In 1926 Mapother stated that in manic depressive psychosis we are dealing with “a merely quantitative deviation” from the normal, morbid only in its undue prolongation or if disproportionate or disastrous in its degree. He included anxiety neuroses along with mania and all varieties of depression as members of the manic depressive group. Perhaps these beliefs reflected the inevitable pessimism of a period when therapy was largely expectant and custodial. Somewhat despondently Mapother goes on to say “sub-division serves little purpose unless the types discriminated are correlated with differences in the unknown—for example in causation, prognosis and treatment”.

Since its first formulation, the concept of manic-depressive illness has been subject to successive modification and, on the whole, to progressive enlargement. It was Kraepelin, following on the attempts of Baillarger, Falret and Magnan, who grouped together all the various nosographic forms distinguished by isolated depressive or manic crises, periodic or alternating (and even the form designated as involutional melancholia), including them all under the sole class name of manic-depressive psychosis. The morbid entity thus defined was regarded as distinguished by the periodicity of the crises, each with a tendency towards social remission. Aetiologically the causation was seen as preponderantly hereditary.

The question of the specificity of anorexia nervosa is at present unsettled. Mayer-Gross et al. (8) describe it as a syndrome with its own particular psycho-physical characteristics, and others have drawn attention to consistencies in family history, personality and symptoms in series of cases (3, 10). But no statistically controlled study has confirmed its specificity, indeed the one such study of recent years, reported by Kay (6) and Kay and Leigh (7), concluded that there is no specific anorexia nervosa, that the label covers psychogenic anorexia occurring in a wide variety of psychiatric settings. This was a retrospective survey of a series of 37 patients diagnosed as suffering from anorexia nervosa in the past. It is possible that the lack of specificity might have been due to the imprecise definition implicit in such a sampling procedure. Although the study failed to demonstrate a specific anorexia nervosa, it did not finally refute the existence of such an entity.

Urinary excretion of adrenal metabolites, especially neutral 17-ketosteroids, is often low in patients with anorexia nervosa (Escamilla, 1949; Bliss and Branch, 1960). This has been taken (Emanuel, 1956; Greenblatt et al., 1951) to provide evidence of adreno-cortical insufficiency secondary to defective pituitary function (Sheldon, 1939; Perloff et al., 1954). According to Perloff et al. (1954) “prolonged starvation may result in functional hypopituitarism, whose differentiation from the syndrome of hypopituitary cachexia due to structural impairment of the anterior pituitary gland is at times extremely difficult, even when the accepted tests for endocrine adequacy are performed”.

The investigation reported compares a group of patients in whom the onset of psychiatric illness was associated with acute environmental stress with another group of patients of similar age and sex in whom no such precipitating stresses were found. The aims were to see what differences, if any, were apparent between the two groups.

The facilities for dealing with the psychiatric patient who presents at the Casualty Department leave much to be desired.

The extent and nature of this problem is shown by the following study, in which one Junior Casualty Officer, who received 1,224 patients presenting with a new complaint over a period of three months, recorded the number of cases which he considered to be suffering from a primarily psychiatric condition. This amounted to 82 (6.6 per cent.), and, allowing for the fact that he was one of three Casualty Officers performing identical duties, this means that 984 such patients can be expected in the year. This is double the number of new cases referred to the Psychiatric Out-Patient clinic of this same hospital.

The differential diagnosis of schizophrenia and depression is clinically important in so far as these diagnoses carry therapeutic and prognostic implications. The Kraepelinian dichotomy was foreshadowed in Griesinger's recognition that “a state of vague, objectless emotion, be it sad or cheerful, and vague general delirium, is always more favourable than the appearance and continuance of fixed ideas … In melancholia, too, the appearance of hallucinations is decidedly unfavourable; those especially which refer the malady to external agencies (to other persons, to witchcraft, etc.) are remarkably persistent, and introduce at a later period a condition of dementia” (Griesinger, 1861). Kraepelin's descriptions of maniacal-depressive conditions and of dementia praecox remain the basis of contemporary systems of classification of the functional psychoses.

In recent years the introduction of neuroleptic drugs into large overcrowded mental hospitals has been accompanied by a striking improvement in their atmospheres which have become more therapeutic and less custodial (W.H.O., 42). Accordingly it has become possible, often for the first time, to organize effective programmes of rehabilitation for the chronic schizophrenics who still constitute a high proportion of mental hospital populations (Brill and Patton, 7). The new programmes have usually included group nursing, planned activities, and graded incentives for patients to strive to regain their positions in society. This approach has placed emphasis on the patient as an individual, having rights and responsibilities, safe, trustworthy, and, with assistance, often able to help himself and others (W.H.O., 41). Because of these changes in the State Hospital, it is not surprising that the literature has been flooded with enthusiastic reports and wholehearted endorsement of the merits of a variety of neuroleptic agents.

The importance of non-drug factors in the response of patients treated with psychotropic agents has been widely commented upon in recent years, though very few investigations have been undertaken specifically to identify and study these factors and to determine their role in pharmacotherapy (Hamilton and Hordern, 1963).

Studies using objective tests have found that two relatively independent types of thought disorder occur in patients diagnosed as “schizophrenic”. In several studies (Payne, 1961) approximately half the acute schizophrenic patients showed an extreme degree of intellectual and motor retardation, more severe than that found even among retarded depressed patients, while half suffered from overinclusive thinking, as measured by the tests used. There was a significant tendency in one study (Payne and Hewlett, 1960) for these two types of thought disorder not to occur in the same acute schizophrenic patients.

