“Fear is more pain than is the pain it fears.”

Sir Philip Sidney.

In the opening chapter of his Body and Mind (1873) the physician and philosopher whom these lectures commemorate wisely insists that our inquiries into human faculties should begin with the elementary and proceed only later to the elucidation of the complex. “Surely,” he says, “it is time that we put seriously to ourselves the question whether the inductive method, which has proved its worth by its abundant fruitfulness wherever it has been faithfully applied, should not be as rigidly used in the investigation of mind as in the investigation of other natural phenomena. If so, we ought certainly to begin our inquiry with the observation of the simplest instances …” In the chapters which follow he applies this principle, and—or so it seems to me—provides a number of healthy correctives to much modern thinking and writing, and not least to the opinions of those who have allowed too little or assumed too much in their appraisals of the body-mind relationship. If we have for too long separated psyche and soma, past and present, organism and environment, individual and society, in our attempts to fathom Man, may not an extension of interest in a primitive emotion such as fear, in which the interdependence of all of these is manifest, have value?

In recent controlled trials, conducted by the authors (1956), we were interested to note the proportion of patients improving with the administration of placebos. A placebo is defined in the Shorter Oxford Dictionary (1944) as “A medicine given more to please than to benefit the patient”. It is presumed that, implicit in this definition, is the qualification that the doctor is aware of the relatively inert qualities of the substance, whilst the patient is not. There is, of course, a type of patient who derives considerable benefit mainly by virtue of the fact that he has been pleased. In spite of the discovery of increasing numbers of drugs with specific properties, the prescription of placebos is still common practice. Dunlop et al. (1952) analysed over 17,000 prescriptions of which about one-third were tonics, stomachics or sedatives; although barbiturates cannot strictly be called placebos, the spirit in which they are prescribed frequently puts them near to this category.

In view of their many inter-connections with the cortical grey matter, the effects of lesions in the basal cerebral nuclei are of the greatest theoretical interest. On account of the rarity of naturally occurring lesions confined to these nuclei, there have been few reports of psychological changes in patients with discrete subcortical lesions. Smyth and Stern (1938) described four cases of intrinsic tumour of the thalamus, all of whom gave evidence of organic dementia early in the course of the disease. Eaton et al. (1939) reported six cases of symmetrical cerebral calcification preponderating in the basal ganglia, with no radiographic evidence of cerebral atrophy, of which the clinical concomitants included mental retardation. Alford (1948) has gone so far as to insist that destruction of thalamic nuclei is alone responsible for intellectual impairment, and that “focal” defects associated with different cortical lesions are related either to sensory disturbances or to the psychiatric state of the patient.

Several recent studies have found markedly increased rates of schizophrenia among West Indian immigrants to the UK. Almost exclusively, authors have sought psychosocial explanations for these findings. This paper hypothesises that environmental causes, notably obstetric complications and perinatal infections, provide more plausible aetiological models, especially for the raised rates of schizophrenia among second-generation West Indian immigrants.

Thirty-nine female out-patients with bulimia nervosa were assessed for personality disorders using the PAS. All subjects then entered a therapeutic trial, comprising eight weeks of cognitive-behavioural therapy with follow-up after eight weeks and at one year. Thirty-nine per cent of the patients were diagnosed as having personality disorders. Patients with personality disorders were more depressed and had a lower BMI than those without. They also had a significantly poorer response to treatment, but the difference between groups did not reach significance when mood and BMI were controlled for. Personality disorder alone does not predict a poor response to treatment, but comorbidity with depression and low weight increases the likelihood of a poor response; these patients are unlikely to respond to brief psychotherapeutic interventions.

Thirty-nine chronic schizophrenic male out-patients and their relatives were interviewed separately to assess their perceptions of their current relationships. Two simple 5-point rating scales predicted the risk of psychotic exacerbation during a one-year follow-up: patients' perceptions of the relatives' attitudes towards them, and patients' own attitudes towards the relatives. Survival analysis of data in a 2 × 2 factorial - combining degree of contact with the key relatives and the patients' perceptions of their relatives - found that patients in frequent contact with a positively perceived relative had significantly better survival rates without psychotic exacerbation. Patients' perceptions of their relatives may help identify patients at risk of exacerbation of their illness.

