Eugen Bleuler has had a major influence on American psychiatry. His theory of schizophrenia, linking descriptive psychiatry to Freud's psychoanalytic concepts, has had an important influence on diagnosis and treatment, especially in America. This paper will summarize first some textbook descriptions of Bleuler's contribution and then some major issues which Bleuler discusses in his book Dementia Praecox, or the Group of Schizophrenias. I hope to demonstrate that the textbook accounts do not adequately describe the complexity and ambiguity of Bleuler's approach.

A follow-up study was conducted on 146 patients, all the first admissions of one year with the diagnosis of neurosis, admitted as in-patients and day-patients to a hospital giving a general psychiatric early treatment service in Birmingham. Tracing exceeded 97 per cent. Various methods of treatment had been used. Patients were followed up with an interview at their home 12 years after discharge. There were two interviewers, a social worker and a psychiatrist. Assessment at follow-up was on a five-point graded scale in which contributions to the total outcome were made by the social and symptomatic state of the ex-patient.

Twenty-six statistically significant predictive factors were found from the detailed initial information when a graded rating for total outcome at follow-up was compared with presence or absence of the factor. When individual factors were combined, unsatisfactory marital and sexual relationship, poor material management, unsatisfactory social state, and unsatisfactory early environment were predictive of poor outcome. Tests for validity and reliability of the method were carried out.

Sixty-nine schizophrenic patients (52 men and 17 women) who were consecutive admissions to Shehar Psychiatric Hospital, Taif, Saudi Arabia, were investigated for the phenomenology and frequency of visual hallucinations. Of these patients 43 (62 per cent) were visually hallucinated. It is concluded that visual hallucinations in schizophrenia are of common occurrence in this country. The need for further investigation as to the part played by cultural and other factors is emphasized.

This paper describes an attempt to validate a behaviour rating scale used to predict the likelihood of discharge among elderly and long-stay patients in a psychiatric hospital. The scale measured behaviour on the ward as rated by nursing staff. The scale was a sensitive predictor of discharge among those with a low score (indicating least disability), except for patients with organic psychoses. However, many patients with low scores were not discharged. In order to improve the scale's use as a screening technique additional information was considered. The significance of the findings is discussed.

Twenty patients with chronic obsessive-compulsive rituals were treated in a partially controlled design by in-vivo (real life) exposure with self-imposed response prevention. Treatment included 4–12 weeks as in-patients, and lasted a mean of 23 sessions. All patients were followed-up for at least two years. No patients dropped out during the trial, though one refused domiciliary treatment after discharge. Significant improvement in compulsions was found after three weeks of real-life exposure, and continued during follow-up. At two years follow-up 14 patients were much improved, one improved and 5 unchanged; in a third year of follow-up the improved patient became symptom-free after further exposure treatment. Improvement after three weeks exposure predicted good outcome at 6 and 12 months follow-up.

Muscular relaxation treatment had no significant effect on rituals. Modelling of exposure conferred no advantage over exposure alone for the group as a whole, though it may help selected patients. The role of response prevention is unknown. Patients' commitment to treatment facilitates exposure. Domiciliary treatment with involvement of family members in therapy seems crucial in some cases. Pilot group treatment of patients and families together suggests that this may be a useful adjuvant to individual treatment by increasing motivation and aiding follow-up.

Compulsive slowness presents special treatment problems but can be improved by a prompting and pacing approach.

The course of rituals was often independent of that of agoraphobia, marital problems and depression where these had initially coexisted with rituals. Depressive episodes were common before, during and after treatment, and required tricyclic medication.

The trial sample was predominantly female but was otherwise typical of patients with compulsive rituals. Of the 125 obsessive-compulsives seen in the first author's unit over four years 96 per cent were offered behavioural or antidepressant treatment. One quarter refused behavioural treatment after it was offered.

Real-life exposure with self-imposed response prevention is usually an effective procedure for lasting reduction of chronic compulsive rituals in well motivated patients.

During the course of research into the reorientating of homosexuals routine EEGs were taken to identify patients with low convulsive threshold to exclude them from treatment (aversion). In an initial series of 28 homosexuals 4 showed EEG abnormalities related to organic conditions, but EEGs of the otherwise apparently normal treatment seeking homosexuals showed more marked overbreathing response than would have been expected by chance.

This investigation has provided evidence against the hypothesis that heterozygous carriers of a schizophrenic gene have a reproductive advantage through enhanced fertility. An advantage arising from lower mortality between birth and the end of the reproductive period was not investigated, but should be examined before we search for other explanations of the apparently stable polymorphism of schizophrenia.

