Ninety-six out of 137 consultant psychiatrists working for the majority of their time in the London area outside academic units returned questionnaires concerning attitudes to their work. Analysis of the 88 fully completed questionnaires suggested the existence of four relatively discrete but overlapping patterns of psychiatric practice in the Regions concerned, of which two largely excluded individual psychotherapy. These findings are discussed in relation to the education in psychotherapy of trainee psychiatrists working in mental hospitals.

Attitudes towards self-poisoning were investigated in 80 psychiatric patients, half of whom themselves had previously taken overdoses. They were asked to comment about self-poisoners in general, and on four specific cases in particular. In addition to motives spontaneously suggested they were asked to choose from a list of alternative motives in explaining each case.

The subjects who had previously taken overdoses differed from the rest in seeing such behaviour as more often due to a disturbed state of mind and less often an expression of hostility. Both groups tended to see self-poisoners as mentally ill; and, unless they were offered a ‘vocabulary’ of goal-directed motives, they tended to see the behaviour as a reaction to events (i.e. expressive) rather than goal-oriented (i.e. Insteurnental). The implications of these findings are discussed.

A doctor is trained, perhaps over-trained, to try to limit his diagnosis to a single disease process or entity. This may lead on occasion to a somewhat blinkered approach to the management of patients. The following case illustrates multiple and concomitant pathology in a single individual.

Several studies have commented upon the false negatives which can result when the General Health Questionnaire (GHQ) is employed as a community screening device for psychological distress. It would appear that some false negatives are the result of individual or cultural factors, whilst others result from the phrasing of the GHQ questions, which may mislead patients suffering from chronic disorders. This paper reports the use of additional questions, designed to detect such chronicity.

There is an increasing use of psychological tests designed to measure anxiety in both psychological and psychiatric research. Yet the theoretical bases upon which the various questionnaires have been constructed in relation to their practical application remain less than clear. For example, the Taylor Manifest Anxiety Scale (TMAS) (Taylor, 1955), was developed from the Minnesota Multiphasic Personality Inventory as a more specific measure of manifest anxiety. The TMAS has repeatedly been shown to correlate highly significantly with the neuroticism score of the Eysenck Personality Inventory (EPI) (Eysenck and Eysenck, 1964). The EPI is purported to measure personality in a general way in two dimensions, one of neuroticism and the other of extraversion-introversion. The association between these two tests, therefore, suggests that either both relate to a general personality variable of emotional instability, or they both more specifically measure a tendency to experience anxiety. It could also mean that these two aspects, one measured by each test, involve a personality characteristic in common.

Zinc deficiency has been reported in association with dementia and linked with its pathogenesis. A group of 45 elderly patients admitted to a mental hospital were given diagnoses in accordance with ICD-9, and their fasting plasma zinc levels were recorded. No difference was found in zinc levels between patients with diagnoses of senile dementia and those with other diagnoses.

One of the earliest studies on limb blood flow, using a volume plethysmograph to enclose the hand and forearm, was carried out by Hewlett and Van Zwaluwenburg (1909). Two of their patients were pronounced neurasthenics “with labile vasomotor systems” and these authors noted that, excluding subjects with thyrotoxicosis, “the majority of the remaining fast rates occurred in neurasthenics of the vasomotor type”. In 1938 Grant and Pearson, who developed forearm plethysmography to determine blood flow mainly in the skeletal muscle rather than the skin, noted transient increases in forearm flow with mental arithmetic in some subjects, but did not pursue this observation further. This response was studied in more detail by Abramson and Ferris (1940). Their conclusion that mental arithmetic produced an increase in forearm flow due to vasodilatation in the forearm muscles was confirmed by the work of Brod, Fencl, Hejl, and Jirka (1959), who attributed the change to emotional stress.

We present a case of acute dystonia in an adolescent, with features that fit the description of the Pisa syndrome. The symptoms developed postoperatively, in a non-psychiatric setting, following administration of antiemetic medication, and the phenomenon was misdiagnosed as a conversion disorder. This case reinforces previous reports cautioning against misinterpretation of dystonic reactions as functional disorders, especially in children and adolescents.

The diagnosis of anorexia nervosa is not always straightforward. Bliss and Branch (1960) regard all non-organic conditions causing anorexia as anorexia nervosa. However, more recent authors like Dally and Sargant (1960), King (1963), Crisp (1965b) and Bruch (1965) limit the use of the diagnostic label anorexia nervosa to a highly specific entity. Many patients who present with loss of weight and/or loss of appetite fit easily into this classical anorexia nervosa category, whilst many others are equally easily excluded.

Over 14 years a patient was admitted at least 91 times to at least 25 general and four psychiatric hospitals and treated for a wide range of conditions that she did not have. She appears to have recovered. The medical and psychiatric care she received probably contributed to the onset of this disorder in a person already vulnerable, and to its maintenance.

Since the classic report in 1888 by the Committee on Myxoedema of the Clinical Society of London, there has been a wide interest in the psychiatric aspects of hypothyroidism. Despite many reports which followed, Asher (who in 1949 coined the term ‘myxoedematous madness’) had this to say: ‘Myxoedema is one of the most important, one of the least known and one of the most frequently missed causes of organic psychosis'. Most studies have been clinical descriptions with no correlation of the degree of affective disturbance with the severity of disease process.

For the study reported in the accompanying paper (Willems et al., 1973), a number of variables, thought to be of prognostic relevance in alcoholism, were selected and categorized in a rank order. These can be regarded as ordinal scales, since in every case (a) each category differs from the others, and (b) each is related to the others. In each case there can be said to be an underlying continuum and in all cases a higher number indicates, in our opinion, a less ‘desirable’ state.

Disorders of body image are reported to be relatively common, and have been observed in some studies to occur in as many as 25 per cent. of psychiatric patients (Lukianowicz, 1967). Reduplication of the body image, however, is comparatively rare. Although classical literature is rich in descriptions of visual hallucinations of the self, it is only comparatively recently that this phenomenon has received medical attention. Coleman (1934) wrote at length on the possible psychological significance of the “double”, but it was left to Lhermitte (1951) to study such autoscopic experiences clinically and to draw attention to their medical importance.