Showing papers in "British Journal of Psychiatry in 1959"

Learning Theory and Behaviour Therapy

Abstract: It would probably be true to say that the present position in the psychiatric treatment of neurotic disorders is characterized by the following features. (1) With the exception of electroshock, the only method of treatment at all widely used is psychotherapy. (2) In practically all its manifestations, psychotherapy is based on Freudian theories. (3) With the exception of intelligence testing, psychological contributions consist almost entirely in the administration and interpretation of projective tests, usually along psycho-analytic lines. I have argued in the past, and quoted numerous experiments in support of these arguments, that (1) there is little evidence for the practical efficacy of psychotherapy, whether strictly Freudian or “eclectic” (8, 17); (2) that Freudian theories are outside the realm of science because of their failure to be consistent, or to generate testable deductions (10); and (3), that projective tests are so unreliable and lacking in validity that their use, except in research, cannot be defended (16). I shall not here argue these points again; the evidence on which these views are based is quite strong, and is growing in strength every year. I shall instead try to make a somewhat more constructive contribution by discussing an alternative theory of neurosis, an alternative method of treatment, and an alternative way of using the knowledge and competence of psychologists in the attempted cure of neurotic disorders. It need hardly be emphasized that the brief time at my disposal will make it inevitable that what I have to say will sound much more dogmatic than I would like it to be; I have to ask your indulgence in this respect, and request you to bear in mind all the obvious qualifying clauses which, if included in this paper, would swell it to three times its present size.

Clinical Syndromes in Depressive States

Abstract: This paper is concerned with the development of results obtained from the use of a rating scale for depressive states. 1. Sixty-four male patients suffering from depressive states were classified, on aetiological grounds only, into four groups: Endogenous, Doubtful Endogenous, Doubtful Reactive and Reactive Depressions. It was found that the means of these four groups differed significantly in their scores in the first factor of the rating scale, and in total score on the scale. This demonstrated that endogenous depression was more severe than reactive, and that the first factor, which appeared to be a measure of retarded depression, was also a measure of endogenous depression. 2. The four groups differed significantly in their scores on certain symptoms characteristic of retarded depression, thus confirming that endogenous depression was of the retarded type. 3. The data suggested that endogenous depression not only differed quantitatively from other depressions, but that such patients constituted a different population. This finding, however, did not reach the accepted standards of statistical significance. 4. A group of eight patients with obviously abnormal (“psychopathic”) personalities was compared with the rest. It was found that this group had a significantly higher score on the fourth factor of the rating scale, thus confirming that this factor was related to abnormal personality. 5. These patients showed significantly lower scores than the others in Guilt, Delayed Insomnia, Loss of Interest, Gastro-Intestinal symptoms, Loss of Weight and Age. It was suggested that these symptoms might be regarded as constituting a special syndrome, a subdivision of reactive depression, found in patients of abnormal personality.

