Since Bleuler introduced his concept of schizophrenia in 1911, there has been a steady growth of clinical and experimental data relating to this disease. However, the literature dealing with early diagnosis is sparse and as yet there is no general agreement as to what symptomatology constitutes the early clinical picture. Older texts (Kraepelin, 1919; Bleuler, 1911) do not elaborate early diagnosis, dwelling more on distinguishing schizophrenia from other disease entities. Likewise, more recent texts tend to refer to the early stages very briefly in rather vague terms, signifying the development of the disease over the first few years from its onset. Although practice varies, the diagnosis of schizophrenia is often reserved until Bleuler's primary symptoms of disordered volition, thinking and affect appear overtly, by which time there may be also some evidence of deterioration. It is recognized, however, that these symptoms may take years to appear (Gillies, 1949) so that early diagnosis cannot readily be made by using these criteria.

The occurrence of obsessions in the course of depression was first noted by Prichard (1835), Esquirol (1838) and Marc (1840). The first series (22 cases) was described by Heilbronner (1912), who agreed with Scheule (1888) that in some cases at least the depression was the primary illness and not merely a secondary result of the obsessions. Further small series were reported by Vurpas and Corman (1933)—27 cases, Lion (1942)—16 cases, and Ingram (1961)—10 cases. Stengel (1945) reported 4 cases and reviewed the literature fully. None of these series are controlled by a parallel series of depressives without obsessions. Lewis (1934) described depressives both with and without obsessions, but did not compare them.

There is a general view that the content of obsessions occurring in the course of depressive psychosis is frequently aggressive, homicidal or suicidal. Prichard (1835), Esquirol (1838), Marc (1840), Maudsley (1895), Heilbronner (1912), Gordon (1925 and 1950), Muncie and White (1937), Henderson (1937), Bowlby (1940), Lion (1942), Oltman and Friedman (1943), Stengel (1945), and Skoog (1959) all express this view on the basis of single anecdotal case reports or series of fewer than ten cases. The largest reported series is that of Vurpas and Corman (1933) who described 27 cases (2 organically based) of homicidal obsessions in depression. Only 3 cases (Nos. 10, 24 and 27) exhibited obsessions before the depression and this is too small a number to serve as a control group.

The effects of institutional environment have been recognized as constituting a major influence on the picture presented by chronic schizophrenic patients. These effects, and measures to mitigate them, have been described by May (1956), Freeman et al. (1958), Barton (1959) and others, and a review of the literature was made by Wing (1962). Many of these studies have suffered from the disadvantages that the degree of the patients' disability was not directly measured, and that the majority were not followed up over a reasonable period of time. This paper examines the results of environmental modification on a ward of severely disabled chronic schizophrenic patients over a period of four years. It also attempts to assess the effects of phenothiazine treatment on the behaviour of these patients.

The ionic theory of cell excitability shows how impulses are generated, conducted and propagated by movements of ions between the cells and the extracellular fluid. It is known that changes in the concentration of sodium and potassium in either the extracellular water (E.C.W.) or the intracellular water (I.C.W.) may have a marked effect on the resting and action potentials of excitable cells. If affective disorders are manifestations of complex but reversible changes in brain excitability, hen these in turn might be caused by alterations in the concentration of electrolytes within the cells of the central nervous system (C.N.S.). Although it is not possible to measure the distribution of electrolytes specifically in the C.N.S. in man, it is possible to measure their distribution in the body as a whole. In previous papers we have shown that residual sodium (intracellular plus a small quantity of bone sodium) is increased by 50 per cent. in depression (Coppen and Shaw, 1963) and by nearly 200 per cent. in mania (Coppen, Shaw, Malleson and Costain, 1965). The present paper shows that there are also abnormalities in the distribution of potassium, the other main cation determining cell excitability, in patients suffering from severe depression.

This report is published with the blessing of the College authorities, although they would challenge one or two elements in it. The main points of contention would be, first, the definition of wastage (it is understood that some of the students who are classified in the report as “wasted” did in fact go on to degree courses in other subjects elsewhere, having realized that they had chosen the wrong subject at first); second, that to quote a single year's figures may be misleading, since there are reasons for thinking that the picture may be changing for the better; and third, that academic inadequacy and idleness are thought to be at least as prevalent, as reasons for failure, as psychological disturbance, whereas this investigation concentrates almost exclusively on the latter.

The importance of personality in determining the likelihood and form of psychiatric and psychosomatic disease is recognized, but relatively little attention has been paid to the intimate personal relationships of adults which both express and to some extent modify their personalities. The neglect of this field in psychiatry has been underlined recently by Post and Wardle (1962) and by Kreitman (1964).

The need for the development of shorter and more effective techniques of psychotherapy justifies a careful investigation of any methods which offer this possibility. A number of therapeutic techniques (7, 15, 18, 20) now often subsumed under the heading of Behaviour Therapy (4) and based on various principles of learning theory call for examination, since their exponents claim that these methods can make therapy both shorter and more effective than can other methods, e.g., those based on psychoanalytic theory. Published reports of results with behaviour therapy to date consist largely of the assessment of results made by a therapist on his own patients, e.g., Wolpe (20, 21), Lazarus (9), Rachman (12). Cooper (2) studied results achieved by other therapists on thirty patients treated with various techniques of behaviour therapy. His survey included a comparison, using “blind” independent assessors, of a group of patients treated with behaviour therapy and a matched group of patients treated by other techniques. Cooper concluded that this comparison showed a definite advantage for behaviour therapy in the symptomatic treatment of phobias, but he could find no evidence supporting the claim of a superiority of the methods of behaviour therapy over conventional techniques in producing general changes. Unfortunately Cooper does not report the experience level of the therapists in his study except to say that they were a “variety of student and staff psychologists”. Evidence for a superiority of behaviour therapy must derive from a controlled comparison of matched groups of patients treated with techniques of behaviour therapy and with other techniques by therapists of comparable competence. But, pending judgment from such a controlled study, we believe ample evidence exists that techniques of behaviour therapy do bring comparable improvements more rapidly than do other treatments in some patients. The greater precision and shortening of therapy for these patients would alone constitute a very notable advance in psychotherapy, apart from claims of a wider or general applicability of these techniques. For this reason we believe it important to investigate these various techniques in as much detail as possible. Wolpe describes the most important of them as systematic desensitization (20, 21).

Severe agoraphobia is difficult to treat. Encouraging immediate results have been reported with diverse treatments, including intensive psychotherapy (Friedman, 1959), acetyl choline injections (Sim, 1964), antidepressant drugs (King, 1962) and more recently with behaviour therapy (Wolpe, 1958). It is this latter claim which this paper examines. Early reports (e.g. Meyer, 1957; Wolpe, 1958) suggested that behaviour therapy might prove to be a rapid and effective treatment, but a small series studied by Meyer and Gelder (1963) demonstrated that results were not always as effective as single case reports suggested, and showed clearly that the treatment was often lengthy, taking 80 hours on the average. A retrospective investigation of a larger series (Marks and Gelder, 1965; Cooper, Gelder and Marks, 1965) again failed to support the early claims, although it was shown that behaviour therapy is an effective treatment for circumscribed phobias such as fears of animals and insects.

In 1963 the Child Psychiatry Section of the R.M.P.A. set up a small committee to study problems concerned with the schools for maladjusted children. The role of the psychiatrist in the ascertainment and subsequent placement of such children varies between one part of the country and another so that there was general uncertainty about the respective roles of the educational and psychiatric services in dealing with maladjusted children.