Thioproperazine (‘Majeptil’) is a recently introduced phenothiazine derivative which readily produces extra-pyramidal disturbances. Its pharmacology was originally described by Courvoisier et al. (1958) and its clinical properties by a number of workers including, in this country, Denham and Carrick (1961). Several investigators have reported impressive results with this drug in a variety of mentally ill patients, including chronic schizophrenics who had failed to respond to other forms of therapy.

Since the introduction of drug therapy in depression, a wide range of pharmacological substances has been made available. It is possible to show that many of these substances are more effective than a placebo in the treatment of depression, but it is not an easy matter to evaluate them in relation to one another.

Benzquinamide (P2647 Pfizer) is a new benzoquinolizine derivative with the structural formula

Animal studies have shown that it is a potent suppressor of conditioned avoidance behaviour, but it does not influence the release of central amines, has little sedative action and is free from serious toxic effect (personal communication, Pfizer Ltd.). An uncontrolled pilot study found it to be effective in relieving anxiety in neurotic patients (Smith, 1962). In the present trial the effect of benzquinamide (P2647) on anxiety symptoms is compared with a placebo and amylobarbitone in the same dosage using the method of sequential analysis.

Over a period of 12 years Denhoff and Holden (1961) tested 8 drugs on pre-school children suffering from cerebral palsy for improvement in neuromuscular function including spasticity, behaviour, taste (acceptability) and toxicity. Objective tests were used for the first. The drugs examined were mephenesin (Myanesin, Tolserol), mephenesin with glycerol-alpha-ethyl-gamma-isopropyl ether (Lissephen), chlorpromazine, reserpine, zoxazolamine (Flexin), alpha-ethyl-beta-methylvaleramine (McN 181), carisoprodol (Soma), and emylcamate (Striatan). Beneficial results were seen in neuromotor function with both mephanesin and placebo. Placebo effects were greater than drug effects in neuromotor function and behaviour with Lissephen, but this drug was not tolerated in doses sufficient to reverse these effects. With chlorpromazine behaviour improved statistically, but the neuromotor effectiveness was secondary, occurring because the child was mentally relaxed and happy. Zoxazolamine gave improved behaviour, but the neuromotor effect was no better than that of the placebo. Reserpine was not tolerated, drowsiness taking place with a dose necessary to produce efficient performance. McN 181 was ineffective in doses tolerated and 6 cases were unchanged or worse as regards spasticity on soma. Striatan gave 6 of 14 improving in anxiety, but 10 of 18 did so with placebo and no statistical differences were found in anxiety score. The beneficial neuromotor effects of the drugs varied from 9 to 56 per cent. (mean 33.4) and of the placebos from 26 to 50 per cent. (mean 38.7). The authors point out that overall progress can be made when the child is mentally relaxed and happy, as when being treated with chlorpromazine.

In a previous paper (Claridge and Herrington, 1960) it was demonstrated that by using a modified version of the sedation threshold technique, originally described by Shagass (1954), it was possible to differentiate neurotics diagnosed as hysterics and those diagnosed as anxiety states (dysthymics). In keeping with Eysenck's theory of neurosis (1955) and drug action (1957), it was found that dysthymics had significantly higher thresholds for sodium amylobarbitone than hysterics. In addition, supporting the earlier findings of Claridge (1960) and again Eysenck's theory of personality, dysthymics were found to have significantly longer visual aftereffects to a rotating spiral than did hysterics.

The results obtained with the Cold Pressor test were considered by the authors to provide further, supporting, evidence that variations in sedation threshold are due, in part at least, to differences in autonomic responsiveness. Further investigation of the problem seemed justified, and in the next stage of the research it was decided to employ as a measure of autonomic lability the response to a drug rather than the cold water stressor.

A positive correlation has been found between changes of blood pressure and sedation threshold in two autonomic tests. In the Cold Pressor test the blood pressure changes were measured following the immersion of the hand in water at + 4-5° C. and in the Mecholyl test following the subcutaneous injection of a parasympathomimetic drug (Mecholyl). Both tests were considered to demonstrate differences in individuals' autonomic lability.

A considerable amount of work has been done on the physiology of sleep (Wolstenholme and O'Connor, 1961; Oswald, 1962) and on psychological functions—reaction time, imagery, etc., in relation to sleep and sleep deprivation (Oswald, 1962). But there have been no systematic investigations of the relationship between sleep and personality differences. The purpose of the present study was to test predictions concerning such relationships generated by general theories and by clinical observation.

As a specialty within a specialty, child psychiatry has now a well-established place in psychological medicine. Yet differences commonly exist between the practice of child and adult psychiatry which seem greater than can be attributed solely to differences inherent in their respective subject matter. A particular instance is the general emphasis in child psychiatry on individual diagnosis, with little attempt at categorization as compared with adult psychiatry. However, Cameron (1955) has drawn attention to the limitation of the growth of knowledge imposed by a lack of clear description and some classification of the manifestations of disturbance in the child. He considers it essential to focus attention on the manifest clinical picture. Again, Kanner (1957) in his diagnostic formulations, attempts in a few words to describe the main features of the clinical picture as well as the factors considered to be of aetiological importance in the individual case. There remains however, the difficulty of attempting to classify the presenting symptomatology, though some success in identifying patterns of maladjustment has been obtained by statistical methods (Hewitt and Jenkins, 1946; Lorr and Jenkins, 1953; Collins, Maxwell and Cameron, 1962).