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Last December I received one of the most surprising letters of my life—an invitation to give the next Maudsley Lecture before this Association. I am deeply grateful for this honour, all the more so since I stand in considerable debt to the hospital which Henry Maudsley founded and which bears his name, having spent two fruitful years there as a research student.
Rapaport (1945) was the first worker to advance evidence that at least two types of formal thought disorder contributed to the disturbance of thinking found in schizophrenia; and furthermore that neither of these types of thinking was specific to schizophrenia. Rapaport administered the Bolles Goldstein Object Sorting Test to 217 psychiatric patients and to a control group of 54 patrolmen. He found that schizophrenics showed a tendency to function more at a concrete level and less at an abstract conceptual level, as described first by Vigotsky (1934). This tendency was also shown by depressives and by persons who were not mentally ill but had a poor cultural background.
Modern hypotheses as to the aetiology of schizophrenia are likely to be multifactorial and to include psychosocial factors. A typical aetiological hypothesis might propose that an “identity” crisis precipitated psychotic symptoms in an individual who was predisposed to schizophrenia; the predisposition could be due both to inherited biological factors and to abnormal personality traits caused by a faulty family environment or other social factors. Hypotheses such as these lead to the expectation that schizophrenia would be precipitated by psychological stress. However, statistical studies which have attempted to relate the onset of schizophrenia to psychological stress have not produced evidence consistent with such an expectation. For example, hospital admissions for psychosis were not increased in England during the blitz (10, 12, 13). Nor was a grossly increased rate of psychosis found in populations of concentration camp survivors (9, 16). Also, it has been claimed that the rate of psychosis was not increased by combat exposure among U.S. soldiers in World War II, whereas the rate of neurosis was clearly affected by combat exposure (6). Consistent with this last point it has been stated that the rate of hospitalization for psychosis in U.S. military personnel has remained relatively constant over the last 40 years apparently independent of war or peace (7, 1), whereas the rate of hospitalization for nonspsychotic disorders has fluctuated widely (7).
This paper has three separate yet interrelated aims. First, it sets out to describe a series of clinical phenomena and attempts to show that they arise from a common source. Secondly, the consideration of this data may possibly amplify statements which have been made in the past regarding the nature of mental activity. Thirdly, there seems reason to believe that some of the phenomena described may help to provide a more rigorous definition of the transference concept.
In 1962, Perley and Guze introduced objective criteria for the diagnosis of hysteria (Perley and Guze, 1962). These criteria were essentially a quantification of clinical observations which had appeared in the literature previously, notably in the work of Purtell, Robins and Cohen (1951). The Perley and Guze criteria for the diagnosis of hysteria offered several important advantages. First, they were derived from observations of the natural history of hysteria. They were straightforward and objective, suggesting that they could be used reliably by different clinicians in different places. Second, the criteria were accompanied by a follow-up study which indicated that diagnoses of hysteria made by means of the Perley-Guze criteria would be stable over a six to eight year period in 90 per cent. of cases. Put another way, these criteria selected a population homogeneous in prognosis. The stability of such a population over time is of particular importance. The original Perley-Guze paper and a further study by Gatfield and Guze (1962) both described the prognosis of patients selected by looser criteria. When conversion (pseudoneurologic) symptoms alone were the criteria of diagnosis, patients developed a bewildering array of psychiatric, medical and neurological illnesses within a few short years. In contrast, the Perley-Guze criteria for the diagnosis of hysteria predict prognosis accurately and represent a significant advance in descriptive, clinical psychiatry.
Since 1962, a series of studies have appeared in the psychiatric literature which define hysteria with increasing precision, differentiating that syndrome from the presence of conversion symptoms alone. Hysteria was described in a recognizable fashion more than a century ago by Briquet (1859). Some fifty years later, the syndrome was redescribed by Savill (1909). After a further period of nearly fifty years, Purtell, Robins and Cohen described hysteria as it occurred in a controlled series of patients (1951). Working from Purtell's clinical data, Perley and Guze introduced specific checklist criteria for the diagnosis of hysteria in 1962. These criteria defined a female population homogeneous in prognosis, a population to be distinguished from that defined by conversion symptoms alone. Conversion symptoms are seen in a variety of medical and psychiatric illnesses, and by themselves, conversion symptoms are of little prognostic value (Gatfield and Guze, 1962; Perley and Guze, 1962; Slater and Glithero, 1965).
In depressive illness disturbance of the sleep pattern is regarded as one of the most important and characteristic of the clinical features. It is commonly believed that the pattern of insomnia is typical or even diagnostic of certain affective disorders. Reactive depressions are said to cause a delayed onset of sleep and endogenous depressions to cause early waking.
