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SYSNOPSISDespite diagnostic imprecision and terminological confusion, the concept of personality disorder remains indispensable to clinical psychiatric practice. In relation to the International Classification of Diseases the problems were examined at a seminar which formed part of the World Health Organization's programme on Psychiatric Diagnosis, Classification, and Statistics. The conclusions of the seminar are presented in this paper.

Most psychiatrists today do not question the possibility that psychoses may develop in children, and the existence of childhood schizophrenia has been generally acknowledged. But views on the principal features, the boundaries, the course, and the fundamental nature of schizophrenia vary widely. Indeed, some psychiatrists do not report any psychosis other than schizophrenia in children whereas others very rarely make this diagnosis. Without going into the special problems involved in understanding the fundamental nature of this disorder, I should like to point out that the divergence of opinion has not prevented numerous groups of scientists from conducting in-depth studies of the psychopathology of schizophrenia in childhood (Bender, Bradley, Creak et al., Despert, Goldfarb, Kanner, Lutz, Potter, Simson, Sukhareva, Trammer, Ushakov, Vrono, and others).

During a symposium on the psychotherapy of the psychoses held under the auspices of this Section,† I took occasion to point out that, owing to the nature of their case material, many psychoanalysts had been forced to undertake this branch of treatment, whether they liked it or not. In the case of psychiatric classification the position is somewhat different. However much the psychoanalyst may choose to procrastinate, he cannot postpone indefinitely the task of correlating psychiatric data with his own systematic formulations on mental development. The more precise and dogmatic these formulations become, the more incumbent it is on the psycho-analyst to test them in the psychiatric field. Already some ventures have been made in this direction, notably in the work of Rickman,† Schilder,§ Stärcke‖ and others. The main justification for a renewal of these attempts lies in the fact that during the past four or five years, appreciable advances have been made in the psycho-analytic understanding of early stages of ego development. A great deal has been achieved by the analysis of small children, largely under the inspired stimulus of Melanie Klein, and already this work has produced reverberations in other directions. I am constrained to make this preliminary explanation in the hope of mitigating an impression which I fear still prevails in some quarters, namely, that in its relations to psychiatry, psycho-analysis displays the dogmatic over-compensation of an ignorant and none-too-welcome parvenu. Indeed, I should like to take this opportunity of stating that psycho-analysis, if even on the barest grounds of economy of effort, looks forward to an increasingly close alliance with pure psychiatry. And I hope to be able to indicate in this paper some problems on which the co-operating energies of the two sciences might well be concentrated.

Now that our Association, by a gracious act of our Sovereign, has been granted a Royal Charter—a signal recognition of its achievements and of the humane principles and aspirations of which it is an expression; a change, too, which is emblematic of the growth of its activities and influence—it is not inappropriate that I should address you on some aspects of the practice of psychiatry, especially in regard to possibilities and lines of progress in the future, and as to how the Association might better assist their materialization. The aspect I wish particularly to dwell upon is that which is the title of my address.

I need hardly apologise to you for my appearance once more before you as a reader of a paper, yet I think it well to give you my reasons for selecting this subject for to-day's discussion. For years past I have been feeling more and more strongly that travel as treatment was being carried too far, and having often in private expressed this feeling, I think it right to assert my belief here, fully recognising that I may be looking at the subject from a wrong standpoint, and being quite ready and willing to learn by the experience of others. I recognise in myself a tendency to believe in my own experience, and thus I may be warped.

SUMMARYProblems arising from the categories used in the Eighth Revision of the International Classification of Diseases, and from some of the definitions included in the British Glossary, are discussed. Suggestions are made for changes which would facilitate the use of the I.C.D., firstly for furnishing quantitative data to answer questions about groups of cases, and secondly for retrieval of information about patients with particular syndromes for purposes of research studies. Finally, a multi-axial system for diagnostic coding is described.

