The aim of the present investigation is to consider the dynamics and the effects of suicidal attempts in 100 female patients admitted to Holywell Hospital in two consecutive years, 1962 and 1963. (Holywell is a psychiatric hospital of 750 beds situated in the town of Antrim, 17 miles north-west of Belfast. It serves County Antrim, which has a population of about 330,000.)

Within a framework of Kelly's Personal Construct Theory (Kelly, 1955; Bannister, 1962a), Bannister (1960, 1962b) considers thought-process disorder (formal thought disorder) to be a loosening of the associations between the constructs of the patient's conceptual system, and an instability over time of whatever pattern of association remains. The disorder appears to be maximal in that construct subsystem which subsumes discriminations relating to psychological attributes (Bannister and Salmon, 1966; McPherson and Buckley, 1970).

The classification of depressive illness continues to be a subject for dispute. Studies in many areas support the view that there are two distinct forms of depression, but until techniques of multivariate analysis became available it was difficult to obtain definite support for either the unitary or the binary view.

Despite extensive research and a vast literature, the diagnosis of schizophrenia remains primarily a clinical decision based upon the presence of some agreed-upon symptom complex. Laboratory studies and special testing procedures have not yet demonstrated their utility in establishing diagnosis in this syndrome. While it is easy to cite studies of diagnostic difficulty (Beck, 1962), it is also apparent that when clinicians state they are ‘certain of the diagnosis' or agree to utilize pre-established diagnostic stereotypes, the diagnostic agreement frequently achieves an 80 per cent reliability (Beck, 1962; Hordern et al., 1968). Clinicians the world over tend to identify gross symptoms in similar ways. However, they may ascribe varying significance to similar symptom complexes and may even use similar symptom constellations to arrive at different diagnoses (Saenger, 1968; Sandifer et al., 1968). There seems to be general agreement on the major symptoms found in schizophrenia (Cooper, 1967; Beck et al., 1962; Hordem et al., 1968); however, diagnostic agreement on subtypes, and on admixtures of paranoid symptoms and depression is much more difficult to achieve (Cooper, 1967; Morgan et al., 1968; Lorr and Klett, 1968; Hordem et al., 1968). The present study attempts to formalize the apparent commonality of clinical features which together establish a diagnosis of schizophrenia through the development of a valid and reliable checklist of symptoms.

Some patterns of deranged function—epilepsy, schizophrenia—have been enshrined as diseases; others, such as depersonalization, have, by and large, escaped this fetter. This is perhaps why there has been no difficulty in accepting that depersonalization, being a pattern of disordered function, can occur in conditions of very different aetiology. It is seen in temporal lobe epilepsy (12), temporal lobe migrane (22), depression (8), LSD intoxication (20), schizophrenia (1), phobic anxiety states (15), sleep deprivation (2) and the hypnagogic state. Shorvon (21) reported cases of depersonalization occurring in the apparent absence of other psychiatric disorder, and Davison (4) investigated in detail seven such cases. Finally the occurrence of depersonalization in people not attending psychiatric or neurological clinics is now well attested (13, 5, 18, 6).

The hopes and fears of many different sections of the population were pinned on the legislation that took effect on 27 April 1968. To some it represented the admission of civil rights long denied, to others it seemed an uneasy compromise. The implications of the new Act have been reviewed by Hordern (1971), but there is still much confusion in the mind of the man in the street (and particularly the woman in the street) about what the legal position now is. Many laymen are under the impression that one can now obtain abortion on demand, but they must be balanced against those cynics who feel that the situation has not been changed in effect from what obtained in earlier years. There is certainly a lot of misunderstanding about what may be regarded as 'social’ reasons for termination of pregnancy, and this extends to a common belief that the majority of terminations are carried out under this category.

In considering the cost of different forms of care for patients with mental deficiency there is a tendency to compare crude averages. Mental deficiency has many manifestations and occurs in people of widely differing degrees of physical ability and behaviour so that comparisons which do not take this into account are not meaningful. An attempt has been made to assess the cost of hospital care for different groups of patients and to show that there is a wide variation in the costs which arc normally expressed as an average. This average is often used to compare with the expenditure, say, in a hostel, when in fact those patients suitable for hostel care are at the lower end of the cost range. Again, whilst everyone would like to see patients dealt with in small groups, the extra cost this would involve is often overlooked. The analysis presented helps to clarify points such as these.

Affective disorder is a serious and disabling illness which has a high suicide rate. Suicide is estimated as the eventual cause of death in 15 per cent of those given this diagnosis (4). Lithium carbonate has been convincingly shown to be an effective prophylactic against further attacks of depression (1, 3). Because suicide is such a common end in those with depressive illness, and per contra depressive illness is found in at least half of those dying by suicide (5, 2), the suicide rate may well go down once lithium is in general use. The reduction will depend on how many cases of suicide are recurrent depressives who might respond to lithium.

