The Purpose of the Present Investigation

In their study “The relation between neurosis and psychosis: an analysis of symptoms and past history of 819 psychotics and neurotics”, Trouton and Maxwell (1956) were the first to apply the statistical technique of factor analysis to the isolation of clinical items representing the independent dimensions of ‘psychoticism’ and ‘neuroticism’. The findings were subsequently exploited for diagnostic purposes by other investigators (e.g. Richmond and Roberts, 1964), and the study and its results extensively quoted by Eysenck (1961) in his provocative review and critique of psychiatric classification to illustrate and lend support to his dimensional approach to psychiatric taxonomy.

The assessment of suicidal intent is one of the most important problems of clinical psychiatry. An earlier study (Robin, Brooke and Freeman-Browne, 1968) has confirmed the high incidence of suicide in admissions diagnosed at first contact as suffering from affective disorders, and found that 8 per cent. male in-patients and 5 per cent. female in-patients so diagnosed committed suicide during a follow-up of 6–11 years. It was also shown that in male patient suicides unemployment at the time of first admission and a previous history of self-poisoning or self-inflicted injury occurred more often than in matched controls, while a history of more than one suicidal attempt was found more often in female suicides than in matched controls. Female suicides were treated less often with E.C.T. than their controls, and more often with tranquillizers.

Prevalence studies of mental subnormality among regional populations are few. Detailed epidemiological enquiries have been carried out in the regions of Northern Ireland (Scally and MacKay, 1964), Wessex (Kushlick, 1965) and, for severe mental subnormality in children, in Middlesex and London (Goodman and Tizard, 1962). The North-East Region of Scotland is especially suitable for epidemiological studies in psychiatric morbidity by reason of its geography, demography and centralization of psychiatric services (Innes and Sharp, 1962; Baldwin and Millar, 1964). A Regional Psychiatric Case Register giving rapid access to social and clinical information on all patients is fully operational (Baldwin et al., 1965). Using this facility as a primary source of data, a prevalence study of mental subnormality among the half million population of the North-East of Scotland was carried out. The objects of the study were three-fold: first and primarily, to establish case rates for known subnormality, examine patterns of morbidity and the factors that influence this and to compare these with the findings of similar epidemiological studies; second, to gain operational data relevant to existing practice, needs and planning of services; third, to provide a data bank within the Regional Psychiatric Case Register for mounting detailed clinical, genetical, social or biochemical studies on an area population of subnormal patients.

Since the Second World War the number of Italians working in Switzerland has greatly increased. In 1962 there were officially 454,000 Italian workers in that country and this is almost certainly an underestimate. In 1960 and 1961 one of the authors (Risso) investigated the social, cultural, genetic and other factors in the mental illnesses of 709 Italian patients in psychiatric clinics and mental hospitals in German-speaking Switzerland. These patients had rather unusual symptoms in that there was a mixture of normal ideas, which appeared to be derived from their cultural background, and psychotic or psychotic-like symptoms. It was therefore often difficult to allot these patients' illnesses to one of the usual diagnostic categories, so that it was not easy to decide if the patient had a schizophrenic episode, a schizophrenic reaction or a non-psychotic psychogenic reaction.

In 1932 Monroe wrote that “inability to read may be one of the prolonged school problems to which parents and agencies become adapted until the child drifts into truancy and incorrigibility”. This observation, if true, is highly pertinent to the problems of present day society, and, for this reason, a personal study was made of delinquent boys between the ages of 12 and 17 years referred by the courts for assessment at a London Remand Home and Classifying Centre.

Most reports on the treatment of drug addiction describe only some form of aversion therapy, either by electrical (Lesser, 1967) or chemical means (Raymond, 1964). There seem few reports in which any attempt has been made to correct the underlying disorder which was responsible for the patient's addiction (Seelye, 1967). The argument is put forward that the basic disturbance in drug addiction is frequently one of social anxiety, and that when this has been corrected the patient no longer requires drugs for his support.

Recent workers investigating psychological dysfunction in schizophrenic patients have stressed the fact that such patients appear to have some specific difficulty in speech perception. It has been claimed that schizophrenics require more cues in order to reproduce verbal material accurately. This disability has been analysed by methods inspired by the work of communication engineers.

Disturbance of functions controlled by the autonomic nervous system may be due to changes in the emotional state, and are part of normal reactions to stress. Their general occurrence is reflected in phrases like “it makes me sick” and “to sweat with fear”. In some groups of people these autonomic disturbances are not confined to stressful situations but become more general and frequent and so more disabling. For instance, in patients with affective illnesses, symptoms of autonomic origin are common and are relieved by successful treatment of the underlying illness. Again, there is a group of patients who complain of these symptoms but who show little affective disorder. In these patients the autonomic symptoms are provoked by specific situations which are not particularly stressful to normal people, e.g. nausea occurs when eating in company or diarrhoea when travelling; outside these specific situations symptoms do not occur. Although these patients may complain of some anxiety, the physical symptom is the major complaint and the anxiety is often attributed to this.

