Gestalt therapy was developed by Frederick (Fritz) Perls, (1893–1970), a German psychoanalyst originally trained in the Freudian tradition; he left Germany in the 1930's for South Africa and emigrated to the United States in the immediate post-war years. Despite the publication of his book “Gestalt Therapy—Excitement and Growth in the Human Personality” (Perls, Hefferline and Goodman, 1950) his work remained relatively little known until Gestalt Therapy was taken up enthusiastically by the growth movement in the early 1960's. Although it is widely regarded as an established therapy in the United States, Gestalt remains relatively little known in the United Kingdom and there are probably few psychiatrists who are familiar with its theory and techniques. This paper is intended to present an introduction to Gestalt Therapy together with some idea of its application in clinical psychiatric practice.

Bipolar and unipolar patients respectively were separated into psychotic and non-psychotic sub-types. The bipolar psychotic patients were more likely to have certain severe symptoms, such as hallucinations and motor abnormalities, than were the unipolar patients, but the family histories of the four sub-groups were identical. The psychotic sub-groups had a different course of illness, in that they were less likely to have had a history of multiple episodes on admission and were more likely to show chronicity for a period of time on discharge. The data are interpreted as being opposed to the concept of a continuum of vulnerability in the affective disorders, and as not favouring either psychotic unipolar or psychotic bipolar illnesses or schizo-affective disorder being considered autonomous. One possible interpretation of the findings is that a trait or propensity to psychosis is transmitted totally independently of the major affective illness, and that this propensity is silent or not observed when the patient is in remission.

The extent to which concordance rates for schizophrenia in monozygotic twins (between 36 and 58%) fall short of 100% is often taken as an index of the role of an environmental factor in schizophrenia, but such an agent remains elusive. That schizophrenic symptoms are observed in some viral illnesses suggests that schizophrenia might be due to a gene-virus interaction, but analysis of age of onset in pairs of siblings with the disease rules out horizontal transmission. An alternative hypothesis is proposed that onset of disease is due to the expression of a ‘provirus', which is integrated in the genome, having been acquired either by prenatal infection or in the germ-line from an affected parent; this could explain why the season of birth effect is accentuated in, and perhaps confined to the group of patients without a family history of the disease.

Germ-line integration is known to occur following infection with agents of the retrovirus class.∗ Such agents can integrate at many sites in the host genome, but their interactions with proto-oncogenes (cellular genes which may act as growth factors) identify one type of integration site, and are. associated with some of their pathogenic effects. Some characteristics of schizophrenic illness, particularly their selectivity for the dominant hemisphere, can be understood on the assumption that the virus (perhaps a retrovirus) responsible for the disease interacts with a proto-oncogene, which induces the asymmetrical brain growth responsible, for laterality and cerebral dominance. The aetiologies of manic-depressive illness and schizophrenia may be related (the season of birth and onset effects are the same for the two conditions) and there is some evidence that the former transmutes into the latter in succeeding generations. The persistence of the functional psychoses may be due to the ability of the psychosis gene (or ‘provirus’) to induce change in the genetic mechanisms responsible for the development of laterality. (∗ See postscript pp 253).

A number of reviews of the effectiveness of cognitive behaviour therapy for depression, though optimistic, have pointed to some difficulties in interpretation of the outcome literature. These difficulties, and the extent to which more recent research has dealt with them, are reviewed. It is suggested that while some of the genuine difficulties have been resolved, and other commonly expressed criticisms may prove to be unfounded, there remain a number of important areas of ignorance which demand further investigation.

Psychometric examination of a group of diabetic patients and a group of age-matched controls failed to provide evidence of impaired intellectual functioning in the diabetic group. The cognitive status of the diabetics was not related to the duration of the illness, the age at diagnosis, or clinical ratings of peripheral or autonomic neuropathy.

A descriptive study of the psychiatric findings in 50 insulin—dependent diabetics is presented. Among the symptoms found were a marked reduction in energy level, increased fatigue and irritability, depression, and delayed psychosexual maturation. Diabetes mellitus is commonly considered to be a disease that, if properly controlled, allows the patient to lead a relatively normal life. We found, however, that these symptoms often made the patients' lives uncomfortable, reduced their functional capacity, disrupted their family life, and disturbed the adolescence of those who were affected at an early age.

In South-East Scotland, 791 subjects treated with lithium for more than two months during 1967–76 were traced, using public and health service records; 751 were traced alive, 33 had died, and seven remained untraced. The standardised mortality rate was 2.83, and excess mortality was attributable to suicide (increased 36-times) and cardiovascular disease (increased 2.15-times); deaths from nephropathy, cancer or leukaemia were not increased. Comparison of the 33 deaths and 33 matched patients, selected from the 751 survivors, showed that patients dying on lithium were similar in most respects to survivors, but when first starting lithium, they had more signs of physical disease.

