent investigation, by Pentreath and Dax, of the work of a London observation ward appeared in the Journal of Mental Science. In the course of their conclusions, they pointed out that: “observation wards are still in their infancy so far as their developmental possibilities are concerned—in fact, we are still in the process of deciding what their purpose should be.” In the ferment of ideas that culminated in the Mental Health Act of 1959, and the fresh insights into administrative psychiatry which have followed, the future function of such units seems to have received little attention. Freeman and Farndale's book Trends in the Mental Health Services (1963) does not introduce the concept of the psychiatric emergency, nor does it consider any special provision for these patients.

Patients with somatic symptoms who fear serious organic disease are frequently encountered in medical practice. Chest pain and palpitation for example may give rise to concern about heart disease, and abdominal pain to fear of cancer. Every case warrants careful consideration, including examination and investigation where necessary. As a result, some will be relieved both of anxiety and symptoms by simple explanation and reassurance, if their fears were ill-founded or misplaced. The outcome may not be so favourable in others, also free of physical disease, who may need expert psychiatric help. Davies, B. (1964), reviewing the literature, reported a mean incidence of 27.3 per cent. of medical out-patients with purely psychiatric illness, and a further 10–40 per cent. with mixed organic and psychiatric conditions in those attending general hospital clinics.

Every medical out-patient clinic contains a percentage of patients who are examined, investigated and eventually discharged, no structural lesion having been found to account for their symptoms. The term “functional” is used in this paper to describe such patients; i.e. those who have a disorder of the function but not of the structure of an organ, whether or not the disorder is regarded as primarily psychogenic. The purpose of this investigation is to examine carefully these out-patients and try to identify them more clearly by comparison with those in whom structural disease can be detected, with particular reference to the mental state.

It is now widely held that many psychiatric patients who would formerly have required institutional care may be maintained in health outside hospital. It is also sometimes suggested that mental illness may be prevented by suitable extramural agencies. For these purposes out-patient clinics, day clinics, domiciliary visiting and social clubs have all been recommended and used in numerous countries. Amongst these measures social clubs for elderly psychiatric patients can be expected to play a useful part, but have so far received little formal description. One of us (Smith, 1963) has reported elsewhere the organization, economics and characteristic atmosphere of such a club. We present here some data on the type of patient who may benefit from such a club and the effect upon his/her record of hospital treatment.

The term “koro” refers to an unfamiliar state of acute anxiety with partial depersonalization leading to the conviction of penile shrinkage and to fears of dissolution. Among the South Chinese (Cantonese) koro is known as suk-yeong. Van Brero in 1897 first discussed the psychopathology of this syndrome on the basis of cases described in South Celebes. He thought it was a peculiar manifestation of obsessional-compulsive illness. After many years the syndrome again received attention from Van Wulftten Palthe (1934), who concluded that it was an unusual form of anxiety neurosis. Slot in the same year also gave an account of it in the Dutch literature. Van Wulftten Palthe (1936, 1937) further mentioned the existence of corresponding female cases who complained of shrinking of the vulval labia and the breasts. He made a distinction between a real anxiety state and an imaginary organic illness based on folk belief, comparable for example to the popular notion in Southern Europe that urinating against the wind would cause a person to “catch a cold” in the metaphorical sense of getting gonorrhoea.

Since 1948 a number of papers published in Great Britain have demonstrated the feasibility of studying the incidence and prevalence of both major and minor psychiatric disorders in general practice (3, 4, 7, 8, 10, 11, 14, 16, 17, 18). Few, however, have focused on the health of West Indian immigrants in Great Britain, some 125,000 of whom have entered the country since that time (2, 12, 13, 20). This paper reports on the results of a six-month psychiatric morbidity survey of a group general practice in Brixton, the main purpose of which was to collect and compare data on the illness and consultation patterns of West Indian and English patients attending the same general practice.

Pregnancy in their wives is known to precipitate mental illness in some husbands (Zilboorg, 1931; Freeman, 1951; Towne and Afterman, 1955). But the fact that it may more commonly cause physical symptoms seems never to have been fully investigated, and has only occasionally been reported in the medical press.

To see a ghost is a most impressive experience, but if the apparition is the observer's double the event must have added impact. The dramatic appeal of such a situation has long been exploited by authors and it would seem that their preoccupation has in some cases been dictated by personal experience, for example Maupassant and Dostoevsky (Coleman, 1934).

There is a good deal of evidence that hereditary factors make some contribution to determining a predisposition to neurotic illness, and some of the relevant literature has recently been reviewed by one of us (Slater, 1964). Raised incidences of neurotic illnesses and neurotic traits of personality of a like kind have been found among the first-degree relatives of obsessional neurotics, anxiety neurotics and persons diagnosed as suffering from hysteria. The evidence is much stronger in the case of the first of these types of illness than in the last. Such observations do not absolutely require a genetical explanation. It is possible that the similarities shown by relatives are not caused by their blood relationship, but by similarities in such aspects of the environment as early upbringing, social milieu, family tradition, etc. However, these findings do suggest that, if there is a genetical contribution to the personality traits which are associated with neurotic illness, this will most likely be due to a number of genes, additive in their action. This again would lead one to expect to find continuous variation between individuals in the degree to which they show such personality traits, and in our view the available evidence supports a multidimensional mode of variation.

Barbiturates arc commonly used in treating anxious, disturbed patients. Well controlled trials have shown that at least amylobarbitone (‘Amytal’) is therapeutically active (Scott, 1955; Raymond, Lucas, Beesley, O'Connell and Fraser Roberts, 1957; Robin, 1959), and that a newer barbiturate, nealbarbitone (‘Censedal’) is, weight for weight, equally effective (Robin, Cronin and Scotton, 1961). Since nealbarbitone is less hypnotic (Ryde, 1959; Hinton, 1963), it may be used in larger doses than are expedient with amylobarbitone, and this could make it more useful in controlling anxiety. Phenobarbitone is widely used, especially in general practice, to relieve symptoms of anxiety. Its activity in experimental animals, for example in preventing electrically induced convulsions without causing sleep, differs considerably from that of amylobarbitone (Merritt and Putnam, 1938), but it appears not to have been compared directly with amylobarbitone in a controlled clinical trial upon patients with anxiety.

In the course of studying the clinical effects of LSD-25 various workers have commented upon its possible use as an aid to psychiatric diagnosis. Stoll (1947) and Becker (1949) considered it to be of limited value in this respect. Condrau (1949) pointed out that it tended to exaggerate catatonic and hebephrenic features in schizophrenics and to produce a caricature of the personality in normal subjects; the latter point also being made by Anderson and Rawnsley (1954). Von Felsinger et al. (1956) considered the primary psychological effect of the drug to be an exacerbation of existing symptomatology, through a weakening of central functions and defence systems.