The occurrence of obsessions in the course of depression was first noted by Prichard (1835), Esquirol (1838) and Marc (1840). The first series (22 cases) was described by Heilbronner (1912), who agreed with Scheule (1888) that in some cases at least the depression was the primary illness and not merely a secondary result of the obsessions. Further small series were reported by Vurpas and Corman (1933)—27 cases, Lion (1942)—16 cases, and Ingram (1961)—10 cases. Stengel (1945) reported 4 cases and reviewed the literature fully. None of these series are controlled by a parallel series of depressives without obsessions. Lewis (1934) described depressives both with and without obsessions, but did not compare them.

An association between certain persistent oral dyskinesias and medication with phenothiazines has been observed in middle-aged and elderly women for several years. In most of the published reports it is held that the phenothiazines are an important cause of the abnormal movements, since phenothiazines are known to exert a selective action on the basal ganglia. Other possible causes, however, are almost invariably present. These are brain damage from disease, leucotomy or electroconvulsive therapy (Hunter, Earl and Janz, 1964; Hunter, Earl and Thornicroft, 1964; Uhrbrand and Faurbye, 1960), and buccal factors such as ill-fitting dentures or the edentulous state (Joyston-Bechal, 1965; Evans, 1965). Similar dyskinesias are also said to occur with brain damage when phenothiazines have not been given (Rosin and Exton-Smith, 1965).

The occurrence of depressive psychosis in the obsessional neurotic has been noted by Prichard (1835), Heilbronner (1912), Gordon (1925 and 1950), Vurpas and Corman (1933), Lewis (1934), Stengel (1945 and 1948), Terhune (1949), Pollitt (1956 and 1957), Reda and Paretti (1958), and Skoog (1959). Apart from Freud (1923), Vurpas and Corman and Pollitt, the general view is that such cases fare worse than other depressives. It is still uncertain in what ways, if any, a pre-existing obsessional neurosis modifies a superimposed depressive psychosis. The uncertainty is due to the lack of a large controlled series, the provision of which is the purpose of this study.

In most instances presenile dementia is based on well-defined organic diseases and it is not necessary to resort to cerebral biopsy to establish a diagnosis. These organic disorders cover a wide spectrum and include cerebro-vascular disease, tumours, trauma and well-defined degenerative states such as Huntington's chorea, vitamin deficiencies, endocrine disturbances, infections (bacterial and viral) and poisons such as alcohol, lead, barbiturates, bromides and carbon monoxide. The effects of liver and kidney failure as well as the hypercapnia of pulmonary insufficiency account for others.

This investigation is concerned with the histological changes found in cerebral biopsy specimens taken from 59 patients with presenile dementia. We have defined the presenile dementias as organic dementing diseases occurring before the age of 65; although 5 of the patients were a few years older than this at the time of biopsy, in all cases there was unequivocal evidence that the dementia was established before the 65th year. The clinical findings in 56 of these patients are described in the preceding paper (Sim, Turner and Smith, 1966).

In recent years there have been an increasing number of attempts to survey the distribution of psychiatric morbidity, or to estimate the need for psychiatric treatment, in the general population. Various methods of defining or diagnosing psychiatric illnesses have been used (Blum, 3; Scott, 20). These methods include interviews by psychiatrists (Lin, 17; Essen-Müller, 13; Hagnell, 14); the judgment of family physicians (11; Kessel, 16; Shapiro and Fink, 21); the use of self-administered symptom check lists (White et al., 23); and structured interviews by non-psychiatrists relating to symptom occurrence, attitudes, personality scales, etc. This paper outlines an attempt to determine some of the relationships between the results of a symptom-questionnaire; the diagnoses recorded by physicians; and the physicians' request for psychiatric consultation.

