The concept of ‘stupor’ is subjected to historical analysis. Particular attention is given to the nineteenth-century, during which three evolutionary stages are identified. During the first stage stupor is considered as a simple state of non-responsiveness. The second stage recognizes that some stupors are accompanied by rich subjective experiences and separates them as ‘psychiatric stupors’. During the third stage some of its symptoms are reinterpreted as resulting from an interaction between patient and environment. A number of historical sources are reviewed in an attempt to illustrate the evolution of the concept and its association with cognate behavioural states.

A significant part of Schreber's illness up to the time of his dramatic ‘schizophrenic switch’ in February 1894 has been systematically re-evaluated in terms of the Research Diagnostic Criteria (RDC) and of certain additional phenomenological characteristics. On this basis it seems that Schreber suffered from a severe major psychotic depressive disorder with tendencies towards bipolarity for the period in question. A more global, non-systematic RDC-oriented interpretation is then offered for the remaining course of the illness until Schreber's death in 1911.

A survey of 355 college students was carried out to determine the prevalence of the psychiatric disorder bulimia (the binge-eating syndrome). Results of the survey indicate that, within the normal college population, 13% experienced all of the major symptoms of bulimia as outlined in the DSM-III. Within the bulimic population, 87% were females (19% of the female population) and 13% were males (5% of the male population). Although self-induced vomiting may accompany other symptoms of bulimia, the results suggest that self-induced vomiting is not a necessary symptom for diagnosis. A significant relationship between laxative use and self-induced vomiting was detected. These forms of behaviour, termed purging behaviour, occurred in an average of 10% of the students. Individuals who experienced the symptoms of bulimia had a history of being overweight or tended to be in the upper portion of their normal weight range (age, sex, and weight corrected) when compared with those individuals who had not experienced the symptoms of bulimia. No significant weight history differences were detected between vomiters and non-vomiters.

Bulimia nervosa is a relatively common eating disorder which has a significant physical and psychological morbidity and a poor prognosis. A behavioural approach to its treatment is described. This focuses on increasing control over eating, eliminating food avoidance and changing maladaptive attitudes. Preliminary findings are promising, with improvement appearing to be maintained. Components of the treatment may benefit patients who simply complain of overeating.

A psychopharmacogenetic strategy was used to investigate a genetic heterogeneity model of schizophrenia. This model consisted of various genetic subtypes represented by patients classified hypothetically according to the types and genealogical (Mendelian) patterns of illnesses in first-degree relatives. The effect of neuroleptics on these subtypes (drug x genetic subtype interactions) were tested for evidence of post-treatment responses which discriminated between them. The findings revealed that schizophrenics who had depressed relatives tended to exhibit (1) depression and more severe pseudoparkinsonism irrespective of types of neuroleptics, and (2) greater remission of paranoid-hostility symptoms when treated with neuroleptics of the aliphatic-piperadine type. Schizophrenics who had schizophrenic relatives failed to show these responses.

Interpretation of these findings emphasized the recognition of these responses as arising from neuroleptic-induced alterations of defective neurologic-neurochemical systems underlying this subtype and as ‘pharmacogenetic criteria’ by which it can be discriminated.

Forty-eight newly admitted schizophrenic patients were treated with a fixed, conservative (6·6 mg/kg) dose of chlorpromazine (CPZ) for 28 days. CPZ plasma levels were measured by a gas chromatography mass spectrometry method (GCMS) using 2H6-chlorpromazine as an internal standard. At the end of the fixed-dose period, ‘responders’ had the same plasma levels as ‘non-responders’, suggesting that lack of response is primarily a matter of the illness' sensitivity to CPZ, not to a plasma level below some therapeutic window. After the fixed-dose period, the dosage of CPZ was increased in the ‘non-responders’ by physician's choice. Improvement occurred over a wide range of 10–225 picomoles (3–72 ng)/ml. Above 300 picomoles (95 ng/ml) 4 inaccessible patients eventually became much worse, suggesting psychotoxicity. It is in the inaccessible patient whose illness is only minimally, or not at all, sensitive to CPZ that a plasma level might be especially useful.

