Since in most cultures it is normal practice for children to be reared by their parents, there is a general consensus of opinion that it is undesirable to be deprived of one's parents in childhood. This can scarcely be disputed, but to assert, as many authorities do, that a variety of severe psychological abnormalities may arise in the child as a result of such deprivation is to make an assumption of some magnitude. It requires an even greater assumption to postulate a causal connection between a long-past occurrence like childhood bereavement and a psychiatric illness which develops in adult life. It will be contended here that, with some exceptions, the evidence for such a connection is meagre. In particular, it will be shown that there is no apparent justification for regarding parental deprivation as an aetiological factor in depressive illness.

Since the time of Esquirol (1838) a discrimination has been made between illusions and hallucinations. The latter are generally taken to be perceptions that spring into being in a primary way and not transpositions or distortions of any genuine perception (Jaspers, 1962). There are, however, various phenomena comparable to hallucinations proper (as defined above), such as various forms of imagery and pseudohallucinations, which may be part of normal experience. This paper is concerned with a comparison of various types of hallucinatory phenomena differentiated on phenomenological grounds.

This enquiry was prompted by a discussion on training in psychotherapy which took place at the Troon Conference on the Teaching of Psychiatry (Ingram, 1963). We felt that more precise information was required about what is meant by the term psychotherapy, which methods are in use and what opinions are held by psychotherapists in training. This information could be of value in assessing the workload of psychiatrists and in deciding what training might be given to psychiatrists and medical students. It was therefore decided to seek the opinions of Scottish psychiatrists on some aspects of their current practice in psychotherapy.

There is still little agreement on the value of frontal leucotomy in the treatment of chronic psychiatric illness (Pippard, 1962). A familiar feature of this uncertainty is the contrast between the enthusiasm of the authors of uncontrolled studies (Pippard, 1955; Scoville, 1960; Sargent and Slater, 1963; Birley, 1964; Sykes and Tredgold, 1964) and the scepticism of those who have included a matched untreated group (Robin, 1958; McKenzie and Kaczanowski, 1964; Brit. Med. J., 1965). These controlled series were only concerned with “standard” leucotomies, which are now generally abandoned. All studies, including those of modified leucotomy, examined heterogeneous psychiatric disorders and concentrated on their final state rather than their progress towards it. This approach may obscure important differences both in type of disorder and stage of follow-up.

“The non-mathematician is seized by a mysterious shuddering when he hears of ‘four-dimensional’ things, by a feeling not unlike that awakened by thoughts of the occult. And yet there is no more commonplace statement than that the world in which we live is a four-dimensional space-time continuum. By this we mean that it is possible to describe the position of a point at rest by means of three numbers (co-ordinates) x, y, z, and that there is an indefinite number of points in the neighbourhood of this one, the position of which can be described by co-ordinates such as x 1, y 1, z 1, which may be as near as we choose to the respective values of the co-ordinates x, y, z of the first point. In virtue of the latter property we speak of a ‘continuum’, and owing to the fact that there are three co-ordinates we speak of it as being ‘three-dimensional’.

Concern is now general (College of General Practitioners, 1958; Hill, 1960; School of Medicine and Human Biology, 1963) that doctors are inadequately trained for a number of the demands made on them in practice. Many doctors are not equipped to treat emotional disorders and to collaborate with psychiatrists in the treatment of psychologically ill patients. Under present conditions many young doctors graduate with a distinct antipathy to the social and emotional aspects of illness (Walton et al., 1963; Walton et al., 1964). Experienced general practitioners sometimes express strong dislike for the psychological component of their practice and disinclination to get any further training in psychological medicine (Rawnsley and Loudon, 1962). Even those doctors who do seek instruction in psychiatry differ widely in the type of teaching they want and in their attitudes to patients (Walton, 1965). Many of those selecting themselves for training are unsuitable (Balint et al., 1966).

Since Kraepelin's classical description of cryptogenic or functional psychoses—manic-depressive, schizophrenia and paranoia—the possible influence of culture on the frequency of these clinical reactions has been considered. Although it is recognized that there are other types of mental disorders peculiar to certain cultural groups (8, 12), it is acknowledged that the kinds of psychoses mentioned above are repeated in the various cultures (5).

An association between certain persistent oral dyskinesias and medication with phenothiazines has been observed in middle-aged and elderly women for several years. In most of the published reports it is held that the phenothiazines are an important cause of the abnormal movements, since phenothiazines are known to exert a selective action on the basal ganglia. Other possible causes, however, are almost invariably present. These are brain damage from disease, leucotomy or electroconvulsive therapy (Hunter, Earl and Janz, 1964; Hunter, Earl and Thornicroft, 1964; Uhrbrand and Faurbye, 1960), and buccal factors such as ill-fitting dentures or the edentulous state (Joyston-Bechal, 1965; Evans, 1965). Similar dyskinesias are also said to occur with brain damage when phenothiazines have not been given (Rosin and Exton-Smith, 1965).

