An account is given of attachment theory as a way of conceptualizing the propensity of human beings to make strong affectional bonds to particular others and of explaining the many forms of emotional distress and personality disturbance, including anxiety, anger, depression and emotional detachment, to which unwilling separation and loss give rise. Though it incorporates much psychoanalytic thinking, many of its principles derive from ethology, cognitive psychology and control theory. It conforms to the ordinary criteria of a scientific discipline.

Certain common patterns of personality development, both healthy and pathological, are described in these terms, and also some of the common patterns of parenting that contribute to them.

Recent losses occurring in the two years before onset of depression in women are distinguished from past losses occurring at any time before this. Of past losses only loss of mother before 11 is associated with greater risk of depression—both among women treated by psychiatrists and among women found to be suffering from depression in a random sample of 458 women living in London. Past loss of a father or sibling before 17 (or a mother between 11 and 17), or a child or husband, is not associated with a greater chance of developing depression. However, among patients all types of past loss by death are associated with psychotic-like depressive symptoms (and their severity) and other types of past loss with neurotic-type depressive symptoms (and their severity). It is argued that these associations probably reflect direct causal links, and a socio-psychological theory to explain them is discussed.

The literature on the purely psychiatric aspects of mental handicap is remarkably limited. In the third edition of Mayer-Gross, Slater and Roth's Clinical Psychiatry, apart from one or two brief incidental mentions elsewhere in the text, the main references consist of just one paragraph on psychoses and two short paragraphs on neuroses included in the section on ‘The Association of Mental Subnormality with Other Syndromes’! Similarly the only reference to mental illness in mental handicap in the eighth edition of Henderson and Gillespie's Text-Book of Psychiatry was a mere four lines on psychosis; by the ninth edition, this had grown to seven lines covering both neuroses and psychoses, but with two of those lines devoted to an admission by the authors of their own lack of knowledge.

In three recent articles, Slater (1972, 1973, 1975) has made certain claims concerning the nature of science, especially as it applies to psychiatry. Most recently (Slater, 1975), he has applied his criteria for assessing science to psychoanalysis, and has found it seriously lacking. In this article Slater's criticisms of psychoanalysis are used as a foil to attack his criteria for science. It is argued that his methodological criteria are extremely conservative and would be likely to cause the demise of scientific activity if at all seriously applied. Further, it is argued that psychoanalysis is a science on any reasonable application of Slater's criteria.

An account is given of how a clinician guided by attachment theory approaches the clinical conditions to which the theory is held to apply, which include states of anxiety, depression and emotional detachment. Assessment of a patient is in terms of the patterns of attachment and caregiving behaviour which he commonly shows and of the events and situations, both recent and past, which may have precipitated or exacerbated his symptoms. The problems posed by relevant information being suppressed or falsified are noted.

Viewed in this perspective a psychotherapist is seen to have a number of interrelated tasks: (a) to provide the patient with a secure base from which he, the patient, can explore himself and his relationships; (b) and (c) to examine with the patient the ways in which he tends to construe current interpersonal relationships, including that with the therapist, and the resulting predictions he makes and actions he takes, and the extent to which some may be inappropriate; (d) to help him consider whether his tendencies to misconstrue, and as a result to act misguidedly, can be understood by reference to the experiences he had with attachment figures during his childhood and adolescence, and perhaps may still be having.

Parasuicide admissions to the Regional Poisoning Treatment Centre in Edinburgh are reviewed over the seven year period 1968–74. Special emphasis is given to trends in parasuicide rates for Edinburgh City, but social and clinical data are also described. Though the mean annual increase for admissions is 10 · 6 per cent, recent years have shown a fall in the rates for men and a levelling off for women. There have been increases in the rates for the young, for men in social classes 4 and 5 and for divorced women, and in poisonings with psychotropic drugs and alcohol consumption among women. At the same time it is important to note variables which have not changed: the relative risks by age and sex, repetition rates, the diagnostic picture, poisoning with non-prescribed drugs, and the rank order of municipal ward rates: and variables which have diminished: the rates for divorced men, overcrowding, domestic gas and barbiturate poisoning, and drug misuse. A comprehensive explanation of parasuicide in the contemporary scene would have to explain both the consistencies and the changing trends. The answer to the central question of why parasuicide is changing remains elusive.

This paper attempts to define the areas of applicability of behavioural and mentalistic explanations of neurotic behaviour. It is argued that intentional behaviour requires mental concepts for its explanation on the grounds that the statement of reasons which form the basis of intentions cannot be submitted to a stimulus-response analysis. This argument applies to situations in which the therapist uncovers the reasons for purposeful action of which the agent may initially be unaware. It is further argued that behaviour of this kind is rule-conforming and not law-abiding and therefore is not susceptible to explanations of the kind that are available in other areas of science. It is nevertheless argued that causal explanations can be given in terms of reasons for action.

The existence of a nation-wide twin register and central psychiatric register has made possible a catamnestic investigation of an unselected and representative sample of twins with manic-depressive disorders.