Although there is now universal agreement that the reduction of food-intake is the central phenomenon in the syndrome of anorexia nervosa, the cause of the food refusal is still incompletely understood. One of the difficulties in elucidating the psychogenic roots of the anorexia is the fact that the patients themselves are unable to explain their thoughts and feelings. Conversations with them give the impression that one is speaking to a very young child who cannot or dare not express herself, so that the interviews are reduced to monosyllabic answers to questions and long periods of silence without relevation of pertinent material. After having spent much time with such patients in the past, we have since tried to obtain additional information from parents and other family members, neighbours and family doctors who knew the patients and their environment. Although we are well aware that this kind of information pertains more to outward behaviour than to “endopsychic” processes and therefore will probably be considered as of limited value by those who are interested in the so-called psychodynamics of the disease, we were able to formulate at least a tentative hypothesis that seemed to fit the life situation in our patients and bring them under a common denominator. From this hypothesis, which will be formulated below, a simple prediction followed as to how these patients should be treated. In the present paper we wish to formulate the hypothesis and present the preliminary results of a form of treatment, based on this prediction.

The following case study offers an exceptional opportunity to illustrate the wish-fulfilling nature of auditory hallucinations in a hysteric (Breuer and Freud, 2; Freud, 11), the conditions under which these hallucinations are experienced, and their response to treatment.

A previous study of depressive psychosis—Gittleson (1966a) showed that depressives with obsessions attempted suicide six and a half times less often than depressives exhibiting obsession-delusion transitions (without change of content) or those without any obsessions at all. It was suggested that the essential “protective” factor against suicidal attempts was the phenomenological form of the obsession as an obsession and its persistence as such throughout the course of the depression.

Eighty years ago Gilles de la Tourette (1885) described the syndrome which has become eponymous. It has been usual to consider it as a relatively rare constellation of symptoms, sometimes the concern of the neurologist, sometimes of the psychiatrist; but in recent years three papers (Bockner, 1959; MacDonald, 1963; Polites, Kruger and Stevenson, 1965) discussing the syndrome and its treatment have appeared in British journals alone. All comment on the infrequency of the syndrome, but one does suggest that it may be less infrequent than has been thought in the past.

The adult adjustment of children who were partially reared in foundling homes or other child care institutions is largely unknown. There is ample proof that major personality and character disturbances attributed to lack of maternal or emotional nurture appear in many children during or soon after periods of institutional care. Several authoritative reviews of the subject have appeared (Bowlby, 1952; Yarrow, 1961; Ainsworth et al., 1962). The later history of such children is much less clear. Retrospective studies of persons located through psychiatric clinics or delinquent groups suggest that considerable psycho-social disability persists well into adolescence. In particular, shallow feelings and loyalties, inability to form or tolerate emotional relationships, and asocial behaviour are frequently described (Bowlby, 1946; Goldfarb, 1947). However, other evidence supports at least partial spontaneous recovery (Beres and Obers, 1950; Clarke and Clarke, 1959; Stott, 1956). The adult fate of children who receive institutional care, though of compelling theoretical and practical interest, remains speculative.

El-Zar is one of the most popular traditional healing cults in Egypt, and it seems to have been introduced into the country from Sudan through Ethiopia. The word “Zar” means, in Amharic, the “devil” or “spirit”. Literally, the word is a derivative of the verb “to visit” and implies the intermittent visit of some wicked spirit. In practice, it generally connotes the gathering of some women, headed by a woman called “kodia”, with the purpose of exorcizing evil spirits.

In a number of previous communications (10, 11, 12) I have advanced the thesis that in successful psychotherapy what goes on is a unique kind of learning process in which the therapist employs his particular theoretical frame of reference as a rational basis for explaining the patient's past and present difficulties, and by non-verbal as well as verbal cues uses the instrument of a warm empathic human relationship as a means of helping the patient to persist in the difficult task of combating his anxieties, overcoming his resistance to change, and learning more mature patterns of adaptation. This underlying modus operandi is essentially the same in different “schools” of dynamic psychiatry, despite their ideological variations. In the present communication I propose to outline some of the significant areas in which the findings from learning theory experiments are applicable to what goes on in psychotherapy.