Claims have been made that thyroid hormone treatment benefits some schizophrenic patients. Earlier studies reported the use of dried thyroid in a dose of 48 gr. (2·9G) daily in a schizophrenic (Hoskins and Sleeper, 1929) and in other psychiatric states up to 60 gr. (3·6G) daily (Minski, 1927), but recent papers describe the use of l-triiodothyrgnine in place of dried thyroid in treating schizophrenics (Lochner, Scheuing and Flach, 1963; Flach, Celian and Rawson, 1958). Huxley, Mayr, Osmond and Hoffer (1964) believe that schizophrenics are more resistant to the effects of some physiological substances, including thyroxine, as part of a genetic polymorphism.

The need for a long-acting phenothiazine has been long recognized, especially since it has been shown (Parkes et al., 1962; Renton et al., 1963; Kline, 1964; Willcox et al., 1965; Wilson and Enoch, 1967) that a high proportion of schizophrenic patients do not take their prescribed medicines.

In 1962, Perley and Guze introduced objective criteria for the diagnosis of hysteria (Perley and Guze, 1962). These criteria were essentially a quantification of clinical observations which had appeared in the literature previously, notably in the work of Purtell, Robins and Cohen (1951). The Perley and Guze criteria for the diagnosis of hysteria offered several important advantages. First, they were derived from observations of the natural history of hysteria. They were straightforward and objective, suggesting that they could be used reliably by different clinicians in different places. Second, the criteria were accompanied by a follow-up study which indicated that diagnoses of hysteria made by means of the Perley-Guze criteria would be stable over a six to eight year period in 90 per cent. of cases. Put another way, these criteria selected a population homogeneous in prognosis. The stability of such a population over time is of particular importance. The original Perley-Guze paper and a further study by Gatfield and Guze (1962) both described the prognosis of patients selected by looser criteria. When conversion (pseudoneurologic) symptoms alone were the criteria of diagnosis, patients developed a bewildering array of psychiatric, medical and neurological illnesses within a few short years. In contrast, the Perley-Guze criteria for the diagnosis of hysteria predict prognosis accurately and represent a significant advance in descriptive, clinical psychiatry.

Clinical observation as well as experimental results have indicated abnormalities in the responses to sensory stimulation in autistic children. Observers have noted occasional over-responsiveness in the absence of any obvious sensory defect, though more frequently under-responsiveness to visual or painful and particularly to sound stimulation is reported. Thus, Goldfarb (1961) observed the frequent absence of startle responses to sound in autistic children, and Anthony (1958a) and Rutter (1967) also noted a lack of reaction to auditory stimuli. Hermelin and O'Connor (1964) and O'Connor and Hermelin (1965) found marked under-responsiveness to sound, if compared with the response to light and touch, though they also reported impairment of visual discrimination.

It is by now widely recognized that patients undergoing a course of electroconvulsive therapy (E.C.T.) may frequently be troubled by some form of memory disturbance. Despite some thirty years of research and speculation on this subject, we are still a long way from understanding the precise nature of these disturbances or their physiological basis. Opinions vary as to their severity and duration and even as to the possible role they may play in the therapeutic process itself. It is, however, generally agreed that a very considerable number of patients complain of memory disturbance during or after a course of E.C.T., and that this may constitute a source of anxiety and distress, if not of practical inconvenience. Treatment is occasionally refused or discontinued on these grounds, and some psychiatrists are reluctant to prescribe E.C.T. in cases where a patient's work might be handicapped by memory impairment. Some degree of disturbance is, however, usually accepted as a calculated risk when prescribing this treatment.

The practice of psychiatry overlaps appreciably that of the other branches of Medicine. A high incidence of psychiatric illness has been found in out-patients attending medical and surgical clinics (Shepherd, Davies and Culpan, 1960; and Davies, 1964), and among in-patients in general medical and surgical wards (Meyer and Mendelson, 1960; Fleminger and Mallett, 1962; Eilenberg, 1965; Granville-Grossman, 1967). Other studies have shown an appreciable incidence of physical illness in out-patients attending psychiatric clinics (Davies, 1965), in psychiatric in-patients in a teaching hospital (Marshall, 1949; and Herridge, 1960), and in patients with mental disturbance attending general practitioners (Shepherd, Cooper, Brown and Kalton, 1964, 1966). The extent to which ordinary psychiatric in-patient practice involves dealing with non-psychiatric problems does not appear to have been extensively studied, although Davies, D. W. (1964) has indicated the presence of considerable physical morbidity within a psychiatric hospital population. We here describe an investigation into the incidence of physical morbidity among in-patients admitted to a general hospital psychiatric unit with a total responsibility to a catchment area population of 90,000, and into some of the factors affecting this incidence.