An interview with the patient is the main method of examination in the functional psychoses, following which the diagnosis is made. This diagnosis is fundamental in communicating about the patient, in clinical discussions between psychiatrists or in comparing research results. It is essential that the diagnosis should be reliable and valid. Kreitman (1961) has defined reliability as the amount of agreement between psychiatrists examining the same patient, or a comparable series of patients. He also argues that the frame of reference of the examiner should be that of general clinical psychiatry. It should also avoid personality traits in psychiatrists which are associated with different kinds of orientation (Kreitman, 1961). Another problem, that of nomenclature, may turn out to be an argument about the choice of labels. These problems are of great concern to the clinical psychiatrist and are made worse by weaknesses in interview techniques. It is important to look for improvements, and the present study examines the reliability and validity of the In-patient Multidimensional Psychiatric Scale (I.M.P.S.). This is a scale for rating psychotic syndromes following an interview with the patient. These syndromes have been established by repeated factor analyses (Lorr and Klett, 1967). The initial work was based on psychotic American patients, but similar factor syndromes appear from studies of psychotics in other countries (Lorr and Klett, 1968, 1969a, 1969b).

Obsessional neurosis, inasfar as it comes to the attention of the psychiatrist, is a comparatively rare disorder, comprising not more than about 3 per cent of all cases of neurosis. Its rarity is reflected in the fact that the largest series so far described, that of Pollitt (1957), consisted of only 150 cases, though a limited amount of information has been available from the somewhat larger series of the Bethlem-Maudsley Hospital (Blacker and Gore, 1955) and of the Registrar General (1964).

Scientific studies of the families of depressed patients have shown that the risk of development of similar illnesses for close relatives is greater when the illness of the index case began relatively early in life than when it began later. These studies have included both manic-depressive and single episode endogeneous depressions, and no account has been taken of the mode of precipitation of the illnesses. It has been postulated that (a) the penetrance of the gene may be lower in those families with late onset of depression, and (b) that depressive illness may be of diverse aetiology, so that genetically determined forms appear earlier in life and those which are not genetically determined occur later (Hopkinson and Ley 1969).

It is accepted as professionally unethical for doctors and nurses to be influenced by their (negative or positive) feelings in their behaviour towards patients. ‘Emotional involvement’ with patients, though seldom defined, is usually sternly discouraged during medical and nursing training. As a result many graduates deny not only that they are influenced by their feelings towards their patients but even that they have any feelings at all.

Since the long-term results of the treatment of elderly depressives admitted to the writer's care between 1949 and 1951 were communicated (1962), further experiences (e.g. Colwell and Post, 1959; Post, 1968) have confirmed that affective illnesses in late life are associated with much subsequent mental invalidism and needs for further treatment. It was hoped that these needs might be met by increased use of out-patient and community care as well as by the introduction of thymoleptic drugs. A follow-up investigation of a further consecutive series of depressives over the age of 60 receiving inpatient treatment from the same psychiatrist in the same hospital during the years 1966–67 was undertaken with the following aims in view:

Firstly, it was intended to test the proposition that the less reluctant use of electro-convulsive therapy in old persons, as well as the introduction of antidepressant drugs and of more active after-care measures, had improved the long term outlook in the affective illnesses of late life. It was realized that a comparison of two series of patients separated from one another by some 15 years might be vitiated by differences between the samples other than those due to changed methods of treatment. It would, however, have been unethical to withhold the new forms of management from a control group.

The aim of this study was to determine the relationship between loose or ‘allusive’ thinking and conditioning performance. The theoretical proposition examined was that looseness of thinking is associated with weak internal inhibition of autonomic responses in classical conditioning.

To demonstrate how 'senile dementia emerged as an important psychiatric concept is not an easy task. Although the history of general psychiatry can be satisfactorily traced to the spirited endeavours of Hippocrates (460–375 B.C.), Celsus (circa 30 a.d.), Soranus the elder (circa 100 a.d.), and Aretaeus (circa 150 a.d.), the psychiatry of old age unfortunately lacks such a clear and well-defined genealogy. The term 'senile dementia’ itself seems to have been first used by Aretaeus, the physician of Cappadocia, but exactly how it had evolved and how it was differentiated, if at all, from normal senescence is not at all clear. Certainly modern psychiatry has inherited a wealth of graphic description of old age in general, and for a detailed account of the relevant ethnographic literature the reader is referred to the excellent article by Rosen (1961). From a scientific point of view, however, it is unfortunate that the spirit of enquiry and the descriptive contributions of the early writers seem to have been tempered more by the degree of optimism or pessimism with which they anticipated the intellectual and behavioural foibles of old age, than by a desire to explore and evaluate systematically its possible deviations.

