The pupils of a normal subject are generally described as equal, reacting by constriction or dilatation to various stimuli. Inequality of the pupils as an isolated finding is said to be relatively common, but impairment of the light reflex, especially in conjunction with pupillary inequality, is held to be strongly indicative, if not pathognomonic, of organic disease of the nervous system. An exception is the “tonic pupil,” for whose abnormally protracted reactions to light and accommodation an organic lesion has not yet been demonstrated. However, impairment of the light reflex is known to occur in subjects in whom there is no evidence of organic nervous disorder. These abnormalities of the light reflex have attracted little attention in this country, and are ignored almost entirely in text-books of neurology and psychiatry. Redlich (1908) made the important observation that muscular exertion might lead to dilatation of the pupil with impairment of the light reflex. Levine and Schilder (1942), in an extensive investigation of this phenomenon, concluded that muscular effort would produce dilatation and impairment of the light reflex in any pupil which initially retained its response to light, and would accentuate a pre-existing abnormality or bring out a latent tendency to impairment of the light reflex. Westphal (1907) first described the pupillary abnormality in catatonic schizophrenia to which the term “catatonic pupil” has been applied. This abnormality consists of pupillary dilatation with impairment of the light reflex, and is usually bilateral. The reactivity to light may vary from moment to moment, or from day to day; or pupillary rigidity may persist for a considerable time, with transient periods of brisk reactivity. Estimates of the frequency of the “catatonic pupil” vary remarkably—from 54 per cent. (Schilder and Parker, 1931) to 3.4 per cent. (Reichmann, 1913). Apparently a higher incidence has been found where repeated examinations have been carried out on the same subjects, but proper comparison is impossible, as the technique of examination has not been detailed by any of the authors.

For this study, calcium level in the blood was studied in 20 normal individuals between the ages of 20 and 25 years to find out the normal serum-calcium level in them in order that this finding might serve as a control. It was found to vary from 8·9 to 11·0 mg. per cent. (see Table I).

Introduction Since the 1914–1918 war, when high psychiatric casualty rates were recorded amongst military aircrews, a considerable amount of research has been focussed on the psychiatric problems associated with aviation. Reported symptoms have included morbid anxiety, lethargy; anorexia, weight loss; restlessness, tremors, palpitations; depression, insomnia, nightmares; personality changes, loss of flying skills and avoidance of risks. Diverse opinions have been expressed on the genesis and therapeutic management of the syndromes. Some authors have drawn attention to the so-called neurasthenic features and concluded that the symptoms were predominantly physiogenic, reflecting a state of exhaustion arising from neural, biochemical or other mechanisms (e.g. Ferry, 1919; Josué, 1919; Head, 1919; Flack, 1920; Porton, 1936; Miller, 1936; Lottig, 1937; Walshe, 1941; Cobb, 1942). Some have distinguished between ‘neurasthenic’ symptoms and overt anxiety, ascribing the former to physical exhaustion and the latter to neurotic disturbance in predisposed individuals (e.g. Gotch, 1919; Armstrong, 1936; Hastings et al. 1944; Murray, 1944).

The previous and subsequent convictions of all those charged with rape in 1961 were studied, together with circumstances of the criminal offence. The proportion of victims whose names were published in newspapers was high (26 per cent), and a high proportion of accused were acquitted (22 per cent). They fell fairly obviously into paedophiliac rapes of girls under 14 (30 per cent), ‘aggressive’ rapists (20 per cent) with a record of other aggressive offences, and ‘others' (50 per cent) with few if any other convictions. Various aspects of the records of these groups are considered. The paedophiles tended to have a wider age range and more often pleaded or were found guilty, and more of them received a medical disposal, rare in others. A small but similar proportion of acquitted and convicted were subsequently convicted of another rape.

