Introduction There have been many theories put forward to explain the not uncommon symptoms of depersonalization. They were aptly summarized by Ackner (1954) in the following way. There are theories which regard depersonalization as a symptom with an organic basis; there are theories which consider it a disturbance of a particular psychological function; there are analytic theories; and finally there is a theory which would suggest that depersonalization is a form of schizophrenia. This paper is concerned with a re-appraisal of all these theories in the light of recent and current research on the subject.

As is well known, there has been a good deal of discussion about the unitary or binary nature of depression. Mapother (1926) and Lewis (1934) made a strong case for the unitary view on clinical grounds, Curran (1937) concurring. Kendell (1968) has reviewed the history of this argument; it is marred by confusion which has persisted through recent attempts to use statistical techniques of factor analysis and discriminant function analysis in an effort to find a more objective and empirical solution. It is the purpose of this brief note to draw attention to this confusion, to show how it has affected arguments of both adherents and opponents of the binary position, and to argue that the data are in fact in sufficient agreement to make possible a valid answer to both problems. It is suggested that the apparent disagreement between workers such as those of the Newcastle group (Kiloh and Garside, 1963; Carney, Roth and Garside, 1965) and the London (Maudsley) group (Kendell, 1968) is in fact quite irrelevant and is based on a misunderstanding of the statistical properties of factors, a misunderstanding apparently introduced in one of the first studies of this kind to be concerned with the problem of the classification of depressive illness, that by Hamilton and White (1959).

It has often been said that no one knows what psychoanalysis is—whether it is a science, one of the humanities, a particular type of therapeutic art, a religion or a form of semantic theory (Ryecroft 1968). There are those who postpone judgement, waiting to see whether psychoanalytical theory is refuted or accepted. This raises the question of the nature of theories developed to explain human nature, as opposed to those designed for the purpose of explaining physical nature. Failure to distinguish between them leads to much confusion. Consideration of human nature leads to what is exclusively and most significantly human—human experience, so-called psychic reality, a phenomenon unique to human beings, but shared to a certain extent by them, and capable of communication between them. Physical nature, both organic and inorganic, is of a different order of abstraction. Psychic reality, which cannot be directly perceived through the physical senses, is only directly experienced in the self, but can be communicated by language—and can be inferred from observation. Physical reality can only be perceived through the physical senses.

Non-restraint in the mid nineteenth century was a watchword, a battle-cry, a symbol of that movement for the reform of the treatment of the insane which has been called ‘one of the finest flowers of Victorian philanthropy’. The need for such watchwords and symbols to dispel stagnation and stimulate progress has been well exemplified in our specialty in these times; and, strange as it seems to one of my generation, ‘mechanical restraint’ has even in the last few months again become a subject for discussion.

I have chosen as the subject for my Blake Marsh Lecture the influence of sex chromosome aberrations on intelligence, mental health and social adjustment. This subject provides a fascinating example of how a branch of research, beginning in the field of mental retardation, arrived at discoveries which proved to be of significance to quite other fields of psychiatry. Ten years ago we learned that sex-chromatin-positive males, that is, males with additional X chromosomes, at least in some cell lines, were more often encountered among the intellectually retarded than among the average population of males. Shortly after this we learned that the same was true of women with double Barr bodies, that is, women with more than the usual two X chromosomes, at least in some cell lines. Today we have facts showing that an abnormal sex chromosome complement may have an unfavourable effect on mental health, and this in several different ways; thus we know that it may contribute to the development of functional psychoses, and may even influence such a complex variable of behaviour as our ability to adapt ourselves to the laws of the community. Myself, I am convinced that study of aberrations in the sex chromosomes will prove to have a radical effect on large sections of psychiatric thinking.

This paper reports on the personality changes found in 261 patients after proven subarachnoid haemorrhage, and in particular on the association between these changes and the site and severity of damage to the brain. Psychiatric symptoms and details of intellectual impairment are not considered but will be reported elsewhere.

The main contention of this paper is that some of the transient side-effects of electroconvulsive therapy on human memory resemble, in kind if not in degree, those more severe and chronic learning defects that are known to appear as an incidental result of temporal lobectomy in man. If this claim can plausibly be supported it would imply a pressing need for the more systematic study of other modes of therapeutically effective ECT that would interfere as little as possible with the normal activity of those parts of the human brain that are essential for adequate learning and memory function.

The present study is a preliminary report of the frequency and type of criminality in men with Klinefelter's syndrome and the XYY syndrome; it has been made on the background of previous findings of a comparatively high frequency of criminality among such patients.

