“When man experiences that certain sequences of mental events lead to behavior which has, as a matter of fact, survival value, he calls such mental facts ‘right’. It would be better, however, if instead of this word some neutral symbol were being used for those particular events; because the word ‘right’ leads to the unfortunate notion that some combinations of mental facts are intrinsically better than others. …”

It is twenty years since the appearance of Stoll's paper: “Lysergic acid diethylamide, a hallucinatory agent of the ergot group” (23). In this he sought to reproduce in a group of subjects Hofmann's personal experiences of the drug, and so set the LSD snowball on its way. Some 1,500 papers must by now have been gathered to it; they deal with a greater range of uses than has been thought of for any drug, a greater variety of benefits and disasters, and a confusing number of claims. Yet we have little hard information about this curious substance.

An attempt is reported here to evaluate the results of a modified form of leucotomy. Subjects of the investigation were 64 consecutively operated patients, for all of whom the same technique of bimedial leucotomy was employed. This operation is similar to the full division of white matter (as described by Poppen, 1948) through a superior frontal approach, but the cut is limited to the medial 2 cm. (Greenblatt and Solomon, 1952). The operation is carried out under direct vision through two 4 cm. trephine openings placed immediately anterior to the coronal suture on either side of the midline. The plane of the cut is found with a brain needle and extends from the middle of the trephine opening (2 cm. in front of the coronal suture) to the line of the sphenoidal ridge. The white matter is cut with a metal sucker for a width of about 2 cm. subjacent to grey matter medially and inferiorly. The incision skirts the front of the lateral ventricles and divides the thalamo-frontal bundle, thereby isolating the cortex of the frontal pole and also interfering with the fibres to the remaining anterior prefrontal areas which lie in the midcentral segment of white matter. This cut does not necessarily extend sufficiently far back to interfere with all the fibres related to area 13, but is free from the disadvantages of misplacement into the septal area.

Since 1952 over 200 patients have been treated in the Guy's-Maudsley Neurosurgical Unit for intractable temporal lobe epilepsy by anterior temporal lobectomy. Each case has been evaluated before and after operation by a neurosurgeon, psychiatrists, and psychologists. Electroencephalography and air encephalography have been routine and the operative technique standardized. The resected portion has been removed in one piece allowing detailed pathological examination. The results in terms of relief of seizures, effects on personality, effects on psychological test scores, and the pathological findings have been reported at intervals (Hill, Pond, Mitchell and Falconer, 1957; Falconer and Serafetinides, 1963; Falconer, Serafetinides and Corsellis, 1964).

Although systematic desensitization has been used for a decade in the treatment of phobias, its mode of action is not yet fully understood. During treatment by desensitization patients are relaxed while they are asked to visualize situations which evoke progressively more fear. Desensitization is given in the context of routine psychiatric management, and it is obvious that many variables may contribute to the overall effect of treatment. Among those which it is important to examine are: exposure, i.e. visualization of the imagined phobic stimulus without relaxation; relaxation without presentation of phobic images; densensitization, i.e. the pairing of the graded imagined phobic stimuli with relaxation; repeated suggestion of improvement; the relationship to the therapist, and finally the many non-specific effects of routine hospital care.

Disturbance of functions controlled by the autonomic nervous system may be due to changes in the emotional state, and are part of normal reactions to stress. Their general occurrence is reflected in phrases like “it makes me sick” and “to sweat with fear”. In some groups of people these autonomic disturbances are not confined to stressful situations but become more general and frequent and so more disabling. For instance, in patients with affective illnesses, symptoms of autonomic origin are common and are relieved by successful treatment of the underlying illness. Again, there is a group of patients who complain of these symptoms but who show little affective disorder. In these patients the autonomic symptoms are provoked by specific situations which are not particularly stressful to normal people, e.g. nausea occurs when eating in company or diarrhoea when travelling; outside these specific situations symptoms do not occur. Although these patients may complain of some anxiety, the physical symptom is the major complaint and the anxiety is often attributed to this.

