It is widely accepted by clinicians that many so-called suicidal attempts' function as a form of communication between the patient and the key figures in his environment, most often conveying an appeal for attention (Stengel et al., 1959, Farberow and Shneidman 1961). Yet little rigorous research has been directed to the communicational aspect of attempted suicide, possibly because the concept of communication is itself complex and difficult to define operationally. One line of enquiry has been to examine the consequences of the act for the patient, his family, and friends (McCulloch 1965). The present study, on the other hand, focuses particularly on attempted suicide as a subcultural phenomenon.

Much early research on attempted suicide looked upon this phenomenon as failed, frustrated or bungled suicide, an attitude which still persists among the general population. Conceptually, attempted suicide was viewed as a special case of suicide, and theories about the latter were used to explain the former, without much success. Stengel's influential monograph (Stengel and Cook, 1958) made an important contribution to the study of suicidal behaviour by contending that attempted suicide presented issues peculiar to itself as well as sharing problems with suicide. The definition of attempted suicide offered by Stengel (1964) is as follows, ‘A suicidal attempt is any act of self-damage inflicted with self-destructive intention, however vague and ambiguous. Sometimes this intention has to be inferred from the patient's behaviour.’ Suicidal attempts as thus defined are frequently insufficient to cause death, and must be related to the social setting of the patient. In situations which might be called crises of despair some people injure themselves in order to appeal for help, to spite others or to submit themselves to trial by ordeal. Stengel's definition has found general favour, although Kessel (1966) tried to promote the term self-poisoning, arguing that this term aroused fewer preconceived notions in the minds of the uninitiated.

Despite the increased understanding of the motivation behind acts of attempted suicide (e.g. Stengel and Cook, 1958) and their personal, social and ecological correlates (McCulloch, 1965; Kessel, 1965; Philip and McCulloch, 1966) the incidence of such acts as reflected in admission to hospital continues to rise. A comparison of admissions for the City of Edinburgh in 1962-3 and 1967 (Aitken, et al., 1969) showed a striking increase for men from 108.5 per 100,000 in the earlier year to 181.5 in 1967. The corresponding figures for women were 166.3 to 210.0. The Regional Poisoning Treatment Centre at the Royal Infirmary treats about 90 per cent of all cases of attempted suicide admitted to hospitals in the area (Kessel, et al., 1964), and the increase is unlikely to be accounted for by redirection of patients from other hospitals. An increase has also been demonstrated in other parts of Britain, including the Oxford Region (Evans, 1967) and Cardiff (Graham and Hitchens, 1967).

This study is based upon data derived from reported cases of suicide in Afghanistan.

A distinction has to be made between psychiatric illnesses on the one hand and the various forms of abnormal personality on the other hand.

It is often said that psychopaths mature and settle down later in life. Authorities differ as to when this occurs; some say between 25 and the early thirties (Curran and Partridge, 1963); Henderson and Batchelor (1962) say that improvement may occur up to the age of 36; others say about the mid-forties (Davis, 1967); Cleckley (1952) held that the prognosis is almost hopeless. Most of their descriptions are of young adults, and one wonders what happens to them thereafter; do the majority settle down? and if they do not what happens to them?

The Henderson Hospital is a 68 bed unit for the in-patient treatment of young people of both sexes who are described as psychopaths, sociopaths, personality disorders or character disorders. Treatment is by means of a Therapeutic Community, and prospective patients are referred by external psychiatrists with no working commitment in the hospital, by prison medical officers and sometimes by Probation Officers and other social workers with the medical backing of a general practitioner. All prospective patients are seen at a group interview and on the basis of this will be selected for admission or not.

Behavioural symptoms suggestive of the so-called functional psychiatric disorders are often observed during the course of sub-acute or chronic encephalitides, particularly sub-acute sclerosing panencephalitis. This has been regarded as an invariably fatal neurological illness, but Cobb et al. (1) have recently presented two non-fatal cases and have drawn attention to rare scattered reports of others, some with behavioural disorders. We have therefore made a survey of cases of sub-acute encephalitis at the Yale-New Haven Hospital, especially noting their behavioural aspects.

