In a well-known, very influential and frequently quoted paper, ‘On the Characteristics of Total Institutions,’ Goffman (1961) calls attention to ideological disputes which are centred on total institutions. As he puts it: ‘It is widely appreciated that total institutions typically fall considerably short of their official aims. It is less well appreciated that each of these official goals or charters seems admirably suited to provide a key of meaning—a language of explanation that the staff, and sometimes the inmates, can bring to every crevice of action in the institution. Thus, a medical frame of reference is not merely a perspective through which a decision concerning dosage can be determined and made meaningful; it is a perspective ready to account for all manner of decisions, such as the hours when hospital meals are served or the manner in which hospital linen is folded…. Paradoxically, then, while total institutions seem the least intellectual of places, it is nevertheless here, at least recently, that concern about words and verbalized perspectives has come to play a central and often feverish role.’ (pp. 83–84.)

A man presenting with factitious alcohol abuse and its alleged complications is described. It is argued that chronic factitious disorders are more logically viewed as part of that spectrum of conditions where there is abnormal illness behaviour, including somatoform disorders and other related conditions, than as separate nosological or diagnostic entities.

A case report of a 37-year-old woman with Munchausen syndrome which differs in many respects from the classical picture is described. Attempts are made to examine the motives behind the syndrome and to make a link with the common pattern of deliberate self-harm.

In a cross-national comparison of the frequency of occurrence of various diagnoses among elderly psychiatric patients admitted to public mental hospitals in London and New York, a short battery of psychological tests was administered to all patients independently of psychiatric examination. The psychological assessment was focused on the differentiation between dementing and affective disorders. The test performance showed a highly significant difference between the two groups as diagnosed, and when patients were allocated to groups on the basis of tests alone these allocations showed a high rate of agreement with initial psychiatric diagnosis. There was a similar high rate of agreement between test allocation and hospital diagnosis in the U.K., but this was not so in the U.S.

No significant differences were found between the test performance of U.K. and U.S. patients, except on the WAIS Vocabulary and the Angles Error measurement of the Bender-Gestalt test. When the effects of age and Vocabulary score were eliminated these differences disappeared.

The hypothesis that the diagnosis of affective disorder would be confirmed by a relatively greater improvement in test performance over time in this group of patients was not upheld by the non-parametric analysis of change scores. However, an analysis of covariance utilizing age and initial score did indicate the expected differential improvement.

This case is considered to merit a brief report, mainly for the following reasons which will be further considered in the Discussion: (1) the extent of the sexual deviation and its true nature were not immediately apparent; (2) there has recently been a suggestion that the success of aversion therapy in similar cases may have been in a large measure dependent on a “transference situation”. We think that this case may contribute some evidence to the contrary.

The serum levels of lactoferrin, eosinophil cationic protein (ECP), lysozyme and β2-microglobulin have been measured in schizophrenic patients in an attempt to elucidate the activity and turnover of neutrophil and eosinophil granulocytes, macrophages/monocytes and lymphocytes, respectively. Serum-lactoferrin and serum-ECP levels were significantly (P <0.001) higher in the patient group as compared to healthy controls in contrast to blood cell counts and serum-lysozyme and serum-β2-microglobulin levels which all were within normal limits. The results were not affected by anti-psychotic therapy. A significant correlation was found between serum-ECP and serum-lactoferrin levels which may suggest a common underlying cause of the elevated levels. The findings suggest an increased eosinophil and neutrophil activity and/or turnover in schizophrenia and may have a bearing on the well-known altered inflammatory response associated with this syndrome.

Ninety-nine neurotic patients from a controlled trial of CPN v. psychiatric out-patient aftercare were followed up seven years later. Of the 92 survivors, 76 were successfully interviewed. Few differences were found between the groups. Chronic mild symptoms and moderate social disability persisted, and tended to worsen a little. Treatment patterns persisted for one to two years beyond the original study; the CPN group had more CPN contacts, fewer psychiatric out-patient contacts and less psychiatric care. Thereafter, more out-patients were discharged from psychiatric care and care patterns for the two groups became similar. Out-patients attended more non-psychiatric out-patient clinics than the CPN group, but it is possible that this reflected pre-existing differences. About a third of patients remained in contact with the psychiatric service during follow-up.

Evidence-based medicine is fine in principle, but needs to demonstrate tangible benefits to clinicians and their patients in practice. The main obstacles to its implementation are: (a) identifying information needs; (b) delivering reliable and clinically useful information to the ward/clinic; and (c) ensuring the information is regularly updated. How can this be achieved in psychiatry?

