In this paper we consider another aspect of the marriages of male neurotic patients and their wives, namely the pattern of role-playing within the marriage and the family. Though no formal predictions were made regarding the differences that might be found between the marriages of the patient and control groups, it was hoped that examination of the role-activity patterns would illuminate the data already reported in Part I and II on health, personality, time-sharing and social activity.

One of the many possible ways of obtaining information about the marital relationship is by observing the marital partners together, a procedure being increasingly used in clinical practice. Little is established, however, for either clinical or research purposes, about how such observations may be ordered, with what reliability they can be made, or how they relate to other aspects of marital function and to the psychological health of the partners. This paper is concerned with just such issues.

Comments have been frequently made on the differences in the symptomatological pattern of depression in different cultural groups. Kraepelin (1921), in his study on the incidence of depressive illness in Asian countries, mentioned that depression in Java was characterized almost exclusively by excitement and confusion and that ideas of sin and suicidal tendencies were absent. Carothers (1958) could not elicit feelings of guilt or self abasement in depression among the Africans of Kenya. Lambo (1956), of Nigeria, thought that the rarity of depression observed by many workers in African countries might be due to erroneous diagnosis, and that most of the cases remain concealed by the label of ‘neurasthenia’. Out of fifteen cases of definite affective psychosis seen by him only one showed guilt feelings, self-condemnation and anticipation of punishment. Multiple somatic features, phobic and obsessional symptoms and anxiety were common. Yap (1965), commenting on the findings of various workers about depression in African countries, states ‘there is agreement among these authors on the rarity of outspoken affective illness, lightness and short duration of depression with an absence of ideas of sin and guilt, the relative frequency of manic pictures, the common association with confusional symptoms, and a very low suicide rate.’ He also refers to Pfeiffer's findings about the frequency of hypochondriacal depression in the Chinese. The absence of delusions of sin in Chinese as well as in Japanese depressives has also been noted by Yap (1958). On the other hand, Eaton and Weil (1955), in a study concerning the Hutterites, have reported a high incidence of guilt-ridden depression.

In depression alteration in mood is accompanied by pronounced physical and behavioural changes. Characteristically there is a decline in appetite, weight and libido, insomnia and a disturbance of diurnal rhythm. A slowing of thought and movement to the point of severe retardation or even stupor may occur. Anxiety is often present and in agitated depression is accompanied by restless psychomotor activity. As lesions in the hypothalamus may produce disturbances in appetite, weight, libido and sleep, it has been suggested that hypothalamic dysfunction may play a part in the aetiology of those depressions in which physical symptoms predominate (Pollitt, 1965).

There are well over 50 published reports since 1949 on the use of lithium salts in psychiatric disorders, most of them in the decade since 1960. Considering only those studies reported in acute manic states, it is difficult to arrive at a reliable assessment of the specific therapeutic effect of lithium because quantitative evaluations were seldom employed, so that comparisons of outcome have to be based on statements of degree of improvement which are subject to varying interpretations. Furthermore most of the studies were not adequately controlled, and the diagnostic criteria used were not always clear.

The reports on the good effect of L-DOPA on Parkinson's syndrome and on some forms of depression have prompted us to investigate if it might alleviate mental disorders not responding to conventional methods. Pare et al. (1962) suggested distinguishing between types of depression according to how they respond to antidepressant drugs. If L-DOPA were shown to be effective, it would provide another means of differentiating between obscurely defined mental states. We present five cases of psychic disorders in which depression was a prominent symptom. All were treated with L-DOPA after a wide range of conventional treatments over many years had proved of little use.

Since the classic report in 1888 by the Committee on Myxoedema of the Clinical Society of London, there has been a wide interest in the psychiatric aspects of hypothyroidism. Despite many reports which followed, Asher (who in 1949 coined the term ‘myxoedematous madness’) had this to say: ‘Myxoedema is one of the most important, one of the least known and one of the most frequently missed causes of organic psychosis'. Most studies have been clinical descriptions with no correlation of the degree of affective disturbance with the severity of disease process.

Cohen (1960) defined risk-taking as ‘embarking on a task without being certain of success', and he agreed with Stengel (1958) that it is possible to gain a better understanding of attempted suicide if we regard it as conveying a degree of uncertainty that the attempt will succeed or fail. Investigation after a suicide attempt usually reveals that the patient was at the time uncertain about the toxic effects and lethality of the overdose, and uncertain of whether others would intervene before the poison could take effect. Taking the widely held view that in most cases of so-called attempted suicide the prevailing motives are directed towards survival with all the advantages of having risked self-destruction, it might be argued that the attempt succeeds by avoiding rather than causing death. The alternative term ‘parasuicide’ suggested by Kreitman et al. (1969) is less paradoxical.

