In the search for an explanation of the aetiology of psychiatric illness, the study of the family as a unit for psychiatric research is becoming increasingly necessary. That family members resemble one another in many respects seems an intuitively correct idea. Children resemble their parents in both physical attributes and temperament; the former is mainly attributed to heredity and the latter to an interaction of heredity and social learning. Previous psychiatric studies of the family have indicated two areas for further investigation: firstly, sex concordance, and secondly diagnostic concordance among psychiatrically ill first degree relatives. The literature relating to these areas is abundant, and the main conclusions are summarized below.

In July 1983 the Regional Medical Officer of the North East Thames Regional Health Authority (NETRHA) appeared on television to announce the closure of Claybury Hospital and much of Friern Hospital over a ten-year period.

When NETRHA announced its decision, the policy to be pursued was innovative because it involved psychiatric hospitals serving inner-city populations, and because there was apparently no intention to achieve its aim by decanting patients into other psychiatric hospitals, as had been done with the closures of St Wulstan's and Banstead Hospitals. Although the run-down of psychiatric hospitals had been occurring at a steady rate in the United States and in England and Wales since the early 1950s, there had been few attempts to evaluate the policy, and none had been in any sense comprehensive (this supplement, paper 7). Clinicians and research workers in the field of social psychiatry were well aware of the need for large-scale evaluative studies, since protagonists and opponents of the policy of deinstitutionalisation were locked in a polemical argument which was pursued with increasing stridency through lack of reliable information.

It is now well recognized that many of the syndromes previously described as pellagra, such as nutritional retrobulbar neuropathy, the ataxic, and burning feet syndromes, may occur as isolated manifestations of nutritional deficiency. The term “pellagra,” as it is often used, is no more than a generic title embracing a wide variety of nutritional disorders. The clinical status of the individual deficiency syndromes has been elucidated of late years in America (Spies et al., 1939; Harris, 1941), and with particular regard to the neurological disorders, in groups of prisoners of war in the Far East (Denny Brown, 1947) and Middle East (Spillane, 1947). The majority of the pathological studies of pellagra were completed in the era before advancing biochemical knowledge provided the impetus to further these clinical studies, and this is reflected in the great diversity of neuropathological changes described as “pellagrous.” The extensive literature contains many excellent studies of cases dying from malnutrition, and it now seems possible to attempt a correlation between the pathological findings and the more recently described individual syndromes. A review, therefore, of the neuropathological changes encountered in “pellagra” might be not untimely.

Turpin and Bernyer (1947), working on the influence of heredity on the Arneth count (Cooke and Ponder's (1927) modification), found that in mongols it was shifted to the left, i.e., that their polymorphonuclears had fewer lobes and were therefore more immature.

Clown: … Nay, I'll never believe a madman till I see his brains.

Substantial contributions to clinical medicine have come from the many accounts of abnormalities in the brains of mental defectives, our knowledge of certain conditions such as epiloia, amaurotic family idiocy and microcephaly being largely based on them. But, in the main, these reports have concerned cases selected for some special interest and few workers have attempted to relate morbid-anatomical changes to the general problem of mental deficiency. The most complete description, chiefly histological, of lesions in the brains of idiots is that of Schob (1930), who summarized in his valuable contribution the wide experience of German neuropathologists. The brains of 120 unselected cases were later studied by Berry (1938), the results being published in an atlas illustrating, case by case, the differences between normal and mentally defective individuals. More recently, Christensen and Vestergaard (1949) presented a short account of a routine autopsy series of 46 mental defectives, finding some structural abnormality in every one of these cases. Other researches covered more restricted aspects of the problem and some of these will be referred to below.

A study was carried out to compare the antecedent factors, phenomenology, treatment required and prognosis in 30 cases of Reactive Psychosis and 30 cases of Acute Psychosis without antecedent stress, matched on age and sex. Both groups were followed up for 7 months.

It was found that the two groups differed markedly on several dimensions: The Reactive Psychotics had more hysterical and affective features, more vulnerable personality, higher stress experience in their life prior to illness and relatively better prognosis compared to the Acute Psychotics. The difference still remained when those in either of the groups who at the end of the follow-up turned out to be schizophrenics or suffering from affective disorder were excluded from analysis.

Although the electrical treatment of mental disorders is still in the empirical stage, its use is well established. Certain features and principles of treatment have been elucidated in the published reports, and all are agreed that it is specific for melancholic states.

The evaluation of the scope and usefulness of E.C.T. would be enhanced by the comparative study of case material from various clinics, but much in the published reports is not strictly comparable because of the unavoidable variation in the assessment of diagnosis and the degree of recovery. In our case material collected over a period of five years we have endeavoured to present the facts with a minimum of subjectivity by limiting our observation as far as possible to measurable data. In order to reduce the variable factor of diagnosis, some 700 psychotics treated with electrically induced convulsions have been reconsidered and 500 selected for analysis after carefully excluding the overlapping types, particularly those cases presenting features of both affective and schizophrenic psychoses. The selected cases can therefore be regarded as classical examples clearly separated into the two large groups of biogenetic psychoses—schizophrenic and manic-depressive, including involutional melancholia.

