This paper is the first in a series reporting a study of the effects of neurosis on the patient's marriage and marital partner, in which we repeated and extended observations made in a previous inquiry (Kreitman, 1964) and tested certain hypotheses arising from these data.

Too few psychiatrists in Britain have received an adequate training in psychotherapy, and the teaching of human personality growth and development is often woefully inadequate at both undergratuate and postgraduate levels—a state of affairs sometimes justified on the basis that existing knowledge has not been scientifically validated. For some psychiatrists their only training in communication with their patients is in clinical interviewing and their only understanding of their patients emotional life is derived from a study of gross psychopathology.

In the context of Scots urban crime patterns, territorial and indiscriminate, considerable emphasis has currently been placed on physical environment. Although the opinions of magistrates, social workers and various celebrities have been freely forthcoming, a systematic study of the young Glasgow offender's view of his physical and emotional background has been singularly absent. Investigators in the past have attempted to show that when housing is improved, social problems such as delinquency automatically decrease; yet, as early as 1939 Wood commented that it was a popular fallacy that substandard housing was the direct cause of delinquency and crime and that its elimination would result in a crimeless world.

The manifestations of the chronic brain syndrome associated with cerebral arteriosclerosis are notoriously diverse, ranging from disturbance of cerebral functions which can be recognized by physical examination to those which can be identified by examination of the patient's mental state. With widespread arteriosclerotic involvement of the cerebral circulation there are important alterations in the individual's thinking and behaviour. There is disturbance of memory, accompanied by disorientation, at first in time and place and later as to person; and intellectual functions including comprehension, problem solving, learning, and judgement are also impaired.

Introduction The therapeutic community method of treatment was developed by Maxwell Jones at Belmont Hospital (Jones et al., 1952; Jones, 1954; Rapoport, 1960) for the treatment of psychopathic personalities. The method has been applied to an admission unit by Wilmer (1958) and to psychopathic personalities by Craft (1965). Clark (1964) has differentiated between ‘the therapeutic community approach’, of increased activity, freedom and responsibility for all patients in the hospital, and the ‘therapeutic community proper’, the small unit with face-to-face gatherings of all members, social analysis of events, opening of communications, flattening of the authority pyramid and blurring of roles.

Physicians and patients frequently assume a causal connection between life events and subsequent episodes of psychiatric illness. It seems to ‘make sense’ that an illness which is to some extent manifested by disordered emotions could be caused in part by emotion-producing events. But plausibility alone is no proof of the truth of such an assumption. Realizing this, several investigators have conducted systematic studies of the interrelationships of life events and illnesses, both psychiatric and medical. Such work has been reported by Adamson and Schmale (1), Holmes, et al. (3, 7, 9, 10) Brown and Birley (2) Clayton, et al. (4) Morrison, et al. (11) Murphy, et al. (12, 13) and Hudgens, et al. (8). These authors differed regarding the specific question of whether illnesses may be caused by emotion-producing stress. The first six of the above papers presented positive evidence for such a cause-effect relationship. The last four papers reported that psychiatric patients had significantly more interpersonal conflicts than did well persons or medically ill persons, at least while their psychiatric illnesses were in progress; but the latter authors were unable to find evidence that any type of stress, interpersonal or otherwise, played a causative role in the illnesses. Disagreements among all these workers may be traced to differences in both theoretical approach and methodology.

This paper is concerned with certain aspects of the marital interaction of male neurotics and their wives: more specifically it was designed to test hypotheses advanced to explain the findings of an earlier study (Kreitman, 1964), partly confirmed in Part I of this inquiry. The findings in question were (i) that the patients' spouses had a higher level of morbidity than controls, a discrepancy which tended to increase with lengthening of the marriage, and (ii) that patients and their spouses had low or zero correlations on measures of personality and pathology in the early years of marriage, but with the passage of time the interspouse correlation increased, with the spouse coming increasingly to resemble the patient, especially with regard to symptoms: conversely, the control couples generally showed positive correlations early in marriage, but thereafter declined in their level of similarity.

