I should like, in the first place, to express my deep and humble appreciation of the honour of your invitation to me to deliver this year's Maudsley Lecture. I am very sensible indeed of the honour, and equally of the responsibility, which you have conferred upon me. In my attempt to carry out that responsibility I should be in total despair, were it not for one sentence in the letter of invitation which I received from your impeccable Secretary. He wrote ‘What we want is to listen to people in other fields talking on their own subject with sufficient of a bridge for some degree of mutual understanding.’ That modest hope seemed to me to be conceivably possible of fulfilment.

The main reason why I have dared to accept our Council's invitation to deliver this lecture is that it gives me the opportunity to pay tribute to Dr. Blake Marsh with whom I had the privilege of working in the Mental Deficiency Section of the Association.

The question at issue now, as it was in 1954 when Meehl's book Clinical versus Statistical Prediction was published, is how may we best, most accurately and most efficiently predict the socially, clinically, and theoretically significant characteristics and behaviours of our patients. In the introduction to his book Meehl said ‘My thesis in a nutshell: there is no convincing reason to assume that explicitly formalized mathematical rules and the clinician's creativity are equally suited for any given kind of task, or that their comparative effectiveness is the san*e for different tasks. Current clinical practice should be much more critically examined with this in mind than it has been.’

It is widely accepted by clinicians that many so-called suicidal attempts' function as a form of communication between the patient and the key figures in his environment, most often conveying an appeal for attention (Stengel et al., 1959, Farberow and Shneidman 1961). Yet little rigorous research has been directed to the communicational aspect of attempted suicide, possibly because the concept of communication is itself complex and difficult to define operationally. One line of enquiry has been to examine the consequences of the act for the patient, his family, and friends (McCulloch 1965). The present study, on the other hand, focuses particularly on attempted suicide as a subcultural phenomenon.

Northamptonshire is a county in which details of pedigrees containing patients suffering from Huntington's Chorea have been kept for the past 14 years. In some families these details cover a span of eight generations. Pleydell (1954) found the prevalence of this illness to be five cases per 100,000 in 1954 (eight choreic families in the county), but in 1955 he found four new affected patients in one family, making 6-5 cases per 100,000 in nine choreic families for the county. Reid (i960) found two new subjects in the tenth choreic family of the county.

The present study of a correlation between stature of male psychiatric patients and character disorder as well as criminality has been made on the background of the findings of such a correlation in persons with the XYY syndrome by Jacobs et al. (1965), Casey et al (1966), Price et al. (1966 and 1967), Welch et al. (1967), Bardett et al. (1968), Court Brown et al (1968), Hunter (1968), Nielsen (1968) and Wiener et al. (1968), and to a certain extent also in persons with a large Y chromosome (Nielsen, 1968). These findings indicate that males with two Y chromosomes, and probably also males with a large Y chromosome, have a higher disposition to tall stature, character disorder and criminality than is found in the general male population. There might be a Y-linked inheritance of tall stature, character disorder and criminality irrespective of the size of the Y chromosome. If these hypotheses are true, one would expect to find a higher frequency of patients with character disorder and criminality among males with a stature above 181 cm. compared with males below 181 cm., and the present study has been made in order to compare the frequency of character disorder and criminality in psychiatric patients in these two stature groups.

The Maudsley Personality Inventory (Eysenck, 1959a) measures the two factors of neuroticism and extraversion, which are considered to be independent and relatively stable aspects of personality in normal subjects. Bartholomew and Marley (1959) tentatively concluded that changes in the mental state did not greatly affect the N and E scores, and Mezey et al. (1963) found that the scores re mained relatively constant during depressive illness, although there was a slight increase in neuroticism. McGuire et al. (1963) noted that the relationship between N and E scores ceased to be orthogonal during illness when the scores became negatively correlated. Knowles (1960) found relatively high test-retest correlations in both a normal group and a neurotic group after a year, although the correlations in the neurotic group were lower than in the normal group; he also found some evidence that fluctuations in clinical state influenced the stability of the N scores. Moreover, on measuring neuroticism and extraversion with the Eysenck Personality Inventory (Eysenck and Eysenck, 1964), Knowles and Kreitman (1965) concluded that N (but not E) scores were influenced to a small but significant degree by changes in the patients' clinical state. Coppen and Metcalfe (1965) found that the mean N score of a group of depressed patients decreased significantly on recovery and that there was an associated significant increase in the mean E score. These changes were most marked in patients with endogenous depression. The scores of the recovered patients were within normal limits. Ingham (1966) demonstrated essentially similar changes over a three year period in a group of neurotic patients.

The study of mental deficiency can be said to be based upon measurement. It is biometrical in a way that the rest of psychiatry is not, because the ultimate criteria for diagnosis of mental defect (or subnormality) are quantitative. Some kind of intelligence measurement or rating is always implied, and even at the lowest level quite often a measurement is actually made. In this lecture I shall only be able to outline my subject by giving examples.

The complex interaction of genetic and environmental influences in Huntington's disease results in successive generations living in deteriorating social circumstances. As the disease is untreatable (other than by palliative measures), spouses and unaffected children also suffer indirectly from its socio-psychiatric consequences.

Truancy has been called the kindergarten of crime (Healey and Bronner, 1926) and it is very common to find delinquents with a history of truancy (Glueck and Glueck, 1950). Children who truant are also frequently convicted of criminal offences later (Schulman, 1928). It is, therefore, not surprising to find great similarities in the backgrounds of truants and delinquents.