An Experimental Study of Schizophrenic Thought Disorder

Abstract: 1. A review of the literature suggests that there is no conclusive evidence in support of the theory that schizophrenics are abnormally “concrete”. On the other hand, a number of studies have clearly supported Cameron's theory that schizophrenics are “over-inclusive”. No study appears to have been carried out to determine what the result would be if measures of “concreteness” and “over-inclusion” were given to the same schizophrenic group. The present study investigated this. 2. The theory of “over-inclusion” was reformulated, and a number of predictions were made from it. 3. A large battery of tests was given to 16 neurotics and 18 schizophrenics matched for age, educational attainment, Mill Hill Vocabulary Score, Progressive Matrices score and Nufferno “Level” score. The group contained no chronic schizophrenic patients. 4. Three Nufferno intellectual speed tests (A1 , A2, and B1) were given under various conditions. Measures of “speed-level” discrepancy, “stress gain” and “persistence” were also obtained. Only two measures differentiated the groups significantly at the 5 per cent. level, and it was concluded that intellectual slowness is not an important aspect of schizophrenic thought disorder. It was hypothesized that intellectual slowness is a by-product of “over-inclusive” thinking in schizophrenics. 5. Four of the Babcock psychomotor speed tests failed to differentiate the groups significantly. It was concluded that motor retardation is not an important characteristic of the present schizophrenic group. 6. The following measures of “concreteness” were given: the Goldstein Scheerer Colour-Form test, the Goldstein Scheerer Object sorting test, Benjamin's proverbs test, and a test of concept formation modified from Feldman and Drasgow's test. Of five measures of “concreteness” used, only one (based on the Object Sorting test) differentiated the groups significantly. It was concluded that this result was due to the heterogeneous nature of the material, which favoured the production of unusual, “over-inclusive” responses, some of which are labelled “concrete” when Goldstein's criteria are applied. 7. “Over-inclusion” measures were obtained from the following tests: the Benjamin Proverbs, the Goldstein Scheerer Object Sorting Test, a specially designed “Object Classification Test”, the Epstein test for “over-inclusion”, and the Leiter-Parting pathways test. Of 13 different “over-inclusion” scores used, 7 differentiated at well beyond the 1 per cent. level of significance. Only 4 scores failed to achieve significance, but these produced differences in the predicted direction. It was concluded that these results support the theory that “over-inclusion” is a fundamental aspect of schizophrenic thought disorder. 8. There was no evidence that “over-inclusive” thinking significantly affects performance on the Wechsler picture-arrangement subtest, although this had been thought likely. 9. There was no evidence that “over-inclusion”, which could produce a defect in “set”, can account for slowness of simple reaction time in schizophrenia. Indeed the present group of schizophrenics surprisingly were significantly faster and less variable than the neurotics in reaction time. 10. An experiment with the Klein and Krech “figural after-effect” test produced slight evidence (significant at the 5 per cent. level) that schizophrenics show less “satiation” effect. This was related to the theory of “over-inclusion” although the results were not thought to be unambiguous.

A Paired-Associate Learning Test for use with Elderly Psychiatric Patients

Abstract: A paired-associate learning test for use with elderly psychiatric patients has been outlined. The test has been shown to be of some value descriptively, and other aspects of its possible clinical usefulness are currently being tested.

The influence of amobarbital (amylobarbitone) and methamphetamine on the focus of attention.

Abstract: 1. Using a combination of the Stroop colour-word interference test and Witkin's coloured Embedded Figures test to assess the focus of attention, ( a ) methamphetamine was found to narrow attention, and ( b ) amobarbital was found to broaden attention. 2. A theoretical basis for expecting a correlation between measures of narrowed attention and the Maudsley Inventory measure of introversion is presented. The data, however, fail to bear out such a supposition since observed correlations between measures of narrowed attention and introversion were significantly negative. 3. The significance of the above findings, as well as certain reservations, are discussed.

Observations on the Pathology of Insidious Dementia Following Head Injury

Abstract: A case of progressive dementia following a head injury is described in which the neuropathological findings were those of Alzheimer's Disease. Reports of other rather similar cases, especially in relation to boxing, are summarized. The possible relation of trauma to the onset of dementia and to the pathological changes is briefly discussed. The remarkable lack of information on this subject is pointed out.

Size Constancy and Abstract Thinking in Schizophrenic Patients

Abstract: 1. The relationship between Size Constancy and Concept Formation in schizophrenic patients has been investigated. 2. A technique has been developed for measuring “Abstractness vs. Concreteness” of concepts and “Publicness vs. Privateness (Autism) of concepts”. 3. It was found that there is a positive correlation between poor size constancy and impaired ability for abstract thinking in schizophrenic patients. 4. It was found that both size constancy and abstract thinking are related to the ability to “break down” gestalts. 5. A cognitive theory—“Selectivity” theory—has been proposed as an explanation of these relationships. 6. The theoretical implications of the “Selectivity” theory have been discussed.

