Psychiatric disturbances in a student population span a broad spectrum and include overt illness, a heterogeneous group of psychosocial problems with varied and changing symptomatology and normal crises of development. Complaints of work difficulty often form part of the symptomatology of all these groups, and not infrequently may be the presenting symptom. Quantification is difficult because the symptoms vary in degree and form, and change over time. They may be unreported or voiced only to friends or tutors. Their prevalence and significance is therefore hard to assess. In a cohort study spanning a four year period, Lucas (unpublished data) found that of the 15 per cent of the cohort who received brief psychotherapy, more than three-quarters had a work difficulty of some kind. Of the 26 per cent of the cohort who never attended the Student Health Centre nearly half replied ‘yes' to a question asking whether they had experienced recurring work difficulty.

In any psychotherapeutic endeavour, it must be recognized that psychogenically based mental illness is generally the product of childhood experience in the context of intrafamilial interpersonal relationships. Involvement in treatment of the whole original family might therefore be considered a logical approach, if this were either possible or practicable. Rarely, however, is this the case, save when the patient happens to be a child or adolescent. On the whole, mental hospitals and psychiatric units are populated by adults, many of whom, voluntarily or otherwise, have gained a considerable degree of physical independence from their first families. Many too have already committed themselves to a second family. In these cases the selection of a spouse has often been determined by unconscious pathological needs and expectations, resulting in a ‘neurotic’ object choice, and an unsuccessful ‘sick’ marriage. Thus the second family can frequently be seen as a precipitating factor in the development of mental illness, although not ultimately as causative in the true sense of the word.

This paper describes the development of a standardized report intended for the assessment of the work behaviour of psychiatric patients in hospital workshops and clerical units. The report form was developed in the Rehabilitation Unit of the Maudsley Hospital, and primarily within the workshops and clerical section which are integral parts of the coordinated unit.

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.

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.

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.

Goldman, Gomer, and Templer (2) found that the Bender-Gestalt and Benton Visual Retention Test performances of male chronic schizophrenic in-patients with a history of 50 or more electroconvulsive treatments (ECT) were significantly inferior to those of control patients matched for age, level of education, and race. However, the authors maintained that it cannot be inferred with certainty that ECT causes permanent brain damage since it is possible that schizophrenic patients more likely to receive ECT are those whose psychosis is more severe. It has been reported that patients with the so-called functional psychiatric disorders tend to do poorly on tests of organicity (5).

Previous investigations have suggested that desensitization is the treatment of choice for simple phobic disorders, but is less effective with agoraphobia, particularly when the phobias are accompanied by much generalized anxiety (Gelder and Marks, 1966). Even the milder agoraphobias usually respond incompletely despite prolonged treatment. An alternative treatment that offers more rapid or effective results, particularly with agoraphobia, would therefore be of value. The technique of flooding or implosion has recently been the subject of a number of studies, and some, but not all, have shown evidence of considerable therapeutic power. The method is also of some theoretical interest since it breaks the rules which are thought to be important in desensitization. Thus, according to early proponents (Stampfl and Levis, 1967) success depends on exposing patients to fantasy material of an extremely intense and anxiety-provoking nature, so that extinction to cues associated with the original traumatic situation may take place. From this theoretical viewpoint desensitization can be only partially successful, since these traumatic origins are neither sought for nor presented to the patient. Even if the necessity of dealing with original anxiety-provoking cues is not accepted, the use of material which evokes maximal anxiety for prolonged periods is contrary to the counter-conditioning theory of desensitization (Wolpe, 1958). Indeed, this theory predicts that flooding would rarely be successful and might make the phobia worse because uncontrolled increases in anxiety may cause reconditioning.

The therapeutic effect of flooding was thought originally to depend on the induction of high levels of anxiety by the presentation of intensely frightening situations in imagination or practice (Stampfl and Levis, 1967; Marks et al., 1971). More recent evidence indicates that high arousal may not be essential in flooding and may even be disadvantageous. Hussain (1971) reported that patients with agoraphobia and social phobias responded better to imaginai flooding when it was accompanied by the intravenous infusion of thiopental. Marks et al. (1972), treating patients with specific phobias, found that flooding carried out by exposure to the phobic situations was more effective if combined with an anxiolytic drug, oral diazepam. There was some evidence that flooding was most effective if it took place several hours after administration of the drug.

Screening examinations are widely advocated for the early detection of disease in the elderly (Williamson et al., 1964; Lowther, McLeod and Williamson, 1970; Williams et al., 1972; Richardson, 1964; Anderson and Cowan, 1955; Isaacs, Livingstone and Neville, 1972). There have been several successful experiments in the use of health visitors and district nurses in the initial interview (Burns, 1969; Hodes, 1971; McNabola, 1970; Williamson et al., 1966).

In the United States of America, many centres are now running automated data programmes in the psychiatric field (Kline and Laska, 1968; Ulett and Sletten, 1971). In Britain, such developments have been much more restricted; prominent examples however are the North-East Scotland psychiatric register, and the Maudsley Hospital—Institute of Psychiatry check-list, together with the Camberwell register. As a clinical itemization, the ‘Present Psychiatric State’ (Wing et al., 1967) presents a comprehensive listing of over 400 symptoms, the evaluation being confined to the previous four weeks of the patient's experience. This is a valuable research tool, but for routine clinical history requirements it would be both too detailed and, by definition, too limited in scope.

Dipotassium clorazepate is a new benzodiazepine derivative with pharmacological and clinical properties resembling diazepam. This report concerns a double-blind placebo-controlled crossover comparison of clorazepate and diazepam which was carried out simultaneously at four centres in the United Kingdom.