Bereavement is a crisis from which few people are spared. In spite of its universality, there have been few carefully designed, well documented, systematic studies describing its natural history and its relationship to other affective disturbances.

The incidence of tattooing is known to be high in certain selected groups.

Phobic imagery is used extensively in the treatment of phobic disorders by psychological means. The physiological and subjective accompaniments of such imagery are thus of some importance for both treatment and assessment. An earlier report (Marks et al., 1971a) described a standardized method of assessment of phobic imagery and results in one trial of 16 phobic patients. To date the method has been used in the assessment of 77 phobic patients before and after treatment in 6 different studies. This report summarizes our experience with it and its sensitivity to clinical changes. The main finding was that subjective report was a more consistent discriminator between phobic and neutral images than were measures of heart rate or skin conductance. Nevertheless physiological measures were often useful indicators of clinical changes.

The value of chlorpromazine in combating psychosis and its various symptoms has been firmly established in the last twenty years. The occurrence of sudden death and severe hypotensive reaction after being given the drug has been documented in the world literature (Kelly et al., 1963; Graupner et al., 1964; Rosati, 1964; Hollister et al., 1965; Grollman, 1965; Leestma et al., 1968).

To rely on a system of drug administration based on a transcribed drug list is to court disaster. The high incidence of errors of transcription has been documented by Crooks (1964) (1), Wallace (1965) (2), Watt et al. (in press) (3).

The literature of familial pre-senile dementia is adequately reviewed by McMenemey (1963) and Pratt (1967) and that on familial forms of Alzheimer's disease by Tandy and Bain (1970). In non-familial cases of Alzheimer's disease it has been possible to correlate the clinical features with the histological diagnosis obtained from cerebral biopsy (Sim and Sussman, 1962; Sim et al., 1966), and the present paper is an attempt to see whether, by using similar diagnostic criteria as listed in Table I, including cerebral biopsy, a similar consistency could be demonstrated in the affected members of each family.

Transitory depression and tearfulness occurring on one or two days during the early Puerperium (commonly known as ‘mother's' or ‘maternity blues', ‘third, fourth, or tenth-day blues', or ‘the transitory syndrome’) is often mentioned as a normal finding after from 15 per cent (Oppenheim, 1962) to nearly 80 per cent (Robin, 1962) of deliveries. Physical discomfort and psychological difficulty at the onset of lactation, ‘narcissistic loss' before discovery of the child (Sclare, 1955), perineal soreness and hormonal changes (Railton, 1961) have all been invoked as causes.

The psychiatric out-patient department fulfils a comprehensive role in the diagnosis and treatment of a wide range of psychiatric disorders; it is no longer an annexe of the mental hospital principally concerned with providing follow-up and support for discharged patients. But despite the enormous growth of out-patient facilities and treatments, there have been few studies analysing the out-patient services. The Bethlem Royal and Maudsley Hospitals present detailed accounts of their out-patients, but although they serve a defined area their special functions possibly make their clientele unrepresentative. Diagnoses of out-patients in Buckinghamshire were analysed by Kessel and Shepherd (1962), but this survey gives no information about the treatment or disposal of patients. Innes and Sharp (1962) presented detailed statistics for combined inpatient and out-patients in the North East of Scotland, but did not separate the two classes of patients. The most comprehensive information concerning patients attending a hospital psychiatric out-patient department—their diagnosis, treatment and disposal—comes from Kessel and Hassall (1965 and 1971) in their evaluation of the functioning of the new Plymouth Nuffield Clinic, and from Kaeser and Cooper (1971) who investigated a group of general practitioner referrals to the Maudsley Hospital to assess the satisfaction gained by the patients and family doctors from such consultations.

Lindsten (5), Mellbin (7), and Pitts and Guze (8) have described a total of three cases of anorexia nervosa occurring in conjunction with gonosomal aneuploidy (Turner's syndrome or gonadal dysgenesis with XO sex chromosome pattern). The incidence of both conditions is low, and the small likelihood of their concurrent appearance in one individual by chance can be estimated from the following figures. According to Maclean et al. (6), the XO chromosome abnormality occurs in four out of 10,000 live births. Baikie et al. (1) have found that the incidence of the XO gonosome pattern in the general population is not significantly different from that at birth. Anorexia nervosa has an average annual incidence of 45 (Theander (9)) or 61 (Kidd and Wood (4)) cases per 10,000,000 people. On the assumption that the two conditions are independent, the probability of their occurring together would therefore be 0.18 to 0.24/100,000,000. Since the incidence data for the XO anomaly and for anorexia nervosa were obtained from different populations, it must be recognized that these figures are only order of magnitude estimates. Nevertheless, we considered it of interest to examine the available case records of anorexia nervosa patients seen at the University of Iowa Hospitals from 1920 to 1972 for Turner's syndrome and other anomalies of the urogenital tract.

Eysenck (1952a) has postulated the existence of three main dimensions of personality: Extraversion, Neuroticism and Psychoticism. These are conceived of as independent of each other, and as continuous, with neurotics and psychotics respectively marking the extreme ends of the N and P dimensions. Within each dimension, the particular type of neurotic or psychotic illness is considered to be determined by the degree of extraversion of the patient; thus dysthymic and hysterical disorders mark the introverted and extraverted types of neurotic illness (Eysenck, 1947), while within the psychotic field degree of social withdrawal might be considered to be the variable most closely related to introversion/ extraversion (Venables and Wing, 1962). Hypotheses have also been formulated to account for the causal factors underlying E and N (Eysenck, 1967), although no such hypotheses have been elaborated with respect to P. A special statistical technique (criterion analysis—Eysenck, 1950) has been worked out to test the crucial question of continuity between normal and abnormal (neurotic and psychotic) populations with respect to N and P; application of this method has given support to the theory of continuity (Eysenck, 1950, 1952b).

