Periodic brain stimulation, particularly in the limbic system, at stimulus intensities initially too low to produce any behavioural or EEG effects, progressively produces EEG changes, motor automatisms, and eventually convulsions, an effect called kindling. Data are presented and reviewed that suggest that the severity of alcohol withdrawal symptoms progressively increases over years of alcohol abuse in a stepwise fashion similar to the kindling process. The model is presented that the limbic system hyperirritability which accompanies each alcohol withdrawal serves over time to kindle increasingly widespread subcortical structures. These long-term changes in neuronal excitability might relate to the progression of alcohol withdrawal symptoms from tremor to seizures and delirium tremens, as well as the alcoholic personality changes between episodes of withdrawal.

Now that the evidence for genetic factors in the major psychoses is very strong but still essentially circumstantial (what is transmitted is unknown), there is a danger that myths about the nonexistence of mental illness may be replaced by equally misleading myths about its inheritance. The need for genetic counselling is therefore likely to increase (counselling is advice given as a result of consultation). Admittedly, the literature on counselling in mental illness is scanty, the author's own experience slight, and the public demand small. Reed (1972) stated that less than 1 per cent of the 3,000 cases seen at the Dight Institute over 20 years were concerned with schizophrenia. Nevertheless, it is probable that much unrequested and ill-informed advice is being given.

The effectiveness of a voluntary organization which aimed to help destitute men contacted by means of a ‘soup run’ was evaluated. The assessment was carried out in stages. At the end of each stage results were discussed with the organization and a set of recommendations for further action put forward. At the end of the first stage, it was agreed that the organization's aim should be restricted to attempting to help men settle in one of its houses (staffed by young volunteer workers) for a period of at least three months. A number of recommendations intended to achieve this result were unsuccessful. Following the setting up of a night shelter, it was observed that many men attended regularly. An assessment procedure was instituted which resulted in the selection of men who did settle in the houses for long periods, so much so that no further admissions became possible.

The Maudsley Bequest lectures have traditionally been intended for trainee psychiatrists. No previous lecture in the series has been concerned directly with epidemiology, and the trainee who seeks enlightenment in the British textbooks of psychiatry is likely to be disappointed or misled, for the standard view of the subject is epitomized in the statement which appears in their weightiest representative: ‘In this field the epidemiological approach concerns itself with investigation of the frequency with which definable forms of psychiatric disorder occur in carefully delineated populations' (Slater and Roth, 1969). While this aspect of the discipline is central to the interests of workers in the field of public health and administration, the notion of epidemiology as primarily an exercise in head-counting is unlikely to suggest the relevance of the discipline to clinical activities, especially if these are conceived as being focused primarily on the individual patient. In this lecture I propose to try and correct this impression and indicate the provenance and scope of epidemiology as a major branch of scientific inquiry which is indispensable to clinical psychiatry.

There are in the eyes of the world different sorts of ‘good’ psychiatrists. It depends who is making the judgement; it depends what is asked of the psychiatrist, what role he is expected to take and how successfully he has measured up to it. One would expect that the qualities of a doctor would be judged to a very large degree by his capacity to treat patients. This is what his long period of undergraduate and postgraduate training and education is about. Recently this concept of the doctor, and particularly that of consultant psychiatrist, has been challenged. The expectation that in the future he will continue to treat patients personally seems to be doubted. I wish to make my own attitude clear at the outset. The psychiatrist in my view is a physician in psychological medicine—a clinician—which means that his business and his professionalism are the personal care of patients. He is now called upon to do much more than this, and the reasons are several and complex. But the old view of a psychiatrist as physician may be lost if he accepts only the role of administrator, PR man, member of a multiprofessional team with far-ranging, ubiquitous responsibilities.

A matched controlled study of 84 depressed women confirms the findings of Brown et al, that loss of mother before 11, three or more children at home under 14 years of age, lack of a confiding marital relationship and lack of employment may be vulnerability factors predisposing to depression in working-class women.

A 10 per cent probability sample of the population of Clydebank was interviewed, using an indirect questionnaire, to assess the extent of alcohol-related disabilities. Eighty-two per cent of 4,397 persons gave information and weighted symptom-scoring analysis showed 5.0 per cent of adult males and 1.1 per cent of adult females could be classified as problem drinkers and 5.2 per cent and 0.5 per cent respectively could be labelled alcoholics. These figures are compared to existing Scottish and English alcoholism prevalence statistics.

Is there an increased relative risk of death in severe neurosis? 1,482 patients from three psychiatric units in different hospitals in Birmingham were followed-up after a mean of 10.9 years. 91 per cent of the sample were traced and 139 patients were found to have died; a highly significant increased mortality for both sexes for all causes of death. Although suicide and accidents contributed disproportionately, particularly in early follow-up, there was still a markedly increased mortality from the combined categories of nervous respiratory and cardiovascular disease, more evenly distributed in time.

Twelve patients who feigned bereavement are described. Most appeared depressed on admission, and in over half bereavement was erroneously believed by staff to be an important cause of their depression. This type of behaviour, leading to admission to hospital, may be regarded as abnormal illness behaviour, and reasons are given for considering most of the cases as variants of the Münchausen syndrome. Motivation for these deceptions is discussed, and reference is made to features which might arouse suspicion that bereavement is feigned.