The occurrence of obsessions in the course of depression was first noted by Prichard (1835), Esquirol (1838) and Marc (1840). The first series (22 cases) was described by Heilbronner (1912), who agreed with Scheule (1888) that in some cases at least the depression was the primary illness and not merely a secondary result of the obsessions. Further small series were reported by Vurpas and Corman (1933)—27 cases, Lion (1942)—16 cases, and Ingram (1961)—10 cases. Stengel (1945) reported 4 cases and reviewed the literature fully. None of these series are controlled by a parallel series of depressives without obsessions. Lewis (1934) described depressives both with and without obsessions, but did not compare them.

The occurrence of depressive psychosis in the obsessional neurotic has been noted by Prichard (1835), Heilbronner (1912), Gordon (1925 and 1950), Vurpas and Corman (1933), Lewis (1934), Stengel (1945 and 1948), Terhune (1949), Pollitt (1956 and 1957), Reda and Paretti (1958), and Skoog (1959). Apart from Freud (1923), Vurpas and Corman and Pollitt, the general view is that such cases fare worse than other depressives. It is still uncertain in what ways, if any, a pre-existing obsessional neurosis modifies a superimposed depressive psychosis. The uncertainty is due to the lack of a large controlled series, the provision of which is the purpose of this study.

In most instances presenile dementia is based on well-defined organic diseases and it is not necessary to resort to cerebral biopsy to establish a diagnosis. These organic disorders cover a wide spectrum and include cerebro-vascular disease, tumours, trauma and well-defined degenerative states such as Huntington's chorea, vitamin deficiencies, endocrine disturbances, infections (bacterial and viral) and poisons such as alcohol, lead, barbiturates, bromides and carbon monoxide. The effects of liver and kidney failure as well as the hypercapnia of pulmonary insufficiency account for others.

This investigation is concerned with the histological changes found in cerebral biopsy specimens taken from 59 patients with presenile dementia. We have defined the presenile dementias as organic dementing diseases occurring before the age of 65; although 5 of the patients were a few years older than this at the time of biopsy, in all cases there was unequivocal evidence that the dementia was established before the 65th year. The clinical findings in 56 of these patients are described in the preceding paper (Sim, Turner and Smith, 1966).

In recent years there have been an increasing number of attempts to survey the distribution of psychiatric morbidity, or to estimate the need for psychiatric treatment, in the general population. Various methods of defining or diagnosing psychiatric illnesses have been used (Blum, 3; Scott, 20). These methods include interviews by psychiatrists (Lin, 17; Essen-Müller, 13; Hagnell, 14); the judgment of family physicians (11; Kessel, 16; Shapiro and Fink, 21); the use of self-administered symptom check lists (White et al., 23); and structured interviews by non-psychiatrists relating to symptom occurrence, attitudes, personality scales, etc. This paper outlines an attempt to determine some of the relationships between the results of a symptom-questionnaire; the diagnoses recorded by physicians; and the physicians' request for psychiatric consultation.

Although there is now universal agreement that the reduction of food-intake is the central phenomenon in the syndrome of anorexia nervosa, the cause of the food refusal is still incompletely understood. One of the difficulties in elucidating the psychogenic roots of the anorexia is the fact that the patients themselves are unable to explain their thoughts and feelings. Conversations with them give the impression that one is speaking to a very young child who cannot or dare not express herself, so that the interviews are reduced to monosyllabic answers to questions and long periods of silence without relevation of pertinent material. After having spent much time with such patients in the past, we have since tried to obtain additional information from parents and other family members, neighbours and family doctors who knew the patients and their environment. Although we are well aware that this kind of information pertains more to outward behaviour than to “endopsychic” processes and therefore will probably be considered as of limited value by those who are interested in the so-called psychodynamics of the disease, we were able to formulate at least a tentative hypothesis that seemed to fit the life situation in our patients and bring them under a common denominator. From this hypothesis, which will be formulated below, a simple prediction followed as to how these patients should be treated. In the present paper we wish to formulate the hypothesis and present the preliminary results of a form of treatment, based on this prediction.

The following case study offers an exceptional opportunity to illustrate the wish-fulfilling nature of auditory hallucinations in a hysteric (Breuer and Freud, 2; Freud, 11), the conditions under which these hallucinations are experienced, and their response to treatment.