Amark (1951, p. 154) discovered a high frequency of ixoid and ixothymic personality traits resembling those encountered among epileptics in a clinical material (49.5 per cent), and institutional material (38.0 per cent) and a material from the Temperance Board (37.1 per cent). Amark's description of these ‘epileptoid’ personality traits (1951, p. 151)) which also covers normal character variations, is fairly wide and includes a tendency to perseveration, adhesiveness, explosions or dysphoric states of dejection, querulousness and paranoid reactions. In a previous study (Kristianson, 1970, p. 173) it was suggested that Amark probably overestimated the frequencies of ixoid and ixothymic personalities, because alcoholics are so often explosive. But this quite unspecific pattern of behaviour is not sufficient for the diagnosis of ‘epileptoid’ traits, if this concept is to have a reasonable definition. Explosive aggressiveness is scarcely a primary personality trait, but is one of the symptoms of a deterioration in the chronic alcoholic's mental condition. However, it is important to differentiate these explosive aggressive reactions caused by chronic alcoholism from the adequately defined personality traits of epileptics. This problem of differentiation will be analysed in greater detail in this study.

Folie à deux, the psychosis of association, has been defined as ‘the transference of delusional ideas and/or abnormal behaviour from one person to one or more individuals who have been in close association with the primary affected person’ (8). At least three conditions have been regarded as pre-requisite for its diagnosis: (a) definite evidence that the partners have been intimately associated, (b) identical content of the delusional ideas in both the patients, and (c) unequivocal evidence that the partners share, support and accept each other's delusions (7).

Previous electroencephalographic studies of persons with sex chromosome aberrations have indicated that there might be more electroencephalographic aberrations in males with double Y and double X than in the general population. A survey of these studies has recently been made by Fenton et al. (1971).

While the beneficial effect of lysergic acid diethylamide (LSD) in the treatment of carefully selected patients as an adjunct to psychotherapy has been amply reported (Robinson et al., 1963), concern has been expressed regarding the damage to chromosomes in those taking the drug.

Surreptitious ingestion of anticoagulant drugs is a rare condition which presents as an obscure bleeding tendency associated with gross depletion of the vitamin K dependent factors (factors II, VII, IX and X). In all previously reported cases the patients have denied taking drugs but chemical analysis of the plasma has shown the presence of members of the coumarin or indanedione groups.

Psychiatrists, psychologists, and nursing staff are increasingly making direct observations and ratings of ward behaviour. Characteristically, a nurse may be asked to complete a multi-item rating scale on a group of patients during the course of a drug trial. Several factors are involved in the choice of an appropriate scale for a particular purpose. Among these factors are the number of points per item, which defines the sensitivity to change of the item, and the total number of items in the scale, which affects the time taken to complete the scale and hence the frequency of rating that can be permitted in an assessment schedule.

Variables measured before or during psychological treatment may be used in several related ways: as an empirical guide to prognosis with any given treatment, as a means of studying possible treatment mechanisms, or as a method of identifying which stage or process in treatment is associated with therapeutic change. Using data from the same patients already described in a recently published study (Gelder et al., 1973), questions of relevance to each of these areas will be examined in turn.

Sleep disorders are important diagnostic and therapeutic aspects of many common psychiatric syndromes. Clinicians have to be content with the patients' own assessment of their sleep patterns, or at the best, those of a night nurse; both methods are known to be unreliable, particularly where insomnia is present (Kuper et al., 1970). In a previous paper, Johnson and Kitching (1972) described a simple device for assessing the duration of sleep in ward situations. It depended upon the patient's ability to signal wakefulness by pressing a mechanical switch in response to an intermittent light stimulus throughout the night. This was considered to indicate a level of cerebral arousal compatible with wakefulness: failure to respond to the light stimulus indicated that the patient's level of cerebral arousal was lowered to the level of ‘sleep‘. A number of objections were anticipated, however, which might invalidate these assumptions. Most important of these were:

1. (i) The intermittent occurrence of the light stimulus, every 15–20 minutes, limits the device to an approximation of the duration of sleep. The system of scoring was to assume a period of 10 minutes of sleep on either side of a missed stimulus.

2. (ii) The possibility that the patient could press the mechanical switch in response to the light stimulus whilst in Stage I or even Stage II of sleep (Rechtschaffen et al., 1968) without returning to wakefulness.

3. (iii) The intermittent light stimulus might itself act as a disruptive stimulus to sleep, producing arousal and thus altering the sleep level.

Peripheral whole blood uridine diphosphate glucose (UDPG) has been found to be significantly elevated in psychotic depression (Hansen, 1969; 1972a, b), and this was related to an equally significant lowering of whole blood adenosine triphosphate (ATP). Addition to healthy human blood of UDPG accelerated the hydrolysis of ATP in vitro (Hansen, 1972a), and UDPG concentration dependently enhanced the activity of a vegetable ATP di-phosphohydrolase (EC 3.6.1.5), which was also inhibited by adenosine 3’, 5′-cyclic monophosphate (cyclic AMP) in a concentration-dependent manner (Hansen, 1972b). Other workers have recently published a similar inhibition of a rat heart ATPase by cyclic AMP (Dietze and Hepp, 1972), and another research group have found that sodium-potassium exchange pump changes and changes in erythrocyte membrane ATPase activity correlate significantly with mood alterations in psychotic depressive patients (Dick, Dick, Le Poidevin and Naylor, 1972; Naylor, Dick, Dick, Le Poidevin and Whyte, 1973). This paper reports a study of the relationship between blood ATP levels and mood in patients suffering from manic-depressive predictable (Jenner, 1971) short term cycle psychotic states, and in depressive patients receiving electroconvulsive treatment.

