The world as a whole, and to a lesser extent this country, is confronted with the strong possibility of an unprecedented increase in its population. Pressure of population will produce tensions which will pose problems to psychiatrists. But other social events will give rise to generally similar tensions which will thus have multiple causes. It will then be difficult to separate the effects of population pressure from the effects of other causes and there may be illjustified swings of opinion such as we have seen in the past.

Increase in weight is a well-known side effect of phenothiazine drugs (Dally, 1967). There have been scattered reports of weight gain on tricyclic antidepressants (Arenillas, 1964; Dally, 1967; Kline, 1969), but this possibility has received little systematic study. Investigation is confounded by the fact that depression itself often produces weight loss. Crammer and Elkes (1968) reported weight gain in responders to desipramine, but regarded this as a limited phenomenon which never built up to obesity and was due to reversal of depression-induced weight loss.

The problem of classification of depressive illness has in recent years been reviewed by Kiloh and Garside (1963), Sandifer et al. (1966), McConaghy et al. (1967), Kendell (1968 and 1968a), Roth (1969) and Roth and Kerr (1970). Among the parameters differentiating types of depression, response to antidepressants has been employed by Pare et al. (1962), Lopez Ibor (1962) and Kiloh et al. (1962); their results suggest that one type of depression responds to the tricyclic group of antidepressants and the other to the monoamineoxidase inhibitors.

There is a commonly held conviction among physicians and the lay public that oral contraceptive agents are associated with a high incidence of adverse psychological effects, particularly depressive symptoms. This belief is enhanced by a body of literature which includes case reports, studies of small samples, and overall side effect incidence rates (1–22). Careful, adequately controlled, objective studies of emotional reactions are, however, lacking, and this can be ascribed to the serious problems inherent in the design of such studies. For example, adequate control groups are difficult to establish, and contraceptives cannot easily be randomly assigned. Studies using a placebo must also introduce other contraceptives; nonrandom processes operate in the selection of women for study. Suggestibility secondary to use of medication requires placebo double-blind studies in order to differentiate the psychological from the pharmacological effects.

The unwanted effects of the phenothiazines can be divided into two categories; those effects which represent the pharmacodynamic actions of a particular drug and occur as a function of dosage and individual susceptibility; and the hyper-sensitivity reactions (Shepherd et al., 1968). This latter group of side-effects is relatively rare, and there is no suggestion in the literature that they occur more frequently with the injectable long-acting phenothiazines (LAP) than with the oral forms. With the first available long-acting phenothiazine (fluphenazine enanthate) motor side-effects were frequently observed, particularly during the first few days after injection (Millar and Daniel, 1967; Lowther, 1969; Malm, 1970). Initial studies have suggested that fluphenazine decanoate is less likely to produce these unwanted extrapyramidal effects (Neal and Imlah, 1968; Ayd, 1970). So far, however, no study has attempted to make a quantitative evaluation of the problem of side-effects in the clinical situation of longterm medication. Since both the therapeutic efficacy and the unwanted extra-pyramidal side-effects are dose-dependent, it is meaningless to measure the incidence of side-effects without also recording the therapeutic gain: a low incidence of side-effects might only reflect a non-therapeutic dose of medication. Further, any such study should be continued for at least two months after the last reduction in dosage, as it is well recognized that loss of clinical control may be postponed for many weeks after phenothiazines have been discontinued.

Altered thyroid states may influence the effects of psychotropic drugs. Prange (1963a) reported a case in which moderate factitious hyperthyroidism and Imipramine treatment seemed to interact to produce paroxysmal auricular tachycardia. Later, this author and his colleagues described increased lethality in imipramine in hyperthyroid mice (Prange et al., 1962) and decreased lethality in hypothyroid mice (Prange et al, 1963b). Similar effects have been found for phenothiazines (Ashford et al., 1968). More recently it has been shown that a variety of physiological and behavioural effects of phenothiazines are amplified in hyperthyroid mice (Park et al., 1973). Furthermore, Selye and Szabo (1972) found that thyroxine sensitized the rat to the toxic effects of haloperidol.

Since 1949 the diagnoses given to all patients admitted to psychiatric hospitals in England and Wales have been collected and tabulated, initially by the General Register Office and more recently by the Ministry of Health and its successor the Department of Health and Social Security. These data are published regularly and have been used for many purposes—to follow trends in admission and discharge rates, to predict future bed and manpower needs, and in international comparisons. Before 1970 there was no official nomenclature and psychiatrists used whatever diagnostic terms they wished when completing the S.B.H.15 index cards provided for each patient (Department of Health and Social Security, 1970, Appendix A). In the Department of Health these diagnoses were converted into 3-digit numbers, using a complex code developed by the General Register Office (D.H.S.S., 1970, Appendix B), and finally these code numbers were grouped together to make them conform as well as possible with the nomenclature of the 7th edition of the International Classification of Disease (ICD 7). Inevitably this procedure was unsatisfactory. It was cumbersome; it only permitted a few broad diagnostic categories to be distinguished with any confidence; and it involved making a number of arbitrary assumptions about the relationship between the different nomenclatures involved.

In discussion of the wider issue of the characteristics of, and the relationship between, the classes ‘psychosis' and ‘neurosis', Maxwell (1972) wrote: ‘… the majority of all patients tend to have a basic core of symptoms, neurotic in type, which lend themselves to a dimensional description, but one whose prominence decreases somewhat as we pass from neurotic through affective psychotics to schizophrenics. In addition there are the psychotic type symptoms, which are rare and haphazard in occurrence. These are virtually absent in neurotics: they are most common in schizophrenics, but still not sufficiendy numerous or patterned to support a clear-cut typology or to lend themselves to a dimensional description.’

