Two dominant themes of alcohological thinking and practice are considered in this paper; the disease concept and the concept of motivation. Both are examined in terms of (a) the rights, obligations and responsibilities associated with different types of illness and degrees of severity, and (b) the routine care and treatment of alcoholism in two out-patient alcoholism clinics. The allocation of responsibility and attribution of motivation in psychiatric alcoholism consultations are examined. Finally, the relationship between responsibility allocation, motivation attribution and judgements of a potentially moral nature is considered. It is concluded that a Mutual Participation model of sickness behaviour and doctor-patient relationship is operative in the psychiatric treatment of alcoholism, based upon patients' self-responsibility and strength of character (willpower). In this respect, the psychiatric treatment of alcoholism contrasts with other (particularly non-psychiatric) conditions and treatments.

I came across Creutzfeldt-Jakob disease within a few weeks of starting work in the neuropathological laboratories at the Maudsley Hospital. The time was the 1940's, and Alfred Meyer, who had known both Creutzfeldt and Jakob in Germany, had already published his study on the possible link between amyotrophic lateral sclerosis and Creutzfeldt-Jakob disease (or spastic pseudosclerosis of Jakob as it was then called). Meyer's interest in the condition was therefore well known to British psychiatrists and neurologists, and patients who were thought to be suffering from this illness were referred to him. Routine post-mortem examinations would be duly carried out, perhaps by the psychiatric staff, and the brain, sometimes with the spinal cord, would be hardened in formalin and sent in a parcel to the Maudsley laboratories.

The symptoms of schizophrenia can be interpreted as the result of a defect in the mechanism that controls and limits the contents of consciousness. This defect can be understood as excessive self-awareness. Normally most of the complex information processing which is continuously required by even simple acts of perception, language and thought goes on below the level of awareness; whereas in schizophrenic patients some of this processing, or the results of this processing, not in themselves abnormal, become conscious. This excessive awareness can account for the typical symptoms of schizophrenia and explains many of the specific cognitive abnormalities found in schizophrenic patients.

It is now ten years since the Drug Clinics were set up. In the early 1960's a long established equilibrium broke down, and the number of narcotic addicts known to the Home Office began to rise steeply. The new addicts were predominantly in their early 20's, and drugs were being obtained either from the over-generous prescribing of a handful of doctors or from the spill-over of this prescribing to the black market (Bewley, 1965 (1), 1966 (2)). Heroin was the essential agent of this epidemic, with cocaine as the major ancillary.

The received version of the history of the care of the insane consists largely of myth and folklore, tempered by a strong dash of wilful ignorance, and is capable of absorbing any number of incongruous features. It runs roughly as follows, give or take a century or two here or there (which is about the accepted level of precision): from the dawn of history, or just before, or just after, until about the middle of the nineteenth century, nothing happened at all: or (depending on where you received your version) the mentally disordered were indiscriminately exorcised, or burnt, or left to wander at will, or chained up and beaten, or all four. From the middle of the nineteenth century they were all rounded up and driven into enormous asylums (where, according to a subtle sociological variation, mental illness was invented) and were left to vegetate until the 1950s. Around 1960 dawned the enlightenment, and it was suddenly revealed that everything that had ever happened before—whatever it was—was completely wrong, and probably intentionally malicious too: and over the years following there were gradually also revealed a number of brand-new ways of putting it right, all different and mutually incompatible (not to mention expensive), and revealed respectively to different Departments of State, working parties, committees and unions—or sometimes successively to the same one.

455 male and 120 female opiate addicts were treated at two London drug dependence clinics between 1968 and 1975. The delinquency pattern of 117 female addicts and of a systematic sample of 119 male addicts was analysed in relation to stages of their addiction career and outcome. Treatment had no effect on overall crime rate but there was a significant increase in the proportion of drug offences during the treatment stage. Comparisons between the sexes showed that the outcome of treatment was worse in women. In male addicts a history of delinquency had no prognostic significance, but in females convictions for non-drug offences before entering treatment might predict poor response to treatment of drug dependence.

During a 6 year period (1970–75) 89 women charged with the killing or attempted murder of their children were examined in a female remand prison. Six types of maternal filicide were distinguished: battering mothers (36 cases), mentally ill mothers (24 cases), neonaticides (11 cases), retaliating mothers (9 cases), women who killed unwanted children (8 cases) and mercy killing (1 case). Types of filicide were compared on a number of social and psychiatric characteristics and on their offence patterns and court disposals. The operation of the Infanticide Act is discussed in the light of these findings.

The phenomenological criteria of prominent Anglo-American researchers on certain so-called passivity experiences, sense deceptions and delusional phenomena, reflecting their interpretations of Kurt Schneider's first rank symptoms of schizophrenia, are examined. In this way the frequent discrepancies and difficulties in delimiting the clinical boundaries of these phenomena more clearly come to light.