The evidence that potent tranquillizers are useful in the long-term treatment of elderly patients with dementia in psychiatric hospitals is conflicting.

Seager (1955), in a double-blind, controlled trial involving 48 elderly women, 29 of whom suffered from dementia, found a highly significant improvement of social adjustment associated with chlorpromazine therapy. Schulsinger (1961), Exton-Smith (1962) and Post (1963) claimed promazine to be of particular value for agitated elderly patients. Robinson (1959), on the other hand, compared the effects of prolonged administration of chlorpromazine, reserpine, leptazol and a placebo upon 84 senile female patients in a double-blind trial and found no statistically significant improvement associated with the active drugs. Indeed, in the case of chiorpromazine, he found a significant lowering of the level of functioning. Abse and Dahistrom (1960), in a double-blind controlled trial involving 8o patients over 60 years of age with various symptoms (including some with confusion), found that chlorpromazine did not give better results than placebo.

There have been many reports of the high incidence of early parental loss among groups of patients suffering from various psycho-pathological disorders. Bowlby (1951) cited numerous relevant studies in his influential monograph, and Gregory (1958) has critically reviewed a dozen others. More recently Brown (1961) reported a significantly higher incidence of parental loss in childhood among depressed patients than among the general population, and Beck et al. (1963) found that the incidence among highly depressed psychiatric patients was higher than among non-depressed patients. Both these writers aver that their findings provide evidence that parental loss in childhood is a significant factor in the development of a depressive illness in adult life.

There is a general view that the content of obsessions occurring in the course of depressive psychosis is frequently aggressive, homicidal or suicidal. Prichard (1835), Esquirol (1838), Marc (1840), Maudsley (1895), Heilbronner (1912), Gordon (1925 and 1950), Muncie and White (1937), Henderson (1937), Bowlby (1940), Lion (1942), Oltman and Friedman (1943), Stengel (1945), and Skoog (1959) all express this view on the basis of single anecdotal case reports or series of fewer than ten cases. The largest reported series is that of Vurpas and Corman (1933) who described 27 cases (2 organically based) of homicidal obsessions in depression. Only 3 cases (Nos. 10, 24 and 27) exhibited obsessions before the depression and this is too small a number to serve as a control group.

In the controversy over the nature of schizophrenic “dementia” the weight of opinion has fallen on the side that emphasizes the differences which exist between this state and organic cerebral degenerations. While acknowledging these differences, it is important also to draw attention to the similarities between the impairment of chronic schizophrenia and the defect of organic dementia as it occurs in the elderly. We have chosen to compare the extent of perseveration in the two groups because this is a neglected field and because objective tests of such behaviour are readily devised.

Although the main value of hospital statistics is administrative, in connection with planning future needs of the mentally ill, they have been used by Shepherd (1957a), Brown et al. (1961), Barr et al. (1962), and Ratcliff (1964) to study trends in the characteristics and fate of patients admitted to mental hospitals. Since the factors that govern the admission of patients to psychiatric hospitals are both complex and varied, as has been shown by Svendsen (quoted by Reid, 1960), it would be more correct to say that the studies referred to describe the end-results of a number of factors interacting with each other and changing from time to time, such as hospital policy, demands of the mentally ill, available resources, therapeutic advances, attitudes of the community to admission, the state of the law, and so on. All these factors could be expected to influence the number and characteristics of patients admitted, especially for the first time.

Whenever one person seeks to influence the behaviour of another, the outcome may be affected by a multiplicity of factors. When the deliberate manipulation of one of these is followed by a given response, we regard the manoeuvre as specific and causal for that event. While this conclusion is acceptable logically, in practice it frequently proves to be misleading because certain implicit assumptions are overlooked.

This study concerns a two-year follow-up of all the male alcoholics discharged from the Alcoholic Unit at Warlingham Park Hospital between January 1960 and October 1961.