The question of the specificity of anorexia nervosa is at present unsettled. Mayer-Gross et al. (8) describe it as a syndrome with its own particular psycho-physical characteristics, and others have drawn attention to consistencies in family history, personality and symptoms in series of cases (3, 10). But no statistically controlled study has confirmed its specificity, indeed the one such study of recent years, reported by Kay (6) and Kay and Leigh (7), concluded that there is no specific anorexia nervosa, that the label covers psychogenic anorexia occurring in a wide variety of psychiatric settings. This was a retrospective survey of a series of 37 patients diagnosed as suffering from anorexia nervosa in the past. It is possible that the lack of specificity might have been due to the imprecise definition implicit in such a sampling procedure. Although the study failed to demonstrate a specific anorexia nervosa, it did not finally refute the existence of such an entity.

The linguistic philosophers have tended to maintain that philosophy is reducible to the ways in which language is used. Without going all the way with them I believe that they have made a valuable contribution to thought, and that it is often illuminating to look at current problems in that way. In attempting to do this for psychiatry my object is to draw attention to the existence in psychiatric thought of what may be called a number of different languages, to consider briefly the rules which apply to each and those which govern the attempt to translate one language into another, and also to look at the relations between psychiatric languages and certain other types of language.

The wording of the Mental Health Act, 1959 makes it clear that an application under Section 29 replaces both the old Urgency Order and the D.A.O.'s three-day order as a means of compulsory admission to a mental hospital or the psychiatric ward of a general hospital. It was intended to be limited to cases where the patient's mind is so acutely deranged as to make him a grave and immediate danger to himself or others, so that the delay in obtaining a second medical recommendation required for admission under Section 25 might spell disaster.

Hughlings Jackson has exerted a considerable influence in psychiatry. This statement will surprise most psychiatrists because the work of “the father of British neurology” is not known to have made any direct impact on their specialty. It is true that striking similarities between Jackson's basic principles and those of so-called dynamic psychiatry have for some time been noted. But they have been regarded either as incidental or as indicative of the general influence of the theory of evolution.

Legal adoption has gained enormously in popularity over the last thirty-five years. Beginning in 1927 with under 3,000 cases, a peak was reached in the early post-war years with over 21,000 orders granted in 1946, while over the last decade this figure has stabilized at an annual average of 13,500. Something like a third of these adoption orders are for mothers wishing to confer legitimate status on their own children born before or out of wedlock, while in a small proportion of other cases children are adopted by relatives acting in loco parentis. We are left with a clear majority of cases (probably about 60 per cent.) in which the purpose of adoption is to create or complete a family where fertility is known or believed to be impaired. Only rarely will a couple adopt in preference to reproducing, although there are certain circumstances in which such a decision would be justified, for example where pregnancy carries serious risks for a woman healthy in all other respects or where there is a likelihood of inherited abnormality in her child.

Depressive illness is protean in its manifestations. The symptoms may be primarily psychological, such as misery, indecisiveness, irritability, inability to concentrate, or insomnia. They may be mainly physical, and the patient may present with one or more of a bewildering number of somatic complaints, often blaming those for his change in mood (Watts, 1957). Pain is a common and diagnostically puzzling presenting symptom of depression and other psychiatric disorders (Walters, 1961). It may take the form of generalized or poorly localized aches and pains, often associated with a feeling of tension, or it may be sharply delimited (Critchley, 1935). This form of localized pain may so dominate the symptomatology that the patient is referred by his general practitioner to a variety of specialists, who may perform a series of special investigations or even exploratory operations. Clearly, every effort must be made to exclude organic disease, even if positive signs of psychiatric illness are recognized, as an organic disease can obviously co-exist with a psychiatric one. In spite of thorough investigation, there will remain a proportion of patients in whom no lesion can be found to account for their symptoms.

The literature concerning this rare syndrome, alternatively known as maladie des tics, has been mainly descriptive since it was first mentioned by Itard (1825) and later by Gilles de la Tourette (1885 and 1899). Its nature remains in doubt, and until recently it has been believed to be a progressive condition inevitably ending in psychosis or pursuing a chronic course.

Urinary excretion of adrenal metabolites, especially neutral 17-ketosteroids, is often low in patients with anorexia nervosa (Escamilla, 1949; Bliss and Branch, 1960). This has been taken (Emanuel, 1956; Greenblatt et al., 1951) to provide evidence of adreno-cortical insufficiency secondary to defective pituitary function (Sheldon, 1939; Perloff et al., 1954). According to Perloff et al. (1954) “prolonged starvation may result in functional hypopituitarism, whose differentiation from the syndrome of hypopituitary cachexia due to structural impairment of the anterior pituitary gland is at times extremely difficult, even when the accepted tests for endocrine adequacy are performed”.

