The possible role of environmental stress in precipitating the onset or relapse of acute schizophrenia was investigated by Brown and Birley (1968), Birley and Brown (1970). They enquired about events which could be dated to a definite point in time and which usually involved either actual or threatened danger or important fulfilments or disappointments. They distinguished between independent events, which were outside the control of the subject, and possibly independent events, which were not so clearly out of his control but which seemed unlikely to be produced by unusual behaviour of the subject himself. In their main group of patients a significant concentration of independent events (about 60 per cent) was found in the three weeks preceding onset or relapse of schizophrenia. In examining two small sub-groups they found that 4 of 13 patients (31 per cent) who relapsed after reducing or discontinuing phenothiazine therapy had experienced a life event in the three weeks before relapse, compared with 3 of 5 patients (60 per cent) who had been taking phenothiazines regularly at the time of relapse. Although these proportions are very different, the numbers in the groups are too small for the difference to reach significance. Furthermore the groups were not matched in any way, and there may be important differences between patients who discontinue medication themselves and those who carry on taking it regularly.

Since 1949 the diagnoses given to all patients admitted to psychiatric hospitals in England and Wales have been collected and tabulated, initially by the General Register Office and more recently by the Ministry of Health and its successor the Department of Health and Social Security. These data are published regularly and have been used for many purposes—to follow trends in admission and discharge rates, to predict future bed and manpower needs, and in international comparisons. Before 1970 there was no official nomenclature and psychiatrists used whatever diagnostic terms they wished when completing the S.B.H.15 index cards provided for each patient (Department of Health and Social Security, 1970, Appendix A). In the Department of Health these diagnoses were converted into 3-digit numbers, using a complex code developed by the General Register Office (D.H.S.S., 1970, Appendix B), and finally these code numbers were grouped together to make them conform as well as possible with the nomenclature of the 7th edition of the International Classification of Disease (ICD 7). Inevitably this procedure was unsatisfactory. It was cumbersome; it only permitted a few broad diagnostic categories to be distinguished with any confidence; and it involved making a number of arbitrary assumptions about the relationship between the different nomenclatures involved.

Diurnal variations in symptom intensity have long been recognized as a characteristic feature of depression, and have always had a prominent place in clinical descriptions of the illness. A worsening of depression in the morning has classically been associated with endogenous depression, while a worsening in the evening has been described as characteristic of reactive or neurotic depression (Kiloh and Garside, 1963; Winokur, Clayton and Reich, 1969). Yet, in spite of the widely held belief of the diagnostic relevance of diurnal patterns, little systematic research on these patterns has been reported.

The concept of brain disconnection derives from work in which the two cerebral hemispheres are surgically separated by division of the corpus callosum. The patient behaves as if his two half-brains function to some degree independently. The syndrome of brain disconnection is exemplified by such split-brain cases (Geschwind, 1965). Neither hemisphere shows an awareness of the functions of the other, and there is a marked failure to cross-match stimuli across the midline of the body. The integrity of the corpus callosum is essential to normal integration between the hemispheres.

During the last decade, social psychologists and ethologists have become increasingly interested in the non-verbal elements of social interaction, as recent reviews testify (Argyle, 1969; Vine, 1970; Hinde, 1972). Research into facial expression, visual interaction, posture, gesture, non-verbal aspects of speech, etc., has considerable clinical implications, but carefully conducted investigations of non-verbal social interaction in psychiatric patients have been rare (Grant, 1972). The purpose of this paper is to review the evidence concerned with one aspect of social behaviour in psychiatric patients, namely visual interaction, in an attempt to summarize the current state of knowledge and to suggest ways in which research in this area might develop.

Few studies have been published about psychiatric illness among relatives of patients with anorexia nervosa. Even less information is available concerning alcohol abuse in relatives of such patients. Theander (10) found a 2.5 per cent incidence of alcohol abuse among uncles and aunts of patients with anorexia nervosa. Six out of 94 fathers, 6.5 per cent, were alcohol abusers, whereas none of the 94 mothers so indulged. In a recent report of 13 male cases of anorexia nervosa Crisp and Toms (3) describe one father who was a severe alcoholic. Kay and Leigh (6), in a study of 38 patients with anorexia nervosa, noted alcoholism in four parents out of a total of 76 (5 per cent). Alcoholism in actual anorexia nervosa patients has been mentioned, but no incidence figures were given. Crisp (2) commented that ‘those chronic patients who have progressed to a state of overeating and vomiting not infrequently appear to become dominated by oral behaviour, and may sometimes present with alcoholism’. Toms and Crisp (11) hold that alcohol and drugs may be used as substitutes or diversions for the suppression of normal appetite.

