One of the major problems encountered in rehabilitating psychiatric patients is that work motivation cannot be assumed but must often be created (Benney, 1964). Several investigations (e.g. Goldin, Margolin and Stotsky, 1968) have suggested that staff approval can be a particularly powerful incentive for some patients' rehabilitation. Wing and Freudenberg (1961) have shown that even some chronic schizophrenics improve their production level when staff encouragement is made contingent upon work behaviour. Although it has been suggested that a number of variables, such as age and diagnosis, are related to the magnitude of the increase in production, very little is known about the actual significance of these factors; in particular, virtually nothing has been written about the possible relevance of contemporary social interactions outside the rehabilitation setting. In most treatment regimes attention is focused on the present situation and past life experiences to the exclusion of a systematic consideration of the nature and quality of social relationships outside the treatment situation. Clearly, it would be of great value if it could be established which social environments were conducive to success within a given therapeutic regime. This study attempts to correct this imbalance by using systematic observational techniques to explore the interaction between response to social reinforcement in a rehabilitation unit and social relationships outside it.

One of the better known facts about suicide rates is their remarkable stability in terms of the sex of the victim, the methods used and the age-specific rates in different societies over considerable periods of time. Suicide studies suggest that the frequency and methods of suicide are determined largely by the culture, social mores and a number of other factors— possibly demographic—which remain relatively stable over fairly long periods (Whitlock, 1971). Methods of suicide can vary from country to country (Dublin, 1963; Stengel, 1964). In Australia, there has been a remarkable consistency in the major methods of suicide throughout this century (Saint, 1965), although Hetzel (1971) has pointed out the marked rise in rates from self-poisoning in the last twenty years. Burvill (1970) has contrasted the methods of suicide in Western Australia with those reported in America and Britain, as has Whitlock (1971) among the various immigrant groups in Australia, although he warned that his results were based on comparatively small numbers of suicides in minority population groups. Overall age-standardized suicide rates among immigrants to Australia are substantially higher than those prevailing in their country of origin and among the Australian-born population (Whitlock, 1971; Burvill et al., 1972).

There is a commonly held conviction among physicians and the lay public that oral contraceptive agents are associated with a high incidence of adverse psychological effects, particularly depressive symptoms. This belief is enhanced by a body of literature which includes case reports, studies of small samples, and overall side effect incidence rates (1–22). Careful, adequately controlled, objective studies of emotional reactions are, however, lacking, and this can be ascribed to the serious problems inherent in the design of such studies. For example, adequate control groups are difficult to establish, and contraceptives cannot easily be randomly assigned. Studies using a placebo must also introduce other contraceptives; nonrandom processes operate in the selection of women for study. Suggestibility secondary to use of medication requires placebo double-blind studies in order to differentiate the psychological from the pharmacological effects.

Previous reports (1 and 2) have shown that very simple questions to a mother about her own childhood, particularly whether she was ever separated from one or both parents, can identify a group of women who are likely to experience difficulty in managing their baby.

It has long been accepted that inadequate or abnormal cognitive performance is a characteristic of those patients described as schizophrenic (Cameron, 1938, 1939; Goldstein, 1939). A number of theories have been advanced to suggest that the basic deficit underlying this abnormal performance lies in impaired information processing. McGhie (1969, 1970) and Payne (1960) consider the defect to be in the filter that normally operates to exclude irrelevant stimuli, while Yates (1966a, 1966b) suggests that the impairment may reflect a slowed rate of information transfer in the primary processing channel. Hawks and Marshall (1971) also argue for slowed processing, but although they talk about overload due to inappropriately filtered input they appear to identify their position with Broen's (1968) response interference theory.

The unwanted effects of the phenothiazines can be divided into two categories; those effects which represent the pharmacodynamic actions of a particular drug and occur as a function of dosage and individual susceptibility; and the hyper-sensitivity reactions (Shepherd et al., 1968). This latter group of side-effects is relatively rare, and there is no suggestion in the literature that they occur more frequently with the injectable long-acting phenothiazines (LAP) than with the oral forms. With the first available long-acting phenothiazine (fluphenazine enanthate) motor side-effects were frequently observed, particularly during the first few days after injection (Millar and Daniel, 1967; Lowther, 1969; Malm, 1970). Initial studies have suggested that fluphenazine decanoate is less likely to produce these unwanted extrapyramidal effects (Neal and Imlah, 1968; Ayd, 1970). So far, however, no study has attempted to make a quantitative evaluation of the problem of side-effects in the clinical situation of longterm medication. Since both the therapeutic efficacy and the unwanted extra-pyramidal side-effects are dose-dependent, it is meaningless to measure the incidence of side-effects without also recording the therapeutic gain: a low incidence of side-effects might only reflect a non-therapeutic dose of medication. Further, any such study should be continued for at least two months after the last reduction in dosage, as it is well recognized that loss of clinical control may be postponed for many weeks after phenothiazines have been discontinued.

