During the past year the question of lithium prophylaxis has been the subject of lively debate (Blackwell and Shepherd, 1968; Hullin et al., 1968; Houghton, 1968; Baastrup and Schou, 1968a; Lader, 1968; Sargant, 1968; Saran, 1968; Baastrup and Schou, 1968b; Melia, 1968; Fieve and Platman, 1968; Cole, 1968; Kline, 1968; Kerry, 1968; Editorial, 1968; Berlyne, 1968; Silverman, 1968; Laurell and Ottosson, 1968; Lancet Editorial, 1969; Whybrow, 1969; Melia, 1969; Angst et al., 1969c). This discussion has revealed considerable uncertainty about the design and assessment of prophylactic trials, and there have been misunderstandings on important points.

This study is based upon data derived from reported cases of suicide in Afghanistan.

The treatment of phobic states is one of the most challenging psychiatric problems that face doctors today. Many treatments have been advocated, including intensive psychotherapy (Friedman, 1959), behaviour therapy (Wolpe, 1958; Cooper, Gelder and Marks, 1965) and desensitization under drugs (Yorkston et al., 1968). None of these treatments has proved to be completely effective, and many patients still remain ill and incapacitated for many years. In the series to be reported here, some patients had been ill for as long as 40 years, despite many types of treatment.

The Eysenck Personality Inventory (EPI) was designed by Eysenck and Eysenck (1964) to measure two dimensions of personality—extraversion (E) and neuroticism (N). A high N score on the EPI has been found to dis criminate neurotic patients from normals (Knowles and Krietman, 1965; Eysenck and Eysenck, 1964).

Since the first description of persistent oral dyskinesia following phenothiazine treatment by Sigwald in 1956 a good deal of evidence has accumulated indicating the regular occurrence of this syndrome. However there is a disagreement over its incidence and the aetiological role played by phenothiazine drugs. Kline (1968) in a recent review found a total of 114 cases of ‘irreversible’ oral dyskinesia and concluded that the incidence had been misrepresented since less than two dozen of these recorded cases were previously non-brain damage.

A distinction has to be made between psychiatric illnesses on the one hand and the various forms of abnormal personality on the other hand.

Preliminary validation of the Middlesex Hospital Questionnaire (M.H.Q.) was described by Crown and Crisp (ig66). The M.H.Q. is a self-rating scale of psychoneurotic symptoms and traits comprising six sub-tests which are designed to measure free-floating anxiety (FFA), phobic anxiety (PHO), obsessional traits and symptoms (OBS), somatic concomitants of anxiety (SOM), depression (DEP), and hysteri cal personality traits (HYS). McKerracher, Loughnane and Watson (1968) used the Eysenck Personality Inventory (E.P.I.) and the M.H.Q. to delineate the personality of self-mutilating female psychopaths at Rampton Hospital compared with a matched group who had not behaved in this way during the previous year. There were no significant differences between the groups on the E.P.I. neuroticism, extraversion or lie scales. On the M.H.Q., totalscoresand three sub-test scores showed significant differences, which led to clinically relevant hypotheses to account for variations in the patients' behaviour. Mair and Crisp (1968) and Ryle and Lunghi (1969) used the M.H.Q., and the E.P.I. as well as the Kelly Repertory Grid to assess personality changes in individuals during psychotherapy.

Following the first reports of a prophylactic lithium action in recurrent affective disorders (Hartigan, 1963; Schou, 1963; Baastrup, 1964; Schou and Baastrup, 1966; Baastrup and Schou, 1967), a large number of research projects on this subject have been started. Prophylactic studies yield results slowly, and reports published to date are mainly of a preliminary nature. Some have been negative; the authors found little or no evidence of prophylactic lithium action (Fieve et al., 1968; Zall et al., 1968). Other observations seem to confirm the ability of lithium to prevent manic and depressive relapses (Achté et al., 1968; Blinder, 1968; Christodoulou, 1968; Dyson and Mendels, 1968; Gershon, 1968; Gottfries, 1968; Haastrup et al., 1968; Hofmann and Boleloucky-Bolen, 1968; Hullin et al., 1968; Kerry and Owen, 1968; Lauter, 1969; Levy, 1968; Melia, 1968; Sargant, 1968; Vaadal and Robak, 1968; Annell, 1969; Forssman and Wålinder, 1969; Fries, 1969; Uddenberg, 1969). The reports are based on samples which range from a few patients to about seventy. Few deal with systematic studies.