The Origin and Spread of Dementia Paralytica

Abstract: Dementia paralytica is a declining disease. Deaths due to it in England and Wales were first recorded by the Registrar General in 1901 and since that year, when the number was 2,272, the annual figure has fallen steadily until in 1957 it was only 68. Moreover, there is evidence (adduced below) that not more than a small part of this decline can be attributed to improvements in medical treatment. The fear that there might be a recrudescence of dementia paralytica as a result of the spread of syphilis during the second world war has not so far been realized and it seems likely that what is now, in Great Britain at all events, an obsolescent disease will soon become a rarity. Yet there are many unsolved problems in its history. We do not know, for example, why the alleged references to this striking disease were so few and so inadequate until the third decade of the nineteenth century. We do not know why its recognition in many countries was so tardy in spite of the clear description given by the French alienists. Nor do we know why the disease, which at the start of the nineteenth century seems to have been predominantly one of males, has gradually—and at different rates in different countries—become much more evenly distributed between the sexes.

The treatment of depressive states with imipramine hydrochloride (tofranil).

Abstract: Tofranil was tried on 101 patients. The results were encouraging, particularly in states of retarded endogenous depressions. Although this drug is not a substitute for E.C.T., it has a definite place in the treatment of depressed patients who fail to respond to electroplexy or who are physically unfit to have E.C.T. Further trials should be undertaken to assess its further indications. The drug proved to have few side-effectsand comparatively low toxicity.

Sensory deprivation and schizophrenia.

Abstract: Twelve schizophrenic patients were placed in conditions of sensory deprivation for short periods. They were more tolerant than normal subjects of these conditions, which seemed to reduce the intensity of hallucinations. I am indebted to the British Broadcasting Corporation for the gift of a soundproof cubicle which had been used in one of their programmes, to the House Governor and Chief Engineer of Bethlem Royal Hospital and the Maudsley Hospital for its erection in a disused padded room and to Doctors Cohen and Penfold for help with the observations.

A Comparison of the Psychological Effects of Acute and Chronic Administration of Chlorpromazine and Secobarbital (Quinalbarbitone) in Schizophrenic Patients

Abstract: Twelve male schizophrenic patients who had been hospitalized for one or more years were tested on four psychological tests after both single doses and chronic (11 days) oral administration of chlorpromazine and secobarbital The effects of single doses of both drugs were compared to those effects found in normal subjects after single oral doses of the same drugs in a previous experiment The following conclusions were drawn from the data: 1 Single doses of 200 mg of both drugs caused a significant deficit in test performance 2 After 11 days of chronic administration (seven days of 100 mg twice daily and four days of 200 mg twice daily) a 200 mg test dose of chlorpromazine no longer impaired functioning; a 200 mg test dose of secobarbital, given after a similar schedule of secobarbital administration, still significantly reduced level of performance 3 Single doses of 100 and 200 mg chlorpromazine caused less impairment in schizophrenic patients than in normal subjects 4 Secobarbital impairs performance of schizophrenic patients and normal subjects to the same extent

Prognostic factors in the electroshock treatment of depressive states. I.-Clinical features from history and examination.

Abstract: 1. The importance and historical development of the search for reliable prognostic guides for the electroshock treatment of depressive states is briefly indicated. 2. The design of an investigation into alleged prognostic indices is described, using a rating scale of depressive symptoms and signs for the assessment of clinical status. Fifty female patients, aged 41–60, with primary depressive illnesses were investigated, their physique measured, and later treated by E.C.T. Re-assessments of clinical condition were made at 1 and 3 months after the completion of treatment, and the association between specific clinical factors and quantitative symptom-ratings examined statistically. 3. A significant relationship with response to electroshock was found between patient's age, physique and a clinical-item scale (Hobson) derived from the history and examination. 4. Certain of the results support the view that there are at least two clinically separate varieties of depressive illness.

A Follow-Up Study of Criminal Psychopaths

Abstract: One of the most important questions in dealing with psychopaths is the prognosis. In 1948 two of us made a study (Stafford-Clark, Pond, Lovett-Doust, 1951) of a number of criminal psychopaths and a control group of ordinary criminals in prison by clinical and EEG methods, with the object of revealing the characteristics which most significantly distinguished psychopaths from others, and which were, therefore, most crucial in diagnosis. The psychopaths were carefully chosen in collaboration with two experienced prison medical officers. The later criminal behaviour of these psychopaths and controls is equally interesting, however, if we are to understand what the diagnosis implies (Gibbens, 1951). The third author (T.C.N.G.) has therefore been conducting a continuous follow-up, with the collaboration of the Prison Commission and Criminal Records Office. The results of the first follow-up, from 1948–1953, have been published (Gibbens, Pond and Stafford-Clark, 1955), and were reproduced in the transactions of the Royal Commission on the Law relating to Mental Illness (1957). The present paper deals with a further period of study, so that the follow-up is now from 1948-June, 1957.

