Psychosurgery has always been, and is likely to remain, a controversial subject. Blind operations lack precision and can lead to adverse personality changes or other serious side-effects. Open surgery is becoming less acceptable because of the difficulties of accurately assessing the extent of a lesion and its exact location. The introduction of stereotactic techniques enables far smaller lesions to be placed with a high degree of accuracy, and increased knowledge of the limbic system has contributed to advances in this field.

I am no expert in the field of mental handicap and what I have to say derives from a general rather than a special acquaintance with the subject you are to discuss. That may be no bad thing, because much of the extensive change which has come over the psychiatric field in the past twenty years has been due to a change of outlook by those outside psychiatry, giving better opportunities for those within.

The world as a whole, and to a lesser extent this country, is confronted with the strong possibility of an unprecedented increase in its population. Pressure of population will produce tensions which will pose problems to psychiatrists. But other social events will give rise to generally similar tensions which will thus have multiple causes. It will then be difficult to separate the effects of population pressure from the effects of other causes and there may be illjustified swings of opinion such as we have seen in the past.

For the purposes of this paper the South-East Asia region has been taken to include India, Ceylon, Burma, Thailand, Indonesia and the Philippines. The region thus demarcated is not merely an area of geographic contiguity but also comprised almost entirely of developing countries involved in a process of social change as a result, principally, of exposure to the West. The traditional economy of agricultural self-sufficiency in all these countries is coming to be replaced increasingly by an industrial economy which is essentially tied up with world trade. Most of the countries in the region have emerged from a colonial status into independent states with a renascent and sensitized nationalism. There is in these countries abundant enthusiasm for new goals set up after achieving independence; but this is dampened with a sense of self-doubt that prevails as much amidst the leaders as amidst the led. Thus in this region a generation of people appears to be trying to outlive its history and live on hopes for a new future.

Psychiatric disturbances in a student population span a broad spectrum and include overt illness, a heterogeneous group of psychosocial problems with varied and changing symptomatology and normal crises of development. Complaints of work difficulty often form part of the symptomatology of all these groups, and not infrequently may be the presenting symptom. Quantification is difficult because the symptoms vary in degree and form, and change over time. They may be unreported or voiced only to friends or tutors. Their prevalence and significance is therefore hard to assess. In a cohort study spanning a four year period, Lucas (unpublished data) found that of the 15 per cent of the cohort who received brief psychotherapy, more than three-quarters had a work difficulty of some kind. Of the 26 per cent of the cohort who never attended the Student Health Centre nearly half replied ‘yes' to a question asking whether they had experienced recurring work difficulty.

This paper represents part of a study into what determines the action taken by individuals in distress. More specifically we were concerned to elucidate why some people attempt to find relief by seeking support and guidance from an appropriate agency, while others resort to self-aggressive behaviour. Two groups of subjects have been investigated, one consisting of certain clients seeking help from the Telephone Samaritans organization, while the other comprises patients who had engaged in acts generally described as ‘attempted suicide’ but better termed ‘parasuicide’ (Kreitman et al., 1969) or ‘deliberate self-poisoning or self-injury’ (Kessel, 1965).

When a Western-trained doctor first encounters the practice of medicine in the Third World, he cannot fail to be impressed by the apparently limitless sea of morbidity—infection, faulty sanitation, malnutrition, congenital and acquired malformations—with which a very small number of trained personnel have to cope, as best they can. In public health planning of these countries priority has to be given to arresting the killing diseases, such as malaria, tuberculosis and other deadly infections, and to the provision of basic hygiene, of pure water, and of adequate nutrition. The next priority goes to deploying preventive measures against debilitating disease, wherever such measures are known, and their application has been shown to be feasible; and finally when the expectation of life has been satisfactorily increased, attention is given to interventions which improve the quality of life.

This paper outlines one method of investigating the phenomenology of spontaneous hallucinations in a mental hospital population; and considers the possibility of using the method as an aid to differential diagnosis.

The neurophysiological aspects and operative technique of stereotactic limbic leucotomy have been described in a previous paper (Kelly, Richardson and Mitchell-Heggs, 1973). The present investigation is a prospective study designed to assess the results of such surgery in a group of 40 severely ill psychiatric patients, who had failed to respond satisfactorily to every other type of treatment. The results have been assessed clinically, psychologically and physiologically, in a very detailed way, at six weeks; a similar follow-up at one year is in progress. A comparison is made between the results of the present series and those of a previous: study (Kelly et al., 1972), in which more extensive leucotomy operations were carried out, and similar means of assessment were employed.

This phase of the study was concerned only with the 93 parasuicides already described in Part I. It was designed to ascertain their knowledge of help-giving services, and to elucidate their attitudes towards help-seeking both in general and in the specific context of their parasuicidal behaviour.