Admissions of mentally handicapped patients over a ten-year period to a hospital group with a catchment area population of 213, 000 are described and discussed. During this time, there was a progressive increase in temporary admissions for assessment, day care, and for both planned and emergency respite care. There were also 89 admissions for permanent care associated with conditions such as psychiatric disorder, multiple handicap, and changed family circumstances.

In a study of the evolution of behavioural symptoms in severely and profoundly mentally retarded adults in hospital over a period of six years, items of abnormal behaviour were found to be remarkably persistent. There is a high prevalence rate of psychiatric disorder in this population, when this disorder is defined in a widely descriptive sense. A substantially improved living environment, and increased staff-patient ratios, are prerequisites for improving disturbed behaviour in these patients.

Zetidoline (ZTD), a compound chemically unrelated to any available antipsychotic, with selective dopamine receptor-blocking properties, was compared with haloperidol (HLP) in a double-blind study on 56 in-patients who had either first episodes or acute relapses of schizophrenia. ZTD was found to be safe, as effective as HLP, and to produce significantly fewer extrapyramidal side-effects (EPS).

The occasional abuse of anticholinergic drugs for their psychotropic and specifically hallucinogenic properties has been known for over a century, but benzhexol (trihexyphenidyl) abuse has only recently attracted attention in the literature, mainly in case reports. This paper reports on a study of 21 benzhexol abusers. They were a young, single, and disadvantaged group of poyldrug abusers with poor employment, educational, and social skills, who abused benzhexol mainly for its euphorogenic properties. The two major diagnostic categories were antisocial personality disorder and schizophrenia. An unexpected finding was cognitive impairment persisting after acute intoxication.

In a double-blind, placebo-controlled study, ten chronic schizophrenic patients with pronounced symptoms of tardive dyskinesia (TD) were withdrawn from anticholinergic medication. All patients had previously been under long-term treatment with neuroleptics and anticholinergics for at least two years. The rating-scales used were the AIMS, our own TD Scale, and the Simpson-Angus scale for extra-pyramidal side-effects. The severity of TD decreased significantly in nine patients within two weeks; this improvement, most pronounced in the oral region (P <.001), persisted during a six-week placebo period. There was a slight increase in parkinsonian symptoms (P <.05), which was not a prerequisite for improvement in TD. Hence, discontinuation of anticholinergic medication is a possible therapeutic approach in patients with TD.

Over a six month period, 142 consecutive referrals of patients over 65 to a community-orientated psycho-geriatric service in North London were studied. The psycho-social factors determining referral were quantified and their relationship to diagnosis analysed. Therapeutic strategies are described, devised to deal with the presenting psycho-social problems. It is suggested that a family-centred approach is of some value in the management of the elderly mentally ill.

It is known that the development of maternal feelings for a newborn baby is often delayed or may not occur at all (Robson & Moss, 1970); something is also known about the psychopathology of the mother-baby relationship (Margison, 1982) but little has been written about the natural history and treatment of child rejection. The case reported here demonstrates that long-lasting rejection can be successfully treated.

Twenty-seven consecutive male patients suffering from anorexia nervosa were fol lowed-up 2–20 years after presentation; 20 had been treated with an in-patient refeeding/psychotherapy regime. The outcome of the series compared very closely with a similar group of female anorectics: 12 (44%) had a good outcome, stable weight restoration and normal sexual functioning; seven (26%) had an intermediate outcome, and eight (30%) poor (weight more than 15% below normal, and poor or no sexual activity). No patient had died. Good outcome in terms of weight was associated with good psychological and social functioning, while poor outcome was clearly associated with a longer duration of illness, previous treatment, and greater weight-loss during illness, although not with any specific dietary behaviour. Poor relationship with parents during childhood and the absence of normal adolescent sexual behaviour premorbidly were also strongly predictive of poor outcome.

In spite of the comparative rarity of anorexia nervosa in African patients, the case of a young black Zimbabwean woman which fulfils Feighner's diagnostic criteria is presented. Special reference is made to several unusual features which include the social and psychological conflicts engendered by changes of culture, the clinical symptoms, and the role of a traditional healer in her recovery. A speculative hypothesis concerning aetiology is suggested.

‘KORO’ (head of turtle) or ‘suk-yeong’ (shrinking penis) names a symptom characterized by the belief that: 1. the penis is shrinking; 2. it will disappear into the abdomen; 3. it will cause death. It is usually accompanied by intense fear and by preventive manoeuvres such as tying or clamping or grasping the penis. It tends to be short-lived and may affect single individuals or groups.

‘Koro’ has been described as a culture-bound syndrome with localised depersonalisation confined to the penis, occurring in the context of a panic state with fear of impending disaster (Yap 1965,1969). Because ghosts are not thought to possess genitals, penile shrinkage is believed to be potentially fatal, with the risk that the victim will himself turn into a ghost. Until recently the syndrome was thought to be restricted to Southern Chinese emigres in Hong Kong and South East Asia. We wish to report two such cases, one in a West Indian and the other in a Greek Cypriot, admitted to Friern Hospital.