Human consciousness includes the dimension of time: As history it reaches back into the past, and as prediction it gropes towards the future. Knowledge of the future must have been felt as a necessity as long as the human mind has existed, and the need for such knowledge was being met on a high level of organization even before culture reached a written stage. Prophets came before authors. At one time prophecy was more important than history because it was nourished by the ancient and powerful mental force of anxiety, anxiety in its true psychiatric form as fear of the unknown.

Until quite recently the prestige of Science was enormous, and in its glow basked innumerable earnest workers who firmly believed that their meticulous ant-like activities were advancing the health, wealth, welfare and spiritual ascent of man. In the last few years that prestige has quite suddenly collapsed. We do not deny the loftiness of aim which inspired our forerunners, but we have begun to realize that the secondary consequences of the most nobly motivated activities may lead to disaster. The main consequence of the advance of scientific knowledge has been the proliferation of technologies which have armed and powered a materialistic culture in the exploitation and progressive erosion of a fragile living environment. The scientist of an earlier generation had some notion of seeking after an aspect of the truth, and relied in the main on his own insights and ingenuity. Today, all too often, he knows himself for an expendable member of a professional team, depending on the routine deployment of technical resources for the manipulation of an established paradigm.

The purpose of this communication is to present a group of patients who, while receiving treatment with one of the phenothiazine derivatives in average range of doses regarded as suitable for adults, developed a syndrome comprising mutism and a number of other neurological features. In the majority of these patients speech loss is almost complete; but, unlike aphasics, they may respond to repeated questioning by simple utterances usually spoken in a whisper, or else are capable on rare occasions, quite unexpectedly, of delivering remarks which are appropriate and may be spoken normally. Speech deprivation is as a rule associated with an inability to communicate either by gestures or writing and also an inability to perform many customary tasks. Mutism is, therefore, not an isolated disability, but is associated with a wide range of disturbances of behaviour and of level of consciousness. In addition, some of the patients exhibit one or more of the neurological toxic phenomena encountered in the course of medication with phenothiazine derivatives, e.g. akathisia, buccal dyskinesias, dystonias, tremor and parkinsonism.

Although accounts of neurological complications resulting from the use of neuroleptic drugs have consistently appeared in the psychiatric literature since the introduction of reserpine in the 1930's, serious concern about the permanence of these effects has been a rather recent development. As early as 1956, reports by Ey, Faure, and Rappard (10) and by Hall, Jackson, and Swain (13) called attention to the persistence of extrapyramidal symptoms several months after the cessation of extended chlorpromazine treatment. Emphasis on the persistence of dyskinetic symptoms after extended treatment subsequently appeared in reports by Broussolle and Rosier (2), Sigwald, Bouttier, and Courvoisier (20), and Ayd (1). In a survey of reversible and irreversible dyskinesia after treatment with reserpine, chlorpromazine, perphenazine and electroconvulsive therapy, Uhrbrand and Faurbye (22) noted the late appearance of the complication and termed it ‘tardive dyskinesia’.

Greiner and Nicolson (1965) put forward the hypothesis that schizophrenia was associated with a state of increased melanogenesis which they attributed to a biochemical defect in the pineal gland. Isolated literature reports had documented the occurrence of hyperpigmentation in schizophrenia. These observations might be relevant, as the neurone and melanocyte have common features: both are ultimately derived from the neural plate; both require tyrosine as precursor in the biosynthesis of their specific products (catecholamines and melanin respectively); and many neurocutaneous diseases show coexistent neuropsychiatric and pigmentary disorder.

In recent years a number of new hypnotics have been introduced which are claimed to give a more natural sleep than barbiturates, and to be free from the dangers of addiction and of respiratory depression when taken in overdosage. Among these drugs is methaqualone, which is used either on its own (Melsed), or in combination with the antihistamine diphenhydramine hydrochloride (Mandrax).

UK 3557 is a new indoline derivative with antidepressant properties (Canas-Rodriguez, 1969), and the following formula:

In considering the cost of different forms of care for patients with mental deficiency there is a tendency to compare crude averages. Mental deficiency has many manifestations and occurs in people of widely differing degrees of physical ability and behaviour so that comparisons which do not take this into account are not meaningful. An attempt has been made to assess the cost of hospital care for different groups of patients and to show that there is a wide variation in the costs which arc normally expressed as an average. This average is often used to compare with the expenditure, say, in a hostel, when in fact those patients suitable for hostel care are at the lower end of the cost range. Again, whilst everyone would like to see patients dealt with in small groups, the extra cost this would involve is often overlooked. The analysis presented helps to clarify points such as these.

It is accepted as professionally unethical for doctors and nurses to be influenced by their (negative or positive) feelings in their behaviour towards patients. ‘Emotional involvement’ with patients, though seldom defined, is usually sternly discouraged during medical and nursing training. As a result many graduates deny not only that they are influenced by their feelings towards their patients but even that they have any feelings at all.