In view of the increasing demand for paediatric psychiatric services a separate department of Child and Family Psychiatry was set up at Stratheden Hospital, Cupar, in 1958 to provide a comprehensive service in the County of Fifeshire, Scotland. The establishment consists of one consultant, one senior registrar, two registrars, three social workers and one psychologist. The department also has 12 beds to which children are admitted for psychiatric assessment and treatment. Out-patient clinics are held in general hospitals throughout the county and emergencies are seen both in the department and at out-patient clinics.
So far there has been a failure in psychiatry to establish any really adequate and universally accepted classificatory systems. This failure has proved a stumbling block to effective research, it has often frustrated communication and has held back the development of scientifically based treatment methods. Even now there still lingers some controversy over the appropriateness of the use of any classification in psychiatry (Kessell, 1964).
It is a common clinical observation that emotional disturbance can influence a patient's response to sedative drugs. In recent years these effects have been studied in both normal and emotionally ill subjects. Kornetsky and Humphries (1957) found that in ten healthy adults the response to small doses of secobarbital sodium correlated with the scores on the depression and psychasthenia scales of the MMPI. Von Felsinger et al. (1955), in a study of the effect of a variety of psychotropic drugs, including pentobarbitone, on “normal” subjects, observed that those who responded in an atypical fashion tended to have abnormal personalities and to suffer from depressive episodes. Beecher (1955) has pointed out that the degree of placebo effect on post-operative analgesia varies with the severity of the stress to which the patient is exposed.
The nutritional disturbance in anorexia nervosa almost invariably leads to striking physiological changes, which include amenorrhoea, bradycardia, hypotension and relative hypothermia with reversal of the usual diurnal temperature rhythm (Bliss and Branch, 1960; Mayer-Gross et al., 1960; Crisp and Roberts, 1962; Crisp, 1967a). Crisp (1965a, 1967a) has commented on the characteristic and excessive alertness, restlessness and insomnia displayed by anorexia nervosa patients, whom he regards as showing a specific type of malnutrition associated with carbohydrate starvation. Russell (1967) has also recently demonstrated that patients with this illness restrict especially their carbohydrate intake.
There is a large body of research that has established change in reaction time as one of the major psychological performance deficits in schizophrenia (Shakow, 1963). In addition to consistent differences between patients and normals, relationships have been reported (Rosenthal, Lawlor, Zahn and Shakow, 1960) between general severity of illness and reaction time within a group of chronic schizophrenics. More recently, Zahn and Rosenthal (1963) have shown that acute schizophrenics also perform deficiently in reaction time; they hold an intermediate position between normal subjects and chronic schizophrenic patients. Shakow (1963) reports that in some of the earlier work with chronic patients “paranoids” tended to show little, if any, reaction time deficit, but that it was the hebephrenic patients who performed poorly. Thus it seems unlikely that reaction time is a general measure of deficit in schizophrenia, since available evidence shows it to be related to chronicity (in terms of duration of illness), general severity of illness, and schizophrenic subtype. The deficit reflected in reaction time has been characterized by Shakow (1963) in terms of associative interference. That is, the schizophrenic is distracted by “irrelevant aspects of the stimulus surroundings—inner and outer—which prevent his focusing on the ‘to-be-responded-to’ stimulus”.
The observation of a higher incidence of sex-chromosome abnormalities amongst patients in mental deficiency and subnormality institutions than in the general population (Maclean et al., 1962; Court Brown et al., 1964) suggested that a sex chromatin survey of a theoretically related chronic psychotic population might be of interest. Mott (1919) observed a high frequency of testicular atrophy in dementia praecox, particularly in patients dying in early adolescence, and Forster (quoted by Mott, 1919) reported on the ovarian findings in similarly affected women. Hemphill et al. (1944) found a high incidence of testicular atrophy in a series of ninety male schizophrenic patients.
The demonstration of either the association of a genetic marker and primary affective disorder, or linkage between a genetic marker and primary affective disorder would provide incontrovertible evidence for a genetic factor in primary affective disorder. Disease association and linkage are two separate processes. Linkage is said to occur if two genes, each responsible for a separate trait, are on the same chromosome and are close enough together that they assort in a dependent fashion. In any single family the physical proximity of two genes on the same chromosome makes it likely that the characteristics of both genes will be found in a single individual. Association, on the other hand, occurs when two genetically separate traits have a non-random occurrence in a population. Association of a disease with a specific marker may occur fleetingly on the basis of linkage. This kind of association occurs only for a few generations, so that when enough generations have passed and enough crossing over has occurred between chromosomes the association disappears. Therefore, linkage produces no permanent association in the population, but may only be found within the family. The mechanism of association is, therefore, not that of linkage, but may be more likely explained by pleiotropic effects of a single gene.