The reprinting by the Institute of Psychiatry, on its fiftieth anniversary, of Dr. Peter Scott's paper (1) describing Maudsley's work as a pioneer in criminology reminds us of the prominent part Maudsley played in the debate between psychiatrists and lawyers which has been in progress for nearly a century and a half, with, for much of that time, little satisfaction for either side. It is a classic example of the difficulties of inter-disciplinary communication. My only qualification to be the Maudsley Lecturer is that I happen to be doubly qualified in law and medicine, and, as Chairman of the Institute, a good deal closer to psychiatry than most lawyers. My qualities as an interpreter must therefore make good the intellectual deficiencies of which a glance at the list of my forty-seven distinguished predecessors makes me acutely conscious.

The aims of this study were to compare the psychiatric morbidity occurring in the close relatives (N = 332) of patients showing nuclear forms of schizophrenia with that of a control group (N = 201), and to consider the findings in relation to the concept of the schizophrenic ‘spectrum’ and to some genetic theories of schizophrenia. About one third of each group were interviewed by a psychiatrist using defined diagnostic criteria, and information of varying degrees of completeness was obtained about the remainder. After considering possible biases, it was concluded that the ‘spectrum disorders' most likely to be biologically related to schizophrenia were personality disorders of non-neurotic type, either alone or in combination with another diagnosis. The results, however, did not fit well with the model of dominant inheritance of schizophrenia and schizoid disease proposed by Heston (1970).

This paper presents a study of patients' social and domestic functioning preceding admission to a psychiatric hospital. A method is described for the quantitative assessment of ‘social breakdown’ in the areas of work, domestic performance and social group activity, based on reports from the patient and from another household member. Complementary changes in the domestic tasks carried out by other family members are also investigated. The sample consisted of 28 women and 17 men. Their usual level of functioning and their degree of breakdown are related to psychiatric diagnosis on admission, to the patient's position within the family and to the social class of the household. Discrepancies between reports are also investigated in relation to these variables.

The self-reported child-rearing practices of 214 parents of battered babies were characterized in a few but not all respects by demanding behaviour which exceeded that to be expected in relation to their social class and age. Inconsistency in child management was noted in the comparison between lack of demonstrativeness and emotional over-involvement, and between physical punishment and a tendency to be lax in the supervision of the child, and was reminiscent of parents of delinquents. Unhappiness and hostility in relationships with members of their families of origin, with unsupporting partners and with people in general were other important features. Generally, identified perpetrators were characterized by features significant for the sample as a whole.

It has often been suggested in recent years that there is no such thing as mental illness; that the conditions psychiatrists spend their time trying to treat ought not, properly speaking, to be regarded as illness at all, or even to be the concern of physicians. Szasz is the best-known exponent of this viewpoint, and the core of his argument is essentially this: that as prolonged search has never demonstrated any consistent physical abnormality in those regarded as mentally ill, and as their ‘illness' consists simply in behaving in ways that alarm or affront other people, or in believing things which other people do not believe, there is no justification for labelling them as ill, and to do so is to use the word illness in a purely metaphorical sense (Szasz, 1960). Schneider had previously been led by the same reasoning to the conclusion that neurotic illness and personality disorders were ‘abnormal varieties of sane mental life’ rather than disease, but he took care to exempt schizophrenia and cyclothymia by assuming that both would in time prove to possess an organic basis (Schneider, 1950). The argument Eysenck puts forward in the first edition of his textbook, though written from the quite different standpoint of academic psychology, is a similar one. After observing that ‘the term psychiatry does not denote any meaningful grouping of problems or subjects of study’ he went on to suggest that the traditional subject-matter of psychiatry should be divided into a small medical part ‘dealing with the effects of tumours, lesions, infections and other physical conditions' and a much larger behavioural part ‘dealing with disorders of behaviour acquired through the ordinary processes of learning’, thereby implying that most of what doctors regarded as mental illness was really learnt behaviour rather than disease, and therefore much better understood, and dealt with, by psychologists than by physicians (Eysenck, 1960). A third line of attack is provided by R. D. Laing, and a fourth is exemplified by the sociologist Scheff. Laing argues that schizophrenia, far from being a disease or a form of insanity, is really the only sane or rational way adolescents have of coping with the intolerable emotional pressures placed on them by society and their families (Laing, 1967). Scheff has developed the somewhat similar argument that what psychiatrists call mental illness is largely a response to the shock of being labelled and treated as insane and the expectations this produces; in other words that schizophrenia is created by the people and institutions that purport to treat it (Scheff, 1963).

The assumptions and properties of the Multifactorial Model of Disease Transmission are described, using the principles of quantitative genetics. No assumptions are made about the relative importance of genetic and environmental factors in the transmission of a disorder. The usefulness of the Model is discussed as a device for quantifying family data, discriminating between different modes of transmission and studying variations in disorders according to such clinical variables as age, sex, and severity of illness.