A representative sample of elderly people residing in the community was examined to establish their psychiatric status. An interview with a close friend or relative, focusing on a one-week period in 1981, was used to investigate each subject's functional limitations and troublesome behaviour, these being the two components of the Social Breakdown Syndrome. The data from the sample were weighted to allow estimates of the characteristics of the general population. No cases of SBS at its most extreme were identified, and almost the entire population was found to be functioning at an adequate or near-adequate level: all cases of severe SBS were attributable to troublesome behaviour. Severe SBS was shown to increase with age and to be most common in non-white males. Persons with dementing disorders were more likely than their non-demented counterparts to show severe/moderate SBS, but in the majority of cases of SBS there was no mental disorder.

A 40-year-old woman suffering from major depression with psychotic features was unresponsive to conventional therapy. After the administration of a wide range of drug treatments and ECT, she received clozapine. Depressive symptoms improved and psychotic features disappeared. It is suggested that clozapine could be efficient in psychotic refractory depression.

Urinary MHPG (3-methoxy-4-hydroxyphenyl-ethylene glycol) was measured in seven anorexia nervosa patients during a bed rest and refeeding programme. MHPG levels were positively related to increase in body weight.

Sixty agoraphobics were treated by behavioural therapy (self-exposure in vivo) either with their partner involved in all aspects of treatment or without their partner. The two treatment formats were about equally effective. Behavioural treatment directed at the agoraphobia resulted in improvement irrespective of marital quality and partner involvement in the therapy. The effects of treatment led neither to a deterioration of the marriage nor to adjustment problems in the partner. Avoidance behaviour, intropunitivity and overprotection were found to predict treatment response. The partners of agoraphobics were not found to have psychological problems themselves.

Do the relatively high N-scores observed in neurotic patients reflect a stable characteristic of the neurotic's personality, or are they temporary manifestations occurring only in the acute phase of the illness? Similarly, do the relatively low E-scores of dysthymic patients remain low through variations of clinical state or are they also temporary? The temporal stability of M.P.I. scores is of some practical importance. Criteria for psychiatric diagnosis often include assessments of personality before the illness. Fairly reliable information about this can often be obtained from relatives, but in other cases the clinician is faced with a problem that might appear insoluble. How is he to assess previous personality during an acute illness which may influence the behaviour on which personality is judged?

Already an extensive literature exists on affective disorders, particularly depressive illness, in various developing countries of the world (Carothers, 1947; Tooth, 1950; Lambo, 1956 and 1960; Asuni, 1962; Pfeiffer, 1962 and 1963; Yap, 1965). Different authors have commented on different aspects of these disorders, and variations in their incidence, symptomatology and course have aroused widespread speculation regarding possible cultural influences on aetiology and clinical picture.

The increasing use of tranquillizers in the treatment of mental disorders has made it imperative to study both the immediate and long-term effects of these drugs in order to establish their limits of safety. One of the approaches that appeared important to us was the correlation of the histological findings (Roizin, True and Knight, 1959) with tissue levels of the drug. In addition to its significance from the pathological standpoint, such a study may also furnish information towards a better understanding of the mechanism of action of these drugs.

The treated one-year prevalence and point-prevalence of schizophrenia, schizoaffective psychosis, and paranoid state in the city of Salford were derived from the Salford Psychiatric Case Register. The high rates found are attributed primarily to the effects of selective migration from the area. A breakdown of the use of health services in the area by patients with these diagnoses is given; hospital care was found to be the major form of treatment.

Munchausen's syndrome in a man of subnormal intelligence is described. The case is unique for the extent of detailed, corroborated history. This man has been a voracious consumer of NHS and other services, and an estimate has been made of his cost to the health and prison services. The case raises various ethical, forensic, and resource issues.

The environment of most out-patients involves driving and also drinking. ‘Tranquillisers’ alone or in conjunction with alcohol may contribute to the road toll (Milner, 1969). Animal laboratory and human studies indicate that a variety of drugs may potentiate the effects of alcohol (Forney and Hughes, 1968; Milner, 1970).