It has been suggested in a previous paper (Sedman and Reed, 1963) that depersonalization phenomena were most likely to occur in patients with premorbid insecure personalities during a phase of depressive mood. Schneider (1958), includes under the term Insecure Personalities both Anankasts (obsessionals) and Sensitives. In such individuals there is “… a nagging inner uncertainty under various forms of compensatory or over-compensatory activity, especially where the inferiority feelings are of a physical or social character”. The purpose of this paper is to examine further the suggested linking of depersonalization, insecure personality and mood change in schizophrenia.

A prime obstacle in the training and socialization of the severely subnormal child is behavioural abnormality; drug therapy is most widely used in its control. Until the introduction of tranquillizers, sedatives were normally used. Unfortunately these caused not only motor, but mental retardation. The advent of phenothiazines appeared to offer a solution to this problem.

Over a period of 12 years Denhoff and Holden (1961) tested 8 drugs on pre-school children suffering from cerebral palsy for improvement in neuromuscular function including spasticity, behaviour, taste (acceptability) and toxicity. Objective tests were used for the first. The drugs examined were mephenesin (Myanesin, Tolserol), mephenesin with glycerol-alpha-ethyl-gamma-isopropyl ether (Lissephen), chlorpromazine, reserpine, zoxazolamine (Flexin), alpha-ethyl-beta-methylvaleramine (McN 181), carisoprodol (Soma), and emylcamate (Striatan). Beneficial results were seen in neuromotor function with both mephanesin and placebo. Placebo effects were greater than drug effects in neuromotor function and behaviour with Lissephen, but this drug was not tolerated in doses sufficient to reverse these effects. With chlorpromazine behaviour improved statistically, but the neuromotor effectiveness was secondary, occurring because the child was mentally relaxed and happy. Zoxazolamine gave improved behaviour, but the neuromotor effect was no better than that of the placebo. Reserpine was not tolerated, drowsiness taking place with a dose necessary to produce efficient performance. McN 181 was ineffective in doses tolerated and 6 cases were unchanged or worse as regards spasticity on soma. Striatan gave 6 of 14 improving in anxiety, but 10 of 18 did so with placebo and no statistical differences were found in anxiety score. The beneficial neuromotor effects of the drugs varied from 9 to 56 per cent. (mean 33.4) and of the placebos from 26 to 50 per cent. (mean 38.7). The authors point out that overall progress can be made when the child is mentally relaxed and happy, as when being treated with chlorpromazine.

In recent investigations of the neuroses by Foulds and Caine (1958, 1959), certain psychological tests were found to relate to diagnostic category (dysthymia or hysteria) whereas others were related to personality type (hysteroid or obsessoid) as rated by psychiatrists. The diagnostic measures included combinations of the Hypochondriasis (Hs), Depression (D) and Psychasthenia (Pt) scales of the Minnesota Multiphasic Personality Inventory (MMPI). The measures related to personality type included psychomotor and intellectual speed measures and two specially constructed extra-punitive and intropunitive attitude scales drawn from the MMPI (Foulds, Caine and Creasey, 1960). This distinction between symptoms and traits has been discussed in some detail by Foulds (1961) and no attempt will be made to review his arguments here. In a subsequent investigation, however (Foulds, 1959), he found that following treatment of approximately one month's duration symptom measures changed in psychoneurotic women relatively more than did the personality measures. It was suggested that therapists who were dissatisfied with the mere alleviation of symptoms might try to change some of the personality scores. The implication is that changes in test measures related to symptomatology are more readily accomplished than are changes in tests related to personality traits. This differential suggests a possible parameter for comparative studies of different treatment methods. Therapies directed at personality reorganization and attitude change should produce more profound and enduring changes in the personality measures than should those therapies directed at symptom relief only. These changes should be more systematic and predictable than should those to be expected simply from the passage of time.

The purpose of this trial was to evaluate the drug Taractan in the treatment of chronic schizophrenia.

Taractan (chlorprothixene) is chemically α-2-chloro-9-(w-dimethylamino propylidene)-thioxanthene. It is claimed to have neuroleptic and tranquillizing properties as well as thymoleptic activity. It is also claimed to be relatively free from side-effects. This property facilitated its use in a double-blind study.

In a previous paper (Claridge and Herrington, 1960) it was demonstrated that by using a modified version of the sedation threshold technique, originally described by Shagass (1954), it was possible to differentiate neurotics diagnosed as hysterics and those diagnosed as anxiety states (dysthymics). In keeping with Eysenck's theory of neurosis (1955) and drug action (1957), it was found that dysthymics had significantly higher thresholds for sodium amylobarbitone than hysterics. In addition, supporting the earlier findings of Claridge (1960) and again Eysenck's theory of personality, dysthymics were found to have significantly longer visual aftereffects to a rotating spiral than did hysterics.

Among recent developments in human chromosome studies a triple-X state has been recognized in females in whom the chromosome number is 47, composed of 44 autosomes and 3 X chromosomes (Jacobs et al., 1959). Early surveys of nuclear sex have shown that the triple-X state is a not uncommon chromosomal anomaly. A survey of Edinburgh babies gave a frequency at birth of these abnormal females of 1.78/1,000 births (Court Brown, 1962) and by combining data of surveys from Edinburgh (Maclean et al., 1962), Glasgow (Fraser et al., 1960) and Baltimore (Johnston et al., 1961) the estimated frequency of the triple-X state in mental subnormality institutions is 4.51/1,000 in-patients.