The psychiatric services in the field of community psychiatry in Israel have developed in a number of directions over the past decade. Following the establishment by the Workers' Sick Fund (Kupat Holim) of a Rehabilitation Unit for chronic psychiatric patients (Wijsenbeek and Lindner (53)) and the opening of a Day Hospital for acute cases in conjunction with a psychiatric hospital (Ramot and Jaffe (45)), a Day Hospital was established in October 1968, at the Out-Patient Mental Health Clinic (Ramat Chen), to serve acute psychiatric patients. This represented the first attempt of its kind in Israel. The professional literature on Day Hospitals, which in the main describes a ‘half-way out’ type of hospital (Farndale (16); Epps and Hanes (14); Kramer (32)), also reports the existence of a ‘half-way in’ type of institution, operating as an autonomous service catering to a particular geographical region, without being attached directly to a mental hospital. This kind of Day Hospital, specifically designed for acute cases, has not yet been tried in Israel.

An account is given of an active treatment programme at a Canadian Provincial Mental Hospital. This programme was designed to reintegrate institutionalized patients, mainly schizophrenics, into the community.

In a previous report records were studied of 256 in-patients who were discharged as undiagnosed, i.e. in-patients who at the time of discharge did not have a definable psychiatric illness (Welner, Liss, Robins and Richardson, 1972). In that study it was shown that when rigorous criteria for psychiatric research (Feighner, Robins, Guze, Woodruff, Winokur and Munoz, 1972) were used 68 per cent of these patients met the criteria for an established psychiatric disorder. It was concluded that: (1) The chart review diagnoses for a population of undiagnosed patients consisted of a variety of established psychiatric disorders and the population was not homogeneous. (The chart review diagnosis is a diagnosis obtained by review of the patients' hospital records and evaluating the information by using diagnostic criteria for psychiatric disorders.) (2) The most efficient way to arrive at a diagnosis was by structured rather than conventional narrative interview. This study is a follow-up study of these patients and attempts to evaluate the validity of the chart review diagnosis. A concordance between the chart review diagnosis and follow-up diagnosis supports the above conclusions. The follow-up study also served to establish diagnosis in patients who had too few symptoms initially to meet the criteria for a diagnosis.

The diagnosis of hysteria has seemed a hazardous one since Slater (1965) pronounced it ‘not only a delusion but also a snare’. His conclusion was based on the demonstrable fragility of the diagnosis when usually accepted criteria are used. Against this, Guze (1967) has put forward evidence which suggests that when his criteria are applied the diagnosis is a stable one. Lader and Sartorius (1968), in a study of 10 patients, also seemed to show that those with conversion hysteria were a single group on the criterion of their failure to habituate to 20 repetitions of a standard stimulus, a disability which distinguished them from other neurotic groups. Slater, however, in criticizing the Perley and Guze (1962) concept, remarked that two residual groups, rather than one, remained as diagnostically unchanged in his 10-year follow-up.

Notwithstanding Hamilton's remark that childbirth is responsible for a great deal of neurotic illness, the literature is heavily weighted in favour of studies of puerperal psychosis, even though this condition occurs in only one in a thousand births. Since the milder forms of illness tend to pass unrecognized they are often responsible for stress in the individual and family; thus it is right and proper that more attention has recently been paid to these. Pitt (1968), for example, found an incidence of 10–17 per cent of atypical depression and psychosomatic illness that persisted for several weeks and in some cases for as long as one year following childbirth. Between normality and psychotic or neurotic illness lies the mild affective disorder that so often characterizes pregnancy and the early Puerperium, but does not amount to an ‘illness'. Perhaps because women regard it as an expected hazard from which they will recover it has not generally been considered to merit serious study. Jarrahi-Zadeh et al. (1969) looked at this and found that as many as 55 per cent had one or more depressive symptoms during pregnancy. If anything it was less common post-partum, and they furnished evidence for a brain syndrome of mild degree occurring at this time. Yalom et al. (1968) have described the post-partum blues syndrome as occurring in 66 per cent of their subjects and hold it to be a self-limiting condition of only a few days duration. It is likely that patients with the blues have a greater risk of developing a neurotic depression, which might reflect upon personality factors, but the same cannot be said to hold for post-partum psychosis.

This study has arisen out of the work of the Newcastle group (Kiloh and Garside, 1963; Kay et al., 1969) and that of the London group (Kendell, 1968) on the forms of depressive illness. In the present investigation, unlike those mentioned, a subjective approach was employed; that is, what the patients actually reported about themselves rather than a psychiatric appraisal of the patient was used as the data. A similar approach was employed by Pilowsky, Levine and Boulton (1969) in their taxonomic study of depression. The object of this paper is firstly, to investigate the systematic and the taxonomy of depressive phenomena; secondly to look at this taxonomy in depressive illness and non-depressive illness patients; and thirdly to investigate the psychiatrist's notion of the endogenous-reactive dichotomy within this taxonomy. Essentially the question is whether there is a continuum of depression, at one pole being reactive depression and at the other pole endogenous depression or whether these two classical diagnoses represent separate empirical entities. The former view is taken by the London workers and the latter by the Newcastle workers. In a recent review article, Eysenck (1970) favoured the binary or separate entity model, although he suggests that both views of depressive illness are over simplistic in their formulations.

Delusions of poisoning often dominate the clinical picture in schizophrenia. In an earlier publication (6) we have suggested that these cases may be phenomenologically distinct from other schizophrenics. Patients who believed they were poisoned or gassed reported more somatic symptoms, headaches, decreased visual acuity and disturbances of taste and smell.