In discussion of the wider issue of the characteristics of, and the relationship between, the classes ‘psychosis' and ‘neurosis', Maxwell (1972) wrote: ‘… the majority of all patients tend to have a basic core of symptoms, neurotic in type, which lend themselves to a dimensional description, but one whose prominence decreases somewhat as we pass from neurotic through affective psychotics to schizophrenics. In addition there are the psychotic type symptoms, which are rare and haphazard in occurrence. These are virtually absent in neurotics: they are most common in schizophrenics, but still not sufficiendy numerous or patterned to support a clear-cut typology or to lend themselves to a dimensional description.’

Previous investigations have suggested that desensitization is the treatment of choice for simple phobic disorders, but is less effective with agoraphobia, particularly when the phobias are accompanied by much generalized anxiety (Gelder and Marks, 1966). Even the milder agoraphobias usually respond incompletely despite prolonged treatment. An alternative treatment that offers more rapid or effective results, particularly with agoraphobia, would therefore be of value. The technique of flooding or implosion has recently been the subject of a number of studies, and some, but not all, have shown evidence of considerable therapeutic power. The method is also of some theoretical interest since it breaks the rules which are thought to be important in desensitization. Thus, according to early proponents (Stampfl and Levis, 1967) success depends on exposing patients to fantasy material of an extremely intense and anxiety-provoking nature, so that extinction to cues associated with the original traumatic situation may take place. From this theoretical viewpoint desensitization can be only partially successful, since these traumatic origins are neither sought for nor presented to the patient. Even if the necessity of dealing with original anxiety-provoking cues is not accepted, the use of material which evokes maximal anxiety for prolonged periods is contrary to the counter-conditioning theory of desensitization (Wolpe, 1958). Indeed, this theory predicts that flooding would rarely be successful and might make the phobia worse because uncontrolled increases in anxiety may cause reconditioning.

The therapeutic effect of flooding was thought originally to depend on the induction of high levels of anxiety by the presentation of intensely frightening situations in imagination or practice (Stampfl and Levis, 1967; Marks et al., 1971). More recent evidence indicates that high arousal may not be essential in flooding and may even be disadvantageous. Hussain (1971) reported that patients with agoraphobia and social phobias responded better to imaginai flooding when it was accompanied by the intravenous infusion of thiopental. Marks et al. (1972), treating patients with specific phobias, found that flooding carried out by exposure to the phobic situations was more effective if combined with an anxiolytic drug, oral diazepam. There was some evidence that flooding was most effective if it took place several hours after administration of the drug.

The ability to distinguish separate types of disorder among patients who seem at first sight to have similar symptoms has been a powerful factor in the progress of medicine. It is for this reason that the attempt to distinguish different varieties of depressive illness is important. In Britain recent studies have been concerned with the presence (as rated by the examining physician) of various symptoms and signs which from clinical experience have been thought likely to distinguish a neurotic from a psychotic type of depression. The investigators agree on the presence of these two types but disagree on the nature of the distinction, one school holding that there are two largely distinct types of illness and the other that the types merely represent the opposite ends of a continuum. The holders of the latter view accept that there may well be distinct types of depressive illness, but maintain that, if so, they cannot be distinguished by present methods of clinical examination. The divergence of view has been attributed by Kendell (1968) to sampling differences and to the subjective bias of raters, and by Eysenck (1970) to disagreement on whether the two types of depressive illness are of a categorical nature (i.e. specific disease entities) or of a dimensional nature (i.e. each has a graded distribution in a population of depressed patients).

Obsessional neurosis can be more resistant to treatment, and sometimes even to amelioration, than almost any other form of psychiatric illness. Pollitt (1969) has pointed out that, ‘true obsessional states are among the few illnesses that can still torture patients almost for a lifetime’, and other reports have shown that a generally bad prognosis is to be expected among such patients (Kringlen, 1965; Templer, 1972). As a means of helping patients with obsessional illnesses, various types of psychosurgical operation have been attempted (Lewin, 1961; Knight, 1964; Post, Rees and Schurr, 1968; Knight, 1969). In this paper we present a detailed review of a series of patients who had undergone stereotactic psychosurgical operations for these conditions, in order to assess the value of this method of treatment and also to attempt to identify factors which might have prognostic significance. Some of the patients reviewed had also had second operations of other types.

In a previous paper (Tresise and Stenhouse, 1968a), the authors quantitated the normal time response patterns in the phases of electroplexy, where the four anaesthetics, methohexitone sodium, thiopentone, amylobarbitone sodium and diazepam were used in sub-anaesthetic doses. Patients treated without anaesthesia were included in the study. The dependence of the times of subsequent events on the time of clonus onset in the orbicularis oculi muscles were also established. The statistical technique employed in that study was simple linear regression. The interrelationships between the various factors indicated the desirability of extending the study by the use of multiple regression techniques. This paper presents the results of the extended study.