Psychiatrists have for long paid attention to mental illness in different communities and cultures. In Java, Kraepelin noted that melancholia and mania were rare and that depressive reactions rarely contained elements of sinfulness (9). Later, Bleuler commented upon differences between English and Irish patients and between Bavarian and Saxon patients (2). Others have described various “culture-bound” syndromes such as amok, the windigo psychosis of the Cree, Salteaux and Ojibwa, latah and Arctic hysteria (23, 5, 8, 11, 26). More recently Tooth has described a special category of “delusional” states in West Africans while Carothers has reported on “ill-defined” states and “primitive” psychoses among the West Africans (22, 4). Other workers have stressed the significance of cultural factors in the distribution of mental illness. Seligman noted in 1929 that confusional states were more common than systematized insanities among the Papuans of New Guinea and could not find any cases of manic depressive illness (17). Berne noted that toxic confusional psychoses rather than the schizophrenias were the predominant illness among hospitalized Malay (1). Carothers related Westernization to an increase in manifest paranoid behaviour among patients in Kenya (4). Similarly Spiro noted that the Ifaluk in the Carolines had violent paranoid outbursts only after Japanese occupation and Slotkin emphasized the paranoid schizophrenia phenomena among acculturated Menomini (20, 19). Opler found that lower class Filipinos had a high proportion of affective disorders and catatonic confusional states among the Hawaiian hospitalized, while Carothers and Tooth in Africa both found statistically low incidences of depression and suicidal states with relatively high rates of confusional states among African natives (13, 4, 22).

Attempted suicide has been described as the prime emergency of general practice. Although this may represent a slightly exaggerated claim, the present writers have certainly found attempted suicide to be a frequent reason for the referral of patients to the psychiatric department of a general hospital. The expression “attempted suicide” is usually taken to refer to an unsuccessful attempt to kill oneself: yet such a description is often somewhat inappropriate to describe a dramatic episode of behaviour, during which an assault upon the self occurs as the result of a mood of despair or rage. Death may not be consciously sought and it is more satisfactory to define attempted suicide as a non-fatal act of self-damage.

Behaviour therapy is defined as the application of the principles of modern learning theory to the treatment of neurotic disorders (Eysenck, 1960a, 1963). It defines neurotic “symptoms” as unadaptive conditioned autonomic responses, or the skeletal and muscular activities instrumental in moderating these conditioned autonomic responses. Treatment consists essentially in the extinction of autonomic, skeletal and muscular responses of this type. This extinction may be produced in a great variety of ways, but experience has shown that the most useful and important is probably the method of counterconditioning or “reciprocal inhibition” (Wolpe, 1958). This method takes two forms, according to the nature of the symptom. (1) When the symptom is of a dysthymic character (anxieties, phobias, depression, obsessive-compulsive reactions, etc.) it is assumed that the disorder consists of conditioned sympathetic reactions, and the treatment consists of reconditioning the stimulus (or stimuli) to produce parasympathetic reactions which, being antagonistic to the sympathetic ones, will weaken and finally extinguish them. These disorders we will here call “disorders of the first kind”. (2) When the symptom is of a socially disapproved type in which the conditioned stimulus evokes parasympathetic responses (alcoholism, fetishism, homosexuality), or where there is an entire absence of an appropriate conditioned response (enuresis, psychopathic behaviour), treatment (aversion therapy) consists of the pairing of the stimulus in question with strong aversive stimuli producing sympathetic reactions. These disorders we will call “disorders of the second kind”. (In putting the distinction between these two types of treatment in this very abbreviated form, we have used the terms “sympathetic” and “parasympathetic” in a rather inexact shorthand notation to refer to hedonically positive and negative experiences respectively; the reader familiar with the complexities of autonomic reactions will no doubt be able to translate these blanket statements into more precise language appropriate to each individual case. We have retained this use of the terms here because it aids in the general description given, and indicates the physiological basis assumed to exist for the hedonic reactions.)

In the investigation of prognostic factors relevant to remission in schizophrenia little attention has been paid to positive heredity for affective psychosis. One result of this relative disinterest has been to foster the opinion that heredity is of no prognostic value. Although his own work (8) supports the assumption that manic-depressive heredity is of good prognostic import in schizophrenia, Langfeldt (8) cautions: