“… they both felt, after the conclusion of their work, very doubtful as to the possibility of definitely proving the existence of a real differential incidence of any character in order of birth. The whole question seemed so open to fallacious possibility in different directions.”

[Report of comment by G. Udney Yule in the discussion following his joint paper with M. Greenwood at the Royal Statistical Society in 1914.]

Recently there has been an upsurge of interest in the association between behaviour, both normal and abnormal, and birth order. For instance, Barry (1967) has pointed out that in certain societies excessive parental demands are made on the first-born child, and “excessive parental demands could lead to superior achievement in a robust individual or to psychiatric illness in a child who was especially vulnerable …”; thus putting into modern language an interesting genotype-environment interaction which was summed up in the ancient Chinese proverb “fire burns wood but tempers iron”.

In a previous paper (Price and Hare, 1969) we drew attention to some types of bias which may complicate the search for a useful association between disease and birth order. In particular, we considered biases occurring in a sample of adult patients where the patients' mothers have all passed their reproductive period and where, therefore, the sibships of the patients are complete. In such a sample, the recognized methods of searching for an association between disease and birth order are based on the assumption, that, for a null hypothesis, the sample will be randomly distributed among the birth ranks for each sibship size. But in fact the distribution may be non-random, and there are two main causes for this. These are (i) changes in the birth rate of the population, and (ii) changes in the birth rank distribution of the patients between birth and the age-range from which the sample is selected (e.g. differential rates of mortality or migration). The principal aim in the present paper is to illustrate the bias arising from the first of these causes.

A possible association between birth order and schizophrenia has been sought by a number of investigators. The question considered as early as 1916 by Rüdin has not been resolved satisfactorily since; late birth order has been indicated in some samples of patients (e.g. Granville-Grossman, 1966; Schooler, 1964), early birth order in others (e.g. Solomon and Nuttall, 1966; Sundararaj and Rao, 1966) and an absence of any birth order effect has been reported for still other samples (e.g. Burton and Bird, 1963; Gregory, 1959; Smith and McIntyre, 1963).

Physicians are often faced with the problem of determining whether long-stay schizophrenics require continuous treatment with tranquillizers. Prolonged ingestion of ataractics has both physical and economic disadvantages. Recent reports on oculo-cutaneous changes (3, 13, 20, 27, 28), persistent dyskinesia (6, 18) and sudden deaths (16, 25) have focused attention on the potential dangers of prolonged use of tranquillizing medication. On the other hand, discontinuation of medication may lead to recurrence of acute psychotic behaviour. The literature on drug withdrawal provides no solution to the dilemma. The results from drug discontinuation studies are complex and contradictory. Some investigators report extremely high relapse rates while others report little deterioration even when drugs are withdrawn for long periods of time. A brief review of the literature will give some indication of the contradictory nature of results.

Oculo-cutaneous pigmentation has often been reported (Brit med. J., 1967) in patients receiving heavy doses of phenothiazines. This paper sets out to investigate, (a) the incidence of ocular pigmentation in such patients; (b) whether the measures suggested by Valentine and Jardine (1966) for minimizing this complication are effective; (c) the relationship of ocular pigmentation to extrapyramidal symptoms (and hence whether the pigmentation can be regarded as a sign of brain damage).

Since Delay and Deniker's (1) report on the efficacy of chlorpromazine, phenothiazines have become the cornerstone of treatment for schizophrenia. However, the unreliability of patients in taking oral drugs is a major disadvantage which the introduction of fluphenazine enanthate has helped to remedy.

This paper describes a comparison of two therapeutic regimes for depressive illness: (a) imipramine, and (b) a preparation containing amitriptyline hydrochloride and perphenazine in the ratio 25:2 (Triptafen-DA).

The purpose of this study was to evaluate the extent of depressive side effects in women of child-bearing age currently taking oral contraceptives. The incidence of depression has been variously reported as between 2 per cent. and 5 per cent. (Any Questions, 1965), but clinical impression has been that this is an underestimate. Rather alarmingly, also, there has been a tendency to explain away symptomatology on a “scapegoat effect” basis (Bakker and Dightman, 1966). By blaming the Pill the patient has been held to increase her own self-esteem and avoid responsibility for lethargy, irritability, etc. Nevertheless, alert physicians have consistently recommended caution (Kaye, 1963; Grant, 1965).

The diagnosis of pre-senile dementia is a clinical one and implies a state of intellectual and/or emotional impairment due to organic cerebral change.

Although the literature relating to the prognosis of male potency disorders and the factors that influence this is vast, there is a dearth of factual data on the subject. Most of the opinions expressed, without supporting figures, are clinical impressions, and the majority indicate that the outcome of therapy in these disorders is generally favourable (Ellis, 1948; Jones, 1919; Rees 1935; Allen, 1962; Stafford-Clark, 1954; Gutheil, 1959). However, Johnson's (1965b) recent important contribution has challenged this consensus; he suggests that; with or without treatment, the prognosis in disordered potency is much worse than has hitherto been believed.

The majority of “behaviourally oriented” treatments for non-consummation due to vaginismus combine (a) teaching the patient how to relax the perineal muscles, (b) simultaneous vaginal exploration and dilatation, preferably performed by the patient herself, and (c) some form of psychotherapy (Lazarus, 1963; Malleson, 1942; Friedman, 1962; Brady, 1966). Surprisingly perhaps, active participation by the male spouse is considered unnecessary by some experts (Malleson, 1942; Friedman, 1962). Friedman has shown there was no statistical relationship between actively involving the male in therapy and the outcome of treatment.

Results with relationship psychotherapy and with behaviour therapy in the treatment of homosexuality have not differed significantly as far as can be assessed, considering the different criteria used to measure response to treatment. Woodward (1956) reported that 36 per cent. and Bieber (1962) that 27 per cent. of their homosexual patients became exclusively heterosexual following psychotherapy; MacCulloch and Feldman (1967) reported a similar response in 33 per cent. of their patient group following behaviour therapy. The last authors also stated that 58 per cent. of their patients became heterosexual on the Kinsey scale (Kinsey et al., 1948). Mayerson and Lief (1965), using a similarly less rigorous definition of heterosexuality, concluded that 50 per cent. of their group achieved this state following psychotherapy. Freund (1960) considered that 18 per cent. of the group he treated showed a satisfactory response in that they had heterosexual intercourse regularly for several years after aversion therapy. He has been the only worker so far to utilize such a long follow-up period, and also the only one to report that some of his patients at later interviews admitted that they had lied about their degree of response at earlier interviews.