When only one form of a disorder can be distinguished, the degree to which the disorder is transmissible can be measured, and the relative importance of familial factors in the aetiology can be assessed. The assumptions which underlie the Model cannot be tested.

When two or more forms of a disorder can be distinguished, family and population data can be used to test the underlying assumptions of the Model. A good fit of the Model to the observed data indicates that the two subforms of the disorder represent different degrees of the same normally distributed process. This implies that the relative importance of transmissible and non-transmissible factors is the same in determining each subform of the disorder. The testability of the Multifactorial Model with multiple thresholds offers an opportunity for relating and understanding heterogeneous subforms of a disorder, for specifying the relationship between spectrum disorders, and for classifying psychiatric disorders.

Recent work has revealed that autistic children's predominating tendency to avoid social interactions is actually enhanced by the ‘friendly’ approaches of others. In this study it was recorded on video-tape how eight autistic children reacted to four styles of adult behaviour. The adult reacted to the child's looks at her by (i) smiling, (ii) gaze averting, (iii) gaze averting plus other ‘timid’ behaviours and (iv) doing nothing except continuing to look back. For this last condition—when the adult did not react—it was found that autistic children showed less avoidance behaviour after eye contact and spent more time within one metre of the adult. The implications for treatment are contrary to much modern practice and to what seems to be adults' ‘natural’ response. Reactivity by others appears to enhance the child's avoidance, and it is suggested that adults should be circumspect in the degree of sociability with which they respond to autistic children.

The effect of attitudes of therapists, patients and researchers on the conduct and outcome of combined drug and psychotherapy research was examined in a brief crisis-oriented psychotherapy clinic. Seventy-seven consecutive patients were given one of two anti-anxiety drugs or a placebo in conjunction with the typical psychoanalytically-oriented treatment used in the clinic. The therapists' attitudes favouring psychotherapy over drug therapy (and psychotherapy research) were clearly conveyed to the patients. Indicative of this are the following: (a) 82 per cent of the patients dropped out of drug taking, although a similar percentage remained in treatment; (b) only a third of the patients perceived it as being important to their therapists that they should take medication; (c) 87 per cent of the patients were rated as improved; and 75 per cent of patients completing forms considered that most or all of their improvement was attributable to talking.

The research team, made up of members of the same department who therefore had similar values as the therapists, diligently collected outcome data, but ignored its responsibility to enforce drug-related portions of the protocol. Overall, patients remained in therapy, improved and participated in completing forms, so that only the research goals of combined therapy were thwarted, while traditional clinic service and training goals proceeded as usual.

Sociopathy is highly familial in both white and black families. Sociopathy in men and women clusters in the same families, but is much more frequent in men than in women. It is more prevalent among relatives of sociopathic women than among relatives of sociopathic men. The sex difference in its prevalence appears to be due to sex-related cultural or biological factors causing the threshold to be more deviant in women. There is no evidence of a genetic difference in its prevalence and transmission according to race.

The two-threshold Multifactorial Model of Disease Transmission provides an explanation for the striking sex difference in the transmission of sociopathy. Such a pattern of transmission is obtained only in diseases whose genetic component is polygenic or, if only one or a few genotypes are relevant, where each of these has a small effect relative to environmental factors.

Assortative mating accounts for a large proportion of the observed similarity between relatives. However, the familial clustering of male and female sociopaths is not dependent on assortative mating.

The high correlation among siblings that is expected under conditions of random mating indicates that environmental factors common to siblings contribute to the aetiology of sociopathy. The greater deviance of the parental home experiences of sociopathic women compared to sociopathic men is further evidence of the importance of familial environment.

Sixty-eight psychiatric in-patients who had completed the Delusions-Symptoms-States Inventory (D.S.S.I.) on admission were retested after one month. On first testing 92.6 per cent conformed to the hierarchy of classes of personal illness model, and on the second occasion 91.2 per cent. Of those who could improve, 72 per cent did so, most commonly by moving down one hierarchy class, e.g. from the Neurotic Symptoms class to the Dysthymic States class. (On the other hand only 30 per cent of the 61 patients who originally reported symptoms did not do so after one month.) Thus although it is clear that the patients as a group changed markedly, they have not departed from the hierarchy. These results indicate that either the symptoms further up the hierarchy remit before those lower in the hierarchy or they remit together. Certainly those lower in the hierarchy do not go first. It is suggested that the results would be difficult to accommodate within strict disease-entity models, and that they have different implications for both treatment and the assessment of change in current state.

The hypothesis that schizophrenia and some non-psychotic abnormalities occurring in the close relatives are both manifestations of a unitary ‘schizoid state’ due to a major dominant gene is further examined. Comparisons are made (1) of the observed and expected frequencies of the different types of parent mating; and (2) of the observed and expected risks among sibs in families with neither, or with one or both, of the parents abnormal. It is concluded that the results do not fit well with the model of inheritance of the schizoid state through a major dominant gene.