The purpose of this paper is to outline the application to various psychiatric conditions of a test which measures peripheral capillary oxygen saturation and to discuss the significance of the findings. It is convenient to commence with a brief review of some previous work concerning the relevance of anoxaemia to psychiatry.

Since the beginning of the century, group methods have played an increasingly important role in the treatment of patients suffering from psychological or physical disorders.

Altered serum proteins in mental illness have been reported by workers in various parts of the world, and a review of these studies has led to the consideration of an autoimmune mechanism in the pathogenesis of some functional psychoses (Fessel, 1962a). Several reports have appeared in recent years which suggest the presence of antibodies in the serum of certain psychiatric patients to central nervous system tissue. Many of these have been reviewed by Vartanyan (1963). Fessel (1962b, 1963) demonstrated agglutination of latex particles coated with monkey brain extract and agglutination of tanned sheep red blood cells coated with human brain extract, but no precipitins in double diffusion in agar of the sera against monkey brain extract. As an alternative to antibrain antibodies he suggested a less specific physicochemical abnormality of the serum which caused the agglutination. Yokoyama, Trams, and Brady (1962), using a sheep red blood cell haemagglutination technique, showed the presence of anti-asialoganglioside antibodies in the sera of 3 of 14 schizophrenic patients and anti-ganglioside antibody in the serum of another. Kuznetzova and Semenov (1961), by complement fixation, demonstrated antibodies in the sera of 22 of 84 schizophrenics, mainly to human brain and not to other organs. The antibodies appeared more frequently in the later stages of the illness (Semenov, Morozov, and Kuznetzova, 1961). Skalickova and Jezkova (1961), also with a complement fixation technique, demonstrated blood and cerebrospinal fluid antibodies to grey and white matter during the “infectious” onset of schizophrenia, but not in the chronic, demented phase.

With mentally handicapped people now being moved into the community, information on mentally handicapped criminal offenders is valuable. A group of such offenders was examined by reviewing the case-notes of 92 patients referred on hospital order to two mental-handicap hospitals over 10 years. Compared with the general criminal population, these offenders' ages were higher, the ratio of male to female offenders was similar, and the proportion of married people was lower. The offences committed were for the most part serious, with a greater number of offences against property and public order in the subgroup whose intelligences were in the mentally handicapped range. Their tested intelligences fell almost entirely into the normal and mild mental-handicap range, suggesting that factors other than intelligence testing, such as social skills, were considered in their admission to the hospitals.

The introduction of single-photon emission computerised tomography (SPECT) has markedly enhanced the study of brain function. The development of SPECT was the culmination of a series of investigations of cerebral blood flow (CBF) pioneered by Kety and Schmidt in the late 1940s combined with the introduction of transmission computerised tomography (CT) in the early 1960s, in which three-dimensional images are derived from two-dimensional data. Positron-emission tomography (PET), in addition to providing information on cerebral blood flow, also allows the evaluation of brain metabolism and neurotransmitter receptor function. However, the technology required for PET is expensive and sophisticated, with little prospect for general clinical application. Fortunately, SPECT is relatively cheap and is widely available for clinical use. We aim to review the principles and basic techniques of SPECT, its present utility and application to clinical practice, and its future potential in the investigation of brain function.

Using a classical click/flash paradigm the contingent negative variation (CNV) was recorded from 60 consecutive male admissions to Broadmoor Hospital. Clinical and psychometric Minnesota Multiphasic Personality Inventory (MMPI) assessments were made independently of the electroencephalography (EEG) data. A trend for higher amplitude CNV's to be recorded from patients with a clinical diagnosis of antisocial (psychopathic) personality was observed. Patients with a Mental Health Act diagnosis of psychopathic disorder had significantly higher voltage CNV's than those in the mental illness category. These CNV differences were only found in the primary (non-anxious, sociable) psychopaths. Secondary (neurotic, unsociable) psychopaths did not differ from staff controls. A positive association between CNV voltage and the personality factor of sociability(sociable-shy dimension) was observed. A weak, negative correlation between CNV amplitude and impulsivity (impulsive-controlled dimension) was also apparent. All subjects showed an habituation effect across trials. No difference in response variability between successive series of trials was apparent in any of the patient groups.

The strategy of high-dose intramuscular haloperidol as routinely applied in a general hospital psychiatric ward to 74 successive patients, 33 of whom stayed only up to seven days, and a further 34 up to 15 days, led to a complete recovery in only six, and complete lack of change in 23. Adverse reactions were recorded in 42, severe enough to stop treatment in eight; there were three deaths. In view of this risk-benefit analysis, systematic application of this high dose strategy to get a more rapid turnover of patients is unjustified.