Twenty-six patients with proven myasthenia gravis were interviewed to assess the length of time between onset of symptoms, presentation to the general practitioner and diagnosis. In one third the initial diagnosis was psychiatric and the average time between presentation and correct diagnosis was 2.8 years for men, 1.2 years for premenopausal women and three weeks for postmenopausal women. Diagnosis could have been made much earlier if doctors had been familiar with early symptoms in this relatively rare disease. Symptoms and signs fluctuated and were at times absent, especially in the mornings.

One specific hypothesis concerning the biochemical lesion in schizophrenia was put forward by McIsaac (1961) on the basis of the close chemical relationship between the pineal hormone melatonin and the hallucinogenic drug harmine. On this basis Nicholson et al. (1966) conducted a clinical trial of D-penicillamine plus a low copper diet in schizophrenics, with encouraging results. They used 1,200 mg. daily in a double-blind trial against placebo for six weeks. Hollister et al. (1966) also treated schizophrenic patients with D-penicillamine, but for a different reason—they suggested that depolymerization might be effective if schizophrenia is an autoimmune disorder. They used doses of 1,000 mg. daily for five weeks following an initial build up, and noted no clinical amelioration in 13 schizophrenics studied. A normal diet was given. Walshe (1967) failed to find any improvement in 4 chronic patients on penicillamine for one year.

Naylor's recent hypothesis that vanadium ‘poisoning’ could be a factor in the severity of manic-depressive illness drew attention to the normal and even essential presence of vanadium in the diet, and in human living tissues. The whole brain may contain only about 45 micrograms of vanadium (Underwood, 1977; 1979), as against 500 micrograms of manganese, 130 μgm selenium, and less than 20 μgm molybdenum—others of the 12 or so essential metals required in traces. We might take copper as the principle trace metal—an important component of over 50 enzymes, including monoamine oxidase and dopamine β-hydroxylase—with a total in the whole man of about 100 mg. In contrast, metals like potassium (140 gm), magnesium (35 gm), iron and zinc (3–4 gm) are not present in traces but in gram quantities. Lithium, present naturally in the body in extremely minute amounts, is raised in therapy to occupy a borderline position in the scale, rather more than copper, less than zinc.

Nitrazepam is a benzodiazepine closely related to diazepam and chlordiazepoxide. It has been marketed as a sleep-inducing drug, and as such has proved to have an overall effectiveness comparable to that of the barbiturates and related drugs (3, 4, 5, 6, 8, 12).

This is the first report of a six month survey of treated psychiatric illness in Lebanon, carried out with the collaboration of all three psychiatric hospitals in the country and twenty of the twenty-one psychiatrists practising within and outside of these institutions.

Four case reports are presented of psychotic patients seen in clinical practice in Nairobi over a period of one year, who inflicted serious bodily harm to themselves during that period. Possible psychopathological basis for this self-damage is briefly considered. A review of the literature reveals paucity of similar reports from Africa and the third world. Reasons for this paucity are hard to come by.

Fifty-five dependent (DSM-III) male alcoholics, chosen for good social adjustment, were personally followed up about 20 years after their first admission to hospital. The conditions of all the alcoholics were evaluated with a multidimensional diagnostic schedule when first admitted. At the follow-up, 11 were abstainers, 11 reported a change to social drinking via abstinence, and 10 reported a change to social drinking by gradual stages. Improvement after the age of 45 was mainly due to gradual change to social drinking. This type of improvement was in half of the cases attributed to a decreased tolerance for alcohol. In the present sample, there were no indications of any relationship between premature ageing and gradual change to social drinking. It is hypothesised that physiological processes of normal ageing with concomitant changes in reactions to alcohol may be of importance for remission from alcoholism in middle-aged and older alcoholics. The relationships of personality, social factors and the degree of alcohol-dependence to patterns of successful long-term adjustment are discussed.

A case of folie à deux in a 29 year-old man with Down's syndrome, whose mother had a paranoid psychosis, is described. Successful treatment of the mother's illness also resulted in full recovery of the son without the need for medication.

A prospective study was carried out on post-influenzal depression. Four hundred patients presenting with psychiatric illness for the first time took part. The results show that there is no correlation between depressive illness and the demonstration of influenza antibody titres, an indication of recent influenza infection.