The care of the mentally subnormal in Britain has quite suddenly become a live and prominent issue, but public indignation fades quickly and political interest is soon transferred to other issues that are constantly arising. The time seems ripe to re-think the overall philosophy of provision for the mentally subnormal in a developed industrial society, and in particular, the place of the large institution (Craft, 1970; and McKeown, 1970). These institutions resulted from conditions which no longer exist, and they now attempt to carry out a variety of functions, which many think ought to be separated. However, the subject remains a very controversial one (Shapiro, 1969, 1970; Freeman, 1969a).

This investigation is an extension of a study carried out recently (Lowe, 1966) with educationally subnormal school children.

Systematic desensitization is unquestionably the most popular of the behaviour therapies. To circumvent several difficulties specific to this technique we devized a new treatment paradigm—the reciprocal inhibition of anxiety by aversion relief (Solyom and Miller, 1967), from which 31 of 40 phobic patients (80 per cent) benefited (Solyom, Kenny and Ledwidge, 1969). The present paper reports on a systematic comparison of the two treatment techniques in terms of: (1) the rate and degree of improvement; (2) the specificity versus the generality of improvement; (3) prognostic indicators favouring one treatment over the other.

Since Wolpe (1958) developed the idea of psychotherapy by reciprocal inhibition, systematic desensitization has emerged as an effective method of treatment in phobic states. There exists, however, a group of phobias which cannot be effectively treated with these techniques. These include fears of death, illness, harming other people, etc., and have been recognized by other authors as a separate group by themselves (Marks et al., 1969; Marks, 1969, 1970): phobias of internal stimuli. The search for a suitable method to treat these cases led us to use the thought stopping procedures described by Wolpe and Lazarus (1966, p. 132). There has been a notable lack of literature concerning this method, although Wolpe refers to J. A. Bain who used this technique in 1928.

This is a case in which it seems reasonable to assume that a patient developed a maladaptive conditioned response, which was symbolic of an underlying conflict. She was treated successfully by a single session of behaviour therapy. Not only did the symptom disappear, but there seems to be an improvement in the underlying unconscious conflict.

Most psychiatrists who have made a study of abnormal psychosexual development accept Money's postulate as to the manner in which heredity and education determine sexual development. This assumes that genetical and hormonal factors influence psychosexual development only through bodily shape, while sexual behaviour is learned like the native language. Nevertheless, Money himself raises the question as to whether patterns of sexual play, activity and distractibility in the two sexes are not elements of a strong genetical determinism.

Sexual jealousy is both an attitude of mind and an emotional state: the latter resulting from a blending of emotions aroused by an affront to the instincts of mating, self-assertion and acquisition. Sexual jealousy is of particular interest to the psychiatrist, since in its morbid manifestations it destroys marital harmony (Gillard, 1896) and may lead to homicide or suicide (Mowat, 1966). Sexual jealousy may be regarded as a normal reaction but it is abnormal when: (a) the jealous person is haunted by what the ‘man in the street’ would recognize as a groundless conviction that his or her sexual partner has been, or will be, unfaithful; or (b) jealousy engendered by actual infidelity is of such intensity as to render the person dangerously aggressive. Examples of the second category are Ruth Ellis, who shot dead her unfaithful lover; and Pilar Garcia-Compte, who killed her husband after he had refused to break with his mistress.

Repertory grid testing (Kelly, 1955; Slater, 1965) of psychiatric patients, using people of significance in the patient's life as elements and eliciting the patient's own constructs has been employed in the clinical setting to demonstrate aspects of psychopathology (Ryle, 1967; Ryle, 1969), to measure change with treatment (Ryle and Lunghi, 1969; Rowe, 1971a) and to assess how far a therapist could predict a patient's responses (Rowe, 1971b). However, no systematic examination has been reported so far into the characteristic features of the construct systems of neurotic as opposed to normal subjects, although some apparent equivalences between grid features and psychological or psychopathological formulations such as identification or splitting have been described. While repertory grid testing remains an essentially ideographic exercise, it is important to identify features characteristic of neurosis if the method is to have more than a descriptive function in the investigation of patients. As a contribution to this we have tested with an identical method a series of students consulting with neurotic problems and a control sample of new students tested on arrival at the University.

Hypomania can be considered as a defence against anxiety, a reaction to the patient's perception of his environment. Perception of the environment in a particular way can ensure the maintenance of a depression (Rowe, 1970). If hypomania is a defence, the cessation of the hypomanic state should mean that the patient then perceives his environment differently.