The syndrome of transsexualism has become widely known in psychiatry and is now clearly distinguished from both homosexuality and transvestism, as well as from hermaphrodism (Benjamin, 1953). Other authors such as Wålinder (1968), Hoenig et al. (1964) and others have given definitions of the syndrome, which might be circumscribed as follows: The transsexualists, although physically apparently normal, are nevertheless convinced that they are ‘inwardly really’ persons of the opposite sex; they claim to ‘feel’ like a person of the opposite sex, but think that the body has somehow—by a freak of nature—developed abnormally, and not in accordance with their ‘true nature’. They seek medical treatment, if necessary surgery, to have their body changed into what they conceive to be their ‘real’ sex.

Primary affective disorder is defined as an illness which is characterized by depressions or manias or both. This illness is seen in an individual who has no history of any preexisting psychiatric illness except for uncomplicated episodes of depression or mania. Clinically there are two types of primary affective disorder. The first is manic depressive disease (bipolar psychosis) which may be considered as a primary affective disorder in which mania is seen; usually, but not always, depression is also seen in this kind of patient. The other type may be called depressive disease; a synonym that might be used is unipolar psychosis; here only depressive episodes are seen (one or more episodes). In addition to the difference in the clinical picture, considerable genetic data exist which indicate that the two illnesses are quite distinct from each other.

There have been few cases of this syndrome published since the original papers by Kleine in 1925 and Levin in 1929. Critchley (1962) described 26 cases in his paper, in which he reviewed the condition fully. Earles (1965) mentioned 44 cases in the literature: a female case was recently discussed by Duffy and Davison (1968). According to Critchley the characteristic symptoms of this syndrome are ‘recurring episodes of undue sleepiness lasting some days, associated with an inordinate intake of food and often with abnormal behaviour’. Invariably male adolescents are affected; they are normal in between attacks and the condition tends to disappear in later life.

There is a body of opinion which regards psychiatrically ill individuals, or at least one great class or subdivision of them, as suffering primarily from disturbances in personal relationships and social interaction processes generally. Sullivan, Horney and Fromm have made the most significant theoretical contributions to this subject, and empirical applications have been reported by Balint (1957), Maxwell Jones (1968), Rapoport (1960) and Laing (1961). These writers have at least this in common, that they take the point of view that since the pathology of the illness lies in social relationships the fundamental treatment process must lie there also—must, in fact, consist of re-experiencing social interaction within a therapeutic re-educative framework. In the past attention has been directed principally to the doctor-patient relationship as a heuristic model of social interaction, but Rapoport has extended the operational range of significant interaction to include all staff-patient, staff-staff and patient-patient encounters. As the recent Subcommittee of the Central Health Services Council has pointed out (1968), little has been written of the nurse as therapist, but a considerable literature has accumulated concerning the role of the social worker or caseworker or counsellor (e.g. Halmos, 1965). Halmos investigates the nature of such relationships, and finds therapeutic utility to be unrelated to intellectual skills. The therapeutic process is adjudged to lie in the relationship, true enough, but the essential qualities have more to do with the interpersonal styles of the therapist, than with his analytical expertise. Such is his conclusion. Apparently social skills are necessary for the professional worker, but intellectual skills for the problems to be unravelled are of little importance, and are largely irrelevant.

This paper presents the results of electric aversion therapy in 24 patients with transvestism, fetishism, and sado-masochism. Preliminary findings have been reported elsewhere, together with a review of the literature and a discussion of the process of change during treatment (Marks and Gelder, 1967; Bancroft and Marks, 1968; Gelder and Marks, 1969). In these studies the available evidence indicated that the manifestations of the sexual disorder were diminished by treatment, and this appeared to be directly due to aversion rather than to non-specific components of treatment. The present report is concerned with the clinical outcome of these cases, with prognostic variables, and with the part aversion therapy should play in the treatment of these sexual disorders.

A number of hypotheses have been put forward (Gregory, 1959; Penrose, 1944) to explain the generally found higher incidence of psychiatric disturbance in the spouse of patients with mental illness. The relevant literature has been reviewed by Nielsen (1964). More recently, interest has centred around two contrasting hypotheses which seem best able to explain the available evidence.