Patients are occasionally referred to a psychiatrist with the primary complaint of a cosmetic defect in their appearance, and in a previous communication 45 such patients, dissatisfied with their noses and requesting cosmetic surgery, were studied (Hay, in press).

There have been many studies (3,15,4) on the effects of oral contraceptive hormonal agents, though relatively few have concerned themselves with the possible adverse emotional reactions accompanying their use. To date, seven women (8, 6, 5, 13) have had psychotic episodes in temporal association with drug use, one patient having reported two such episodes. Four of these seven women had a history of severe postpartum disturbance in the past, and two others had previous psychiatric illness. There have been reports of varying incidence of depression, anxiety, increased or decreased sexual desire and relief of premenstrual tension. We wish to present data from a pilot double blind study of one combination oral contraceptive.

It is often said that psychopaths mature and settle down later in life. Authorities differ as to when this occurs; some say between 25 and the early thirties (Curran and Partridge, 1963); Henderson and Batchelor (1962) say that improvement may occur up to the age of 36; others say about the mid-forties (Davis, 1967); Cleckley (1952) held that the prognosis is almost hopeless. Most of their descriptions are of young adults, and one wonders what happens to them thereafter; do the majority settle down? and if they do not what happens to them?

Prophylactic maintenance treatment with lithium presents a number of features not shared by conventional therapies. Patients suffering from recurrent affective disorders are offered the possibility of avoiding further psychotic episodes (Baastrup and Schou, 1967; Angst et al., 1970), but the treatment also makes demands on doctors and patients.

Affective flattening is a disorder of emotional expression, of which a good definition is ‘a gross lack of emotional response to the given situation’ (Fish, 1962). It is a clinical sign whose assessment depends upon the clinician's intepretation of the patient's facial expression, tone of voice and content of talk (Harris ' Metcalfe, 1956). Although these are subtle cues, it has been shown that experienced clinicians can assess the severity of affective flattening with a high level of inter-rater agreement (Miller et al., 1953; Harris ' Metcaife, 1956; Wing, 1961; Dixon, 1968). The disorder is usually associated with a diagnosis of schizophrenia, although it may occur in other conditions, such as the organic psychoses (Bullock et al., 1951).

Environmentalists have long attempted to demonstrate relationships between various deficiencies in upbringing and adult mental illness. Early parent death is one of the most obvious and one of the most easily measured of such deficiencies, and many investigators have been tempted to the deceptively simple task of comparing the incidence of early parent death in patients and the general population. That there is so little agreement in the findings of the now considerable number of studies is a reflection of the methodological pitfalls which exist.