In any psychotherapeutic endeavour, it must be recognized that psychogenically based mental illness is generally the product of childhood experience in the context of intrafamilial interpersonal relationships. Involvement in treatment of the whole original family might therefore be considered a logical approach, if this were either possible or practicable. Rarely, however, is this the case, save when the patient happens to be a child or adolescent. On the whole, mental hospitals and psychiatric units are populated by adults, many of whom, voluntarily or otherwise, have gained a considerable degree of physical independence from their first families. Many too have already committed themselves to a second family. In these cases the selection of a spouse has often been determined by unconscious pathological needs and expectations, resulting in a ‘neurotic’ object choice, and an unsuccessful ‘sick’ marriage. Thus the second family can frequently be seen as a precipitating factor in the development of mental illness, although not ultimately as causative in the true sense of the word.

Increase in weight is a well-known side effect of phenothiazine drugs (Dally, 1967). There have been scattered reports of weight gain on tricyclic antidepressants (Arenillas, 1964; Dally, 1967; Kline, 1969), but this possibility has received little systematic study. Investigation is confounded by the fact that depression itself often produces weight loss. Crammer and Elkes (1968) reported weight gain in responders to desipramine, but regarded this as a limited phenomenon which never built up to obesity and was due to reversal of depression-induced weight loss.

Researchers agree that suicides are under-reported, although estimates of the extent vary. Dublin (1963) suggested that recorded figures were understated by one fourth to one third. Seager and Flood (1965) estimated that possible suicides among deaths reported as accidents, misadventure or open verdicts might be as many as 50 per cent of those actually returned as suicide. Important sources of under-reporting lie in the methods of ascertaining and recording suicide as well as in religious and social attitudes, which tend, in certain countries, to look upon suicide as a stigma and to avoid a verdict of suicide where possible.

Capgras syndrome and de Clérambault's syndrome are ‘uncommon psychiatric disorders' (Enoch, Trethowan and Barker, 1967). The literature contains accounts of one or very few cases of each. With both conditions, nosologists have been in dispute as to whether the syndrome is a description of specific bizarre symptoms occurring in the context of another psychosis or is a distinct entity.

The investigation which is reported here was designed as a pilot project for a possible later research programme into the prevention of emotional disturbance in mothers and young children. The idea came through the clinical experience gained by one of us (E.A.F.) during eight years' work in a Day Unit for disturbed children under five and their families at St. Thomas' Hospital, London (Frommer, 1967). It had become clear over the years that many of the mothers of such children had themselves experienced a disrupted childhood, with separations from their parents or siblings, mental and physical ill-health of family members, and even cruelty and physical violence to themselves or a parent or sibling.

This paper describes the development of a standardized report intended for the assessment of the work behaviour of psychiatric patients in hospital workshops and clerical units. The report form was developed in the Rehabilitation Unit of the Maudsley Hospital, and primarily within the workshops and clerical section which are integral parts of the coordinated unit.

The problem of classification of depressive illness has in recent years been reviewed by Kiloh and Garside (1963), Sandifer et al. (1966), McConaghy et al. (1967), Kendell (1968 and 1968a), Roth (1969) and Roth and Kerr (1970). Among the parameters differentiating types of depression, response to antidepressants has been employed by Pare et al. (1962), Lopez Ibor (1962) and Kiloh et al. (1962); their results suggest that one type of depression responds to the tricyclic group of antidepressants and the other to the monoamineoxidase inhibitors.

Longitudinal studies of psychiatric disturbance in communities are important in order to determine the natural history of mental disorders. Most studies have focused on the prevalence of known psychiatric disorders and response to treatment, but only a few on the follow up of a population not previously recognized as psychiatrically ill (Beiser (1), Hagnell (5), Helgason (6), Myers and Bean (10)). The present study is an attempt to do this, and also to follow up untreated disorder within a community.

Since the French psychiatrists Capgras and Reboul-Lachaux published their paper first describing the ‘illusion of doubles' in 1923, other cases of the syndrome have been published giving the impression that it really occurs only in affective disorder and in schizophrenia. This viewpoint was definitely expressed in the excellent review of the Capgras syndrome in Some Uncommon Psychiatric Syndromes by Enoch, Trethowan and Barker (1967)— ‘Since it occurs in a clear sensorium, it is obvious that there is no organic basis to the condition, but it is rather a functional illness and, as such, is explained on a psychodynamic basis.’

Hospital-treated parasuicides∗ have been studied intensively in recent years, and on the basis of these hospital studies aetiological theory is advancing and expensive endeavours in prevention are being put into operation. Yet hospital studies can be misleading because cases selected for admission may not be representative. This prospective survey, based on general practice in Edinburgh, was carried out to study the prevalences of parasuicide uncontaminated by factors influencing hospital referral.