Over a hundred years ago Griesinger (1861) identified hypochondriasis with melancholia; and quite recently, Kenyon (1964) in a study of 512 patients with a diagnosis of hypochondriasis concluded that it was always part of another syndrome, most commonly a depressive or anxiety state. Many patients with a depressive illness experience localized somatic symptoms. The question arises why, during an episode of depression, some patients have localized somatic symptoms, sometimes consistently in the same site in recurrent episodes, whilst others have none. The head, chest and abdomen have been reported as the most common sites (Schneider, 1959; Gittleson, 1962). Jaspers (1913–46) pointed out that ‘we should distinguish between phenomenological description of actual bodily experiences and any discussion of the significance for the individual of his own body in terms of the effective meaningful connections where there are hypochondriacal narcissistic or symbol-forming tendencies influencing the self-awareness'. The present study is concerned with the possible meaningful connections related to the localization of symptoms to the chest in depression, and follows a descriptive account of respiratory symptoms in depression (Burns, 1971). These symptoms include sighing respiration, hyperventilation, ‘vital feelings' on the chest and depressive delusions directed towards the chest.

In a study by Hinchcliffe, Lancashire and Roberts (1971), results of verbal behaviour analysis are described which purport to show objective, quantified evidence of ‘psychological defence mechanisms' in the speech of depressed patients. The method employed was based on earlier work by Weintraub and Aronson (1962, 1964), involving the tape-recording of speech during interviews of both patients and controls. Analysis is made of both temporo-physical events (e.g. speech rate; pausing) and lexical and semantic content. Regarding the latter, particular emphasis was placed on frequency of ‘negators', defined as ‘not, never, nor, nothing’ (Hinchcliffe et al., 1971) and ‘All negatives, e.g. “not“, “no”, “nothing“, “never”.’ (Weintraub and Aronson, 1964). Such ‘negators' are taken to indicate ‘denial’ in the psycho-analytic sense. Hinchcliffe et al. used a group of ten depressed in-patients and a control group of ten surgical in-patients ‘matched for age, sex and socio-economic position’, but sharply demarcated in terms of their scores on the Zung Self-Rating Scale for depression (Zung, 1965). They found a preponderance of ‘negators' in the speech of the depressed group which was statistically highly significant (P < 0·005), comparing well with the findings of Weintraub and Aronson (P < 0 · 01). In a subsequent communication (Silverman, 1971), the present author expressed doubt as to the validity of the inference that ‘negators' do indicate ‘denial’ in depressed patients, and suggested an alternative experiment of which this is a report.

The psychiatric services in the field of community psychiatry in Israel have developed in a number of directions over the past decade. Following the establishment by the Workers' Sick Fund (Kupat Holim) of a Rehabilitation Unit for chronic psychiatric patients (Wijsenbeek and Lindner (53)) and the opening of a Day Hospital for acute cases in conjunction with a psychiatric hospital (Ramot and Jaffe (45)), a Day Hospital was established in October 1968, at the Out-Patient Mental Health Clinic (Ramat Chen), to serve acute psychiatric patients. This represented the first attempt of its kind in Israel. The professional literature on Day Hospitals, which in the main describes a ‘half-way out’ type of hospital (Farndale (16); Epps and Hanes (14); Kramer (32)), also reports the existence of a ‘half-way in’ type of institution, operating as an autonomous service catering to a particular geographical region, without being attached directly to a mental hospital. This kind of Day Hospital, specifically designed for acute cases, has not yet been tried in Israel.

Tests involving the arrangement of pictures to tell a story have long been included among tests of intellectual ability. First devised by De Croly (1914), one or more items of this type have appeared in a number of experiments and standardized tests; and the Wechsler intelligence scales (1944, 1955) include a Picture Arrangement subtest consisting of six or eight items ranging in length from three to six pictures. However, apart from its possible use for psychiatric interpretation (e.g. Wechsler, 1958; Ch. 10) its specific value as a component of the scale has not been established. Some critics, suggesting that the test has a low reliability, are inclined to omit it from short forms of the Wechsler scales; yet test-retest reliabilities of about 0.65 (Wechsler, 1958) are similar to those of Arithmetic and Object Assembly, which are rarely omitted. Perhaps a more cogent reason for its omission is uncertainty as to what ability the test measures. Wechsler (1958) suggests that it shows the subject's ability to ‘comprehend and size up a total situation’; and that, as all the stories concern human activities, it may be a measure of social intelligence and awareness. Identification of the ability or abilities involved by factor analysis is also inconclusive: the test does not show significant association with Picture Completion, the other pictorial subtest in the Wechsler scale; and in different analyses it has shown associations with a Memory factor or with a factor described as ‘freedom from distractibility’.

The Child Psychiatric Clinic of the Paediatric Department at St. Thomas' Hospital has had a relatively large number of referrals of disturbed children under 5 years of age, because of the existence of a day hospital where they and their families can be offered treatment together (Frommer, 1967). As there are few reports on psychiatric disturbance in this age-group, we thought it worthwhile to report on some aspects of their problems as we have seen them. Clinical experience led us to the supposition that we would find recurring patterns of family disturbance and symptoms accompanying the main behavioural disturbances for which they were brought. For this reason, we undertook an analysis of the presenting features, symptoms, behaviour, and family circumstances of all pre-school children who were referred to this Clinic during six years from August, 1962, when the day hospital first opened as a part-time pilot venture, to August 1968. The following is an account of some of our findings.