Husbands and wives admitted to mental hospital.

Abstract: The nature and frequencyof mental disorders affectingboth husband and wife are relevant to the possibility of assortative mating with respect to certain of these disorders. Eleven couples admitted to the Ontario Hospital, London, Canada, during the past few years, have been studied, and the results compared with those of a similar investigation by Penrose (1944). It is concluded that a variety of factors may be responsible for the unexpectedly high frequency of admission of both marital partners to mental hospital. Observed similarities in diagnosis of spouses admitted at different times, however, suggest a true increase in the frequency of similar disorders in the spouses of certain patients, which may be at least partly attributable to assortative mating among those predisposed to these disorders.

The thirty-third Maudsley Lecture: Trends in child-psychiatry.

Abstract: Too deeply moved to search for originality of expression, I hope that you will allow me to fall back on some of the well-worn phrases in acknowledging the honour conferred on me when I was chosen to be this year's Maudsley lecturer. My reaction was summarized in my reply to the notice which reached me in May, 1957. I wrote: “I accept amidst an understandable struggle between pride and humility. The name ‘Maudsley Lecture’ has an almost hallowed connotation among my professional contemporaries, and this invitation comes to me as a sort of crowning acme of my career.” I am delighted to share my laurels with the Johns Hopkins University, which I joined exactly thirty years ago at the call of Adolf Meyer, whose gigantic contributions to psychiatric theory and practice were attested by the Royal Medico-Psychological Association when he was nominated to be the fourteenth Maudsley Lecturer in 1933. In going over the list of my illustrious predecessors in this series of addresses, beginning with Sir James Crichton Browne and Sir Frederick Mott, I find that I am the second United States psychiatrist to receive so great a distinction. I am certain that I voice the sentiments of my University when I say that it considers this event as an added and happily displayed feather in its richly decorated cap. The Johns Hopkins University has recognized the growing importance of child psychiatry by creating a full professorship in this discipline, and I am pleased to be the symbol of this recognition. And now your Association has indicated its desire that I speak as a child psychiatrist “as this specialty has not been covered in a Maudsley Lecture before”. To have been selected as the first spokesman for child psychiatry in this group is a thrilling experience laden with heavy responsibilities.

Gilles De La Tourette's Disease

Abstract: Gilles de Ia Tourette's disease is described, and a further two cases of this rare condition are presented. Treatment with chlorpromazine, not previously described, was remarkably effective. The prognosis is usually poor, the disease often terminating in psychosis. The aetiology is reviewed, and the differences between tics and compulsive neurosis are discussed. The occurrence of tics after organic brain disease suggests that there may be an organic basis to this disease.

A preliminary experiment on paranoid delusions.

Abstract: This paper advances the view that the experimental clinical psychologist should concern himself, more than he has done hitherto, with the direct experimental manipulations of the psychological disorders which bring patients into the mental hospitals. As an illustration of this point of view an account is given of a preliminary experiment, with a patient diagnosed as a paranoid schizophrenic, on the effect of rational discussions upon persecutory delusions and feelings of guilt. The outcome of the experiment was consistent with the following conclusions: 1. The rational discussion of paranoid beliefs diminished their strength. 2. The discussion of guilt had little effect on the strength of guilt feelings but increased the strength of persecutory beliefs. 3. The effects of a series of discussions were delayed and appeared only after a period in which there was no discussion. It is made clear that further experimentation is necessary before the generalizations described above could be accepted with any confidence, and that the results serve, primarily, to indicate that the direct experimental analysis of psychological disorder might lead to useful results.

