When choosing a title for this Lecture, I hesitated between two possible ones, the one above which I selected finally and another, termed ‘Links between Adult Psychiatry and Child Psychiatry’ Although in wording they seem different enough from each other, I hope to show in what follows where the two subject-matters meet.

A large part of medical practice is complicated by two problems; the degree to which treatments are specific (the placebo problem) and the extent to which they are implemented (the adherence problem). Depending on setting and circumstance, up to half of the benefits of treatment are either non-specific or never obtained. This review considers the problem of adherence in the context of use of medication in psychiatry.

To psychiatrists who entered clinical practice in the decade 1955–65, ‘behaviour therapy’ probably conjures up the names of Eysenck, Lazarus and Wolpe; the invocation of learned maladaptive anxiety as the basis of most neurotic illness; desensitization by graduated exposure in imagination and real life to anxiety evoking situations. Neurotic ‘symptoms' were maladaptive habits and the ‘symptoms' were the disease, not merely outward manifestations of underlying disorder. Eysenck (1959) described behaviour therapy as all methods of treatment which were based on ‘modern learning theory‘. The ‘bell and pad’ treatment for enuresis and aversion therapy for alcoholism were appropriated and refined. Operant conditioning crossed the Atlantic and the application of Skinnerian principles was illustrated by Krasner and Ullman (1965). In the early sixties, at the very least behaviour therapy offered a possible treatment for a small proportion of psychiatric patients, for example those with phobias, tics or alcoholism, a group for whom other treatments were of little value.

A brief historical introduction traces the evolution of the concept of hypochondriasis. It is suggested that the term should now be used only as a descriptive adjective when there is a morbid preoccupation with health or body. Social and cultural factors are outlined, as well as problems of measurement. The psychopathology, as formulated by Freud and others, is also described. Clinical aspects are discussed under the headings of general symptoms, pain, smell, bodily appearance, sexual, gastro-intestinal, cardio-respiratory, eyes, and ears, nose and throat. Psychiatric syndromes mentioned are: hypochondria as a possible primary state, personality disorders, phobic-anxiety state, neurasthenia, obsessional neurosis, hysteria, depression, paranoid psychosis and organic. In general, hypochondriacal symptoms seem to make the prognosis rather worse. Treatment is to be aimed at the primary condition, which is most commonly depression, anxiety state or conversion reaction.

The study of the sexual disorders has made considerable strides during the past 90 years since Krafft-Ebing published his Psychopathia Sexualis in 1886. There were earlier beginnings which had provided very important insights into the nature of abnormal sexual behaviour, but it fell to Krafft-Ebing to bring sex research into the discipline of medicine, thereby giving it a methodology and a framework within which to unfold. The subsequent history has been described by Wettley and Leibbrand (1959) and constitutes the development of the basis of modern ‘sexology'—a translation of the term ‘Sexualwissenschaft’ created by Iwan Bloch in 1906. The period from the Psychopathia Sexualis to the time of the First World War saw the development of ideas which are still important for modern sexology, although the discipline has since matured into an experimental science using the methodologies of the biological as well as the behavioural sciences—psychology, sociology and anthropology.

Psychodrama, a method of human relations training and psychotherapy, is traced from its creation by Moreno fifty years ago to its present resurgence with the growth of ‘humanistic’ psychology. The basic techniques are described, together with Moreno's concepts of social interaction, e.g. encounter, spontaneity, the moment, catharsis and role playing. Its uses and limitations are discussed briefly.

The effects on patients, volunteers and staff of using volunteer adolescents in adolescent group therapy are examined. From 40 candidates eight volunteers were selected and oriented to the group process. Four volunteers and four patients were placed in each of two groups, and eight patients were placed in the third group. Patients and volunteers were aware of their identities in the first group session. Attendance in the groups with volunteers was better than in the group without. The volunteers themselves gained new knowledge and skills, and their presence was even helpful to the group leaders.

A comparison was made of the social and domestic background, prepsychotic personality and symptomatology of deaf (‘hard of hearing’) and non-deaf patients aged 50 or over with paranoid or affective psychoses. The deaf patients were found to be a very heterogeneous group in respect of age of onset, duration, severity and pathological basis of their deafness, but there was a substantial subgroup of paranoid patients with deafness beginning before the age of 45 in whom the personality appeared to have been less deviating than in the remainder. It was thought that the deafness in this subgroup had possibly played a relatively specific role in causing the psychosis. Some problems in identifying deafness and assessing its significance are discussed.

Let us try to project ourselves back into the places and minds of physicians and psychiatrists in, say, 1900. When they spoke of disease, what did they mean? They meant, typically, something like syphilis. ‘Know syphilis in all its manifestations and relations,’ declared Sir William Osler (1849–1919), ‘and all things clinical will be added unto you.’ (1). Obviously, this is no longer true. Indeed, how many cases of syphilis do modern medical students see between the time they enroll in school and the time they graduate? In the United States, Osier's maxim has been replaced by another which asserts that ‘mental illness is our number one health problem‘. This would make schizophrenia—the most common and most disabling of the so-called mental diseases—the successor of Osier's syphilis, showing us immediately what a gulf separates us from him. For, clearly, a physician may know all there is to know about schizophrenia, and yet be totally ignorant of medicine.