Interpretation of plasma levels is complicated by the speed of response: some initial non-responders improved by the 56th day of treatment on very conservative plasma levels.

An epidemic of suicide by burning in England and Wales occurred during the one-year period October 1978 to October 1979, following a widely publicized political suicide. For the 82 cases, death certificates were obtained and coroners' inquest reports sought. The victims were predominantly young single men or older married women; both groups had strong psychiatric histories; and there were no suicides which had political overtones, apart from the index case. Compared with suicides by this method in the past, a higher proportion of victims were born in the UK. It is proposed that a code of practice for the reporting of suicides by the media is required.

There is little evidence of a curvilinear relationship between pre-operative emotionality and post-operative adjustment, as predicted by a model which supposes that moderate preoperative anxiety assists adjustment. This paper suggests that the negative affect, or stress, associated with the work of worry should be distinguished from the active coping orientation which it also implies. In this study stress and arousal were assessed pre-operatively in a sample of cholecystectomy patients, and correlations between these scores and various indices of post-operative adjustment were computed. Stress before surgery was positively related to stress and pain experienced post-operatively. Arousal, by contrast, was negatively related to pain, medications and period before discharge. Female patients had higher stress scores than the males, while the direction of the difference was reversed in the case of arousal. These findings are interpreted as support for the significance of the role of coping orientation, as represented by arousal, in promoting adjustment, with emotionality or stress playing a less significant and even negative role.

The perception of and attitude to drinking patterns in recovering problem drinkers (N = 29) is analysed, utilizing a similar methodology to that of Richard & Burley (1978). Fault is found, however, in the latter study both in a failure to define variables and in the authors' statistical handling of the results. In the present study, it was found that controlled drinking is only seen as close to the problem drinker's concept of himself when it entails reasonably high levels of consumption. The importance of this finding for therapy is outlined. The possible negative effects of role conflict are mentioned. It is also found that problem drinkers perceive themselves as having quite different characteristics from those they themselves attribute to alcoholics. This finding is interpreted in terms of the fundamental attribution error (Jones & Nisbett, 1972).

Three statistical models are presented to describe different aspects of the natural history of depression (as recognized by a general practitioner) during a 20-year study of a single general practice. After controlling for age, the prevalence of recognized depression in men increased during the 20 years of the study (1957–76), but there was little change in women. In any given year, however, women are both more likely to become depressed than men, and are less likely to recover. The changes in prevalence are shown to be due to changes in observed incidence and recovery rates. Taking into account attendances over the previous 5 years at which a diagnosis of depression was made, the models enable one to predict, for example, incidence rates for ‘first episodes’ of recognized depression, and recovery rates for ‘chronic’ patients. In all situations there is a significant sex difference (women always being more likely to be recognized as depressed), but this difference is smaller at the end than at the beginning of the 20 years.

Nine thousand persons admitted to three large psychiatric hospitals, over a period of four years, were classified according to the aircraft noise exposure of their home address, using the Noise and Number Index. The analysis searched first for simple associations between exposure and admission rates, then for complex interactions with socio-economic characteristics of the area of residence. There was no common pattern of admissions across the three hospitals: in one case the rates decreased with aircraft noise; in the other two the rates increased with noise exposure. However, since in all cases the trends could be attributed to non-noise factors characteristic of the population, it was concluded that the effects of noise, if any, could only be small, weakly influencing other causal variables but not overriding them. Further analyses showed that positive associations between noise and admissions occurred in some groups and in some districts. People 45 years old and over exhibited higher admission rates than expected in the highest noise zone in one hospital. The districts where a positive trend between noise and admissions was evident were those with a higher proportion of one-person households, a higher proportion of immigrants, or a higher proportion of professionals and managers; however, these results were only found in one hospital with counterexamples in others. No strong, significant noise effect could be found. Limitations of the hospital records and specific difficulties in setting up the data for these studies are discussed.