The ability to distinguish separate types of disorder among patients who seem at first sight to have similar symptoms has been a powerful factor in the progress of medicine. It is for this reason that the attempt to distinguish different varieties of depressive illness is important. In Britain recent studies have been concerned with the presence (as rated by the examining physician) of various symptoms and signs which from clinical experience have been thought likely to distinguish a neurotic from a psychotic type of depression. The investigators agree on the presence of these two types but disagree on the nature of the distinction, one school holding that there are two largely distinct types of illness and the other that the types merely represent the opposite ends of a continuum. The holders of the latter view accept that there may well be distinct types of depressive illness, but maintain that, if so, they cannot be distinguished by present methods of clinical examination. The divergence of view has been attributed by Kendell (1968) to sampling differences and to the subjective bias of raters, and by Eysenck (1970) to disagreement on whether the two types of depressive illness are of a categorical nature (i.e. specific disease entities) or of a dimensional nature (i.e. each has a graded distribution in a population of depressed patients).

In previous studies we have suggested that there are two types of depressive illness (4, 5). The first of these is depressive spectrum disease which has as its prototype the early-onset female depressive; the second type is pure depressive disease, the prototype of which is the late-onset male depressive. Other family studies support the differences between these two prototypes (1, 8). The early-onset females have a considerable amount of alcoholism and probably sociopathy in their male first-degree relatives. The late-onset males have an ordinary amount of these illnesses in their male relatives. In the families of early-onset females, female relatives outnumber male relatives for the presence of depressive illness; this is not seen in late-onset males, where male and female relatives have equal amounts of depressive illness.

At the present time there is a renewal of interest in the contribution of biological factors to schizophrenic illness. This stems in part from the success of pharmacological treatment and in part from the impressive findings in studies of foster-reared relatives of schizophrenics. While the pendulum of emphasis thus seems to be generally swinging in favour of constitutional influences, recent reports on twin studies have tended to go in the opposite direction. As will be discussed below, this development is largely attributable to a methodological error in the most recent twin investigations.

Aphasia is frequently combined with or mistaken for other behavioural abnormalities, and the psychiatrist is often asked to see patients with aphasia. Recognition and appropriate diagnosis alone present a considerable challenge; in addition, a variety of behavioural disturbances occur in aphasie individuals which need the attention of the psychiatrist. Despite the frequent appearance of aphasie symptoms in medial practice, the disorder remains poorly understood by many medical practitioners, and the specific psychiatric aspects have received very little recognition. These conditions will be the subject of this presentation.

The purpose of this paper is to report on ten cases of this uncommon syndrome admitted to Woodbridge Hospital, Singapore, and studied by the author in a systematic way. No attempt will be made to review the literature, as this has already been done recently by Goldin and MacDonald (1955), Enoch and Irving (1962), Enoch et al. (1967) and Whitlock (1967). The Ganser syndrome appears to be getting rarer in the West, as reports in recent literature have usually covered a few cases only: May et al. (1960) reported three cases and Whitlock (1967), six cases.

Bereavement studies which have correlated mental illness and other pathology with the recent or past deaths of parents have relied on the subject's memory for ascertaining parent death dates. Data given by subjects can be wrong, because of faulty recollection or deliberate misinformation given to conceal something felt to be shameful, such as illegitimacy.

Children who are rejected give a clinical impression of making interpersonal relationships with difficulty. Wolberg (1944) described the consequences of parental rejection as depending upon the age of the child at the time of the rejection, the manner in which frustration was imposed by the parents, the nature and extent of compensatory gratification from others, and the success or failure of spontaneous reparative attempts on the part of the child to establish accepting relationships. Earlier studies of the child's reaction to rejection were marred by the tendency to define rejection too loosely, so that both conscious and unconscious forms were included as well as more frequent ambivalent parental attitudes, with a resultant wide scatter in the form of the children's responses. However, it has been shown by comparison with accepted children that the rejected child is uncommunicative, rebellious, less friendly, and bewildered about life (Symonds, 1938). Rejected children have been noted to be hypersensitive, and it has been speculated that this stems from feelings of insecurity and of not belonging to a permanent setting (Childers, 1935). The types of reaction to rejection were sub-divided into two broad groups—aggressive and submissive (Newell, 1934). Aggressive behaviour, including rebelliousness, disobedience, temper tantrums, quarrelsomeness, stealing and truancy occurred when the parental handling was consistently hostile; while submissive behaviour, including shyness, seclusiveness, cravings for attention, occurred more frequently when the parental behaviour was consistently over-protective (Newell, 1936). The aggressive response to hostile rejection was confirmed by Wolberg, who also thought that the symptoms of delinquency, truancy, enuresis and frustration intolerance should be interpreted in the larger framework of the child's attitudes towards himself and the world.

The aim of the study was to determine whether transsexual and homosexual males differ in their autonomic responses to erotic film sequences.

There is an increasing use of psychological tests designed to measure anxiety in both psychological and psychiatric research. Yet the theoretical bases upon which the various questionnaires have been constructed in relation to their practical application remain less than clear. For example, the Taylor Manifest Anxiety Scale (TMAS) (Taylor, 1955), was developed from the Minnesota Multiphasic Personality Inventory as a more specific measure of manifest anxiety. The TMAS has repeatedly been shown to correlate highly significantly with the neuroticism score of the Eysenck Personality Inventory (EPI) (Eysenck and Eysenck, 1964). The EPI is purported to measure personality in a general way in two dimensions, one of neuroticism and the other of extraversion-introversion. The association between these two tests, therefore, suggests that either both relate to a general personality variable of emotional instability, or they both more specifically measure a tendency to experience anxiety. It could also mean that these two aspects, one measured by each test, involve a personality characteristic in common.