Emotion and Blood-Pressure

Abstract: In an investigation of blood-pressure changes during interview, it was found that random emotional stresses were uncovered which had potent pressor effects in normal controls, in hypertensives and in neurotics. It was notable that the diastolic increases were proportionately greater than the systolic, and that those random emotional stresses on average possessed more pressor effect than a deliberately imposed physiological stress such as breath-holding. Certain individuals also showed marked pressor responses to varied stimuli such as being asked to do mental arithmetic, or the desire on micturate. All subjects showed an increase in systolic and diastolic pressures at the start of interview; in the control group this tended to level off symmetrically as the interview closed, but the hypertensive and neurotic groups showed a sustained rise of pressure and the resting levels after interview did not fall as low as the pre-interview resting values. No consistent topics were found to be pressor in effect, but it appeared that pressor responses occurred (1) with novel or “alerting” stimuli; (2) when the subject talked about herself, about illness or about her husband; (3) when the subject's verbal output increased. The heart rate tended to increase along with the blood-pressure, but subjects having higher blood-pressure levels tended to have slower heart rates. Finger plethysmography showed that peripheral vasoconstriction accompanied pressor responses, and vasodilatation occurred as blood-pressure fell. A neurotic patient with labile blood-pressure was interviewed on 24 occasions, and several unusual features are described. No constant or reliable association was discovered to exist between the temporal electro-encephalogram and the blood-pressure changes. It is concluded that two types of emotionally-caused pressor responses may exist; one which may be keyed to the life-situation and is sustained in effect over a period of hours or days or longer, and another which is more transient and may represent a non specifIc alerting reaction.

National statistics in the epidemiology of mental illness.

Abstract: For a long time epidemiology was a term associated with the study of outbreaks of disease which were sudden and large-scale. The attempt to find common causative agents to which the majority of cases could be attributed has provoked a literature worthy to rank with some of the best detective fiction. So many of the guilty agents have now been either liquidated or rendered impotent that infectious illnesses have ceased to occupy the centre of the public health stage, and have yielded place, as objects of concern, to such chronic diseases as cancer, rheumatism, heart disease and the schizophrenias. These diseases do not generally show explosive outbreaks, although mental disorders have been known to behave in this way, as witness the outbreaks of Dancing Mania which originated in Italy in the thirteenth century. All this has led to a more exact concept of epidemiology as “the study of the distribution of a disease or condition in a population and of the factors that influence this distribution” (Lilienfeld (1)).

Experimental Studies of Rhythm, Anxiety and Cerebral Vigilance

Abstract: Initially, a volunteer who had been subjected to very intense, irregular electric shocks, rapidly went to sleep one day when the shocks were less strong than he expected. Further volunteers, who received regular, strong, electric shocks also went to sleep. Habituation of the galvanic skin response, and feelings of derealization occurred. Other subjects were subjected to the difficult task of listening for brief tones at the lower limit of audibility, occurring at regular intervals. Again there was an insistent tendency for sleep to appear over each session as a whole and for EEG sleep signs to occur between each stimulus-response, coming and going at, e.g. 3-second intervals. Further experiments were carried out in which, for periods of an hour, subjects moved rhythmically to loud jazz music. Once again, EEG sleep signs appeared for long periods, even though movement continued. The quality of the latter tended to become impaired however. Once again EEG signs, as of fluctuation between alertness and sleep, at the rate of movement, were seen. Sleep appeared during movement to the loudest and most violent music, but most markedly when a sweet clarinet solo followed. Also when clapping and cheering helped the subject's escape to a dream-world. In the experiments, the respiration tended to synchronize with the movement rhythm. Jazz rhythms occasionally caused hyperventilation. Characteristic differences between sleep and alertness were apparent in the shape of the respiratory curve. Head's term “vigilance” was considered especially suitable to denote the varying cerebral states revealed by the EEG, especially when such variations were very rapid, or were localized to the rolandic areas, or even to the rolandic area contralateral to the hand in use. The hypothesis that the changes seen in these areas are related to proprioceptive afferents, was not supported. The experimental results were related to those of Pavlov, to the phenomena of animal “inhibitory experimental ncuroses” and “animal hypnosis”, and to comparable human responses. It was argued that all the manifestations can be interpreted together in terms of current knowledge of sleep-wakefulness mechanisms and the phenomena of habituation.

Adaptation and conditioning of the galvanic skin response in psychiatric patients.

