Eighty years ago Gilles de la Tourette (1885) described the syndrome which has become eponymous. It has been usual to consider it as a relatively rare constellation of symptoms, sometimes the concern of the neurologist, sometimes of the psychiatrist; but in recent years three papers (Bockner, 1959; MacDonald, 1963; Polites, Kruger and Stevenson, 1965) discussing the syndrome and its treatment have appeared in British journals alone. All comment on the infrequency of the syndrome, but one does suggest that it may be less infrequent than has been thought in the past.

A previous study of depressive psychosis—Gittleson (1966a) showed that depressives with obsessions attempted suicide six and a half times less often than depressives exhibiting obsession-delusion transitions (without change of content) or those without any obsessions at all. It was suggested that the essential “protective” factor against suicidal attempts was the phenomenological form of the obsession as an obsession and its persistence as such throughout the course of the depression.

In a number of previous communications (10, 11, 12) I have advanced the thesis that in successful psychotherapy what goes on is a unique kind of learning process in which the therapist employs his particular theoretical frame of reference as a rational basis for explaining the patient's past and present difficulties, and by non-verbal as well as verbal cues uses the instrument of a warm empathic human relationship as a means of helping the patient to persist in the difficult task of combating his anxieties, overcoming his resistance to change, and learning more mature patterns of adaptation. This underlying modus operandi is essentially the same in different “schools” of dynamic psychiatry, despite their ideological variations. In the present communication I propose to outline some of the significant areas in which the findings from learning theory experiments are applicable to what goes on in psychotherapy.

The adult adjustment of children who were partially reared in foundling homes or other child care institutions is largely unknown. There is ample proof that major personality and character disturbances attributed to lack of maternal or emotional nurture appear in many children during or soon after periods of institutional care. Several authoritative reviews of the subject have appeared (Bowlby, 1952; Yarrow, 1961; Ainsworth et al., 1962). The later history of such children is much less clear. Retrospective studies of persons located through psychiatric clinics or delinquent groups suggest that considerable psycho-social disability persists well into adolescence. In particular, shallow feelings and loyalties, inability to form or tolerate emotional relationships, and asocial behaviour are frequently described (Bowlby, 1946; Goldfarb, 1947). However, other evidence supports at least partial spontaneous recovery (Beres and Obers, 1950; Clarke and Clarke, 1959; Stott, 1956). The adult fate of children who receive institutional care, though of compelling theoretical and practical interest, remains speculative.

El-Zar is one of the most popular traditional healing cults in Egypt, and it seems to have been introduced into the country from Sudan through Ethiopia. The word “Zar” means, in Amharic, the “devil” or “spirit”. Literally, the word is a derivative of the verb “to visit” and implies the intermittent visit of some wicked spirit. In practice, it generally connotes the gathering of some women, headed by a woman called “kodia”, with the purpose of exorcizing evil spirits.

There is a general view that the content of obsessions occurring in the course of depressive psychosis is frequently aggressive, homicidal or suicidal. Prichard (1835), Esquirol (1838), Marc (1840), Maudsley (1895), Heilbronner (1912), Gordon (1925 and 1950), Muncie and White (1937), Henderson (1937), Bowlby (1940), Lion (1942), Oltman and Friedman (1943), Stengel (1945), and Skoog (1959) all express this view on the basis of single anecdotal case reports or series of fewer than ten cases. The largest reported series is that of Vurpas and Corman (1933) who described 27 cases (2 organically based) of homicidal obsessions in depression. Only 3 cases (Nos. 10, 24 and 27) exhibited obsessions before the depression and this is too small a number to serve as a control group.

The evidence that potent tranquillizers are useful in the long-term treatment of elderly patients with dementia in psychiatric hospitals is conflicting.

Seager (1955), in a double-blind, controlled trial involving 48 elderly women, 29 of whom suffered from dementia, found a highly significant improvement of social adjustment associated with chlorpromazine therapy. Schulsinger (1961), Exton-Smith (1962) and Post (1963) claimed promazine to be of particular value for agitated elderly patients. Robinson (1959), on the other hand, compared the effects of prolonged administration of chlorpromazine, reserpine, leptazol and a placebo upon 84 senile female patients in a double-blind trial and found no statistically significant improvement associated with the active drugs. Indeed, in the case of chiorpromazine, he found a significant lowering of the level of functioning. Abse and Dahistrom (1960), in a double-blind controlled trial involving 8o patients over 60 years of age with various symptoms (including some with confusion), found that chlorpromazine did not give better results than placebo.