Much early research on attempted suicide looked upon this phenomenon as failed, frustrated or bungled suicide, an attitude which still persists among the general population. Conceptually, attempted suicide was viewed as a special case of suicide, and theories about the latter were used to explain the former, without much success. Stengel's influential monograph (Stengel and Cook, 1958) made an important contribution to the study of suicidal behaviour by contending that attempted suicide presented issues peculiar to itself as well as sharing problems with suicide. The definition of attempted suicide offered by Stengel (1964) is as follows, ‘A suicidal attempt is any act of self-damage inflicted with self-destructive intention, however vague and ambiguous. Sometimes this intention has to be inferred from the patient's behaviour.’ Suicidal attempts as thus defined are frequently insufficient to cause death, and must be related to the social setting of the patient. In situations which might be called crises of despair some people injure themselves in order to appeal for help, to spite others or to submit themselves to trial by ordeal. Stengel's definition has found general favour, although Kessel (1966) tried to promote the term self-poisoning, arguing that this term aroused fewer preconceived notions in the minds of the uninitiated.

In an article published in 1961 entitled “MPI results in cases of endogenous depression before and after treatment” (7, in Swedish), the authors (Wretmark, Åström and Ölander) showed inter alia that the Lie scale in the Maudsley Personality Inventory (3, 8) has a certain value when it comes to predicting the ability of patients with endogenous depression to regain social function. In view of the restricted material, the authors are careful in their conclusions, but it appears from the article that “high values on the Lie scale can be seen as an unfavourable prognostic factor with reference to the patient's ability to re-adapt to working life after treatment for endogenous depression”.

Gambling may be defined as an activity which has the following four characteristics:

1. 1. There is an agreement between two or more persons; the participation of others is therefore essential, although sometimes, as in pools and fruit machine gambling, this is more remote.

2. 2. Certain property is transferred between the persons involved so that some gain at the expense of others; this is usually referred to as the stake.

3. 3. The result is dependent on the outcome of a risky or uncertain situation; it therefore involves risk taking.

4. 4. Participation can be avoided and is typically pursued in an active fashion; the motivation for this is not uniform often being unrelated to the property staked and arising out of various psychological needs.

History of term ‘phobia’

The term ‘phobia’ derives from the Greek word ‘phobos’ meaning panic-fear and terror, and from the deity of the same name who provoked fear and panic in one's enemies. Although morbid fears have been described by doctors from Hippocrates onwards, the word phobia has only been used on its own since the beginning of the 19th century, and it gradually gained acceptance during that century in the same sense as today, viz. an intense fear which is out of proportion to the apparent stimulus. Such fear cannot be explained or reasoned away and leads to avoidance of the feared situation where possible.

Despite the increased understanding of the motivation behind acts of attempted suicide (e.g. Stengel and Cook, 1958) and their personal, social and ecological correlates (McCulloch, 1965; Kessel, 1965; Philip and McCulloch, 1966) the incidence of such acts as reflected in admission to hospital continues to rise. A comparison of admissions for the City of Edinburgh in 1962-3 and 1967 (Aitken, et al., 1969) showed a striking increase for men from 108.5 per 100,000 in the earlier year to 181.5 in 1967. The corresponding figures for women were 166.3 to 210.0. The Regional Poisoning Treatment Centre at the Royal Infirmary treats about 90 per cent of all cases of attempted suicide admitted to hospitals in the area (Kessel, et al., 1964), and the increase is unlikely to be accounted for by redirection of patients from other hospitals. An increase has also been demonstrated in other parts of Britain, including the Oxford Region (Evans, 1967) and Cardiff (Graham and Hitchens, 1967).

It has been reported that delinquents of superior intelligence differ from those of average and below average intelligence in their psychological, social, criminal and educational characteristics (Burt, 1944; Simmons, 1956 and 1962; Caplan and Powell, 1964; Cowie et al., 1968). Simmons has suggested that bright delinquents are more likely to be emotionally disturbed. He describes the boys at an Approved School for highly intelligent boys as suffering generally from ‘deep emotional disturbance’, and maintains that ‘the emotional disturbances which turn an intelligent child into a delinquent have usually been far more severe than they would have been in a less intelligent, less sensitive one’.

There have been relatively few studies of Huntington's Chorea in Britain. They include those of Curran (1930), Critchley (1934), Spillane and Phillips (1937), Minski and Gutt- mann (1938), Bickford and Ellison (1953), Pleydell (1954), Lyon (1962), Heathfield (1967), and Oliver (1970). Julia Bell's (1934) monograph was primarily a review of the literature, but included cases previously reported in this country and the results of her own observations.

During the past year the question of lithium prophylaxis has been the subject of lively debate (Blackwell and Shepherd, 1968; Hullin et al., 1968; Houghton, 1968; Baastrup and Schou, 1968a; Lader, 1968; Sargant, 1968; Saran, 1968; Baastrup and Schou, 1968b; Melia, 1968; Fieve and Platman, 1968; Cole, 1968; Kline, 1968; Kerry, 1968; Editorial, 1968; Berlyne, 1968; Silverman, 1968; Laurell and Ottosson, 1968; Lancet Editorial, 1969; Whybrow, 1969; Melia, 1969; Angst et al., 1969c). This discussion has revealed considerable uncertainty about the design and assessment of prophylactic trials, and there have been misunderstandings on important points.

In the last ten years there have been a number of studies reporting an association between certain persistent oral dyskinesias in elderly people (particularly women) and prolonged medication with phenothiazines. Many of the cases described in these studies also showed some evidence of brain damage and because of this it has often been suggested that brain damage is an important contributory cause of oral dyskinesia. Buccal factors such as the edentulous state have also been incriminated (Joyston-Bechal, 1965; Evans, 1965). However, very few controlled studies have been carried out. The literature on this subject has been well reviewed by Crane (1968) and Kline (1968).