Abstract: 1. A review of the literature on classical conditioning in psychiatric patients was presented. 2. An experiment was described in which 70 psychiatric patients were conditioned to respond with GSR to a tone, the unconditioned stimulus being a shock. The patients comprised 27 with manic-depressive disease, depressed phase, 18 with schizophrenia, 15 with personality disorders, and 10 with anxiety neurosis. 3. The subjects with anxiety neurosis took significantly more trials to become habituated to the conditioned stimulus before the conditioning trials began, than the subjects of either of the psychotic groups. 4. The subjects with personality disorders conditioned significantly more quickly than subjects in either of the psychotic groups. The subjects with anxiety neurosis conditioned more quickly than those with schizophrenia, only between the .1 and .05 level of confidence. 5. The subjects with anxiety neurosis and with personality disorder tended to make more conditioned responses during extinction trials than subjects in either of the psychotic groups. 6. A high degree of correlation was found in each group of subjects between the rate of habituation to the conditioned stimulus and the rate ofextinction ofthe conditioned response. 7. The implications of these findings were discussed.

Prognostic factors in the electro-shock treatment of depressive states. II.-The application of specific tests.

Abstract: 1. The application of specific tests of alleged prognostic value to a group of 50 female depressives, subsequently given E.C.T., is described. These included the systolic B.P. response to injected methacholine, the “sedation threshold” to sodium amylobarbitone, the reaction to intravenous methylamphetamine, and a psychological test, the Feldman “Ps” Scale, derived from the M.M.P.I. 2. Difficulties found with the techniques and evaluation of the tests are described and the results discussed in relation to previous work and their significance. 3. With the B.P. response to methacholine only the maximum observed fall of pressure was found to have a moderately high correlation with outcome after E.C.T. This relationship was not sufficiently close for unequivocal prognostic guidance. 4. The sedation threshold to amylobarbitone (using speech-slurring alone) did not distinguish between “neurotic” and “psychotic” depression in this series. Correlations between the threshold and symptom-rating scores after treatment were too small for predictive purposes. 5. The overall clinical response to a 15 mg. dose of intravenous methylamphetamine (“methedrine”) showed a clear tendency to separate patients into two groups closely related to diagnostic category, with lesser prognostic implications. 6. The “Ps” Scale (Feldman), derived from the M.M.P.I., had no significant relationship with outcome to treatment.

Observations on the Psychotogenic Effect of N-N Diethyltryptamine, A New Tryptamine Derivative

Abstract: After discussing the hallucinogenic derivatives of tryptamine known thus far and their significance, the authors outline the symptoms of the model psychosis which followed the intramuscular injection of a single dose of 0.65 to 0.85mg./Kg. body weight of diethyltryptamine. A total of 71 test subjects (30 normal, 41 psychotics including 29 schizophrenics) have been involved in the study. The model psychosis produced by DET can be best likened to a moderate mescaline intoxication, although in some features it resembles the LSD effect. The effect is over in 3 hours. An illustrative protocol is presented and examples showing how the drug may help in psychotherapy are discussed in brief. The EEG changes produced by diethyltryptamine are described shortly; these bear resemblance to those produced by mescaline and LSD. It is suggested that a correlation may exist between the tryptamine derivatives and the exogenous reaction types of mental condition.

The Temporal Reliability of the Maudsley Personality Inventory

Abstract: The value of the MPI as a research tool is alluded to. A test-retest investigation into the temporal reliability of the questionnaire is described. It is concluded that the MPI has a satisfactory temporal reliability in relation to both personality dimensions, E-I and N-N. This reliability appears unaffected by hospital treatment and imprisonment.

Controlled Trial of Straight and Modified Electroplexy

Abstract: 1 A controlled trial of electroplexy was carried out on 118 patients suffering from depressive illness They were given treatment either unmodified, modified by thiopentone alone, or by thiopentone and suxethonium bromide 2 There was no significant difference in number of treatments, length of stay in hospital, clinical outcome or follow-up after six months between the unmodified electroplexy and that modified by anaesthetic and relaxant drugs 3 Comment is made on the improved results produced in patients receiving thiopentone alone prior to treatment