Using a reliable and valid measure of reported parental care and overprotection (the Parental Bonding Instrument) patients with two types of depressive disorder were compared with a control group, and the relationships to depressive experience examined in a non-clinical group as well. Bipolar manic-depressive patients scored like controls whereas neurotic depressives reported less parental care and greater maternal overprotection. Depressive experience in the non-clinical group was negatively associated with low parental care and weakly associated with parental overprotection.

Sixty parasuicide patients admitted to medical wards were assessed by social workers prior to routine psychiatric assessment. Both disciplines completed a rating schedule. The social workers' and psychiatrists' rating schedule responses were compared, and their decisions were examined against further information obtained by a research psychiatrist, which included standardized mental state assessment. Overall the results show that social workers can safely and reliably assess these patients, but they are more cautious. A management approach involving social workers as assessors of parasuicide patients is discussed.

The stability of self-report of 72 skid-row alcoholics over a one to six month interval was explored. Relatively high response agreement on reinterview was indicated for demographic items, but less reliability was observed on items assessing social functioning and drinking patterns. Implications of the findings for the evaluation of treatment programs are discussed.

Dopamine and its metabolites homovanillic acid and dihydroxyphenylacetic acid, noradrenaline, serotonin and its metabolite 5-hydroxyindoleacetic acid, and tryptophan and its metabolite kynurenine have been assayed in 9 schizophrenic and 10 control brains, together with the monoamine-related enzymes tyrosine hydroxylase monoamine oxidase, dopamine-β-hydroxylase, and catechol-o-methyltransferase. In schizophrenic brains dopamine, noradrenaline and serotonin were significantly increased in some areas of corpus striatum, but there were no significant changes in enzyme activity or monoamine metabolite concentrations in any of the brain areas examined. The findings are not consistent with theories that serotonin or noradrenaline stores are grossly depleted or noradrenaline neurones have degenerated, or that monoamine oxidase activity is abnormal, in schizophrenia, and provide no direct support for the hypothesis that dopamine neurones are overactive.

All the children (ages 5–15) of 14 consecutive patients admitted to hospital at the National Institute of Mental Health with a diagnosis of bipolar or unipolar affective disorder were studied. The children were seen twice, four months apart, and assessed by an interview and rating scales. The parents were also assessed. Of 14 boys, five were depressed on both interviews and three were depressed on one interview. Four of the 16 girls were depressed on both interviews and 11 were depressed on one interview. The clinical picture and the ratings showed the boys, but not the girls, to have a significant correlation for depression on both interviews. The children diagnosed as suffering from depression showed the symptoms of a primary unipolar affective disorder without other significant pathology.

By means of a twin study an attempt was made to throw light upon the aetiology and nosology of phobic fears. Factor analyses revealed five factors, namely separation fears, animal fears, mutilation fears, social fears and nature fears. The study demonstrated that, apart from separation fears, genetic factors play a part in the strength as well as content of phobic fears. Environmental factors, affecting the development of dependence, reserve and neurotic traits generally, seemed also to be of some importance. It was further demonstrated that phobic fears were related to emotional and social adjustment and this was true to an even greater extent for separation fears.

Records of 186 suicides among male prisoners in England between 1958 and 1971 emphasize the differences between the prison population and the population at large. The suicide rate may well be three times greater. The records show that sentence of more than 18 months' duration, whether anticipated or actually received, is associated with a greater risk of suicide than shorter sentence, and that suicide is most likely to be committed during the first few weeks in custody.

In an attempt to evaluate the clinical significance of alcohol withdrawal, the rate of symptoms and incidence of treatment were determined in 84 female alcoholics following abrupt withdrawal. Results indicated that abstinence symptoms of an emergency type (delirium tremens, convulsions) only rarely occur and require active treatment, whereas those physical and emotional disturbances frequently seen in alcohol withdrawal need very little medical help. This finding is in contradistinction to current clinical opinion.

A variety of depressive classifications were used to predict response to four weeks' treatment with phenelzine. Better response was found in outpatients rather than inpatients, in atypical depressives, in less severe depressives with a pattern of anxiety and other neurotic symptoms, and in groups characterized as hostile and agitated. The findings, although a little patchy, gave clear support to the concept of a specific clinical group responsive to MAO inhibitors.

Eight male schizophrenics were treated in an open study with d.l. propranolol. The dose was increased by 160 mg/day until a maximum of 2,400 mg/day was achieved on day 15, and this remained constant until day 21. Seven patients showed significant clinical evidence of psychiatric improvement, while the incidence of toxic side-effects was low. There was wide inter-patient variation in plasma levels of propranolol. Despite a significant increase of plasma propranolol between day 15 and day 21 of the study, there was no significant change in serum prolactin.

Forty-five patients with acute schizophrenic illnesses (defined by PSE criteria) were assessed in clinical, cognitive and social terms before being entered in a four week study of the isomers of flupenthixol and placebo. At the end of one year they were re-assessed in the same terms. The clinical and psychological features of the acute illness and the drug treatment given did not predict outcome. Poor outcome in social terms was significantly related to severe social isolation in the initial assessment and to the presence of nuclear symptoms and negative schizophrenic features at follow-up.