The generally accepted (Waelsch and Weil-Malherbe, 1964) reduction in the rate of glucose utilization in cases of severe depression could not be confirmed with specifically determined blood glucose in patients given diets high in carbohydrate for three or four days before testing (Herzberg, Coppen and Marks, 1968; Hansen, 1969). Nevertheless, in numerical agreement with previous findings with older methods for blood sugar determination (Henneman, Altschule and Gonz, 1954; Balter and Efron, 1965), depression as a symptom in psychosis correlated highly with elevation of non-glucose carbohydrate concentrations as determined by the colorimetric anthrone method. It was found that elevated whole blood uridine diphosphate glucose (UDPG), enzymatically determined, correlated with depression in psychosis (Hansen, 1969).

Human consciousness includes the dimension of time: As history it reaches back into the past, and as prediction it gropes towards the future. Knowledge of the future must have been felt as a necessity as long as the human mind has existed, and the need for such knowledge was being met on a high level of organization even before culture reached a written stage. Prophets came before authors. At one time prophecy was more important than history because it was nourished by the ancient and powerful mental force of anxiety, anxiety in its true psychiatric form as fear of the unknown.

In spite of the new methods of treatment and care introduced during the past fifteen years, schizophrenic patients are still liable to relapse with a recurrence of florid symptoms such as delusions, hallucinations and disturbed behaviour, and great suffering can be caused to all concerned (Brown et al., 1966). It has been shown that the onset of florid symptoms is often preceded during the previous three weeks by a significant change in the patient's social environment (Brown and Birley, 1968; Birley and Brown, 1970). Other studies have focused on the influence of more persistent environmental factors, such as the emotion expressed towards the patients by relatives with whom they were living. In an exploratory survey of discharged long-stay men it was found that close emotional ties with parents or wives indicated a poor prognosis (Brown, Carstairs and Topping, 1958; Brown, 1959). In a further study, patients were seen in hospital just before discharge, and their relatives were interviewed at home at the same time, and both were seen together at a joint interview shortly after discharge. It was found that those patients who returned home to live with relatives who were highly emotionally involved with them (as judged by ratings of the relatives' behaviour) were more likely to suffer a relapse of florid symptoms, even when the severity of psychiatric disturbance at the time of discharge was taken into account (Brown et al., 1962). Ratings of the patient's own expressed emotion showed much less involvement, and were much less highly associated with subsequent relapse. There was also a suggestion that short-term and long-term influences might have a cumulative effect; for example, that a raised level of tension in the home made relapse more likely in the event of a critical change in the patient's social environment (Brown and Birley, 1968). These facts, together with the contrasting but just as handicapping reaction of schizophrenic patients to an under-stimulating social milieu, were brought together in a more general theory of environmental influences on the course of schizophrenia (Wing and Brown, 1970). This also took account of the high physiological arousal which had been found in the most withdrawn schizophrenic patients (Venables, 1968; Venables and Wing, 1962). It was argued that in a socially intrusive environment acting upon a patient whose thought disorder was in any case liable to become manifest whenever circumstances became too complicated, a patient would tend to attempt to protect himself by social withdrawal; but this process might easily go too far, both in hospital and outside it, leading to complete social isolation and inability to care for himself. The optimum social environment, for those who remained handicapped, was seen as a structured and neutrally stimulating one with little necessity for complex decision making.

For the purposes of the present report we will include under the generic term of Latin America a group of 20 countries with geographic, historical, political and cultural common links, which because of being former colonies of Spain and Portugal might better be called Iberoamerica. Tied together in regional groups during colonial days, they became independent at the beginning of last century and initiated their republican life as separate countries. In almost all of them Spanish is spoken as the exclusive or major language, the two exceptions being Brazil and Haiti.

Baan was referring to the underdeveloped world, or the ‘third world’ as it is often called. This review is concerned with psychiatry in a small part of it—Sub-Saharan Africa—that part of the African continent inhabited by black Africans. At the time of writing, the term is used more specifically to describe independent black Africa, excluding South Africa—hence a bloc of cultures and sub-cultures with ethnic, economic, religious and customary patterns very different from those of the continents of Europe and North America where the bulk of current data and theory about psychiatric disorders has been obtained and expanded. In view of such major differences in factors long thought to influence the occurrence and nature of psychiatric illnesses, the patterns of these disorders in Sub-Saharan Africa are important in clarifying theories about psychiatric disease despite the paucity of adequate research carried out to date.