The more recent and better designed studies of the reliability of psychiatric diagnosis (Schmidt and Fonda, 1956; Norris, 1959; Kreitman, 1961; Kreitman et al. 1961) suggest that the earlier pessimism may not be entirely justified. At the present time it seems safest to conclude that there are some states that some psychiatrists can diagnose reasonably reliably under some conditions. Nevertheless, even if psychiatrists could be shown to be highly reliable under optimal conditions, their diagnoses could only serve as the criterion by which to develop some more objective, public and quantitative means of classification, since the optimal conditions cannot readily be met in routine practice. It is desirable that any such quantitative scale should be reasonably compatible with existing psychiatric classification. As Eysenck (1960) has argued, “the degree of correspondence observed is of some interest in making possible the translation of experimental findings from one field to the other…. Even if there were no correspondence at all with psychiatric diagnostic classifications, this would not in any way invalidate the empirical findings”.

Plasma concentrations of thioridazine, mesoridazine, sulphoridazine and thioridazine ring sulphoxide have been measured individually by specific gas-liquid chromatographic (GLC) methods, and collectively by a radio-receptor assay, in 16 elderly in-patients during chronic treatment. The sulphoridazine level was above 0.135 μg/ml in 5 out of 6 symptomatically well-controlled patients, and below this level in 9 out of 10 who were poorly controlled. No such division was so clear for the other substances measured. A new assay for the total dopamine receptor-blocking activity of the plasma correlated highly at lower levels with the sum of drug plus metabolites obtained by GLC, but exceeded the sum at higher values. Both sulphoridazine and neuroleptic levels need further study.

Diagnosis of classic psychiatric illness in mentally handicapped individuals remains difficult. Manic-depressive illness has previously been reported in both pre-pubertal and pubertal children with a mental handicap and with a family history. This paper reports a case of manic-depressive psychosis in childhood, with no family history, short-cycle mood swings and good response to lithium therapy.

Neuroleptics are structurally a heterogenous group of compounds which possess antipsychotic activity. They increase dopamine metabolites by blocking dopamine receptors and enhancing presynaptic turnover. This forms the cornerstone of the dopamine hypothesis of neuroleptic action, which is supported by wide-ranging behavioural, physiological and biochemical studies. It is, however, clear that neuroleptics are far less specific for the dopamine receptor than was previously considered. They influence a range of neuronal activities, including calcium-activated potassium conductance, which governs the rate of action potential generation by many neurones. Recent physiological studies indicate that all commonly used neuroleptics alter calcium-activated potassium conductance in central neurones, in concentrations similar to those achieved clinically. An adaptive increase in calcium-activated potassium conductance mechanisms in key sensory processing neurones would render the psychotic patient less susceptible to bombardment by environmental stimuli. This action may explain in part the therapeutic effect of neuroleptics.

This paper reviews the assumptions and efficacy of two strategies for dose reduction during maintenance treatment in schizophrenia: low dose and targeted medication. Studies of low-dose treatment suggest that it can be used for relatively short periods of time or if the dosage reduction is moderate. Studies of targeted treatment suggest that relapse risk increases significantly compared with standard-dose treatment and that there are few offsetting advantages. The paper also reports initial findings from the NIMH Treatment Strategies in Schizophrenia Study, which compares low dose, targeted treatment and a standard dose in the context of two forms of family treatment. Early stabilisation of patients is lower than expected, but patient characteristics are useful in predicting likelihood of stabilisation.

The assessment of change in psychiatric patients is never easy. The problem is accentuated in the chronic inhabitants of psychiatric hospitals, since the period of treatment and observation may have to be prolonged, and the changes found may be small and gradual. A rating scale can be of value, in recording findings in a uniform manner and in preserving the observations from selective amnesia, so making comparison possible over a long period. In the present communication we report a scale devised by two of us (F.J.J.L. and A.D.H.) for use with chronic patients. This scale summarizes the relevant parts of the examination of mental state found in standard text books of psychiatry, and we have tried to avoid presuppositions about the meaning or distribution of symptoms.

The dexamethasone suppression test (DST) was carried out on 143 patients with a major depressive disorder, who were classified into those with a history of weight loss (n = 89) and those without (n = 54). Seventy-three per cent of patients with weight loss and 61% of patients without had an abnormal DST; this difference was not statistically significant. Of the patients receiving prophylactic lithium therapy, 13 were found to have changed their DST status on retesting after a period of 14 months, but there was no significant difference in their weight. It is concluded that weight loss is not a necessary condition for an abnormal DST in depressive illness.