The ‘religiosity’ of the epileptic has been recognized since the time of Esquirol (1838) and Morel (1860). These, and later French workers (including Marchand and Ajuriaguerra, 1948), have sought to explain the epileptic's religiosity as being the result of his disability, social isolation and his enhanced need for the consolation of religion. A specific conversion experience after a fit was reported by Howden (1872–73). The patient believed that he was in Heaven. He would appear to have been depersonalized, as it took three days for his body to be reunited with his soul. ‘He maintained that God had sent it to him as a means of conversion, that he was now a new man, and had never before known what true peace was…. He assured me that he was a converted man and that he was convinced he would have no more fits.’ Howden also reported on John Engellerecht who, after many years of depression, attempted suicide and appeared to die. After visiting Hell and Heaven, he cast off his depression, and acquired a state of religious ecstasy accompanied by visual and auditory hallucinations. Boven (1919) mentions a 14-year-old boy who after a seizure ‘saw the good God and the angels, and heard a celestial fanfare of music’. He regards the religiosity of the epileptic character as being due to experiences acquired in the course of an epileptic aura and in the subsequent confusional state. Eventually the patient becomes preoccupied with a cure which he believes depends entirely on God, and this belief is the basis of his euphoria. Boven stresses the intensified piety of the epileptic after a severe seizure.

The relationship between anxiety state and depressive illness has been debated for many years. On clinical grounds, Mapother (1926) and Lewis (1966) expressed the view that the various forms of anxiety and depressive states merge imperceptibly into one another, while Garmany (1956, 1958) and Stenback (1963) considered that they were fundamentally different disorders. Gurney, Roth and Garside (1970) showed that the two conditions differ significantly in respect of a large number of biographical, personality and clinical indices. They also demonstrated that the disorders could be separated by means of a discriminant function analysis and that the distribution of the patients' scores was clearly bimodal. In a four year follow-up study of the same group of patients, Kerr, Gurney, Schapira and Roth (1970) showed that depressive illnesses carry a significantly better prognosis. Moreover, physiological evidence based on forearm blood-flow measurements has also given tentative support to the differentiation of the disorders (Kelly and Walter, 1969).

Psychoanalytic treatment shares with other forms of psychotherapy the aim of bringing about lasting changes within the patient. In common with other ‘insight’ therapies it makes use of interpretations and other verbal interventions (Sandier, Dare and Holder, 1971). While these are aimed partly at making unconscious content and processes conscious, it has been maintained since the early days of psychoanalytic treatment that ‘making what is unconscious conscious' and the gaining of insight is not sufficient, in the ordinary course of events, to bring about a fundamental change in the patient. In contrast to procedures involving hypnosis and massive abreaction (catharsis), the psychoanalytic method is regarded as depending for its success on a number of additional elements. A number of these have been discussed in previous papers, particularly the elements of treatment alliance (Sandier, Holder and Dare, 1970a), transference (Sandier, Dare and Holder, 1970a, b) and the analysis of resistance (Sandier, Holder and Dare, 1970b). It is the purpose of the present paper to examine those further factors in the psychoanalytic treatment situation which have been encompassed under the heading of working through.

Kurt Schneider (1939) set a high value on certain symptoms in the diagnosis of schizophrenia. He named them ‘first rank symptoms'. This paper gives an account of these symptoms in schizophrenics, on admission to mental hospital; the assumption being that if they are the defining symptoms of the illness then they should be most prominent in the acute phase.

A phobia may be defined as a persistent and inappropriate fear of a specific object or situation; the majority of phobias do not come to the attention of the psychiatrist, as they are readily circumvented and hence do not interfere significantly with the individual's mode of life.

Early workers studying children because of persistent delinquency concluded that the child's inability to make relationships was the central core from which all other behaviour disturbances arose. The long term effects of institutionalization and repeated moves from foster mother to foster mother, it was asserted, were basic in any consideration of aetiology. The difficulty of treating these patients and the permanency of ill-effects was emphasized. In his well-known World Health Organization Bulletin, Bowlby (1951) concluded ‘on the basis of this varied evidence it appears that there is a very strong case indeed for believing that prolonged separation of a child from his mother (or mother substitute) during the first five years of life stands foremost amongst the causes of delinquent character development’. Whilst the practical conclusions of this publication led to a remarkable change in outlook and improvement in the institutional care of children, his theoretical conclusions have drawn heavy fire. Andry (1960) directed attention to the ‘defective role frequently played by the father and not only that of the all-too-often mentioned mother’. Wootton (1959, 1962) regards as an unproven hypothesis ‘that maternal deprivation leads to life-long damage and is a major factor in criminal behaviour’. She argues that Bowlby has overstated the case for the separation experience itself, without due regard to the conditions the child has come from or goes to, and has given scant recognition to hereditary factors. Wootton notes that relatively few investigations have traced the fortunes of the maternally deprived after adolescence, let alone throughout life, and hence there is no definitive proof that the damaging effects of the separation experience are irreversible. Further, the maternal separation hypothesis relates to only a minority of the delinquent population (the ‘affectless psychopath’) and there is no experience of the general population at large of comparable infantile experiences. A review of the recent literature (Lancet, 1966, British Medical Journal, 1967), indicates that various investigations into the long term effects of childhood parental deprivation and bereavement in the causation of adult mental ill health and behaviour disturbance have yielded inconclusive results. Whilst this state of affairs suggests that further studies are necessary to detect consistent patterns of parental deprivation, these patterns by themselves may not indicate precise modes of aetiology, but when taken into consideration with other objective data of family background may yield the development or refutation of hypotheses regarding various determinants of psychiatric disorder. In the light of these contemporary uncertainties we have re-examined the hypothesis that early adverse experiences are related to subsequent delinquency and criminality. By statistical procedures we examined two prison populations, one consisting of short term male first offenders of less serious crime, and the other of male recidivists and those convicted of serious crime. Various groups from the general population at large have been incorporated to act as the control group.

