Ideas of changing sex, and the doubt about sexual identity which these ideas imply, are considered to be “invariable” and “pathognomonic” features of schizophrenia by Macalpine and Hunter (1955). The authors quote, in a footnote, a personal communication from Manfred Bleuler dated 1953 which states that Eugen Bleuler would have agreed that “schizophrenics are almost invariably, if not indeed invariably, in doubt about the sex to which they belong”. Planansky and Johnston (1962), in an uncontrolled study of 150 male schizophrenics, found that only 15 per cent. (22 cases) exhibited “direct expression of confusion of sex identity” and only 4·7 per cent. (7 cases) had clear delusions of having changed into a woman. Jackson (1960), Weckowicz and Sommer (1960), and Skottowe (1964) state merely that these ideas occur, or occur frequently. A check of the standard English language teaching texts reveals that Allen (1962), Bleuler (1911), Mayer-Gross et al. (1960), Noyes and Kolb (1963) and Sim (1963) make only oblique references to ideas of changing sex, whilst Anderson (1964), Arieti (1959), Bellak and Benedict (1958), Curran and Partridge (1963), Fish (1962 and 1964), Freeman et al. (1958), Henderson and Batchelor (1962), Merskey and Tonge (1965), and Stafford-Clark (1964) make no reference at all. In their study of schizophrenic delusions Lucas et al. (1962) similarly do not mention change of sex. They state simply that (in males) 30 per cent. had a sexual content.

A study of the relationship between attempted suicide and parental loss in childhood has been described in a previous publication (13).

The lumbar air encephalogram (L.A.E.G.) was introduced by Dandy in 1919, and in 1929 the first report of its use in schizophrenia was published by Jacobi and Winkler. Since then numerous papers have appeared, most of which have claimed to demonstrate cerebral atrophy in chronic schizophrenic patients. All these studies have suffered from the fact that no adequate series of normal controls has yet been collected. Most of the authors concerned made no attempt to use controls, nor did they consider the possibility of observer error or of the bias which may exist when the reporting radiologist knows the diagnosis and is looking for abnormalities.

There are only three special security hospitals in England and Wales (Broadmoor, Moss Side and Rampton). They provide an opportunity to investigate what amounts to a national sample of severe behavioural problems, with regional bias reduced to a minimum. Since the article by Tong and Mackay (1959) dealing with relationships between certain offence patterns and eventual social prognosis in terms of relapse rate, nothing has been published about the type of male patient sent to Rampton, nor about his conduct after admission. To our knowledge no similar study has ever been carried out in this country on female patients requiring special security treatment.

Behaviour therapy is conducted in this department under combined general psychiatric and behaviour therapist supervision. Patients considered suitable for behaviour therapy are first assessed clinically at a phenomenological and psychodynamic level. On the basis of this assessment an appropriate symptom or number of symptoms are selected for treatment by behaviour therapy. The patient is thereafter observed by the original clinician and assessed at regular intervals. Meanwhile the behaviour therapist treats the specific symptom or symptoms.

A boy prostitute is defined here as one under 16 years old who repeatedly performs sexual acts with other males for reward, and is known for this service by his community. This article is concerned with the antecedents, acts, treatment and follow-up of 33 such boys.

Depressive illness is a major medical problem among psychiatric out-patients (Davies, 1964). Most of the recent investigations of depression have been related to the use of antidepressive drugs and electroplexy, but a deeper understanding of the condition quite apart from the efficacy of treatment is necessary (Lewis, 1964). The importance of cultural factors in mental illness is well recognized (Myers and Roberts, 1959), but their study has been neglected in Britain in spite of the variety of ethnic groups in many British cities, especially London. Many of the cultural groups in London consist of recent immigrants in whom the factors connected with immigration are difficult to separate from cultural influences. However, Anglo-Jews form a long established though distinct group which has been fully accepted in Britain for over a hundred years (Roth, 1964). They are predominantly British-born and English-speaking and number about 450,000, more than half of these living in London (Brotman, 1964). One of the older areas of settlement is the East End of London, but with economic advancement there has been a drift away from there to better class areas (Krausz, 1964). It was felt that a cross-cultural study in the East End of London comparing Jewish and non-Jewish patients suffering from depression might provide some insight into intercultural differences as well as the dynamics of depressive illness.

The effects of institutional environment have been recognized as constituting a major influence on the picture presented by chronic schizophrenic patients. These effects, and measures to mitigate them, have been described by May (1956), Freeman et al. (1958), Barton (1959) and others, and a review of the literature was made by Wing (1962). Many of these studies have suffered from the disadvantages that the degree of the patients' disability was not directly measured, and that the majority were not followed up over a reasonable period of time. This paper examines the results of environmental modification on a ward of severely disabled chronic schizophrenic patients over a period of four years. It also attempts to assess the effects of phenothiazine treatment on the behaviour of these patients.

Chromosomal abnormalities involving the autosomes are nearly always associated with serious defects in intelligence. This is true of the first disease recognized to result from a chromosomal aberration, Down's syndrome (Lejeune, Gautier and Turpin, 1959), and a series of other disorders, including the “cri du chat” syndrome, also first described by Lejeune and his co-workers (1963).