Since some hereditary contribution in schizophrenia can be regarded as established, the excess of personality disorders and heavy drinking in the families is thought to be due to a combination of polygenic inheritance and environmental influences. The findings are regarded only as tentative, but suggest several hypotheses which could be tested.

In 21 widows and 46 amputees a psychological reaction to loss designated as ‘grief’ was commonly reported. This included an initial period of numbness, soon followed by restless pining with preoccupation with thoughts of the loss, a clear visual memory of the lost object and a sense of its presence. Defensive processes, reflected in difficulty in believing in the loss and avoidance of reminders, were also evident.

Widows differed from amputees in showing more evidence of overt distress in the early post-loss phase, but whereas these features diminished in prevalence in the course of the next year the equivalent features reported by the amputee group remained virtually unchanged.

The Maudsley Personality Inventory and the Beck Depression Inventory, with additional items to assess depressive functional shift features and outlook on life values, were administered to 100 patients diagnosed as suffering from depressive illness. Patients’ scores for questions eliciting information about symptoms assumed to be dependent on personality correlated at substantial and significant levels with N scale scores of the Maudsley Personality Inventory. Similar levels of correlation were found for the added items for assessing life values. Items believed to assess changes in functions independent of personality, such as the features of the Depressive Functional Shift, showed no correlation with either N or E scales of the Maudsley Personality Inventory, while demonstrating a substantial level of correlation with the depression scale. It is concluded that whereas changes in innate biological functions independent of environment are direct indications of the depressive illness process, psychological symptoms of the illness may reflect changes in personality dependent on upbringing, education and cultural background, thereby producing greater variation in this group of psychological symptoms.

Only Scandinavian investigators have reported on demographic aspects of reactive psychoses. Data from the National Health Service, Denmark, for age at first admission, sex, and length of stay in hospital in reactive, manic-depressive and schizophrenic psychoses are analysed. Differences in sex incidence ratios, age at first admission and length of stay are evident between the three psychoses. The differences noted are considered to provide indirect evidence supporting the separate diagnostic categories.

Serum copper concentrations were determined by atomic absorption spectrophotometry in 102 schizophrenic patients and 95 healthy control subjects. The serum copper concentrations were significantly higher in the schizophrenic patients than in the normal control subjects. The average serum copper in schizophrenic females was higher than in schizophrenic males, but the difference was not statistically significant

A pair of MZ male twins concordant for early infantile autism (E.I.A.) is presented. A distinction is drawn between E.I.A. and infantile psychosis (I.P.) with associated mental retardation as a guide to prognosis and the necessity to provide suitable social training and education. The relevance of aetiology is discussed, and the importance of abnormal ante-natal history and delivery status, even in cases with strong genetic predisposition, is noted.

Twenty-six psychotic children were examined by means of psychological tests and EEGs. The parents of these patients were also tested with the EPI and the Grid Test of Thought Disorder. The mothers of children with the symptom of autism tended to have some cognitive disorganization, which was less common in the mothers of children without the symptom. The extraversion and neuroticism scores of all parents were not markedly different from population statistics.

The incidence of EEG abnormality in the children was high and not related to diagnosis or other criteria.

These findings are interpreted as providing suggestive evidence for a two-factor theory of childhood psychosis. It is postulated that a neurological disorder is a necessary condition for the development of such a disorder; and that a second process related to parental characteristics is also involved, which has the effect of determining the particular symptomatic manifestations seen in the psychotic child.

Hysteria (Briquet's Syndrome) and sociopathy cluster in the same families instead of segregating as independent traits. Assortative mating between hysterics and sociopaths increases the observed similarity between relatives, but the familial association between sociopathy and hysteria remains after taking assortative mating into account. The Multifactorial Model of Disease Transmission with three thresholds related to severity and sex accounts for population and family data about sociopathic men, sociopathic women, and women with hysteria. The data were obtained for 227 first-degree relatives and for 800 subjects in the general population.

Depending on the sex of the individual and its severity, the same aetiological process may lead to different, sometimes overlapping, clinical pictures. Specifically, analysis indicates that hysteria in women is a more prevalent and less deviant manifestation of the same process that causes sociopathy in women.

Sixty-four per cent of 874 freshmen and sophomore women sent questionnaires about premenstrual and menstrual symptoms returned them. They differed from those not returning the questionnaires only in year of school. As predicted, women reporting premenstrual affective symptoms were more likely than those who did not report them to seek psychiatric care at the Student Health Service and to be diagnosed as affective disorder at the service.

Some conceptual problems in relation to the interaction of genetic influence and social disadvantagement are discussed, and some of the results of a study of 144 families with mentally handicapped children reported. The work of Heber and his associates in Milwaukee is briefly reviewed, and the Edinburgh data discussed in relation to the study in Aberdeen by Birch et al. (1970). Possible strategies for intervention are considered.