Two similar groups of adult psychiatric patients carrying the diagnosis of anxiety neurosis were compared in their response to different methods of training in deep muscle relaxation. One group received EMG feedback and the other a modification of the Jacobson Progressive Relaxation method. The frontalis muscle was chosen as the target for feedback training and for the measurement of tension reduction in both groups, for the reason that this muscle has been shown to reflect the general muscle tension level in anxious patients. Training was carried out under controlled laboratory conditions, and objective muscle tension levels were obtained. Overall changes in the status of the anxiety symptoms, as determined by global ratings from patients and from primary therapists, were also compared in the two groups at the end of training. The results of the study indicated that both EMG feedback and the progressive muscle relaxation training produced significant reductions in frontalis tension levels. However, EMG feedback was found to be generally superior in producing larger reductions in muscle activity, with a concomitant relief in anxiety symptoms, for a greater number of the patients.

The claim of Hansen (1969) and Hansen and Dimitrakoudi (1974) that whole blood adenosine triphosphate (ATP) levels correlate with depressed affect was examined. The findings from 84 patients failed to confirm any relationship between mood and whole blood ATP. One patient showing the highest correlation (r = 0·85; p < 0.001) between the ATP levels and mood in the original report was re-examined; no relationship was now found (r = −0·25; p > 0·1).

Ninety-three chronic neurotic patients whose previous psychiatric treatments had proved unsuccessful were included in this study, and selected patients, relatives and G.P.s were briefed to expect stress during therapy.

Assessment made by therapist and patients before and after therapy was made on the basis of the acceptability of eight aspects of their life. Follow-up lasted 2 ½ years.

Of the 93 patients, 87 per cent showed positive change, a small number showed temporary negative change and one patient became psychotic but later recovered.

The ‘contamination’ of results due to therapist involvement in assessment is offset against corroborative evidence of change, in that 96 per cent of patients became independent of the psychiatric and social services after years of dependency in many cases. There were also marked changes in life situations and relationships.

A need for increased facilities for basic and in-service training of group therapists is indicated.

The ages of 87 patients attending an open out-patient group in a general hospital psychiatric out-patient department are analysed in relation to persistence with treatment. A highly significant correlation (p <.001) is obtained between increasing age and continued attendance, and a significantly greater number are found to attend for six months or more in the age-range 37–47 than at other ages. In a sub-group of 35 patients, all of whom had attended more than four sessions and had returned a questionnaire, significant correlations are obtained between age and symptomatic improvement (p < .05) and between continued attendance and improvement in interpersonal relationships (P < .05).

To study looseness of associations and other theoretically relevant variables of speech pathology, 51 acute psychiatric patients, including 26 schizophrenics, were studied at the acute phase of their disorder by means of a free verbalization interview. The results on these 51 patients during the acute period were.

1. 1. There were clear differences between the schizophrenic patient group and the control patient group, the overall index of deviant verbalizations being significant at the .001 el.

2. 2. Many types of looseness were found in non-schizophrenic patients as well as in schizophrenics. Except at the very mildest levels, however, the variants of overt looseness were strikingly more frequent in occurrence and severe in degree in the schizophrenic group (p < .01).

3. 3. Gaps in communication, vagueness of ideas and blocking, though present to some degree in our control group, were much more common in the schizophrenic sample (p < .001).

4. 4. In the control group of patients, private meanings (including neologisms), repetition and perseveration were extremely rare, and current delusional thinking virtually non-existent. Private meanings and current delusional thinking were conspicuously present in the schizophrenic sample; repetition and perseveration were present to a mild degree in this acute schizophrenic sample.

5. 5. Schizophrenic patients tend to show more looseness of associations when faced with a request to talk about topics not related to their illness.

Comparative studies of first admission rates to psychiatric hospitals have revealed significant differences in the rates of diagnoses of functional psychoses between the United Kingdom and the United States of America.

The present study examined the diagnoses of indigenous patients born between 1921 and 1955 and first admitted to hospitals in New South Wales, Australia, and England and Wales. Admission rates for mania were in striking agreement. The rate in New South Wales for schizophrenia was slighdy higher and for psychotic depression considerably less than in England and Wales.

A similar trend in diagnostic dissonance would appear to exist between England and Wales and New South Wales as between England and Wales and the United States for schizophrenia and psychotic depression, but this is considerably less in degree.