During the last fifty years, and particularly the last twenty, innumerable different classifications of depressive illness have been proposed, and several disputes are smouldering away between the protagonists of rival schools. Much of this is too well known to need, or bear, repetition. But the conflicting claims and proposals are now so numerous, and methodological problems loom so large, that those who are not intimately involved have increasing difficulty in understanding what is going on; while those who are involved are mostly too intent on developing and promoting their own particular schema to review the overall situation in any broader context. This article is an attempt to describe the main elements in a confusing situation, to outline the important problems, and to indicate the areas of agreement that are beginning to emerge, without advocating any particular solution.

A woman aged 20, first presenting with what appeared to be hysterical blindness as part of the syndrome of hysterical pseudo-dementia, soon showed the picture of speech-prompt catatonia, one of the subtypes of chronic schizophrenia described by Karl Leonhard. However, within a short time the neurological, EEG and laboratory findings indicated that the condition was one of subacute sclerosing panencephalitis.

While the phenomena described under the terms transitivism and appersonation are well known, they have not been studied in detail either from the descriptive or from the psychopathological standpoints. Here only a brief reference is made to the descriptive data. An account of the psychopathological hypotheses on which an explanation of the phenomena is based is followed by a discussion of the relevance of the clinical manifestations for a theory of psychosis.

The effect of sodium valproate, a drug which has been demonstrated to increase gamma-aminobutyric acid levels in the CNS, on tardive dyskinesia and psychiatric symptoms was investigated in a double-blind cross-over study on 32 chronic psychiatric patients. The oro-facial dyskinesias were totally or significantly relieved in 17 cases. During the active treatment period the involuntary movements of the extremities and dystonic spasms were also significantly relieved in 7 out of 9 patients. In two patients, however, the extrapyramidal symptoms became slightly worse. A significant improvement was noted in the psychiatric symptoms of 14 out of 32 patients during sodium valproate administration. The psychiatric state of 4 out of 32 patients deteriorated. There was no correlation between the serum concentration of sodium valproate and its effect on the dyskinesia or on the psychiatric symptoms. Some of the elderly subjects showed a slight accumulation of the drug.

One hundred and twenty-seven accidentally poisoned children from the emergency room of the Islamic Girls College, Cairo, were compared with an equal number of controls.

The highest age incidence for both sexes in poisoned children was 36 months. Males outnumbered females at a ratio of 3:2. Behavioural problems such as hyperactivity, temper tantrums, aggression, stubbornness, nocturnal enuresis and impulsiveness occurred more often in poisoned children than in controls and more often in those (24 patients) referred with accidental poisoning on more than one occasion. The families of poisoned children differed significantly from the controls in their large size, low level of education, disturbed home atmosphere and the accessibility to the child of the poisonous substance.

Various premorbid characteristics of a group of patients aged 50 or over suffering from paranoid psychoses (N = 54) were compared with those of patients of similar age suffering from affective psychoses (N = 57). (The diagnoses were those of the consultants.) The presence of deafness was investigated in the manner described by Cooper et al (1974). Using the discriminant function method, the diagnostic groups were highly significantly differentiated by six independent variables, which in combination predicted 40 per cent of the variance. These were: a ‘schizoid personality’ factor, the number of surviving children, precipitating events, deafness, family history and social class.

Anyone acquainted with Dr Thomas Szasz's previous writings about mental disorder, the nature of its relationship to the Law and to the problems of drug dependance (Szasz, 1961, 1963, 1970, 1972, 1975) has learned to look in the first instance for the dualism, the poles of which are to be demonstrated as irreconcilable. For, as Glazer (1965) has pointed out, one of Dr Szasz's main conceptual devices is ‘the dichotomy game‘. A phenomenon may belong to category (x) or another category (y) but not to both. As a first step it is as well to examine the definitions of the categories in question. They are liable to prove inconsistent or idiosyncratic or just to be omitted. In other cases, as Professor Stone (1973) has shown in his detailed and telling dissection of the tortuous and confused logic pursued by Dr Szasz in The Myth of Mental Illness, the definitions are incomplete or erroneous and the implied anti-thesis dubious or false. Beginning with the equation that a lie is to a mistake as malingering is to hysteria, Szasz manages, following a maze of tortuous and self-contradictory arguments, to emerge at the conclusion that it would be ‘… more accurate to regard hysteria as a lie than as a mistake‘.

This study compared matched groups of patients with acute schizophrenia and with depression on three tests used in the assessment of schizophrenic thinking disorder. Most measures derived from these tests significantly differentiated the groups; however, within the schizophrenic group there were no significant correlations between scores on the three tests. Further data were available from a choice reaction-time card-sorting task, from which estimates of distractability, stimulus decision time, response decision time, and movement time, were obtained. Only one significant relation was found between these measures and scores on the clinical tests. The possible confounding effects of intelligence and responsiveness are discussed. It is argued that more direct measures of the latter are preferable to interpreting tests of thinking disorder in terms of information processing deficits.

In A Treatise of the Hypochondriack and Hysterick Passions published in 1711, Bernard Mandeville, writing by way of ‘Information to Patients’ describes three dialogues between an imaginary physician, Philoperio, and his patient, a confirmed hypochondriac, Misomedion. The book is original in its conception inasmuch as it represents an early recorded conversation between a physician and his patient. As such it represents a development in the writing on therapeutic technique of the eighteenth century. Though Mandeville's originality has been emphasized by contemporary medical historians, this book seems to have had little influence on the therapeutic style of the physicians of his day.