The occurrence of hierarchical patterns in the incidence of psychiatric symptoms in individual patients and community subjects is investigated. Data obtained from interviewing a sample of people from the population of Camberwell, south-east London, using the Present State Examination (PSE), were analysed as were similar data concerning three series of patients referred to different kinds of psychiatric service.

The population series showed that each of the common PSE symptoms tends to occur in association with other symptoms. Symptoms that are rarer in the general population are associated with the presence of many other symptoms or with other symptoms present to a severe degree. The rarer the symptom, the higher is the total symptom score indicated by its presence. The more indicative symptoms are also associated with a measure of social disability derived from the MRC Social Performance Schedule, which asks about serious problems in functioning in each of 8 role areas.

The implication of this study is that total symptom score is a valid measure of the current severity of the disorder. The hierarchy model of Foulds & Bedford (1975) is discussed and is shown to be a more specific formulation of the same idea.

Investigation of the referred series confirmed these conclusions. When compared with community subjects, patients tend to have a much higher total PSE score; they display symptoms which are very rare in the community; they tend to be disabled socially. However, they are less likely to fulfil the requirements of a specific formulation for the presence of minor symptoms. In particular, only about half of psychotic subjects display specific neurotic symptoms, although virtually every subject with ‘specific’ symptoms of some sort displayed non-specific neurotic symptoms.

Subjects who were initially free of psychological symptoms completed life event and symptom measures on 3 subsequent occasions 4 months apart. As expected, an association was found between symptoms and life events reported as occurring in the previous 4 months. A path analysis model was then constructed. The association between symptoms and events of the previous 4 months remained, but in neither panel did events reported as occurring more than 4 months previously predict symptoms.

The notions of loss and danger are briefly described. Two groups of raters in London and Canberra were shown to be reliable in rating the degree of loss and the degree of danger associated with a sample of life events previously rated as ‘severe’ on a contextual measure of long-term threat. The life events were reported by 164 young women attending a general practitioner in London. The women were interviewed by a psychiatrist using the Present State Examination. Their psychiatric symptoms were rated by a team of raters who were ignorant of the life events reported by the young women. Three types of cases of psychiatric disorder of recent onset were diagnosed: depression, anxiety, and mixed depression/anxiety. The frequency of life events reported by these three types of cases as occurring in the year before the onset of their disorder was compared with the frequency of events in the same time period reported by a group of women without severe psychiatric disorder. The results were used to argue that severe loss was a causal agent in the onset of depressive disorder and severe danger was a causal agent in the onset of anxiety states in this sample. Cases of mixed depression/anxiety were more likely to report both a severe loss and a severe danger before onset. This supported the argument for recognizing a distinct group of mixed disorders in the classification of depressive illnesses.

One of the principal sources of error in data collected from structured interviews with respondents is the method of measurement or observation itself. In this paper the differential impact of each of a group of interviewers on the responses obtained in an epidemiological survey is examined. The effect is measured and its impact on the interpretation of individual responses, scale scores and model fitting is shown.

The circumstances immediately surrounding compulsory admissions are examined. These circumstances can be seen largely to derive from the long-term psychiatric and social difficulties of patients described in Part I. A constellation of factors is identified which often limits any alternative to a compulsory admission. A number of recommendations are made based on these findings which are designed to diminish the need for compulsion in the future.

A standardized assessment of personality (SAP) based on interview with an informant has been developed to classify a patient's premorbid personality in clinical terms for use for research purposes in or out of a hospital setting. Three preliminary investigations of its use are reported. These indicate that an informant's account of personality can be rated reliably by psychiatrists and is consistent over time. The addition of two extra descriptive types to the schema of ICD Section 301, the anxious and the self-conscious personalities, is found to contribute usefully to a taxonomy of personality in two series of patients investigated with the SAP. Further investigations are indicated to determine the accuracy of an informant's account before epidemiological studies with this instrument can be considered.