We have studied 29 school phobic youngsters (14 boys and 15 girls), of mean age 12 years 10 months (S.D. = 14.7 months) shortly before admission to an adolescent psychiatric in-patient unit. The diagnosis was made when there was severe difficulty in attending school, severe emotional upset at the prospect of having to go to school, staying home during school hours with the parents' knowledge and absence of significant anti-social disorders. Information was gathered from the patient and one parent, usually mother. Most youngsters had completely refused to go to school (23) and the remainder went occasionally with great reluctance; this seemed to depend on the attitudes of parents, school and medical agencies. Psychoses, gross physical illness, truancy, and neurotic disturbances other than school phobia resulting in absence from school were excluded. The cases were classified, reliably, into 19 ‘acute’ (11 boys, 8 girk) and 10 ‘chronic’ (3 boys, 7 girls) school phobics. This was done on the criterion of previous severe reluctance to attend school: at least 3 years of trouble-free attendance led to a classification as ‘acute’, the remainder were ‘chronic’. The mean age of the acutes (13 years 1 month) was significantly higher (P<0.001) than that of the chronics (12 years 3 months). In the acutes, the school phobia had been present 5 months (S.D. =3.5 months) on average in the boys, and 1 year 5 months (S.D. = 16.5 months) on average in the girls; which was a significant difference (P<0.02). The mean time between onset of symptoms and complete refusal was 3.5 months [boys-2 months (S.D. = 2 months) girls-6 months (S.D. = 9 months)]. The following features did not show significant differences between the acutes and chronics; social class of the patient's father (the typical social class was 5a on the Hall and Jones Scale of Occupational Prestige for Males), the mean age of mother when the child was bom, the number of only or youngest children in the family, birth complications, the number of severe illnesses, accidents and operations added to separations from mother in the first decade, missing some school without the parents' knowledge, suicidal gestures, the occurrence of symptoms on transfer to secondary school, somatic symptoms, frank mental illness in parents and I.Q. (W.I.S.C. total score); 4 acute cases had symptoms coming on following a bereavement.

The aim of this study was to examine the relationships between side effects occurring in the first two months of treatment with a contraceptive pill and questionnaire-assessed neuroticism. Because the side effects of contraceptive pills are now widely known, doctors' and patients' expectations could be a significant influence in reporting side effects. In order to control for these non-pharmacological variables we therefore designed a double blind trial of a contraceptive and an inert pill involving an intensive study of a small group of patients. It was assumed that neurotic patients were more likely to report side effects, but that if the degree of neuroticism could be controlled, any significant differences in reports of side effects would be due to the active substance.

The possibility of abnormalities in carbohydrate metabolism in schizophrenia has been stressed by many authors (Mann 1925, Freeman et al., 1943, Braceland et al., 1945, Morgan and Pilgrim 1952, Henneman et al., 1954, Moya et al., 1958, Lingjaerde and Skaug 1959). As there is a close relation between lipid metabolism (in terms of plasma free fatty acids, FFA) and glucose metabolism Mueller (1961, 1962) tested the FFA-response to insulin-induced hypoglycaemia in chronic schizophrenic patients. He found that schizophrenics showed less reduction in FFA-values than healthy controls, in some cases even an increase. Results were later presented which tend to confirm Mueller's data (van Sickle et al., 1966). Interest was focused on increased sympathetic activity in the patients, and infusion experiments with epinephrine (van Sickle et al., 1966) and norepinephrine (Cardon and Mueller 1964) were performed without producing conclusive results.

Studies of the relation between birth rank and schizophrenia (or any other disorder of adults) have hitherto been based on the assumption that, for a null hypothesis, cases will be randomly distributed among the birth ranks. In other words, if the distribution of cases is found to depart significantly from random (i.e. from equal numbers in each birth rank for each sibship size) then an association between birth rank and the disorder is held to have been demonstrated. However, we have recently shown, both from theoretical considerations (Price and Hare, 1969) and from the study of a large sample of psychiatric patients (Hare and Price, 1969b), that birth-rank distribution may depart very significantly from random because of bias arising from changes in the birth rate of the general population. The amount and direction of this bias will depend both on the changes in family size and on the number of families being started during the period of time when the patients (or any other population sample) and their siblings were born. The amount of bias is thus likely to be different in geographically different populations or in the same population at different periods of time.

Reaction to the death of a closely related person is characterized by a period of shocked disbelief, a period of acceptance and suffering, during which time the libidinal attachment to the internalized object is gradually withdrawn, and a prolonged period of readjustment. The first two phases usually last a number of months and correspond to the state of acute grief described by Lindemann (1944), Wretmark (1959) and Parkes (1965). The third phase involves the adjustment to a life without the lost person and in some individuals may persist for a number of years.

Lithium was first successfully used in the treatment of mania by Cade (1949), and its efficacy in reducing mania was confirmed in double-blind trials by Schou et al. (1954) and Maggs (1963).