This paper reports an investigation in which it was found that, by dividing “paranoids” on a scale of “non-integrated psychosis”, two groups were formed which differed significantly from each other on several independent measures. When the same division was made within non-paranoid schizophrenics and within melancholics, very few such differences were disclosed.

The evidence suggests that integrated and non-integrated “paranoids” can usefully be regarded as differentiable groups, the latter being more closely related to other forms of schizophrenia.

In 1953, in an article intended for the general practitioner, Denis Hill made a brief reference to the chronic paranoid psychoses which may develop in association with temporal lobe epilepsy. He described the condition as likely to come on when the seizures were diminishing in frequency, as appearing gradually with onset in middle age, and as resembling a paranoid schizophrenic state. In 1957, D. A. Pond, from the same department of applied electro-physiology at the Maudsley Hospital, gave a more detailed account of the clinical features. He described the psychotic states as closely resembling schizophrenia, with paranoid ideas which might become systematized, ideas of influence, auditory hallucinations often of a menacing quality; and occasional frank thought disorder with neologisms, condensed words and inconsequential sentences. There were, however, also some points of difference, of a quantitative rather than qualitative kind: a religious colouring of the paranoid ideas was common; the affect tended to remain warm and appropriate; and there was no typical deterioration to the hebephrenic state. All the patients had epilepsy arising from the temporal lobe region with complex auras; occasional major seizures occurred in sleep only. EEG foci, always present, were sometimes only to be demonstrated in sleep-sphenoidal records. The epilepsy began some years before the psychotic symptoms, usually in the late teens or the twenties; and the latter often seemed to begin as the epileptic attacks were diminishing in frequency, either spontaneously or with drug treatment.

The results obtained with the Cold Pressor test were considered by the authors to provide further, supporting, evidence that variations in sedation threshold are due, in part at least, to differences in autonomic responsiveness. Further investigation of the problem seemed justified, and in the next stage of the research it was decided to employ as a measure of autonomic lability the response to a drug rather than the cold water stressor.

The present study examines two psychotic groups from the point of view of personality and symptomatological dimensions. It is conceivable that illnesses as devastating and widespread in their effects as the psychoses may complicate and blur relationships which seemed rather clear-cut among neurotics. The thesis of this study is, however, that Caine's Hysteroid-Obsessoid questionnaire (Martin and Caine, 1963) will continue to behave reliably and to account for much of the variance of other measures among the partially integrated psychotics, such as the paranoid and melancholic subjects to be examined here.

Although phenothiazine drugs have been employed in the treatment of schizophrenia for approximately ten years, we are still uncertain of the best method of using these agents. Whilst the indications to start phenothiazine medication may readily be agreed, the point at which to terminate such therapy remains debatable. Some psychiatrists stop the drug before the patient is discharged from hospital, some at discharge, some shortly after, but an increasing number recommend the schizophrenic patient never to stop taking his phenothiazine. On the other hand, the national drug bill has reached such proportions that some hospitals are now cutting down the administration of phenothiazines, and continue them only in those patients whose improvement is marked and clearly related to the drug.

The study to be reported was carried out within the framework of Personal Construct Theory as put forward by Kelly (1955). This theoretical background is summarized and discussed in Bruner (1956) and Bannister (1962).

Previous studies from this laboratory have shown that loading with large doses of certain amino-acids and Marsilid produced marked behavioural change in some chronic schizophrenic patients (Pollin, Cardon and Kety, 1961). Methionine and tryptophane produced qualitatively different effects and there was no overlap between marked methionine and tryptophane reactors. The changes with tryptophane were characterized by mood elevation and increased involvement with the environment and extra-version, in several instances to a dramatic degree.

A positive correlation has been found between changes of blood pressure and sedation threshold in two autonomic tests. In the Cold Pressor test the blood pressure changes were measured following the immersion of the hand in water at + 4-5° C. and in the Mecholyl test following the subcutaneous injection of a parasympathomimetic drug (Mecholyl). Both tests were considered to demonstrate differences in individuals' autonomic lability.

The psychiatric aspects of the investigation of these patients having been covered in the first of the papers of this series, it is the purpose of the present paper to provide details of physical factors, especially those relating to the epilepsy.

Fluphenazine, one of the newest phenothiazine derivatives, has trifluoromethyl and piperazine groups which bring about increase in potency. In Britain it is used in doses of 1 mg. or 2 mg. daily for the relief of anxiety, but American reports indicate that the drug is also of value in psychotic illnesses (Darling, 1959; Niswander and Karacan, 1959; Taylor, 1959, 1960; Darling et al., 1960; Holt and Wright, 1960). Encouraging results were also obtained in a preliminary study conducted in Britain in a group of patients of whom most were psychotic, and daily doses of 2 or 3 mg. appeared to be effective in relieving anxiety and agitation in a considerable proportion of these cases (Gillman and Sutherland, 1961). In reviewing the human and animal pharmacology of fluphenazine, Heseltine (1961) commented on its differences from earlier drugs like chlorpromazine and triflupromazine. The increased potency of the new drug, which in many pharmacodynamic properties may be about 40 times as potent as chlorpromazine, is associated with a rapid and prolonged action, relatively little sedative activity and little or no increase in autonomic and haemodynamic effects. A trial was undertaken to investigate the effectiveness of fluphenazine in the treatment of schizophrenic patients.