A total of 1269 psychiatrists, from 15 European countries, completed a questionnaire assessing treatment choice in depressive and anxiety disorders, with particular focus on diagnostic and other factors determining use of monoamine oxidase inhibitors (MAOIs). Tricyclic and similar antidepressants were used most commonly — MAOIs were used as first-choice therapy for depressive or anxiety disorders only by a minority but were commonly a second-choice treatment for atypical depressives. Use was inhibited by interactions and side-effects rather than by perceived ineffectiveness. Cross-national differences in treatment were considerable but diagnostic differences in case history vignettes were much smaller.

We report on a family with co-occurrence of affective disorder and Hailey-Hailey disease in two brothers and the mother. The putative chromosomal locus of Hailey-Hailey disease, which is a rare dominantly inherited dermatosis, may be a promising candidate region for genetic studies in affective disorder.

British Journal of Psychiatry (1993), 163, 109–110

In the first paper of this series, it was pointed out that one of the reasons why McDougall's theory of drug action and personality was not accepted at all widely was connected with the fact that he failed to provide an objective, experimental test which could be used to diagnose extraversion-introversion, and to assess drug effects. This argument is not entirely correct; McDougall did in fact suggest one such test, namely the rate of fluctuation of so-called reversible perspective figures. Many varieties of these are known, and have been used experimentally; the Necker cube, the staircase, the vase-face, and the windmill patterns being probably the best known. In all of these, there is an ambiguity in the drawing which makes it possible to perceive two distinct patterns in the stimulus; on prolonged inspection these patterns alternate, and it is the rate of alternation, signalled verbally or by suitable mechanical arrangement, which constitutes the score on this test. It is known that different types of pattern give reasonably reliable scores, and also that rates of alternation on different patterns correlate quite highly together, thus demonstrating that one and the same tendency is being measured. That this tendency is of central rather than peripheral character is indicated by the fact that changes in the rate of reversal due to fatigue and other causes can be transferred from one eye to the other.

A case of erotomania (de Clérambault's syndrome) in a female with Schneider-positive schizophrenia is presented. The factors in her environment which may have precipitated the illness are discussed. The secondary nature of the syndrome is further illustrated by a discussion of the literature. In erotomania, the deluded victim, usually a woman, believes that a man, unattainable because of his social status, is in love with her. The nosological purity of the syndrome, despite its relative rarity, remains a subject of considerable debate. We present a case of erotomania in a female with schneiderian first rank symptoms (FRS) of schizophrenia (Schneider, 1959).

Background DSM–IV generalised anxiety disorder (GAD) has a high lifetime prevalence, but subthreshold anxiety states are even more common, particularly in family practice.

Method Generalised anxiety is conceptualised as a spectrum of disorders, with transient anxiety at one end and GAD at the other.

Results Based on longterm experience with family practice patients, the authors suggest that most anxious patients, wherever on this continuum they are placed, could be treated with short-term, possibly intermittent, rather than chronic anxiolytic therapy. Data are presented which show that 50% of chronic GAD patients are only in need of such short-term intermittent therapy.

Conclusions Further clinical research is needed to refine short-term, intermittent treatments for anxiety spectrum disorders, to make effective treatments available to those suffering from anxiety but falling short of diagnostic criteria for GAD, and to target more effectively the different treatment strategies.

In a medium-sized Canadian city, 581 randomly selected households were contacted and responded to a survey on the impact of parental alcohol problems. Twenty-two per cent of the respondents indicated that at least one of their parents had a drinking problem. The biological father was affected in 81%. Compared with the rest of the sample, the adult children of problem drinkers were younger but they did not differ in income or education. Adult children of problem drinkers were more likely to have parents who were divorced or separated; to be divorced, separated, or remarried themselves; to be heavy drinkers and have indications of alcohol problems; and to use more sources of help for problems with stress and anxiety and problems with alcohol. They did not differ from those without parental drinking problems on measures of current positive and negative affect.