Proof that two clinical syndromes are distinct entities depends on a demonstration that patients with features of both syndromes are less common than those with features only of the one or the other. The intermediate forms, the greys, must be shown to be less numerous than the blacks and the whites, which means in graphical terms that a bimodal distribution of scores must be demonstrated on some chosen dimension. The optimal dimension for this purpose is Fisher's discriminant function (Fisher, 1936; Rao, 1948), and it may be useful before proceeding further to describe how this is derived. From the universe of all patients with syndrome X (psychotic depression) or syndrome Y (neurotic depression) every patient is assigned to one or other category, and the two populations are then rated on a series of N items which comprise the recognized discriminators between the two syndromes. From these data the analysis produces a set of weights for the N items which maximizes the ratio of between group to within group variance. The effect of this is that, when a single weighted score is calculated for each patient by combining the weights of the relevant items, the overlap between the scores of members of the two populations, X and Y, is reduced to a minimum. If the distribution of the scores of X and Y combined is bimodal the validity of the distinction between the two is confirmed.

The complaints, ‘I am a stranger to myself; I am unreal’, are manifestations of depersonalization which have been noted frequently by clinicians. Depersonalization has been reported in epilepsy, after drug ingestion, encephalitis, hysteria, manic depression, and schizophrenia, as well as in various neurotic patients. It has also been noted in normals, but usually after emotional shock or physical exhaustion. Most recently, persistent feelings of depersonalization have been elevated to the status of a diagnostic entity in itself.

This report describes an attempt to assess the validity of a number of cognitive tests in distinguishing between brain-damaged and non brain-damaged psychiatric patients over the age of 65 years.

A cogent interpretation of the apparent average ineffectiveness of psychotherapy (e.g. Eysenck, 1960) has been proposed by Bergin (1966) and taken up by Truax and Carkhuff (1967). This explanation is based upon the suggestion that some therapeutic encounters harm patients and hence beneficial effects are cancelled out when the average results of large groups are considered. Rather than beginning with large miscellaneous samples treated in an unspecified variety of ways, our research programme involves detailed experimental and correlational studies of the therapy of a small number of patients with similar diagnoses. This paper is limited to a preliminary study of assessment of change in psychotherapy by means of the Personal Questionnaire (PQ,), (Shapiro, 1961, 1969).

The distinction between schizophrenic and affective illnesses has been one of the cornerstones of psychiatric classification ever since Kraepelin introduced the twin concepts of dementia praecox and manic depressive psychosis at the turn of the century. It has also long been recognized that some patients have both schizophrenic and affective symptoms, and various interpretations have been placed on these mixed states. To some continental psychiatrists they constitute a third group of psychoses distinct from both schizophrenia and manic-depressive psychosis—the degeneration psychoses of Kleist or the cycloid psychoses of Leonhard. By others they are regarded as genuine mixed states, with the implication that elements of both schizophrenia and manic depressive illnesses are contributing, perhaps because the genetic or constitutional endowment is mixed, perhaps because two alternative defence mechanisms are being utilized simultaneously. Often, however, mixed symptomatology is simply ignored, either by discounting the schizophrenic symptoms and focusing attention on the mood change, or, as most American psychiatrists do, by glossing over the affective symptoms and regarding the illness as a form of schizophrenia differing in no significant respect from other schizophrenias.

The Kleine-Levin Syndrome, first categorized by Critchley and Hoffman in 1942, consists of periodic hypersomnia and megaphagia associated with abnormal mental states. Though a case of hypersomnia with doubtful megaphagia was described by J. A. Antimoff as far back as 1898, the first two cases definitely belonging to the syndrome lie hidden in a group of five cases reported by Willi Kleine (1925), a psychiatrist of the Kleist Clinic, Frankfurt, under the title of ‘Periodische Schlafsucht’. The patients were adolescent males who showed periodic hypersomnia with eating of excessive food and an unusual mental state. Writing on narcolepsy, a New York psychiatrist, Max Levin (1929), described a boy who exhibited pathological hunger in association with episodes of sleep of unusual duration. ‘The patient would sleep for long periods at the beginning of each attack. His appetite was enormous. He ate large meals and much in between meals. Max Levin rewrote his original case in 1936, and for the first time made specific mention of a ‘syndrome of periodic somnolence and morbid hunger as a new entity in nosology’ and quoted seven cases as ‘good’ examples of the syndrome.