There have been many reports of the high incidence of early parental loss among groups of patients suffering from various psycho-pathological disorders. Bowlby (1951) cited numerous relevant studies in his influential monograph, and Gregory (1958) has critically reviewed a dozen others. More recently Brown (1961) reported a significantly higher incidence of parental loss in childhood among depressed patients than among the general population, and Beck et al. (1963) found that the incidence among highly depressed psychiatric patients was higher than among non-depressed patients. Both these writers aver that their findings provide evidence that parental loss in childhood is a significant factor in the development of a depressive illness in adult life.

In the controversy over the nature of schizophrenic “dementia” the weight of opinion has fallen on the side that emphasizes the differences which exist between this state and organic cerebral degenerations. While acknowledging these differences, it is important also to draw attention to the similarities between the impairment of chronic schizophrenia and the defect of organic dementia as it occurs in the elderly. We have chosen to compare the extent of perseveration in the two groups because this is a neglected field and because objective tests of such behaviour are readily devised.

Although the main value of hospital statistics is administrative, in connection with planning future needs of the mentally ill, they have been used by Shepherd (1957a), Brown et al. (1961), Barr et al. (1962), and Ratcliff (1964) to study trends in the characteristics and fate of patients admitted to mental hospitals. Since the factors that govern the admission of patients to psychiatric hospitals are both complex and varied, as has been shown by Svendsen (quoted by Reid, 1960), it would be more correct to say that the studies referred to describe the end-results of a number of factors interacting with each other and changing from time to time, such as hospital policy, demands of the mentally ill, available resources, therapeutic advances, attitudes of the community to admission, the state of the law, and so on. All these factors could be expected to influence the number and characteristics of patients admitted, especially for the first time.

Whenever one person seeks to influence the behaviour of another, the outcome may be affected by a multiplicity of factors. When the deliberate manipulation of one of these is followed by a given response, we regard the manoeuvre as specific and causal for that event. While this conclusion is acceptable logically, in practice it frequently proves to be misleading because certain implicit assumptions are overlooked.

This study concerns a two-year follow-up of all the male alcoholics discharged from the Alcoholic Unit at Warlingham Park Hospital between January 1960 and October 1961.

Ideas of changing sex, and the doubt about sexual identity which these ideas imply, are considered to be “invariable” and “pathognomonic” features of schizophrenia by Macalpine and Hunter (1955). The authors quote, in a footnote, a personal communication from Manfred Bleuler dated 1953 which states that Eugen Bleuler would have agreed that “schizophrenics are almost invariably, if not indeed invariably, in doubt about the sex to which they belong”. Planansky and Johnston (1962), in an uncontrolled study of 150 male schizophrenics, found that only 15 per cent. (22 cases) exhibited “direct expression of confusion of sex identity” and only 4·7 per cent. (7 cases) had clear delusions of having changed into a woman. Jackson (1960), Weckowicz and Sommer (1960), and Skottowe (1964) state merely that these ideas occur, or occur frequently. A check of the standard English language teaching texts reveals that Allen (1962), Bleuler (1911), Mayer-Gross et al. (1960), Noyes and Kolb (1963) and Sim (1963) make only oblique references to ideas of changing sex, whilst Anderson (1964), Arieti (1959), Bellak and Benedict (1958), Curran and Partridge (1963), Fish (1962 and 1964), Freeman et al. (1958), Henderson and Batchelor (1962), Merskey and Tonge (1965), and Stafford-Clark (1964) make no reference at all. In their study of schizophrenic delusions Lucas et al. (1962) similarly do not mention change of sex. They state simply that (in males) 30 per cent. had a sexual content.

A study of the relationship between attempted suicide and parental loss in childhood has been described in a previous publication (13).

The lumbar air encephalogram (L.A.E.G.) was introduced by Dandy in 1919, and in 1929 the first report of its use in schizophrenia was published by Jacobi and Winkler. Since then numerous papers have appeared, most of which have claimed to demonstrate cerebral atrophy in chronic schizophrenic patients. All these studies have suffered from the fact that no adequate series of normal controls has yet been collected. Most of the authors concerned made no attempt to use controls, nor did they consider the possibility of observer error or of the bias which may exist when the reporting radiologist knows the diagnosis and is looking for abnormalities.