During the past fifteen years, attention has been drawn to the difficulties experienced by the families of mentally-handicapped children. Early studies showed that a mentally handicapped child in the home constituted a severe burden for other members of the family, particularly the mother (Tizard and Grad, 1961; Holt, 1957; Schonell and Watts, 1957).

The different classifications of homicide used make comparative studies difficult. For our purposes we will sub-divide homicide as follows: (i) ‘Abnormal homicide’, comprising (a) ‘murder-suicide’ in which the murder suspect commits suicide, and (b) ‘abnormal murder’, comprising cases where (i) the murder suspect is mentally ill, or (ii) the court returns a verdict of manslaughter by reason of diminished responsibility. (2) ‘Normal homicide’, a term we will use synonymously with ‘normal murder’, i.e. murder committed by the mentally normal.

The present study was made within the framework of the Sams⊘-project, a psychiatric service and research project in the Danish island of Sams⊘, which had a population of 6,823 in 1957 when the project was started.

Deviant language behaviour is the primary basis for the clinical inference of thought disorder. Bleuler (1950), for example, emphasizes loose associations and disjointed utterances. Mayer-Gross, Slater, and Roth (1960) state that thought disorder is indicated by such conversation characteristics as ‘woolly vagueness', in-consequential following of side issues, direction by alliteration, analogies or clang associations, and the use of words out of context. However, psychological studies have typically used measures of disordered thinking derived from performance on categorization tasks. Such tasks do not obviously measure the abnormality which is definitive for the clinician. The study reported here was an attempt to relate measures of language effectiveness to overinclusive thought disorder.

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.

We present here some findings from a survey carried out in one (former) London borough, of the information known to one or more of a number of agencies such as courts, clergy, employers, doctors, etc. (we term these sources ‘reporting agencies', see Methodology Section 4), concerning those individuals who might have a drinking problem. The results will be interpreted in the light of a house-to-house sample survey which was conducted at the same time, and in part of that same area (Edwards et al., 1972a, b, c, d, 1973): the extent of overlap in case identification will be closely considered. The literature on epidemiology applied to alcoholism has been reviewed by one of us elsewhere (Edwards, 1973), and the relevance of epidemiology to planning the community's response to its drinking problems was discussed. In the present paper the application of those general arguments to the realities of a particular set of data will be tentatively explored.

The unpleasant reaction to alcohol experienced by patients taking disulfiram was reported twenty-four years ago (Hald and Jacobsen, 1948; Martensen-Larsen, 1948). For as long as patients continue to take oral disulfiram they may be too afraid to drink. Unfortunately in practice they often discontinue the therapy, and drink with impunity a few days later. Thus a long-acting preparation of disulfiram would be desirable.

Altered thyroid states may influence the effects of psychotropic drugs. Prange (1963a) reported a case in which moderate factitious hyperthyroidism and Imipramine treatment seemed to interact to produce paroxysmal auricular tachycardia. Later, this author and his colleagues described increased lethality in imipramine in hyperthyroid mice (Prange et al., 1962) and decreased lethality in hypothyroid mice (Prange et al, 1963b). Similar effects have been found for phenothiazines (Ashford et al., 1968). More recently it has been shown that a variety of physiological and behavioural effects of phenothiazines are amplified in hyperthyroid mice (Park et al., 1973). Furthermore, Selye and Szabo (1972) found that thyroxine sensitized the rat to the toxic effects of haloperidol.

Foulds' theory of personality (1965) lays stress on the need to consider the individual as a person in relation to others. Where the ability to enter into mutual personal relations with others denotes the mature individual, egocentricity in thinking and behaving marks out the immature. One feature of egocentricity is the need to apportion blame in any given situation, either to other people or to the self, so that Foulds found punitiveness a useful attitudinal measure of egocentricity. Rosenzweig's (1934) terms extrapunitiveness and intropunitiveness were used by Foulds, Caine and Creasy (1960) to identify punitiveness directed outward on to other people and inward on to the self; these authors devised subscales, three extrapunitive and two intropunitive, to tap various aspects of punitive expression. From the pattern of correlations between the subscales, they tentatively posited a factor of general hostility, while pointing out that the correlations were such as to indicate that the extrapunitiveness subscales were measuring something different from the intropunitiveness subscales.