Gilles de la Tourette's syndrome has not been reported outside Europe and America, and all the patients reported have been of the white or negro races (Singer, 1963). Although the condition was described as early as in 1825 by Itard and later differentiated as a syndrome by Gilles de la Tourette (1885), and although the syndrome is an unusual condition with undetermined aetiology, treatment and prognosis (Eisenberg et al., 1959, Kelman, 1965), and Kinnier Wilson (1940) had given the syndrome ‘a sinister’ outlook characteristically ending in insanity, Fernando (1967) could find only 85 cases published in English literature as cases of the syndrome. He rejected 20 cases, and of the 65 ‘proven cases' 50 were from the United States, 13 from Britain, one each from Finland and Canada. Shapiro and Shapiro (1968) commented on the scarcity of the syndrome even in the Western culture. Extensive search in the literature has shown that Gilles de la Tourette's syndrome has not been reported in Asians. This paper presents a detailed report of the first case from India.

The syndrome of cleidocranial dysostosis was first reported by Marie and Sainton in 1898. It is a congenital condition giving rise to a defect in ossification. The principal clinical features are dwarfism, a large head with a small fades, and a depressed or saddle-shaped nose. The clavicles are incomplete or absent, scapulae are small and poorly formed, and frequently the symphysis pubis fails to fuse.

Patients are usually referred to outpatient departments by their family doctors, and it is generally assumed that after the initial assessment in the surgery they are directed to the appropriate clinic. However, it is clear that this does not always occur. In some cases there is difficulty in deciding to which clinic a patient may most profitably be sent, and this is especially so when a patient complains of both physical and psychiatric symptoms.

This paper aims at introducing a series of articles on basic psychoanalytic concepts. Many concepts which have developed within psychoanalysis have been extended for use within other frames of reference and in very different settings. If psychoanalytic concepts have validity such extension should be possible and useful, but it seems inevitable that in the process of extension changes in their meaning will occur, and it is one of the purposes of this series of papers to examine a number of concepts from this point of view. The philosophical implications of change of meaning when concepts are transferred from their original context has recently been discussed by a number of writers, e.g. Kaplan (1964) and Schon (1963). In this connection psychoanalytic theory presents special problems of its own. It is often regarded as being a completely integrated and consistent system of thought, but this is far from being the case. Psychoanalytic concepts are not all well defined, and changes in their meaning have occurred as psychoanalysis has developed and its theories have changed. We hope to show some of these changes in the papers which follow. Further, the same term has been used with different meanings even at the same point in the development of psychoanalysis. A prime example of this is the multiple meaning of the term ego (Hartmann, 1956), or of terms such as identification and introjection (Sandier, 1960). We find a situation existing within psychoanalysis at the present time in which the meaning of a concept is often only fully discernible from an examination of the context in which it is used. The situation is complicated still further by the fact that different schools of psychodynamic thought have inherited (and then modified for their own use) much of the same basic terminology.

Psychiatry and other medical disciplines have been paying increasing attention in recent years to the relationship between patient and doctor, and psychoanalytic concepts have been applied in order to formulate various aspects of this relationship. One of those most commonly applied is that of transference, which is now often loosely used as a synonym for relationship in general. The concept of transference will be discussed in detail in a further paper in this series, but a distinction has always been made within clinical psychonanalysis between transference ‘proper’ and another aspect of the patient's relation to the doctor which has been referred to in recent years as the ‘therapeutic alliance’, ‘working alliance’ or ‘treatment alliance’ (Zetzel, 1956; Loewald, 1960; Stone, 1961, 1967; Gitelson, 1962; Tarachow, 1963; Greenson, 1965, 1967; Friedman, 1969). The concept has been used in connection with the psychoanalytic treatment situation to describe aspects of what is familiar to all as the ‘therapeutic contract’ between the patient and his doctor (Menninger, 1958), and has been defined as ‘the non-neurotic, rational, reasonable rapport which the patient has with his analyst and which enables him to work purposefully in the analytic situation …’ (Greenson and Wexler, 1969). As far as the psychoanalytic situation is concerned, it has been maintained that the recognition of the difference between treatment alliance and other aspects of the patient-analyst interaction (such as transference) leads to an increased understanding of the processes which occur in that situation and, in particular, of those which enter into therapeutic failure. It is the purpose of this paper to examine the treatment alliance concept as it has developed within psychoanalysis and to consider its applicability outside the psychoanalytic treatment situation (Sandier, Dare and Holder, 1970).