Nowadays the idea of a day hospital is familiar and no longer seems revolutionary or slightly suspect. Considerable growth of such units has occurred since the Marlborough Day Hospital opened in London in 1946. However, there has been no real attempt in this country to accept the challenge of Epps and Hanes (1964) who estimated that 50–75 per cent of patients in psychiatric hospitals could be cared for equally well in day units.

Twin studies and investigations into the relationship between schizophrenia-like psychosis and cerebral dysfunction are of considerable interest. Refinement in twin studies has led to less emphasis being placed upon the genetic factor, but the pitfalls surrounding twin techniques, especially with regard to monozygous pairs and the similarity of their environment, have led Penrose (1971) to the opinion that twin study ‘is especially useful, not for genetical researches but in assessing the effects of environmental influences which lead to discordance in identical twin pairs'.

In Autumn, 1971, the Director of the Office of Health Economics stated that ‘the majority of the population regard homosexuality as an abnormality justifying medical treatment‘.

This paper is an extension of an earlier introductory one (1) and evaluates the results of treatment with parenteral and oral chlorimipramine of 200 patients suffering from depressive states of varying severity. The current research project was started in January 1968, and is still in progress. Further references to the literature may be obtained from the original paper or by application to the author. Fifty-seven of the cases treated were so severely depressed that ECT would normally have been given. All were in-patients and were treated with intravenous infusions of chlorimipramine. The other 143 patients were less severely depressed and were seen as out-patients. They were treated with increasing doses of oral chlorimipramine, but a few cases in both groups also had ECT to expedite recovery. Approximately 50 patients exhibited obsessional features in addition to depression, and their response to treatment was so promising as to merit special mention.

Over the years investigators have described psychiatrically abnormal individuals in the families of schizophrenics. These unusual persons have been given a variety of names: schizoids, schizoid psychopaths, and the condition called schizoidia or schizophrenia-spectrum illness (Kahn, 1923; Planansky, 1966). With recent developments in family and adoptive studies of schizophrenia which have indicated a genetic factor playing a causative role, the schizoid state has assumed more importance, especially in estimating the type of inheritance (Heston, 1970). Furthermore, the schizoid state is of considerable interest from a clinical standpoint since it may represent a ‘forme fruste’ of schizophrenia, and as such a study of schizoids from the point of view of the factors which may have prevented a full-blown schizophrenic process would be of great interest.

The successful investigation and development of effective treatment programmes for any disorder is closely dependent on the development of reliable and valid assessment procedures. Anorexia nervosa would seem to be no exception in this respect. At present, while the diagnosis of anorexia nervosa seems fairly easy to establish, the assessment of severity, response to various treatment regimes, and prognosis pose rather more of a problem. Reliance on criteria such as weight status and gain, return of menstruation, psychosexual adjustment, etc., is inadequate, especially in the assessment of short-term effects of various therapeutic conditions. Recently Slade and Russell (1972) have described an objective technique for measuring ‘perception of body size‘, an area in which they found anorexia nervosa patients to be defective. Clearly, however, other reliable, objective assessment techniques are needed as well.

Many patients in hospitals for the mentally subnormal are very isolated from the community (Ballinger, 1970). McKeown and Leck (1967) suggested that many individuals in these hospitals do not require hospital care and there have been recommendations that hospitals for the subnormal should be smaller in the future (Department of Health and Social Security, 1971).

Much has been said and written about the logical status of diagnoses; their reliability and validity have often been measured and questioned; and several mathematical models of the diagnostic process have been developed for use in computers. But surprisingly little interest has been taken in the practical aspects of diagnosis as a decision-making process. A large and undistinguished literature on ‘psycho-diagnostics' was generated by clinical psychologists in the 1950s, but this was largely concerned with diagnoses derived from cognitive and projective test results and so has little relevance to diagnosis by the traditional medical method of asking the patient about his symptoms. More recently a few people, like Gauron and Dickinson in Iowa and Sandifer in North Carolina, have studied the diagnostic activity of psychiatrists in specially designed experimental situations, and their findings have been both interesting and instructive. But we are still uncertain at what stage in a diagnostic interview a provisional diagnosis is usually arrived at, or how often this initial impression is correct, or is changed later on. Nor do we know the relative importance of the patient's behaviour and the factual information he provides in reply to questions, or what differences exist between psychiatrists in the means by which they reach a diagnosis, or in the speed and confidence with which they do so. The studies described here were designed with the aim of shedding some light on these matters.

Unilateral ECT (U/ECT) produces therapeutic generalized convulsions with less amnesia and confusion than classical bilateral ECT (B/ECT). The clinical effects of these two methods have recendy been compared (Abrams et al., 1972) and reviewed (Abrams, 1972), with the conclusion that U/ECT is less effective than B/ECT in the treatment of depressed patients. Generalized seizures are induced with both methods, and we considered the possibility that the therapeutic advantage for B/ECT lay in its bilateral stimulation of the brain. An opportunity to evaluate the effects of bilateral stimulation exclusive of the temporal lobes arose at the suggestion of Inglis (1970) that seizures induced with treatment electrodes placed over the front of the head should improve mood but have less effect on memory than the other techniques.