Five-hundred women electing salpingectomy for contraception and their husbands were studied by means of structured interviews and questionnaires over periods of three months to two years, beginning before surgery. The post-operative follow-up was completed for 374 couples. The subject's condition was compared before and after operation for emergence of any symptoms, and whether there was any significant difference in frequency of intercourse or other sexual behaviour, changes in sexual functioning, emotional adjustment and marital satisfaction. There was evidence of adverse psychological and sexual changes but these were apparently of a mild nature. Eighty-three per cent of the subjects complained of various symptoms, presumably of psychological origin; in 65 per cent sexual desire had declined, and 29 per cent had not resumed intercourse. The mean score of psychiatric symptoms based on clinical ratings rose from 0.38 before to 4.35 after operation, which is statistically highly significant. Paradoxically satisfaction with the operation was expressed by 92 per cent of the subjects.

Thirty years ago it was suggested that the apparently higher incidence of manic-depressive illness in women might be due to X-linked heredity. The hypothesis was undermined by subsequent reports of the frequent occurrence of father to son transmission. Winokur and his associates recently revived it, providing data which indicated that such transmission is absent or rare in the bipolar form of the illness. Additional support has come from linkage studies with known genetic markers located on the X chromosome. The present study, based on the 400 parents of 100 male and 100 female bipolar manic-depressive probands, failed to discover a lack of father-son compared to other affected parent-child pairs. This finding, together with a review of the literature, would indicate that it is premature to invoke X-linked heredity as a general explanation for bipolar manic-depressive illness, though there is mounting evidence that it may account for the illness in some family pedigrees.

Non-attenders at a psychiatric new-patient clinic were seen and interviewed six weeks after the missed appointment, as were a group of controls who did attend.

The non-attenders were more likely to have had frequent changes of occupation or belong to families where this was the case with the family breadwinner; a history of court conviction; and a history of previous psychiatric treatment. They were less likely to have improved since referral to the clinic; and to have a diagnosis of manic depressive psychosis, depressed type.

The findings are discussed. There appears to be some self-selection, the most treatable patients keeping their appointments.

Plasma prolactin has been estimated in 69 psychiatric in-patients receiving either thioridazine (20–300 mg./day) or chlorpromazine (50–200 mg./day) or other phenothiazines. A homologous radioimmuno-assay was used which depends on an antiserum to human amniotic prolactin. Prolactin levels were significantly increased in these patients compared with control patients, and were dose related. Simultaneous estimation of growth hormone revealed normal levels.

In a factor-analytical study of depression across two cultures, African and European, certain similarities and important differences were found. Depression in African cultures presented principally as depressed mood, somatic symptoms and motor retardation. In European cultures depression presented with depressed mood, guilt, suicidal ideas, motor retardation or anxiety. Both groups lost interest in work and the environment.

Guilt and suicidal ideas and acts are uncommon in African sample, and appear to be culturally determined.

Many severely subnormal patients talk little to each other. In this experiment, three pairs of subjects were reinforced for talking to each other, and learned to do so quite quickly. Whether social speech would continue to occur without the benefit of external reinforcement was examined by observing the subjects through a one-way mirror in a bare interview room adjacent to the teaching room immediately after each training session. On some occasions untrained subjects were observed in the bare room with the trained subjects.

The reinforcement of social speech was demonstrated to be effective by the use of a reversal design (baseline, reinforcement, no reinforcement, reinforcement), where the rate of speech increased considerably when reinforcement was available but decreased when it was discontinued. Generalization of the increased social speech, however, was very poor and only significantly above baseline levels with the pair who seemed responsive to social as well as material reinforcement. The implications of this for training programmes are discussed.

Programmes of suicide prevention require for their planning accurate epidemiological surveys.

Doubt has been cast on the accuracy of many existing surveys because of the realization that suicide is under-reported and because of the lack of consistency in the procedure for suicide ascertainment.

Two studies are described in this paper which attempt to examine the problem.

The first is part of an international study supported by the World Health Organization. In it, Denmark and England are compared, and it is shown that there are striking differences in suicide ascertainment procedure between the two countries. Next, on a blind basis, coroners and their opposite numbers in Denmark examine a sample of each other's case records. It is found that the Danes consistently report more suicides than do the English coroners on the same case material; thus considerable doubt is cast on the supposed difference in suicide rates between the two countries.

In the second study, deaths by poisoning are examined for certain coroners' districts in England and Wales. It is shown that there is considerable variation from one district to another in the relative proportions of these deaths which achieve an accident, an open or a suicide verdict. This suggests that in England and Wales coroners may not be consistent in their suicide ascertainment criteria.

Hypotheses attempting to account for differences in suicide rate based on such epidemiological surveys should be viewed with great caution.