I have chosen as the subject for my Blake Marsh Lecture the influence of sex chromosome aberrations on intelligence, mental health and social adjustment. This subject provides a fascinating example of how a branch of research, beginning in the field of mental retardation, arrived at discoveries which proved to be of significance to quite other fields of psychiatry. Ten years ago we learned that sex-chromatin-positive males, that is, males with additional X chromosomes, at least in some cell lines, were more often encountered among the intellectually retarded than among the average population of males. Shortly after this we learned that the same was true of women with double Barr bodies, that is, women with more than the usual two X chromosomes, at least in some cell lines. Today we have facts showing that an abnormal sex chromosome complement may have an unfavourable effect on mental health, and this in several different ways; thus we know that it may contribute to the development of functional psychoses, and may even influence such a complex variable of behaviour as our ability to adapt ourselves to the laws of the community. Myself, I am convinced that study of aberrations in the sex chromosomes will prove to have a radical effect on large sections of psychiatric thinking.

The present study is a preliminary report of the frequency and type of criminality in men with Klinefelter's syndrome and the XYY syndrome; it has been made on the background of previous findings of a comparatively high frequency of criminality among such patients.

Early workers studying children because of persistent delinquency concluded that the child's inability to make relationships was the central core from which all other behaviour disturbances arose. The long term effects of institutionalization and repeated moves from foster mother to foster mother, it was asserted, were basic in any consideration of aetiology. The difficulty of treating these patients and the permanency of ill-effects was emphasized. In his well-known World Health Organization Bulletin, Bowlby (1951) concluded ‘on the basis of this varied evidence it appears that there is a very strong case indeed for believing that prolonged separation of a child from his mother (or mother substitute) during the first five years of life stands foremost amongst the causes of delinquent character development’. Whilst the practical conclusions of this publication led to a remarkable change in outlook and improvement in the institutional care of children, his theoretical conclusions have drawn heavy fire. Andry (1960) directed attention to the ‘defective role frequently played by the father and not only that of the all-too-often mentioned mother’. Wootton (1959, 1962) regards as an unproven hypothesis ‘that maternal deprivation leads to life-long damage and is a major factor in criminal behaviour’. She argues that Bowlby has overstated the case for the separation experience itself, without due regard to the conditions the child has come from or goes to, and has given scant recognition to hereditary factors. Wootton notes that relatively few investigations have traced the fortunes of the maternally deprived after adolescence, let alone throughout life, and hence there is no definitive proof that the damaging effects of the separation experience are irreversible. Further, the maternal separation hypothesis relates to only a minority of the delinquent population (the ‘affectless psychopath’) and there is no experience of the general population at large of comparable infantile experiences. A review of the recent literature (Lancet, 1966, British Medical Journal, 1967), indicates that various investigations into the long term effects of childhood parental deprivation and bereavement in the causation of adult mental ill health and behaviour disturbance have yielded inconclusive results. Whilst this state of affairs suggests that further studies are necessary to detect consistent patterns of parental deprivation, these patterns by themselves may not indicate precise modes of aetiology, but when taken into consideration with other objective data of family background may yield the development or refutation of hypotheses regarding various determinants of psychiatric disorder. In the light of these contemporary uncertainties we have re-examined the hypothesis that early adverse experiences are related to subsequent delinquency and criminality. By statistical procedures we examined two prison populations, one consisting of short term male first offenders of less serious crime, and the other of male recidivists and those convicted of serious crime. Various groups from the general population at large have been incorporated to act as the control group.

In the context of Scots urban crime patterns, territorial and indiscriminate, considerable emphasis has currently been placed on physical environment. Although the opinions of magistrates, social workers and various celebrities have been freely forthcoming, a systematic study of the young Glasgow offender's view of his physical and emotional background has been singularly absent. Investigators in the past have attempted to show that when housing is improved, social problems such as delinquency automatically decrease; yet, as early as 1939 Wood commented that it was a popular fallacy that substandard housing was the direct cause of delinquency and crime and that its elimination would result in a crimeless world.

Introduction The therapeutic community method of treatment was developed by Maxwell Jones at Belmont Hospital (Jones et al., 1952; Jones, 1954; Rapoport, 1960) for the treatment of psychopathic personalities. The method has been applied to an admission unit by Wilmer (1958) and to psychopathic personalities by Craft (1965). Clark (1964) has differentiated between ‘the therapeutic community approach’, of increased activity, freedom and responsibility for all patients in the hospital, and the ‘therapeutic community proper’, the small unit with face-to-face gatherings of all members, social analysis of events, opening of communications, flattening of the authority pyramid and blurring of roles.

There is a body of opinion which regards psychiatrically ill individuals, or at least one great class or subdivision of them, as suffering primarily from disturbances in personal relationships and social interaction processes generally. Sullivan, Horney and Fromm have made the most significant theoretical contributions to this subject, and empirical applications have been reported by Balint (1957), Maxwell Jones (1968), Rapoport (1960) and Laing (1961). These writers have at least this in common, that they take the point of view that since the pathology of the illness lies in social relationships the fundamental treatment process must lie there also—must, in fact, consist of re-experiencing social interaction within a therapeutic re-educative framework. In the past attention has been directed principally to the doctor-patient relationship as a heuristic model of social interaction, but Rapoport has extended the operational range of significant interaction to include all staff-patient, staff-staff and patient-patient encounters. As the recent Subcommittee of the Central Health Services Council has pointed out (1968), little has been written of the nurse as therapist, but a considerable literature has accumulated concerning the role of the social worker or caseworker or counsellor (e.g. Halmos, 1965). Halmos investigates the nature of such relationships, and finds therapeutic utility to be unrelated to intellectual skills. The therapeutic process is adjudged to lie in the relationship, true enough, but the essential qualities have more to do with the interpersonal styles of the therapist, than with his analytical expertise. Such is his conclusion. Apparently social skills are necessary for the professional worker, but intellectual skills for the problems to be unravelled are of little importance, and are largely irrelevant.

