Weight change and sleep disturbance are well documented features of psychiatric illness. Complaint about difficulty in getting off to sleep is a common feature of neurotic illness, especially anxiety states. Early morning waking has for many years been regarded by some as a clinical feature—almost a diagnostic pointer—for ‘endogenous depression‘. Motor restlessness is also commonly described as a feature of this disorder. However, other clinicians have concluded that such depressive illness is merely one end of the spectrum of the depressive response. In particular, McGhie (1966) has shown that sleep disturbances of all kinds, as reported by the patients themselves, may occur in a variety of psychiatric illnesses. For instance he found that early morning waking was reported in 16 per cent of non-depressed psychiatric patients as distinct from 17 per cent of patients presenting with depression. Moreover, Hinton (1963) has shown that early morning waking when carefully measured does not specifically characterize those types of depressive illness described by others as ‘endogenous', but that it can occur in all types of depressive illness. He also reported his observation that sleep disturbance amongst depressed patients is mostly related to the phenomenon of agitation. Agitated patients lost more sleep, most apparent in the latter part of the night. On the other hand Carney et al. (1965), in their study of over 100 patients with depression, found that certain symptoms clustered into two groups reflecting the usual concepts of ‘endogenous' and ‘neurotic’ depression respectively. Early morning waking and weight loss were important characteristics of their group of patients designated ‘endogenous' depression, and were regarded as important indicators for them of the value of ECT. There was a positive inter-symptom correlation of 0.234 between weight loss (7 lb.+) and early waking. Most studies do not suggest a causal link between weight change and sleep disturbance, but by inference regard these features as being more integral aspects of an underlying biological factor which also promotes the disturbed mood.

If, at this distance in time, neither Mapother's nominalism nor Golla's vitalism-holism are at all satisfying, this is because so much has happened to the philosophy of science in the interval. The writings of Sir Karl Popper have had a revolutionary influence; and the important work he has done over thirty years or so is readily available in The Logic of Scientific Discovery (LSD, 1968) and Conjectures and Refutations (CR, 1969). Popper starts from the position that no logical basis for the accumulation of knowledge can be laid on inductive processes (and he also maintains that this is not the way the mind of the scientist works). From observing crows, and seeing that one after another they are all black, one cannot conclude that all crows are black. In general terms, it is not possible to proceed logically from single existential (‘there are …’) statements to universal statements; and an epistemological process that based itself on induction would be rocky at its very foundations. How is it then that science progresses, making mistakes from time to time, but recovering from them, providing for itself a firmer foundation for further work, anchoring it more deeply and extending it more widely? This could only be if the basic logical processes were not, in fact, inductive, as the nineteenth century scientist supposed. The search for an acceptable basic principle came down to finding a criterion of demarcation which would distinguish the empirical sciences from other branches of learning. Popper found it in the principle of refutability.

Ever since Kraepelin introduced his schizophrenic-manic-depressive dichotomy in 1896, this classification of the functional psychoses has enjoyed virtually unanimous acceptance. However, the frequency with which the differentiation of schizophrenia from manic-depressive psychosis seems to present problems in clinical practice inclines one to question whether Kraepelin's classification was entirely adequate. The object of this paper will be to try and highlight some of the reasons for the existing confusion and tentatively to suggest possible means of clarifying the situation.

In 1965, when this study began, there were no clear guidelines about the optimum duration of in-patient treatment for alcoholics. Davies et al. (1956) had reported that at the Maudsley Hospital the aim was for a ‘short stay’ of between two and three months—but some individuals stayed for up to ten months. The policy at Warlingham Park Hospital as described by Glatt (1955) was for an in-patient stay of at least two months, though ‘on the whole about three months is the optimum period’.

From beginnings in imaginative literature and philosophy, the study of abnormal personality was taken up by clinicians who founded their investigations on the methods of observation and intuition. On the basis of case notes, experience and recollection, the pioneering psychiatrists constructed descriptive classifications which served as an initial taxonomy and enabled diagnostic and therapeutic work to proceed.

Previous studies (McConaghy, 1969, 1970a; McConaghy et al., 1972) evaluated the efficacy of three widely different forms of aversion therapy in treating homosexuality. The methods investigated were aversion-relief, apomorphine therapy, and avoidance conditioning.

The first three cases of tardive dyskinesia were described in a brief communication by Schonecker (1957), and in the following ten years some 600 new cases were reported in 37 papers. Since the literature up to 1967 has been reviewed by Ayd (1967a) and myself (1968a), this communication will deal mainly with the publications of the last five years. I will also report a few personal observations of the last two years, hitherto unpublished.

There has been a reawakening of interest in the classification of psychiatric patients. Clinicians and researchers alike have realized that it is impossible to evaluate methods of treatment, determine aetiology, or measure the course of illness of psychiatric disorders without adequate methods for diagnosis. On the other hand, it has been shown that conventional clinical methods for making psychiatric diagnoses are of distressingly low reliability, except for the broadest categories, and have only marginal relationships to such criteria of validity as common aetiology, common response to treatment, and common prognosis (Baldessarini, 1970; Beck et al., 1962; Jenkins, 1966). Klein (1967) has shown that the usual clinical diagnoses, because of low validity, can actually obscure important relationships between types of psychopathology and such crucial variables as response to treatment.

Several researchers, among them Penrose (1944), Slater and Woodside (1951), Pond et al. (1963), Kreitman (1962, 1968) and others, have found that psychiatric disturbance occurs in both members of marital pairs more often than can be expected by chance. It appears that symptoms in the spouse are more evident when it is the husband who is the patient, and that neurosis rather than psychosis is associated with higher levels of disturbance in the spouse (Kreitman, 1962, 1964).

The Second Cogwheel Report on the Organization of Medical Work in Hospitals reaffirms the need for this type of organization in the impending reunification of the Health Service and describes the functioning of such systems since the First Report. The Divisional structure, with a small Executive Committee composed of representatives from each specialty division, is described again. There is emphasis on the Executive rather than Advisory functions of the Executive Committee, and the need is stressed for Divisional representatives and Chairmen of Executive Committees to be vested with responsibility and authority by their colleagues to take decisions on their behalf. Mention is made of the development of psychiatric Divisional Structures in psychiatric Groups, based on teams serving particular areas of population, and it seems obvious that these should be linked with Cogwheel systems of related general groups. We would only comment that the psychiatric consultant staffs, based traditionally on the psychiatric hospitals and now reaching out to units in district general hospitals, have always functioned as a clear-cut division in the Cogwheel sense, organizing, planning, advising and coordinating in their multi-disciplinary style. Other specialties have tended to organize and function more on a Hospital Staff Committee level without the advantages of the specialty division. The new advantage of Cogwheel for psychiatry seems to lie 8 in its association with other specialties at Executive Committee level.

For the study reported in the accompanying paper (Willems et al., 1973), a number of variables, thought to be of prognostic relevance in alcoholism, were selected and categorized in a rank order. These can be regarded as ordinal scales, since in every case (a) each category differs from the others, and (b) each is related to the others. In each case there can be said to be an underlying continuum and in all cases a higher number indicates, in our opinion, a less ‘desirable’ state.

Hypochondriasis, though recognized as common and important, has not been accorded the study that its ubiquity and prominence might be thought to require. It is not long since anecdotes and uncontrolled observations masqueraded as knowledge.