Introduction

“I can't concentrate, doctor” is a common complaint among psychiatric patients. The phrase is usually applied in a general sense to describe a state in which the patient has ceased to read the newspapers or watch the television and can no longer cope adequately with his work. In clinical practice the performance of the “serial sevens” test has been thought to give an indication of impairment of this function, whatever it may be (Mayer-Gross, Slater and Roth, 1960). As the symptom is so common, a measure of its severity may be of some value. This paper describes an attempt to develop such a measure and discusses the possible implications of its failure.

In previous studies of somatosensory cerebral evoked responses in psychiatric patients, we found that two characteristics of these responses discriminated between patients with psychotic depressions and healthy or psychoneurotic subjects. The amplitude of the initial negative-positive component was larger and its recovery, as determined by administering paired “conditioning” and “test” stimuli, was retarded (11, 12, 13). Furthermore, after successful therapy, the recovery measure changed in the direction of “normal” (11).

Sleep is essential for physical and mental health. In the last 15 years there has grown up the concept of the brain stem reticular activating system. Electroencephalographic studies have shown two qualitatively different and alternating kinds of sleep, the orthodox (“slow wave”, or “forebrain“) and the paradoxical (”hind-brain“, “rapid eye movement”, “activated“, or “dreaming”) phases (Akert et al., 1965). It may be predicted that in the next decade attention will turn increasingly to the chemical basis of sleep. If a man is deprived of sleep for 100 hours, it is extremely difficult to keep him awake and one may suppose that an abnormal biochemical state exists within his central nervous system.

Saxondale Hospital was one of the first in the Sheffield Region to start Industrial Therapy. Since June 1960 the unit has grown, more patients are employed, and we hope for further expansion in the near future. From our experience it seemed that Industrial Therapy was useful in the management of the chronic psychiatric patient. However, we felt that a more objective assessment could be obtained if we surveyed eight comparable hospitals. A personal survey has certain advantages over postal questionnaires, and we decided to conduct a complete survey of one region. All visits were made between November 1964 and January 1965.

The need for the development of shorter and more effective techniques of psychotherapy justifies a careful investigation of any methods which offer this possibility. A number of therapeutic techniques (7, 15, 18, 20) now often subsumed under the heading of Behaviour Therapy (4) and based on various principles of learning theory call for examination, since their exponents claim that these methods can make therapy both shorter and more effective than can other methods, e.g., those based on psychoanalytic theory. Published reports of results with behaviour therapy to date consist largely of the assessment of results made by a therapist on his own patients, e.g., Wolpe (20, 21), Lazarus (9), Rachman (12). Cooper (2) studied results achieved by other therapists on thirty patients treated with various techniques of behaviour therapy. His survey included a comparison, using “blind” independent assessors, of a group of patients treated with behaviour therapy and a matched group of patients treated by other techniques. Cooper concluded that this comparison showed a definite advantage for behaviour therapy in the symptomatic treatment of phobias, but he could find no evidence supporting the claim of a superiority of the methods of behaviour therapy over conventional techniques in producing general changes. Unfortunately Cooper does not report the experience level of the therapists in his study except to say that they were a “variety of student and staff psychologists”. Evidence for a superiority of behaviour therapy must derive from a controlled comparison of matched groups of patients treated with techniques of behaviour therapy and with other techniques by therapists of comparable competence. But, pending judgment from such a controlled study, we believe ample evidence exists that techniques of behaviour therapy do bring comparable improvements more rapidly than do other treatments in some patients. The greater precision and shortening of therapy for these patients would alone constitute a very notable advance in psychotherapy, apart from claims of a wider or general applicability of these techniques. For this reason we believe it important to investigate these various techniques in as much detail as possible. Wolpe describes the most important of them as systematic desensitization (20, 21).

Reorientation of the mental health services towards community care was one of the main recommendations contained in the report of the Royal Commission on Mental Health Law (1957) and accepted as Government policy. It was implied that there would be a considerable expansion in the services provided by local health and welfare authorities for the benefit of the mentally disordered, and local authorities were asked to draw up a proper order of priorities and plan their activities accordingly (Ministry of Health, 1959). The priorities depended upon an assessment of needs and time had to elapse before these became apparent. Since four complete years have passed since the coming into operation of the Mental Health Act, 1959, detailed assessment has become possible and this has revealed the difficulties experienced in the community by two special groups of patients, namely mentally abnormal offenders and patients of no fixed abode (N.F.A.s).