The majority of controlled trials of imipramine against placebo in the treatment of depression have indicated the general efficacy of the drug (9). Recently there has been renewed interest in the use of the phenothiazines in depression, and the question has been raised as to how far the actions of the imipramine-like drugs and of the phenothiazines can be differentiated. Structurally, the iminodibenzyl nucleus of imipramine closely resembles the phenothiazine nucleus, the only difference being replacement of the sulphur atom bridging the two benzyl rings in the latter by a CH2–CH2 group in the iminodibenzyl nucleus. Two controlled trials have suggested that in depressed patients the phenothiazines may be more valuable than has been previously realized and similar in overall efficacy to imipramine. Fink et al. (3) found both chlorpromazine and imipramine significantly better than placebo in the treatment of depressives, with only minor and insignificant differences between them. Similarly, in a relatively large collaborative trial, Overall et al. (11) found thioridazine as effective as imipramine. These authors subsequently employed a special statistical classification technique to stratify their patients into three subtypes according to initial symptom profiles (8). With respect to a variety of symptom ratings, this stratification revealed significant differences in drug effects. Imipramine proved superior in “retarded” depressives and thioridazine in “anxious” depressives, while no differences were found in “hostile” depressives.

It is now widely accepted that tricyclic compounds are of value in a proportion of depressed patients and that drugs of the imipramine group can take four or more weeks to exert their effect (Moody et al., 1967). There is a temptation to assume that one must wait this period before assessing response and that this is necessarily the best time for predicting the ultimate outcome of treatment. In experience with amitriptyline and nortriptyline both authors gained the impression that patients who were going to respond well were already a clinically distinct group after two weeks' exhibition of the drug, and indeed that waiting till four weeks blurred the distinction because by then poor responders might also have improved. It was decided to test this impression further.

Most of the investigators to date have been comparing desipramine with imipramine, and little work has been published on comparative studies of the demethylated compounds of imipramine and amitriptyline, i.e. desipramine and nortriptyline. Arieff (1966) conducted a clinical study, but did not find any difference between the two drugs, and stated “However, the improvement was never as striking or as rapid as when imipramine or amitriptyline was effective.” Steward and Mitchell (1966) in a double-blind controlled study also found no difference between the two drugs.

The literature on involutional psychiatric disorder, as on depressive diagnoses in general, is quite controversial. Since middle-aged women form a significant proportion of medical as well as psychiatric patients, it would seem useful to examine diagnoses within this group.

While the importance of psychological factors in attempted suicide has long been acknowledged, the use of standardized psychological techniques has been neglected. The paper by Vinoda (1966) is the first in Britain to describe the personality characteristics of attempted suicides using a battery of objective tests. She tested and compared a group of female attempted suicides, who had been admitted to the psychiatric ward of a general hospital, with a group of psychiatric patients and a group of non-psychiatric patients from the same hospital. Where differences on testing occurred it was usually the case that the attempted suicide and psychiatric groups were discriminated from the normal controls but not from each other.

Investigations of schizophrenia have shown that the presence or absence of primary paranoid delusions is correlated with differences in dealing with information from the environment (Venables, 1964; Silverman, 1964) which may well relate to stable personality characteristics. Claridge (1967) has recently proposed a psycho-physiological model in which it is hypothesized that paranoid schizophrenics are more sympathetically reactive, but show lower levels of cortical modulation of subcortical functions than non-paranoid schizophrenics. At the descriptive level of behaviour, this theory would predict greater emotionality (neuroticism) and extraversion in the former group, and this proposition was examined in a sample of psychiatric offenders. Since aggressive behaviour is prominent in this population, it was also predicted from Claridge's theory that the paranoids would more frequently have a history of aggressive behaviour and would show higher attitudinal hostility. However, since extreme (i.e. homicidal) aggression appears to occur in individuals who are not characteristically aggressive (Megargee, 1966), it was predicted that such offences would be more frequent among the non-paranoid schizophrenics.

Behaviour therapy is based on the principles of learning theory, and assumes that neurotic behaviour consists of learned maladaptive habits. Following the work of Pavlov (1927) with experimental neuroses, and that of Watson (1920) on the elimination of children's fears, Wolpe (1958) devised a method suitable for treating patients with phobias. This involves deconditioning with the aid of reciprocal inhibition. The patient is introduced to a graduated series of the relevant anxiety provoking stimuli, and at the same time the anxiety responses are inhibited by means of relaxation. The latter state may be induced by hypnosis, Jacobson's method (1938), or by drugs.

The rehabilitation of disabled mental hospital in-patients depends on changing the structure of the hospital itself. Remunerative and realistic employment plays an important part in this respect. Not only does it provide greater emotional satisfaction to the patients, it also enhances their status by changing their role from that of sick people to that of trainees in more normal habits of living and work. It is difficult to create an occupational programme which employs the large population of a hospital according to the patients' varying disabilities, inclinations and needs. It is unsatisfactory to provide occupation only for a small proportion of patients or for those who are easier to resettle. All patients (even those who do not appear disabled) need occupation designed to prevent incapacitating disabilities or to reduce their handicaps.