The experience of another person is never directly available to us, just as our own experiences cannot be directly experienced by other people. ‘We're all of us sentenced to solitary confinement inside our own skins' (Tennessee Williams). We can use empathy to get closer to another person's experience; in other words we imagine ourselves in the same situation as he is in and credit him with the feelings we would then experience. However, it is invariably our own experience that we use as the yardstick. We judge another person's experience from his behaviour, of which speech is one of the most informative parts. If another person says, ‘I see a man’, and there is indeed a man in our shared visual field, then both of us assume we are sharing a common perceptual experience. When there is no external referent, as in the statement ‘I feel sad’, the assumption of a common experience rests on more tenuous grounds. We can sometimes look to an external situation, like the loss of a close relative, to confirm that we understand the statement in the same way. But on many occasions there is no readily understandable link between a person's mood and the situation in which he finds himself. In judging a person's mood we also depend a great deal on non-verbal accompaniments of emotional states, but these are known to vary from culture to culture and from individual to individual. The movements used to express emotion, particularly those of the face, are so complex that very few attempts have been made to describe and categorize them accurately. There is a paucity of studies of this kind between Charles Darwin's pioneering work of 1872, which attempted to show the similarity of emotional expression throughout the races of mankind, and the recent work of Ekman and Friesen (1968) and Grant (1970). The few systematic studies in the intervening century do not support an invariable pattern of expression accompanying specific emotions. However, Ekman et al. (1969) found that subjects from literate cultures accurately identified emotions from photographs of the face, although subjects from pre-literate cultures showed much less agreement.

In a recent survey of the psychiatric outpatient services at three Manchester Hospitals (Johnson, 1973), the diagnoses, treatments and disposals of new patients were discussed. The survey concentrated on the psychiatrist's role in the out-patient department, whereas in fact two other important viewpoints are involved, that of the referring doctor (usually the general practitioner), and the patient. Despite the importance of these viewpoints they have been largely neglected in the psychiatric literature. Only the study of Kaeser and Cooper (1971) attempts to investigate the out-patient department from all points of view, and their findings are likely to be atypical in certain respects since 60 per cent of their patients sample were referred to an emergency clinic, and dealt with by non-consultant medical staff. The present study attempts to answer the following questions about patients referred to the psychiatric outpatient department of a provincial teaching hospital.

There is a wide variety of training programmes in psychiatry in the United States. There are such programmes at most well-known Medical Schools and Universities; at various clinics, some of international reputation; at the psychiatry departments of many large city hospitals, and at many of the state hospitals.

An association between alcohol use and violent behaviour has commonly been reported in the literature, both in the context of alcohol use at the time of the violent act (Wolfgang et al., 1956; McLintock, 1963) and in the context of the alcohol habit of men convicted of violent offences (Gibbens and Silberman, 1970). Similarly a high incidence of severe alcohol addiction has been found in men appearing before courts (Gath, 1969) and in prisons (Hensman, 1969).

The possible role of environmental stress in precipitating the onset or relapse of acute schizophrenia was investigated by Brown and Birley (1968), Birley and Brown (1970). They enquired about events which could be dated to a definite point in time and which usually involved either actual or threatened danger or important fulfilments or disappointments. They distinguished between independent events, which were outside the control of the subject, and possibly independent events, which were not so clearly out of his control but which seemed unlikely to be produced by unusual behaviour of the subject himself. In their main group of patients a significant concentration of independent events (about 60 per cent) was found in the three weeks preceding onset or relapse of schizophrenia. In examining two small sub-groups they found that 4 of 13 patients (31 per cent) who relapsed after reducing or discontinuing phenothiazine therapy had experienced a life event in the three weeks before relapse, compared with 3 of 5 patients (60 per cent) who had been taking phenothiazines regularly at the time of relapse. Although these proportions are very different, the numbers in the groups are too small for the difference to reach significance. Furthermore the groups were not matched in any way, and there may be important differences between patients who discontinue medication themselves and those who carry on taking it regularly.