Reports that schizophrenics have older parents than non-schizophrenics (Barry, 1945; Goodman, 1957; Johanson, 1958; Gregory, 1959) are of considerable importance. If valid, they provide evidence for environmental causes of schizophrenia, and by analogy with other conditions where parental age effects have been noted may give some indication of the nature of these causes. There are, however, inconsistencies in these studies: thus Johanson and Gregory found a significant association between advanced paternal age and schizophrenia, but failed to confirm the maternal age effect noted by Barry and Goodman. These differences indicate the need for further investigation and this paper describes such a study.

This report was stimulated by the fact that two middle-aged depressive male patients killed themselves in the same ward under identical circumstances within a fortnight. It was thought that it would possibly be instructive to examine the hospital records since its opening in 1866 to look at the available information about patients who had committed suicide whilst under inpatient care here. The total number of suicides to date has been 24 and in the years 1901, 1911, 1955, 1957 and 1965 there have been two suicides in each year. There was sufficient information available to suggest that there were certain similarities between those occurring in the years 1901, 1957 and 1965, so these cases are considered in greater detail in the following reports.

In 1954 a programme of “occupation and liberalization” was started at this hospital. Attempts to assess this programme were made and have been reported (Clark and Hoy, 7; Clark and Oram, 8). As a result of these surveys, we possess a complete list of the male patients in the hospital in October 1954 and February 1961, showing the work they were doing at these times; many men's names appear in both lists. This paper reports the analysis of these lists and some interesting facts that emerged.

Merskey, Gillis, and Marszalek (1962) reported that in chronic schizophrenic patients reaction to pain was greatest in those patients showing either over-activity or under-activity as measured by a ward activity rating scale. They also reported a significant difference between certain age groups, the oldest and youngest age groups showing the greatest reaction to pain. The authors attributed the difference between age groups to the effects of tranquillizing drugs, since there existed a high correlation between age groups and their dosage of such drugs. It was concluded that ward behaviour in schizophrenics is a poor indicator of their sensitivity to stimulation.

As currently used, the diagnosis of depression includes a wide range of clinical phenomena. This has not always been the case. Near the end of the 19th century, when the term depression began to evolve the meanings that it has today it was applied primarily to psychotics. The formulations of Freud in Mourning and Melancholia (1917), and of Kraepelin in Manic Depressive Insanity (1921) were based upon observations of patients who were both depressed and psychotic. In their work the contrast was between psychotic depression (or “melancholia”) on one hand, and normal sadness on the other. In the succeeding half-century, however, as psychiatry has extended its boundaries, increasing attention has been focused on non-psychotic depressions, often called “neurotic” or “reactive.” As these “neurotic” or “reactive” depressions reached public attention, a debate began over the way in which the depressive population should be described and the extent to which it should be subdivided. Critical and often sarcastic written battles were fought between the separatists and the unifiers during the 1920's and 1930's. These debates have been informatively chronicled by Partridge (1949). We have found it useful to divide these theorists into unifiers, dualists, and pluralists.

The significance of observations made in clinical work can really only be found by reference to a hypothetical position. It is necessary therefore first to indicate very briefly the theoretical constructs relating to therapeutic community work.

Problem

The existence of impairment in abstract ability for certain abnormal groups has been well documented in the clinical literature (Goldstein, 1936, 1943; Goldstein and Sheerer, 1941). The concept of “abstract ability” involves various types of abilities which may or may not be related to each other in specific ways. For example, the ability to solve syllogisms need not necessarily require the same order of skill as elucidating proverbs, although persons gifted in abstract capabilities may excel in both. Nevertheless, groups of abilities variously referred to as “abstract” seem to undergo appreciable modifications in organic and functional pathologies and disorders.

In one of the outer suburbs of Sydney, along the jagged Pacific coastline, there is a high cliff known as “The Gap” which is notorious for the frequency with which it attracts, often fatally, the person with suicidal intent. Recently a young man entered a Sydney taxi-cab and asked to be driven to an address in the street which leads to this particular area. Having settled comfortably in the front seat he announced cheerfully to the driver, “Well, this is certainly going to be my last ride!” To his apparent surprise and annoyance, his cab promptly deposited him at the nearest police-station, from where he was removed, under considerable protest, to a psychiatric hospital for observation.

The main aim of this investigation is to determine whether patients with psychiatric illness have more somatic illness than those who are psychiatrically well, and conversely, whether those who have more than an average amount of physical sickness also suffer from an excess of psychiatric disability. A subsidiary purpose is to determine how much “psychosomatic” illness occurs in association with physical and with mental illness.

The ionic theory of cell excitability shows how impulses are generated, conducted and propagated by movements of ions between the cells and the extracellular fluid. It is known that changes in the concentration of sodium and potassium in either the extracellular water (E.C.W.) or the intracellular water (I.C.W.) may have a marked effect on the resting and action potentials of excitable cells. If affective disorders are manifestations of complex but reversible changes in brain excitability, hen these in turn might be caused by alterations in the concentration of electrolytes within the cells of the central nervous system (C.N.S.). Although it is not possible to measure the distribution of electrolytes specifically in the C.N.S. in man, it is possible to measure their distribution in the body as a whole. In previous papers we have shown that residual sodium (intracellular plus a small quantity of bone sodium) is increased by 50 per cent. in depression (Coppen and Shaw, 1963) and by nearly 200 per cent. in mania (Coppen, Shaw, Malleson and Costain, 1965). The present paper shows that there are also abnormalities in the distribution of potassium, the other main cation determining cell excitability, in patients suffering from severe depression.

This paper describes some of the characteristics of children included in the National Survey of Health and Development who have been cautioned by the police or come before the Courts before their seventeenth birthdays.