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.

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.)

There are a number of established forms of treatment for neurotic symptoms. In some patients symptoms are relieved by drugs which control anxiety, in others by antidepressant drugs (Sargant and Dally, 1962), still others appear to respond to some form of individual or group psychotherapy. More recently behaviour therapy has been introduced, and there are now a number of reports which claim that it is successful in a variety of neurotic disorders (Eysenck, 1960a).

Slowly but surely the emphasis of the mental health service is moving from the mental hospital into the community which it serves. The trend of these community developments can be seen as far back as the establishment of psychiatric out-patient clinics at general hospitals under the Mental Treatment Act, 1930, together with arrangements for after care, and continued by mental hospitals and regional hospital boards since the advent of the National Health Service. While the new era in British psychiatry awaits the implementation by local health authorities of their mandatory functions under the Mental Health Act, 1959, much can still be done within the hospital services proper to shift the emphasis into the community. One such method is described in this study of a Day Hospital developed within a large general hospital.

Lysergic acid diethylamide (LSD) has been used at Powick Hospital since 1952. During the early years of the treatment it became apparent that many of the dramatic psychic manifestations of the drug, including the vivid hallucinatory experiences, sensory hyperacuity, etc., were of no therapeutic value and that the chief use of the drug lay in its ability to bring into consciousness repressed traumatic experiences and relationships suffered by the patient during childhood. In particular, feelings such as those of parental rejection and hostility, sexual assaults, the sense of loneliness and impending doom engendered by inhalant anaesthetics in a strange hospital environment were repeatedly recovered and abreacted with great release of emotion. LSD appeared to be unique in the ease with which under its influence these deeply repressed memories could be recovered, and analysts using the drug in relatively small doses found that it would produce in one or two sessions unconscious material which would normally only be recovered after some months of analysis.

All who have used lysergic acid diethylamide (LSD-25) acclaim it as a valuable aid to psychotherapy, regarding it as a “deep” abreactive agent, in that in certain cases it erupts early traumatic experiences as far back as infancy, with appropriate emotional catharsis which is believed to be of considerable therapeutic benefit to the patient. It is also claimed that it facilitates and enhances the transference situation.

Amitriptyline hydrochloride (“Tryptizol”) is a new antidepressant with a predominant action on the central nervous system. It is 5-(3-di-methylaminopropylidene) - dibenzo (a,d) (1,4) cycloheptadiene hydrochloride, and is related chemically to imipramine.

Since the first studies of the use of lithium in manic illnesses by Cade (1949), and Noack and Trautner (1951), other investigations have followed in Denmark, France, Italy and Germany. Reference is made to these by Schou (1959) in a recent review of 10 years' use of lithium as psychiatric therapy.

Insomnia is widely accepted as a leading feature of that illness designated by the number 301.1 in the International Classification of Diseases. The name given varies—“endogenous depression”, “manic-depressive psychosis/depressive type”, “melancholia” or “depressive illness”. The present generation of laymen (not to say some psychiatrists) use the word “depression” so freely in order to describe an unpleasant, unhappy mood, whether lasting or transient, that one may prefer the term melancholia, or at least “depressive illness”, to signify that condition which justifies the number 301.1. The adjective “endogenous” implies for many that environmental stress plays little or no part in the onset of the illness; we cannot accept that this is always so. The term “reactive” is used in several ways, generally to indicate that the state of unhappiness arises out of some external circumstance and that it would end when circumstances improved or the individual accepted the realities of practical life. The patients used in the present study were suffering from an illness of a kind which we believe may sometimes develop in the absence of severe environmental stress, while in others it may be clearly provoked by circumstances, but the illness, as it develops, may take on a form which becomes largely independent of the environmental circumstances and may continue even when the provoking factors are past; it has become an autonomous melancholia. It will be apparent that by autonomous melancholia we mean an illness shown by clinical experience to respond especially well to electroplexy.

Vasomotor rhinorrhoea is a condition characterized by a constant or intermittent watery discharge from the nose. This may be accompanied by bouts of sneezing and a feeling of irritation in the nose. It is stated by some of the patients that symptoms occur during, or are aggravated by, periods of mental tension. In a severe case the secretions may be so profuse that the patient may need to use several handkerchiefs in one day.

A spontaneous abortion is usually defined as the involuntary expulsion of the foetus before it is of viable age. A woman who has had three consecutive spontaneous abortions is called an habitual spontaneous aborter. The probability that a woman will abort a current pregnancy I call her abortion-probability. In the course of some uncontrolled studies it has been claimed that this probability can be reduced by psychotherapeutic means. For instance, Javert (1957) reported that, using an eclectic treatment, live births resulted from 81.2 per cent. of 154 pregnancies of women who had been habitual aborters. He attributed his success to the psychotherapeutic aspects of his regime.

A working party (B.M.J., 1961) recently formulated nine points which they felt distinguished the early childhood psychosis or schizophrenic syndrome of childhood, and this paper describes some features of 100 such patients seen at Great Ormond Street. The nine criteria, which were strictly applied, can be summarized as follows: 1. gross and sustained impairment of emotional relationships with people;

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.

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 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.

When we face the crucial problem of the aetiological basis of the psychoses we have described, there are three main possibilities to be considered. Either they are to be regarded as symptomatic schizophrenias of purely epileptic causation; or they are independent schizophrenias which have appeared in these epileptic subjects coincidentally as the result of pure chance; or they are forms of schizophrenic illness which have arisen in individuals predisposed thereto by the stresses produced by the epilepsy. An investigation of the genetical background is capable of producing evidence which would assist in answering this question. If the first hypothesis is correct, the incidence of schizophrenic psychoses in the relatives of our subjects should be no greater than in the general population. If the second hypothesis is correct, the incidence of schizophrenic psychoses in the relatives should be the same as in the relatives of schizophrenics of the usual kind. If the third hypothesis is correct, we would expect an incidence of schizophrenia in the relatives of our patients which would lie somewhere between these two figures.

Between 14.4.60 and 30.9.60 a follow-up enquiry was carried out, combined with the genetical investigation which has been reported in previous pages. The informants for the genetical enquiry were also the ones who gave information about the patient's recent history. The period covered by follow-up was therefore from one to three years after the time at which hospital investigations had been carried out; and if related to the onset of the schizophrenia-like psychosis was at a mean period of 7.8 years later (range from 2 to 25 years). In addition to this the National Hospital patients have continued to be followed up from that time to the present date, as they and their relatives are asked to attend regularly at a follow-up clinic at the hospital. What is reported here relates to the findings in the special enquiry; but the data that have come in since do not suggest any modification of the conclusions that will be based on the survey of 1960. A synoptic view of these findings is given in Table I.

The task now arises to indicate the significance which should be given to the findings described in earlier pages. There are three possible theories by which the combination of a schizophrenia-like psychosis with a pre-existing epilepsy might be accounted for. First the combination might be co-incidental, due purely to chance, in which case there would be no medical problem of any consequence. Secondly the occurrence of epileptic fits might tend to precipitate the psychosis in individuals genetically predisposed, who otherwise would have had better chances of escaping such a development. Thirdly the psychosis might be the direct consequence of the epilepsy, and therefore to be regarded as an epileptic and not a schizophrenic disorder in the aetiological sense. Fourthly it would be possible to suppose that in any given collection of cases representatives of more than one of these causal chains could be found. These theories may be discussed in turn.