Since the initial review of patients in Glenside Hospital (Cooper and Early, 1961), a number of surveys have been carried out—Gore and Jones (1961), Norton (1961), Hassall and Hellon (1964), and Hassall, Spencer and Cross (1965). These studies are not directly comparable and all contain elements of subjective assessment.

This investigation began as an attempt to measure the anxiety shown by patients while awaiting electro-convulsive therapy. One measure used was an assessment of the degree of palmar digital sweating, using the plastic paint technique described by MacKinnon (1963). This is a method by which the number of active sweat glands in a given area at a given time can be counted. In a preliminary trial, the effect on sweating of waiting for E.C.T. was equivocal, but there seemed to be an increase in sweating in depressed patients as their clinical condition improved. In the main trial, therefore, the emphasis was placed on differences in sweating of depressed patients when ill and recovered, though the reading in the E.C.T. waiting-room was retained.

One of the common clinical interests shared by physicians and psychiatrists is the genetically determined syndrome to which Klinefelter has given his name. Over the past few years positive identification has become possible through advances in cytogenetics, and more recently evidence has been accumulating which seems to indicate that a significant correlation may exist between Klinefelter's Syndrome and the development of other diseases, malignant disease in particular. Mental retardation is one of the most common symptoms found in the syndrome, so the psychiatrist is often in the best position to detect it. The case to be described here as well as having a few interesting facets of psychopathology may also provide more evidence of the pathological loading which the basic genetic abnormality seems to carry.

In a previous survey of hospital in-patients it was observed that among schizophrenics the earlier born were affected to a greater extent (Rao and Sundararaj, 1964). Following a suggestion by Slater (personal communication) the work was extended and further data collected on a larger number of patients to determine the role of birth order in schizophrenics. The present communication reports the findings.

Recent developments in the vexed questions of the relative importance to be attributed to genetic and environmental factors in the aetiology of schizophrenia, and the manner in which they interact to produce a phenotypic psychosis, are highlighted by David Rosenthal's series of critical papers (1959–1962) on twin and family studies and the book edited by him chronicling the lives of a set of monozygotic quadruplets all concordant for schizophrenia (1963). In his thorough and open-minded critique Rosenthal argues that previously reported concordance rates for monozygotic (MZ) twins have been misleadingly high. To this point we shall return in a moment. Rosenthal finally concludes that “the best information we now have with respect to the whole broad question of heredity and environment in schizophrenia, is to be found mainly in the five major studies of twins.” Unlike some who have pointed out weaknesses in the studies, he believes that “our task is to determine their source, extent and implications, not to dismiss them offhandedly because they contain errors” (1962a, p. 132).

Patients with idiopathic narcolepsy are seen by both neurologists and psychiatrists. The diagnosis has traditionally been made on the basis of a history of frequently falling asleep against the patient's wishes, attacks of cataplexy or loss of muscle tone upon sudden emotion, episodes of sleep paralysis, and an account of vivid, dream-like experiences during the periods of involuntary sleep.

Tryptophan has attracted attention during recent years for the possible role played by some of its metabolites in the aetiology and treatment of psychiatric disorders. Of these metabolites, serotonin has received special attention and considerable work has been carried out in order to elucidate its physiological and pharmacological actions. Studies from animal experiments are thus available on the function of serotonin in nervous activity (Marrazzi and Hart, 1955; Brodie et al., 1955; Pletscher et al., 1956; Welsh, 1957), but the results obtained thus far in psychiatric patients are uncertain. Recent researches in the affective psychoses (Burgermeister et al., 1963) did not reveal significant differences between patients and normal controls in the urinary output of 5-hydroxyindoleacetic acid (5-HIAA) before or after an oral 5-hydroxytryptophan load.

In 1963 Ödegård published a catamnestic study of the 5,010 boys and girls who graduated (i.e. left after obtaining the “graduation certificate” by examination) from the high-schools (Gymnasiums) of Norway 1916–20. When this population group was followed until 1950, 117 were found to have been admitted to psychiatric hospitals for a psychosis. This material proved too small for a detailed statistical analysis, and the conclusions, although interesting and suggestive, remained inconclusive.