I am glad to have this opportunity to talk about an unfortunate consequence of developments in the Health Service over recent years. My theme will be what is now happening to mentally disordered people who have committed criminal offences. At present, many of them are going to prison. The prison system—already severely overcrowded—contains some hundreds of mentally disordered offenders who in the opinion of prison medical officers need and are capable of gaining benefit from care, management and treatment in psychiatric hospitals. When using the term ‘mental disorder’ I shall, of course, be referring to those states of mind which have been classified and defined in Section 4 of the Mental Health Act 1959: members of the College who work in the National Health Service will be relieved to know that I do not share the view of the citizens of Samuel Butler's Erewhon that crime itself is an illness, whose sufferers should all be placed in the hands of the omniscient psychopathologists. Indeed, when one has the practical responsibility for the provision of health care for prisoners, it is quite irrelevant whether or not they committed their offences as a result of a mental disorder or whether their mental disorder developed before or after the offence or trial. The only thing that matters is their present condition. If a prisoner is suffering from mental disorder of a nature or degree that warrants his detention in hospital for treatment, then the prison medical officer will want to bring about his admission to hospital under the appropriate section of the 1959 Act. This is wholly in accordance with the philosophy of the Act, which does not limit hospital admission to cases in which the criminal offence was causally related to a mental disorder. In this talk I shall want to consider why in so many cases hospital places cannot be found.

This paper presents the results of a prospective controlled study evaluating a programme of directed masturbation against a combined sensate focus and supportive psychotherapeutic approach in the management of female primary orgasmic failure. Of the 20 patients who followed the masturbation programme 90 per cent gained orgasmic capacity compared with 53 per cent of 15 patients who were treated conventionally. Eighty-five per cent of the patients treated by the masturbation programme and 47 per cent of the control group of patients became coitally orgasmic on at least 75 per cent of coital occasions. The difference is statistically significant at the 5 per cent level. The results suggest that directed masturbation is an effective adjunct in the management of primary female orgasmic failure.

The formation of a therapeutic relationship involves the negotiation of a treatment contract which conforms to the general principles of any contractual agreement. Attempts have been made to formalize the therapeutic alliance, and this paper reports the development of a written contract for psychiatric in-patients.

Eleven patients with obsessive thoughts were treated in two pilot studies. In the first of these patients were given thought-stopping, and this was contrasted with relaxation therapy. In the second study patients were treated by a technique described here as ‘satiation’, and this was followed by thought-stopping and finally a course of amitriptyline. The overall results were poor, but one type of obsessive thought responded well to satiation.

In this presentation of two cases it is suggested that many Münchausen syndrome patients present with psychiatric symptoms. This syndrome, however, should be differentiated from other clinical psychiatric conditions.

Four hundred patients aged at least 17 who came to Casualty in one year after deliberately poisoning themselves were randomly assigned between an Experimental social work service (task-centred casework) and a Control (Routine) follow-up service. 139 patients were excluded from the trial, most of whom were already in continuing psychiatric treatment. After one year there was no difference in the proportions of E and C patients who repeated self-poisoning (about 14 per cent), but significantly more of the excluded group had repeated (36 per cent). A random half of the trial patients were re-interviewed four months after admission. Both E and C groups had improved to a significant extent on measures of depressed mood and of social problems. E patients showed more change in social problems and were more satisfied with the service they had received.

The routine air ventriculograms of 66 psychiatric patients, aged from 22 to 73 years, taken during the psychosurgical operation of stereotactic subcaudate tractotomy, were studied. Ventricular size was unrelated to progressive ageing, but a minority of patients over 60 years had abnormally large ventricles, not invariably associated with cognitive impairment on testing. Enlargement was associated with a clinical diagnosis of schizoaffective illness but not with past ECT.

A semantic differential technique was used to elicit concepts of anxiety, depression and irritability from twenty patients suffering from neurosis and ten experienced psychiatrists. It was found that psychiatrists hold concepts of these unpleasant affects that are much more differentiated than those held by patients. In particular, the psychiatrists' concepts of anxiety and depression showed a correlation of zero, whereas the patients' concepts of these affects overlapped to a considerable degree.

Patients were unable to discriminate between anxiety and depression on the basis of 11 somatic symptoms, but were able to use these symptoms to distinguish anxiety and depression from irritability. The psychiatrists were in close accord with the patients over the somatic symptoms that distinguished anxiety from irritability.

During a six-month period, physical disorder was found among 50 per cent of the 133 patients at a day hospital. Few of these cases (5) had organic brain syndromes. Among the remainder (62) physical disorder was not associated with sex, formal psychiatric diagnosis or time of referral to the hospital; of those 33 patients with a neurological disorder, one-third had previously been diagnosed to be hysterical. For this ‘hysterical’ group, however, associations with folate deficiency, organic brain disease, and depression were noted. The need is demonstrated for routine investigations among day hospital patients with particular attention for those with atypical features.

Forty-one out-patients with a history of at least three attacks of depressive illness were randomly allocated to treatment on a double-blind basis for one year with either mianserin 20 mg three times daily plus placebo lithium tablets, or to lithium tablets once daily plus placebo mianserin tablets. After one year, the dosage of mianserin was increased to 30 mg t.d.s. for a further six months. All but three of the patients had previously been stabilized on prophylactic lithium therapy. Lithium was found to be significantly superior to mianserin in avoiding admission to hospital or ECT. The overall affective morbidity index, calculated from global rating, showed no significant difference between drugs, but the index of the mianserin group was higher in the second six months than in the first. The lithium group showed no such change. Lithium remains the choice for the prophylaxis of unipolar recurrent depressive illness.