In 1943 Kanner described a disease entity which he referred to as ‘Infantile Autism’. Creak and Ini (1960) found no evidence of psychogenic aetiology in a study of 200 parents of autistic children. Bender (1955) retrospectively studied children seen at Bellevue Hospital for behavioural or developmental disorders and who had been diagnosed as schizophrenic before seven years of age. No preponderance of the sophisticated, intelligent, well-to-do parents as described by Kanner was found; every racial and religious group was represented, Jews predominating slightly. A strong genetic predisposing factor was indicated—40 per cent of the parents were schizophrenic. Stroh (1962) insists that the child's condition cannot be attributed to maternal mishandling, and Wing (1966) has said ‘It is possible to interpret the data to support both environmental and biological theories of primary causation, but on the whole the former argument is very difficult to sustain.’

Human blood plasma normally contains 500–1,000 mg./100 ml. of lipid material kept in solution by complex formation in various proportions with protein to form lipoproteins of definite size and constitution. Apart from the chylomicrons at least four β-lipoproteins and two α-lipoproteins are recognized, differing from each other in density. The α-lipoproteins correspond to the α-globulins and the β-lipoproteins to the β-globulins as determined by paper electrophoresis. The various lipoproteins have been shown to possess a constant and characteristic pattern both in protein: lipid ratio and in the relative proportions of phospholipid, sterol, sterol esters and glycerides (Jones et al, 1951; Bragdon et al., 1956). The proportions in which the fatty acids are present have also been shown to be constant (Lindgren et al., 1959).

The process whereby neurotic symptoms are generated, and the degree to which they are linked to pre-existent personality traits, is still a matter of debate in psychiatric and psychological literature. On the basis of the medical model, symptoms may be thought of as intruding unaccountably (from the subjective point of view) into the individual's experience as part of a disease process. This standpoint, where it exists, must be accepted as an article of faith, since no convincing demonstration of how a phobia or an obsession, for example, can be accounted for in this way has yet been put forward. However, cogent arguments have been advanced (e.g. Foulds 1965) for regarding symptoms as distinct from personality traits; in part such arguments have been occasioned by the confusion in psychiatric diagnosis between concepts such as ‘hysteria’ and ‘hysterical personality’.

Two reports have shown that a substantial proportion of patients suffering from various psychiatric syndromes have low serum folate concentrations (Hunter, Jones Jones and Matthews, 1967; Carney, 1967). The present investigation was concerned to examine further the prevalence of low serum folate in a series of depressive patients on admission to hospital. As folate deficiency contributes to the development of mental symptoms in epileptic patients (Reynolds, 1968), we also examined the relationship of low serum folate concentrations to the severity of the depressive illness, certain personality traits, and the response to anti-depressant treatment. The relationship of low serum folate to variables which could influence it such as diet and drugs was also examined. In a proportion of these patients serum folate measurements were repeated just before the patient's discharge. Serum B12 concentrations were also estimated.

That there are wide regional differences in the demand for psychiatric beds is common knowledge, and is frequently commented upon. There is no generally accepted interpretation, and it is difficult to draw conclusions from a comparison between different areas when the crucial treatment facilities—in-patient and out-patient services, admission policies, after-care in the community—are far from uniform. It has been argued that much of the variability in admission rates is independent of mental disorder incidence and reflects other forces at work, such as the organization of the services available to the mentally ill.

Most subnormal patients in hospitals are not there because they require active hospital treatment. Leck, Gordon and McKeown (1967), Pilkington (1966) and Tizard (1964) have suggested that respectively 0·4 per cent, 10 per cent and 12 per cent of the hospitalized patients they studied were admitted as the result of medical advice, or were in need of ‘detailed specialist day to day diagnosis, care and treatment’. This study is part of a computer evaluation of medical data concerning 285 severely retarded children, admitted to hospital for very varying periods during 1964–1966. Altogether 375 admissions took place but of these 86 were readmissions, so there were 289 ‘primary’ admissions, 4 of whom had no traceable documentation, thus 285 (76 per cent) of the 375 admissions were studied.

In recent years research workers have shown a relative lack of interest in the constitutional correlates of normal personality. However, recent findings in the field of psychosomatic medicine suggest the need for a careful reexamination of this field of research. Several studies have indicated that breast cancer, lung cancer, and myocardial infarction patients are more extraverted and less neurotic than hospital control group patients (Eysenck, 1965). Also, duodenal ulcer patients have been reported as being both introverted and neurotic (Kanter and Hazelton, 1964).