In the practice of our department at the Middlesex Hospital, the need has been felt for a means of rapid quantification of common symptoms and traits relevant to the conventional diagnostic categories of psychoneurotic illness. Until now, none of the available British scales have fulfilled this requirement. The most widely used is the Maudsley Personality Inventory (Eysenck, 1959) with its subsequent modifications. This, however, although scientifically based, is limited to the assessment of broad categories such as “neuroticism” and “extraversion” which appear to go only a small way towards describing the wide variability of psychoneurotic disturbances. Foulds and his co-workers (Foulds, 1965) have for a number of years developed personality scales in which clinical sophistication and a rigorous methodology are combined. Their Symptom-Sign Inventory, however, consists of eighty questions which have to be presented orally. Furthermore, although the inventory covers psychotic disturbances, it is necessary to use an additional questionnaire, the Hysteroid-Obsessoid Questionnaire (Caine & Hawkins, 1963) to complete the spectrum of psychoneurotic illness. Moreover, the concept of psychiatric illness developed by these workers is individual rather than conventional in a number of respects. The Tavistock Self-Assessment Inventory (Sandler, 1954) is too long for the present purposes (876 items in six booklets). The Taylor Manifest Anxiety Scale (Taylor, 1953) is short and convenient, but it measures one dimension only. As many doctors, including psychiatrists, find it useful to think in terms of orthodox clinical categories for diagnostic, therapeutic, prognostic and research purposes, it was decided to design and attempt to validate a self-rating scale adapted to these categories, taking the patient 5–10 minutes to complete and capable of being rapidly scored by the doctor or an assistant.

In this investigation, the subjects were 180 female patients with pure endogenous depressions. These were divided into six different groups of 30 each. Of these groups, four were treated with nortriptyline, amitriptyline, imipramine and MAO-inhibitors respectively, and the results were compared with those obtained in the fifth group of patients who had been given electroplexy only, and finally with those obtained in the sixth group of patients who had received treatment before 1937.

The place of genetic factors in the aetiology of schizophrenia remains disputed. Several surveys have demonstrated a significantly higher incidence of the disorder in relatives of schizophrenic persons as compared to the general population. Furthermore, the closer the relationship, the higher the incidence of schizophrenia. The studies of Kallmann (1938) and Slater (1953) are especially significant and the research in this area has been thoroughly reviewed by Alanen (1958).

The demonstration by previous investigators (Table I), that more schizophrenics have experienced death of a parent in childhood than have control populations, suggests that the bereavement may be of aetiological importance. Gregory (1958) has criticized the methods of such studies, particularly in regard to their difficulty in obtaining well-matched control groups or data relating to the normal population, and the validity of these findings is therefore uncertain. The investigation described in this paper tries to overcome this methodological difficulty by comparing data on ages at bereavement of schizophrenics with those relating to their non-schizoohrenic sibs.

The validity of judgments based upon clinical methods such as interviews or projective tests has been persistently questioned over the past 15 years. The disappointing results of clinicians' efforts to predict the professional performance of Veterans' Administration clinical psychology trainees or Menninger psychiatric residents are well-known examples (Holt and Luborsky, 1958; Kelly and Fiske, 1950). Other investigators (Glass, et al., 1956; Holtzman and Sells, 1954; Plag, 1964; Thorne, 1960) also have reached highly critical conclusions with regard to the validity of clinical procedures, based upon their studies in military settings. Eysenck (1952), in particular, has strongly rejected claims of validity for the clinical approach. Hunt (1959), after many years devoted to the problem, reports progress in achieving stable validities by application of quasi-experimental approaches to the analysis of clinical judgments. Meehl (1954), in summarizing research on the accuracy of clinical judgments more than a decade ago, suggested that such predictions often err because the clinician typically does not know what weights to give the available information nor how to combine the various cues efficiently.

Endogenous depression appears to be frequently associated with autonomic disturbances, and it has been suggested that in this condition there may be some abnormality of the hypothalamus (Elithorn, 1962; Pollitt, 1965), investigation into which might throw light on its aetiology.