Despite over half a century of intensive research the essential nature of the schizophrenias still remains an enigma. Attempts to account for the disordered behaviour of the schizophrenic have ranged over the full spectrum of the biosocial sciences, explanations being sought both in the biochemistry of the organism and in the interpersonal relationships of the whole individual. Sitting somewhere between these two extremes is the psychophysiological view. As a conceptual and methodological approach to behaviour in general, psychophysiology concerns itself with the problem of integrating neurophysiological and psychological data, attempting to bridge the gap between these two disciplines. Of course, the potential value of describing behaviour at a different level of explanation, either more molecular or more molar, is not denied. However, the peculiar contribution of psychophysiology is its concentration on data gathered at the interface between the brain and behaviour. As such its techniques are chosen so as to allow guesses to be made about the functional systems in the brain that underly behaviour. They naturally include the study of E.E.G. and autonomic response but also extend to the measurement of various phenomena derived from conventional experimental psychology, such as perceptual thresholds and vigilance (Claridge, 1970b). The theoretical concepts of psychophysiology reflect its mongrel background and include such terms as ‘arousal’, a notion originating in academic psychology, but made respectable by neurophysiologists.

Until quite recently the prestige of Science was enormous, and in its glow basked innumerable earnest workers who firmly believed that their meticulous ant-like activities were advancing the health, wealth, welfare and spiritual ascent of man. In the last few years that prestige has quite suddenly collapsed. We do not deny the loftiness of aim which inspired our forerunners, but we have begun to realize that the secondary consequences of the most nobly motivated activities may lead to disaster. The main consequence of the advance of scientific knowledge has been the proliferation of technologies which have armed and powered a materialistic culture in the exploitation and progressive erosion of a fragile living environment. The scientist of an earlier generation had some notion of seeking after an aspect of the truth, and relied in the main on his own insights and ingenuity. Today, all too often, he knows himself for an expendable member of a professional team, depending on the routine deployment of technical resources for the manipulation of an established paradigm.

Torgerson (1968) has suggested that the most appropriate form of classification of functional mental illnesses may prove to be partly categorical and partly dimensional. Everitt, Gourlay and Kendell (1971) have tended to agree with this conclusion since their attempt at validating existing diagnostic categories by means of cluster analysis proved to be only partially successful. In the present paper the dimensional approach is considered in some detail and it is shown that it has limitations which are due in part to the distributional properties of the data which research psychiatrists record for their patients, and in part to the fact that some key symptoms occur only rarely. In the final paragraphs of the paper an attempt is made to clarify the dimensional and categorical roles in the description of functional illnesses. In doing so it becomes clear that some difficulties remain unresolved.

Increased serum creatine phosphokinase (C.P.K.) levels have been shown in acutely psychotic patients on admission to hospital (Meltzer, 1968). Little is known about C.P.K. activity in non-psychotic (e.g. neurotic) patients admitted under similar conditions. Psychotic patients have not been compared with non-psychotic patients over a period of time following admission. Examination of a single serum sample for C.P.K. activity in non-psychotic patients at the time of admission has shown no abnormality (Meltzer et al., 1969).

My choice of subject for this Memorial Lecture is one which I hope would have been approved of by the late Dr. Shorvon, who must have often applied his great therapeutic acumen to the treatment of anxious patients. I intend to present neither a compendious review of some aspect of anxiety nor a catalogue of recent research work. Rather, I shall outline some conceptual and practical problems met in investigating an emotion. Such problems have occupied medical men and also many philosophers, psychologists and theologians. I shall outline the types of anxiety, using the term loosely, and then attempt a scientific analysis ending with some speculative model-making.

The Ganda are the most numerous tribe in Uganda. They live around the capital, Kampala, along the north-west shore of Lake Victoria and up to 50 to 100 miles inland. They are a Bantu-speaking people, surrounded by other Bantu to the east, west and south, with Nilotic people to the north.

Despite extensive gross and microscopic scrutiny, no consistent pathological findings have emerged from studies of autopsy material from schizophrenic patients. Dunlap (1924) carried out the first controlled study involving schizophrenic and control brains and concluded that ‘there was not even a suspicion of consistent organic brain disease as a basis for the psychosis of schizophrenia’. More recently both Wolf and Cowen (1952), and Weinstein (1954), reviewed the neuropathological literature and concluded that there were no consistent findings at autopsy that could be construed as characteristic of schizophrenia. These authors felt that earlier claims were based on failure to appreciate the range of normal variation in the brain as well as a failure to include an adequate control population in the study.

Thirty-four first admissions between the years 1964 and 1970 into the Department of Psychiatry, Erskine Hospital, Madurai, South India, who were diagnosed as general paresis formed the material for this prospective study. Diagnosis was based on clinical and positive blood and CSF serology, and on Lange's paretic reaction in the CSF.