Since 1962, a series of studies have appeared in the psychiatric literature which define hysteria with increasing precision, differentiating that syndrome from the presence of conversion symptoms alone. Hysteria was described in a recognizable fashion more than a century ago by Briquet (1859). Some fifty years later, the syndrome was redescribed by Savill (1909). After a further period of nearly fifty years, Purtell, Robins and Cohen described hysteria as it occurred in a controlled series of patients (1951). Working from Purtell's clinical data, Perley and Guze introduced specific checklist criteria for the diagnosis of hysteria in 1962. These criteria defined a female population homogeneous in prognosis, a population to be distinguished from that defined by conversion symptoms alone. Conversion symptoms are seen in a variety of medical and psychiatric illnesses, and by themselves, conversion symptoms are of little prognostic value (Gatfield and Guze, 1962; Perley and Guze, 1962; Slater and Glithero, 1965).

The value of measuring changes in symptoms in a single patient has been discussed by a number of authors. (1, 3, 4.) The “self-controlled trial” (1) or the “multiple cross-over method”, i.e. the measurement of responses to repeated and systematic changes in treatment, appears to have advantages over the simple cross-over trial, but the method would be extremely time-consuming in group research with psychiatric patients if the ratings had to be carried out by research workers. The use of valid self-rating scales would make the multiple cross-over method feasible in drug trials with groups of psychiatric patients.

The relationship between psychiatric disorder and academic difficulty is clearly a complex one, for some severely disturbed students perform adequately, while clinically mildly disturbed individuals may fail completely. Emotional and psychiatric factors which could be associated with academic difficulty might include both the general factor of severity of disorder, and more specific factors related to the individual's personality motivation and attitude towards achievement and to his tutors. The nature of the demands, pressures and supports presented by the institution or by individual tutors is also likely to be of importance. In a previous psychometric study of all cases of academic and psychiatric difficulty from one year's intake at Sussex University (Ryle and Lunghi, 1968) it was shown that psychiatrically disturbed students in academic difficulty differed significantly from controls on the Nufferno Stress gain measure (Furneaux, 1965) whereas psychiatric patients who were coping academically scored in the same range as the controls. This difference was maintained when psychotic patients were removed from the academic difficulty group. No other psychometric scores distinguished between these two groups. The aim of the present paper is to make a preliminary attempt at defining what clinical features are associated with academic difficulty in a population of psychiatrically disturbed students. The sample studied consists of 38 male and 52 female psychiatric patients personally cared for by the author in a University Health Service encouraging direct consultation and tutor referral of students with personality or academic difficulties. Of these, 28 men and 37 women were the subjects of the previous study referred to above, the additional cases consisting of undergraduates of earlier intakes, and of 8 postgraduate students who had been personally assessed by the author over a two-year period.

Contextual constraint is a measure of the degree to which any one word in a passage is determined by the words which precede it, and can be expressed in terms of dependent probabilities. A recall task devised to investigate this topic was designed by Miller and Selfridge (1950) for an investigation on the statistical structure of words in context. Contextual constraint is at its highest in a passage of English text and at its lowest in a passage of unrelated words selected at random. The Miller and Selfridge task requires the subject to listen to seven passages of words in turn and at the end of each passage to write down the words he can remember. The seven passages are arranged in order of increasing contextual constraint from random words to a piece of text.

The ability to interpret the meaning of metaphorical proverbs has been used not only in intelligence testing but also to investigate abnormalities of thinking in schizophrenia; mainly the theories that schizophrenics are either “concrete” or “overinclusive” in their thinking. The theory of concreteness has been proposed mainly by Goldstein (1946), who held that schizophrenics were unable to adopt the “abstract attitude”, and, having lost the ability to form normal abstract concepts, formed concrete ones instead. Cameron (1946) described overinclusion as one of several abnormalities found in schizophrenic thinking. This abnormality has been adopted by Payne and his co-workers (1957, 1959, 1960, 1962, and 1966) as the basic disorder of schizophrenic thinking. Schizophrenics showing this disorder appear unable to maintain the boundaries of a problem, and so form overbroad concepts. Overinclusion, however, is found in only about 50 per cent. of acute schizophrenics and has also reported in other psychiatric conditions (Payne and Hirst, 1957; Payne and Frielander, 1962; Sturm, 1965).

The majority of controlled trials of imipramine against placebo in the treatment of depression have indicated the general efficacy of the drug (9). Recently there has been renewed interest in the use of the phenothiazines in depression, and the question has been raised as to how far the actions of the imipramine-like drugs and of the phenothiazines can be differentiated. Structurally, the iminodibenzyl nucleus of imipramine closely resembles the phenothiazine nucleus, the only difference being replacement of the sulphur atom bridging the two benzyl rings in the latter by a CH2–CH2 group in the iminodibenzyl nucleus. Two controlled trials have suggested that in depressed patients the phenothiazines may be more valuable than has been previously realized and similar in overall efficacy to imipramine. Fink et al. (3) found both chlorpromazine and imipramine significantly better than placebo in the treatment of depressives, with only minor and insignificant differences between them. Similarly, in a relatively large collaborative trial, Overall et al. (11) found thioridazine as effective as imipramine. These authors subsequently employed a special statistical classification technique to stratify their patients into three subtypes according to initial symptom profiles (8). With respect to a variety of symptom ratings, this stratification revealed significant differences in drug effects. Imipramine proved superior in “retarded” depressives and thioridazine in “anxious” depressives, while no differences were found in “hostile” depressives.