Changes in the excretion of adenosine 3’:5′-cyclic monophosphate (cyclic AMP) have been reported in depressive illness. Abdulla and Hamadah (1970) reported that urinary cyclic AMP excretion was lower than normal during depression and increased with recovery. However, these results were based on single 24-hour urine collections during depression and on recovery, with no creatinine estimations to suggest that the collections were complete. There was no control of diet, drugs or activity. The controls do not appear to have been matched for age. Paul, Ditzion, Pauk and Janowsky (1970) reported that the cyclic AMP excretion in neurotic depression was higher and in psychotic depression was lower than in a control group, but neither difference was statistically significant. However, on enlarging the study by including more psychotic depressives they reported that the cyclic AMP excretion of this group was significantly less than that of the controls (Paul, Cramer and Goodwin, 1971). These workers had controlled the patients' drug and dietary (but not fluid) intake. There appeared to be only minimal control of activity. The results were based on approximately two samples of urine per subject, which were very carefully checked for completeness of collection. Unfortunately the age of the controls (19–22 years) was very different from that of the patients (25–64 years). On two small groups of patients treated with either Laevodopa or lithium carbonate, they reported that changes in affective state were accompanied by changes in the urinary excretion of cyclic AMP. However, in serial studies on manic-depressive patients Paul, Cramer and Bunney (1971) failed to show a correlation between mood rating and cyclic AMP excretion in five out of seven patients; but they reported that the cyclic AMP excretion was increased on the day of rapid switch from depression to mania. The above groups of workers had used an enzymatic-isotope displacement technique to estimate the cyclic AMP. Brown, Salway, Albano, Hullin and Ekins (1972), using a saturation method to assay cyclic AMP, found no correlation between mood and cyclic AMP excretion in two short-cycle manic-depressive patients. Jenner, Sampson, Thompson, Somerville, Beard and Smith (1972) wrote: ‘We have measured daily excretion by a number of depressed and manic depressive patients over periods covering several mood changes without being able to establish any consistent correlation between cyclic AMP excretion and mood, … However, in one unusual case we have found a very marked correlation‘. We (Naylor, Dick, Dick, Moody and Stansfield, 1974) were unable to demonstrate any relationship between urinary cyclic AMP excretion and mood in a patient with recurrent psychotic episodes, in which depressive features predominated.

The enzyme creatine kinase (CK) is present in high concentration in skeletal and cardíac muscle and brain tissue (Dawson and Fine, 1967). Raised serum levels of the enzyme occur in skeletal muscle disease, following myocardial infarction and in hypothyroidism. Raised levels have also been demonstrated in acute cerebral disease (Acheson et al., 1965), but earlier suggestions that this might be due to leakage of enzyme from brain tissue have not been confirmed by isoenzyme separation studies (Dubo et al., 1967), which have shown that the excess enzyme came from striated muscle. Raised serum CK levels associated with acute psychosis have also been reported (Bengzon et al., 1966; Meitzer et al., 1969; Coffey et al., 1970; and Gosling et al., 1972). This has led to the suggestion that serum CK estimation could be used in the differential diagnosis of psychiatric patients (Meltzer et al., 1970; Gosling et al., 1972). Meitzer (1969) has also claimed that the biochemical abnormality reflects ‘a basic patho-physiological process common to the acute psychoses'.

It is over a year since the conference on ‘The Responsibilities and Role of the Doctor in the Care of the Mentally Handicapped’ was held, at which Sir George Godber delivered the opening address published in the Journal for December 1973 (pp. 617–20).

Several surveys of mental illness in husband-wife pairs have all concluded that sick couples occur in the general population with a frequency significantly in excess of the number to be expected by chance (Penrose, 1944; Gregory, 1959; Kreitman, 1962; Ryle and Hamilton, 1962; Pond et al., 1963; Nielsen, 1964). The statistical methods employed in such investigations have been criticized by Hall et al. (1971), but these authors' arguments appear to suggest that the relative excess of conjoint illness has, if anything, been under-estimated.

Postgraduate teaching in psychiatry has always been a function of the provincial mental hospitals, but nothing before has equalled the expansion of theoretical teaching which has taken place over the past ten years. At the heart of the training of a psychiatrist, however, there is the National Health Service job with its own demands, where the practical clinical skills are acquired. The job has not changed much, even though the arrangements for theoretical instruction have improved. Yet changes may be possible which will make the registrar's job more efficient as an educational experience by removing the unsystematic and random elements.

Drugs have been used to control deviant sexual behaviour in recidivist sexual offenders for over 20 years. Oestrogens have been most widely used (Golla and Hodge, 1949; Whittaker, 1959; Scott, 1964) and generally have been considered to be effective though limited by their side effects, in particular nausea, vomiting and feminization. A further uncommon but grave complication has been carcinoma of the breast (Symmers, 1968). Recently, oestradiol implants have been used (Field and Williams, 1970). A similar libido-reducing effect has been claimed with some tranquillizers, notably thioridazine (Litkey and Feniczy, 1967; Bartholomew, 1964), fluphenazine enanthate (Bartholomew, 1964) and a new butyrophenone, benperidol (Sterkmans and Geerts, 1966; Field, 1973). Progestogens have been recognized for some time as having libido reducing qualities in both males and females (Heller et al., 1958; Kupperman, 1963; Money, 1970). The use of medroxyprogesterone in treating sexual deviants has recently been reported (Money, 1970); it was found not only to be effective in controlling behaviour but also to produce marked reduction in circulating androgen. Currently, much interest is being shown in the use of an anti-androgen, cyproterone acetate, for this purpose (Laschet and Laschet, 1969; Briggs and Briggs, 1971; Cooper et al., 1972).