Sedatives such as barbiturates, benzodiazepines and alcohol are valuable reducers of anxiety, but their effects do not endure for long after the drug has been metabolized and excreted. Phobics often become able to enter their phobic situation under the influence of sedatives, but as the drug effect wears off they begin to escape from the situation once more. This might be a form of drug-dissociative behaviour. In animal experiments, behaviour learned in the sedative drugged state often fails to transfer to the undrugged state (Miller, 1964). However, this effect might be more pronounced during the phase of peak drug effect than during the phase when the drug effect is wearing off. In rats, exposure to the phobic situation during slow withdrawal of sedative drugs was found to be effective in extinguishing conditioned avoidance responses (Sherman, 1967). That more lasting behavioural changes can follow treatment given both in the drug and in the non-drug state is suggested by evidence adduced by Baum (1971); he found that, in rats, avoidance behaviour which was learned both in the alcohol and in the non-drug state was more resistant to extinction than avoidance acquired in a non-drug state alone. The same might apply to approach behaviour in human phobics.

Earlier work from this laboratory showed that rheomelanins (blood soluble melanins) form in normal and schizophrenic blood incubated with the catecholamines, with l-dopa, with adrenochrome and with adrenolutin-monohydrate (Hegedus and Altschule (1–4)). This work also showed that the erythrocytes of many patients with a diagnosis of chronic schizophrenia are abnormally susceptible to the haemolytic effects of the rheomelanins or their precursors, formed in their bloods during incubation with most of these chemicals (Hegedus and Altschule (2, 4)). Erythrocytes of the chronic patients showed especially marked haemolysis during incubation of their oxalated blood with adrenochrome, with adrenolutin-monohydrate and with dopamine. A test for routine use was developed on the basis of this phenomenon, and is reported in this paper. The conditions of this routine test were determined as regards quantity of chemicals, time and temperature of incubation, and rate of shaking during incubation so as to give maximum differences between normal and schizophrenic bloods.

The purpose of this communication is to present a group of patients who, while receiving treatment with one of the phenothiazine derivatives in average range of doses regarded as suitable for adults, developed a syndrome comprising mutism and a number of other neurological features. In the majority of these patients speech loss is almost complete; but, unlike aphasics, they may respond to repeated questioning by simple utterances usually spoken in a whisper, or else are capable on rare occasions, quite unexpectedly, of delivering remarks which are appropriate and may be spoken normally. Speech deprivation is as a rule associated with an inability to communicate either by gestures or writing and also an inability to perform many customary tasks. Mutism is, therefore, not an isolated disability, but is associated with a wide range of disturbances of behaviour and of level of consciousness. In addition, some of the patients exhibit one or more of the neurological toxic phenomena encountered in the course of medication with phenothiazine derivatives, e.g. akathisia, buccal dyskinesias, dystonias, tremor and parkinsonism.

Excessive alcohol consumption over a prolonged period of time may result in a variety of neuropsychiatric complications (Victor and Adams, 1953). The most frequent of these is alcoholic tremulousness which may be complicated in 25 per cent of cases by perceptual disturbances ranging from transitory misinterpretations of familiar objects to visual and auditory hallucinations (Victor and Adams, 1953). Closely related to this condition are delirium tremens (Victor and Adams, 1953; Lundquist, 1961; Nielsen, 1965), and acute or chronic auditory hallucinosis (Benedetti, 1952; Victor and Hope, 1958). In clinical practice intermediate or atypical forms of these syndromes are seen (Sabot, Gross and Halpert, 1968).

The psychiatric hospital can be viewed as a social system which is evolving slowly by attempting to improve. In order to systematically study and learn about itself the mental hospital and its care providers need continuous pertinent information. Yet, at present the psychiatric hospital is not organized in a way that readily allows isolation of problems or systematic learning from prior experience (8). In that sense, the hospital is a non-system which lacks an information system necessary for meaningful feedback to the decision-makers of the institution (7).

Little has been done to validate the so-called Newcastle scale for the differential diagnosis of endogenous and neurotic depression: neither are we aware of any validating work with the E.C.T. prediction scale or any investigation of the reliability of these indices (Carney, Roth and Garside, 1965). However, the diagnosis scale items, adapted for use with elderly patients (Post, 1970), and described as ‘highly relevant and clearly defined’, discriminated between deeply melancholic and more ‘neurotic’ patients; more recently Naylor and his associates (1971) found it to agree with clinical diagnosis in separating psychotic and neurotic depressives.

In a series of previous papers fairly detailed studies of an individual patient with a precisely timed forty-eight hour periodic psychosis have been presented. Jenner (1963), and Jenner, Gjessing, Cox, Davis-Jones, Hullin and Hanna (1967) have presented the clinical findings. Essentially, for thirteen years the patient regularly suffered from one day of depression alternating with one day of hypomania. The change of state occurred during sleep, usually between 02.00 and 03.00 hours. There were only eight major defects of the cycle in ten years. The timing of the cycle was however influenced by the environment; this was confirmed when the patient lived in an artificial environment in which a day and night totalled twenty-two hours instead of twenty-four. The psychotic cycle then became one of forty-four hours rather than forty-eight (Jenner, Goodwin, Sheridan, Tauber and Lobban (1968)).