In recent years research workers have shown a relative lack of interest in the constitutional correlates of normal personality. However, recent findings in the field of psychosomatic medicine suggest the need for a careful reexamination of this field of research. Several studies have indicated that breast cancer, lung cancer, and myocardial infarction patients are more extraverted and less neurotic than hospital control group patients (Eysenck, 1965). Also, duodenal ulcer patients have been reported as being both introverted and neurotic (Kanter and Hazelton, 1964).

A proportion of individuals suffering from schizophrenia show either physical or psychological signs of gonadal underfunction or incomplete sexual maturation (Hoskins, 1943; Hoskins and Pincus, 1949; Bleuler, 1954; Sands, 1957; Reiss, 1958; cf. Shader and Grinspoon, 1967). Rey and Coppen (1959) reported significantly lower, that is more feminine, androgyny scores (Tanner, 1962) in schizophrenic patients, although reduced scores were also found to a lesser extent in depressive and neurotic patients. Sex chromosome anomalies were not found in those patients with abnormally low androgyny scores (Cowie, Coppen and Norman, 1960), and it is possible that the abnormal physique is caused by some hormonal malfunction during development which also may be associated with a predisposition to psychiatric illness.

Pollin, Cardon and Kety (18) investigated the effects of large doses of various amino acids in combination with a monoamine oxidase (MAO) inhibitor on the behaviour of schizophrenics. They found that methionine in the presence of such an inhibitor was capable of producing behavioural changes which may ‘represent a biochemically induced acute flare-up of a chronic schizophrenic process on the one hand, or a toxic delirium superimposed upon chronic schizophrenia on the other’. Brune and Himwich (8) confirmed the clinical results of Pollin et al. On the basis of their previous work indicating that tryptamine appeared in increased concentrations in the urine before and during the activation of psychotic symptoms, they suggested that under loading conditions the formation of various N,N-dimethylated indoleamines might be facilitated in the body. The tertiary indoleamines so formed might mediate the psychotic effect of methionine with a MAO inhibitor on schizophrenic patients.

The clinical concept of the negative therapeutic reaction has been included in this series for a number of reasons. It is a concept of particular importance in the history of psychoanalysis, for it represents the clinical phenomenon chosen by Freud (1923) to illustrate the workings of an ‘unconscious sense of guilt’ and to indicate the existence of what he conceived of as a special mental agency—the superego. Moreover, it is a concept widely used in clinical psychoanalysis, although little has been written on the subject since Freud's original formulation of it. Unlike such concepts as transference (Sandler, Dare and Holder, 1970) and acting out (Sandler, Holder and Dare, 1970a) it has not been extensively applied outside clinical psychoanalysis. This may be regarded as surprising in view of the fact that it would seem to be readily capable of application without alteration to a wide variety of clinical situations.

Primary affective disorders, depressive or manic episodes in patients who have been psychiatrically well previously, or who have had episodes of mania or depression without other psychiatric illnesses (Robins and Guze, 1969), are associated with high suicide rates. The following data indicate that the suicide risk among these patients is over thirty times greater than that of the population without these disorders, and that the risk of suicide compared to other causes of death may be increased early in the course of the illness.

Introduction Much has been written in the last ten years on the deleterious effects of high doses of amphetamine drugs on brain function. The majority of published cases of amphetamine psychosis have been cases of addiction or illicit drug taking, thereby making a good premorbid personality questionable and unlikely. Amphetamine psychoses and their association with delinquency was the subject of a paper by Scott and Willcox (1965).

Introduction Obsessional neurosis is considered to be resistant to behaviour therapy; the literature is reviewed by Marks et al. (1969). Wolpe and Lazarus (1966) described a ‘thought-stopping’ technique for this condition, but subsequent workers have largely ignored this method. In the case to be described, it was used experimentally with apparent success, and in view of the therapeutic nihilism felt about obsessional neurosis it was thought worthwhile to report this long-standing and previously resistant case.

In recent studies in alcoholism where systematic desensitization of social anxiety has been used, it would appear that there are many changes in the total behaviour of the patient, as well as the removal of the need for excessive alcohol (Kraft, 1968). This paper aims at evaluating the changes which occurred in nine patients treated in this way, as shown in a variety of psychometric tests. Although the small size of the sample limits the scope of the study, it is hoped that the information might be of use to further investigators in this field.

Many text-books of psychiatry include an inquiry about a history of nail-biting in their scheme of history taking, and if nail-biting is noted when a patient is examined it is often recorded.

Unilateral E.C.T. applied to the non-dominant hemisphere has been tried by several workers in cases of depressive illness. Although Levy (1968) has pointed out that the evidence is not sufficient to recommend unilateral E.C.T. as a routine procedure, its main advantages over bilateral E.C.T. have been demonstrated as reduction of post-E.C.T. memory disturbances (Zinkin and Birtchnell 1968 and Valentine et al., 1968), and diminution of post-E.C.T. confusion (Halliday et al., 1968). The present investigation studies the effect of unilateral E.C.T. on schizophrenic delusions and hallucinations with a view to testing the hypothesis that the apparent superiority represented by the diminished side-effects with the unilateral technique might be therapeutically disadvantageous where treatment of patients with delusions and hallucinations is concerned. According to this hypothesis memory impairment may be part of the therapeutic mechanism responsible for the disruption of delusions and hallucinations and their ultimate amelioration or disappearance. If this hypothesis is correct patients treated with bilateral E.C.T. should do better than those treated with the unilateral technique.