Tasks involving verbal learning and memory are widely used in the differential diagnosis of depressive and dementing conditions. That dements suffer widespread impairments of these functions is self-evident, yet depressives also evince some degree of deficit. For elderly patients suffering from affective illnesses Bolton, Savage and Roth (1967) found 29 per cent to gain organic scores on the Modified New Word Learning Test; of elderly depressives, 16 per cent gained scores in the organic range on the Synonym Learning Test (Kendrick, Parboo-singh and Post, 1965), and this figure increased to over three-quarters when a group was selected to contain a large proportion of patients clinically judged as suffering from ‘pseudo-dementia’ (Kendrick, 1967).

There are many clinical reports on psychotherapy with depressed patients, and an enormous effort has been devoted to psychotherapy research (10, 23, 24, 27, 28). However, there is little quantitative description of the content of psychotherapy—what patients discuss during sessions and how much time is spent reflecting on problems. This situation is partially understandable given the technical difficulties in obtaining psychotherapy process data. Content analysis of transcribed tapes, process records, video-tapes and the coding of words have been among the methods used (7, 9, 12, 14). These methods are inclusive and precise but impracticable in lengthy psychotherapy or with large samples.

It is widely agreed that the MAO inhibitor group of drugs are less effective anti-depressants than the tricyclics in severe depressions, specially those of endogenous type (Medical Research Council, 1965), but a role for them is still claimed, for example, in the treatment of milder depressions or of depressive symptoms. According to Pöldinger (1967) they are ‘thermagasics', i.e. psychic energizers or disinhibitors, and their mood elevating effect is relatively slight. Dally (1965) maintained that MAO inhibitors were most useful in atypical depressions, with tension and anxiety, but were ineffective in patients with inadequate personalities. Kelly et al. (1970) found that these drugs relieved depressive symptoms in phobic anxiety states. In this paper we have attempted to reexamine this question in a double-blind trial of phenelzine and amitriptyline in depressed out-patients.

Bannister (1960, 1962) found that thought-disordered schizophrenics had significantly lower scores on a repertory grid test of the intensity of the relationships between their constructs than did non-thought disordered schizophrenics, normals, neurotics and (in the 1962 study only) depressives. This finding has been confirmed, sometimes in slightly different ways, by a number of subsequent studies (vide infra). On the basis of his results, Bannister put forward the theory that schizophrenic thought disorder is characterized by ‘loosened construing’, which can account for all its clinical signs, and which stems from repeated invalidations of construing. This theory has been followed up in a number of subsequent investigations (Bannister, 1963, 1965; Bannister and Salmon, 1966).

Screening examinations are widely advocated for the early detection of disease in the elderly (Williamson et al., 1964; Lowther, McLeod and Williamson, 1970; Williams et al., 1972; Richardson, 1964; Anderson and Cowan, 1955; Isaacs, Livingstone and Neville, 1972). There have been several successful experiments in the use of health visitors and district nurses in the initial interview (Burns, 1969; Hodes, 1971; McNabola, 1970; Williamson et al., 1966).

Over the past hundred years, a great deal has been written about obsessional neurosis. Much of the literature is theoretical, concerned with putting forward explanations for obsessional behaviour. Little attention has been given, however, to the question of what it is that requires to be explained, what it is about the obsessional symptom that is pathological. It is the aim of this paper to examine this question more closely.

In an earlier study this research group reported iprindole, a relatively new tricyclic derivative, to be an effective drug for use in depressed neurotic out-patients (ii). We found it to produce significantly greater improvement than placebo on a variety of outcome measures. Good response to iprindole as compared to placebo has also been reported by Hicks (5) and Daneman (3). Sterlin et al., comparing iprindole with amitriptyline in a relatively small patient sample, reported that iprindole, while faster acting, produced less overall improvement (15); differences in improvement did not, however, reach statistical significance.

In previous studies we have suggested that there are two types of depressive illness (4, 5). The first of these is depressive spectrum disease which has as its prototype the early-onset female depressive; the second type is pure depressive disease, the prototype of which is the late-onset male depressive. Other family studies support the differences between these two prototypes (1, 8). The early-onset females have a considerable amount of alcoholism and probably sociopathy in their male first-degree relatives. The late-onset males have an ordinary amount of these illnesses in their male relatives. In the families of early-onset females, female relatives outnumber male relatives for the presence of depressive illness; this is not seen in late-onset males, where male and female relatives have equal amounts of depressive illness.