From a total population of 11,288 same-sexed twin pairs born 1870–1920 in Denmark 126 probands from no pairs were ascertained. Among the co-twins of 69 monozygotic probands there were found 46 with manic-depressive disorders, and a further 14 had presented other psychoses or marked affective personality disorders or had committed suicide, yielding a proband rate of strict concordance, C1 = 0·67 and of broad, partial concordance, C2 = 0·87. The corresponding direct pairwise concordance rates were 32/55 = 0·58 and 46/55 = 0·84 respectively. For the dizygotic twins the proband concordance rate of C1 was 11/54 = 0·20 and of C2 20/54 = 0·37, and the direct pairwise rates were 9/52 = 0·17 and 18/52 = 0·35 respectively. The differences between the pairwise rates for the monozygotic and dizygotic twins are significant (P < 0·001 at χ2 analysis). This finding is in accordance with previous twin studies of manic-depressive disorders and confirms the evidence of a strong genetic factor. The concordance with respect to unipolar and bipolar forms was not in contradiction to recent evidence of a genetic difference between the bipolar and unipolar form, the latter probably related to the female sex.

Fifty-six psychiatric patients were interviewed to obtain a record of life events preceding admission to hospital, using a modified version of the Schedule of Recent Experiences. Two control groups were studied for comparison: medical and surgical in-patients and a ‘normal’ population studied independently by Myers. Psychiatric patients reported a significantly larger number of events than the medical-surgical patients, who, in turn, reported significantly more events than the ‘normal’ population. There were no significant differences in the specific life event histories between groups.

The pattern of decline of a mental hospital population over fifteen years is described. Continuing problems are commented on, particularly the presence of ‘old’ long-stay patients and the accumulation of ‘new chronic patients'. The number of beds required for each of these categories is estimated.

The dissolution of the mental hospital service by degradation is deplored, and a suggestion is made that some of the good points of the old service might be salvaged before it is too late.

Six cases are reported in which the bereaved kept the deceased's body for periods ranging from one week to ten years.

Some relevant anthropological and psychoanalytical observations are discussed. This phenomenon does not appear to have been reported in the literature of Western psychiatry.

Fifty-three psychiatric patients who had been receiving treatment with lithium continuously for more than two years were examined to estimate the prevalence of lithium-induced hypothyroidism. It was found to be 20 per cent among women. No men were affected among these patients. In order to study the characteristics of the disorder further cases were drawn from another population. One third of the patients developed hypothyroidism during their first year of treatment, others not until after 9 years. About two thirds of the female patients with hypothyroidism had thyroid antibodies. All cases with lithium-induced hypothyroidism showed elevated levels of serum thyrotropin, which in our experience is the laboratory examination of choice in these as well as other cases of ‘primary’ hypothyroidism. Since the probability of detecting these cases at a given control visit was found to be low, we feel that such visits need not include extensive laboratory investigations. Hypothyroid patients responding well to lithium treatment should continue their medication combined with appropriate thyroxine substitution.

The Gods did not reveal, from the beginning, all things to us; but in the course of time, through seeking we may learn, and know things better.

Xenophanes

Esrath Nashim was the name of the women's forecourt of the Second Temple in Jerusalem. The words can also be interpreted as ‘women's aid’ and were adopted as its title by a ladies' benevolent organization. This body, in 1895, established in the Old City of Jerusalem a one-room asylum where two patients were cared for. In 1905 the Esrath Nashim Hospital was opened in the Jaffa Road in the New City, and after the founding of the State of Israel in 1948 it remained as the only psychiatric hospital in the new State, though others were soon established. The old hospital was a Turkish-style stone building which was impressive of its kind, but the difficulties under which it operated may be illustrated by recalling that when the present chairman of the Hospital Board took office in 1948 and obtained the first grant from the newly-established Ministry of Health it was decided that the most pressing need was to install a hot-water system. In the late 1950s the chairman persuaded the Board that they should build a new hospital, and in August 1968 this was finally opened, the first purpose-built psychiatric hospital in the country. At that time three pavilions, each with 50 beds, were complete.

Chromosome examination was made in 22 monozygotic and 27 dizygotic twin pairs of whom one or both of each pair suffered or had suffered from manic-depressive disorder. We found a significantly higher frequency of chromosome variations among dizygotic twin pairs than was expected from population studies, but not in monozygotic pairs. There was no association between the chromosome variations and manic-depressive disorders. We found no greater intra-pair correlation in monozygotic twins compared with dizygotic twins as regards hypodiploidy, hyperdiploidy and unstable chromosome aberrations, which indicates that the aetiology of such aberrations is mainly of exogenic nature.

Control subjects voluntarily overbreathed to produce end-tidal PCO2 levels similar to those found in patients suffering from neurotic or endogenous non-retarded depression. Red cell sodium content was found to decrease during overbreathing in all the subjects. The changes were similar to those usually reported for depressed patients.

The results imply that red cell sodium levels are in part dependent on respiratory behaviour. They suggest a need for considerable caution in interpreting red cell sodium values from psychiatric patients.

An attempt was made to extend and cross-validate Mayo's (1969) study of ‘normals with symptoms' using the new Personal Illness measures. Groups of psychiatric patients and symptom-free normals were matched with a ‘normals with symptoms' group for age and sex. The two symptom groups were similarly matched on the number of symptoms as assessed by the Delusions-Symptoms-States Inventory. On the Personality Deviance Scales the ‘normals with symptoms' were found to be the most Extrapunitive group, the symptom-free normals had the lowest Intropunitive scores, whilst the patient group were the lowest scorers on Dominance.