The relationship between occupational prestige, socio-economic status, and psychosis has been previously studied and reported by Clark, (1,2) Nolan, (6) Fuson, (3) Tietze, Lemkau, and Cooper. (8) The findings of the last five authors support the position that rates for schizophrenia are greater in the lower socio-economic groups than in the higher socio-economic groups. Clark, in two separate reports, points out that occupational psychoses rates are patterned in the direction of an inverse relationship between psychoses rates and factors of occupational income and occupational prestige.

SynopsisIn close agreement with Essen-Möller, a classification of mental disorders is described. The two basic principles are the application of four independent classifying bases—namely, symptomatology, severity, aetiology, and course, and the breakdown of doubtful disease entities and syndromes to elementary cardinal symptoms and of comprehensive personality terms to simple traits.

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It is a truism that successful treatment in any branch of medical practice, or, indeed, in a wider sense, in any activity in which we may be engaged, depends on an adequate and exact knowledge of the relation of cause and effect, and the conscientious clinician who bears that fact in mind finds the present position of clinical psychiatry one of great difficulty. As a highly esteemed physician remarked a little while ago—during one of those outbursts of professional candour which seem to be necessary at times in the interest of our self-respect, so far as our capacity to really modify the condition of our patients is concerned, we are in the position of interested observers, for we may arrange conditions, we may guard against added stresses, but do what we will, and however hard our endeavour, our patients alter, some to improve, others to deteriorate, with an aggravating indifference to our efforts. It behoves us, then, to be extremely critical of our assumptions in any particular case, to be as precise and as adequate as possible in our description of the whole train of events, and to review very carefully any deductions we may make as to the relation of possible cause and effect.

In discussing this theme before a scientific assembly it is needless for me to say that I make no claim to be the bearer of a new revelation, or the creator of a revolutionary therapeutic. My function is much more modest; it is to raise some questions that may lead to profitable argument, questions which have excited great attention in psychological circles in France, Germany and America, and yet which have scarcely stirred a ripple of interest amongst ourselves. Men of international reputation assure us that they have applied with singular success these psychical methods in the treatment of certain forms of mental disturbance, and our excellent English textbooks in psychiatry either ignore the whole subject or put the reader off with a few superficial remarks that afford no practical insight into the matter. Such men as Freud, Jung and Prince may publish their refined and delicate analyses and we continue to repeat our well-worn formulas, never dreaming for a moment that these men may have something to teach us. Their theories may be right or wrong, but their therapeutic successes are not open to question. Surely here, in Ireland, amid a population peculiarly amenable to psychic influence, it is for us of especial moment to learn how such influence may be exercised and by what methods it can be brought to bear upon disordered personalities. My purpose, then, is to make clear what these methods are, to indicate their strength and their weakness, and to show their bearing on mental hygiene.

The frequency with which I am consulted about both men and women in whom an engagement of marriage has been associated with marked mental disorder, has induced me to bring the subject before this meeting of the Psychological Branch of the British Medical Association, especially as the subject naturally falls into a place in the larger subject suggested by Dr. A. Campbell Clark's papers on the perversions of the sexual and reproductive functions.

A Glossary of Mental Disorderswas published in 1968, prepared by the Registrar-General's Advisory Committee on Medical Nomenclature and Statistics. The document used as a basis the Eighth Edition of the World Health Organization's International Classification of Diseases (I.C.D.), Section V, which deals with mental disorders and mental subnormality. For the first time in this country the meaning of the categories listed in the I.D.C. are described, and the new Glossary stands beside the Second Edition of the American Diagnostic and Statistical Manual (D.S.M. II) which was also published in 1968. The psychiatrists working on the United States-United Kingdom Diagnostic Project at the Institute of Psychiatry, Maudsley Hospital, London, and the Psychiatric Institute, New York, made diagnoses according to the new Glossary descriptions on 820 hospital in-patients drawn from both sides of the Atlantic and interviewed using a standardized interview. The comments contained in this article are based on their experience.

It is interesting at the present time to notice that disorders of the mind are being considered from a broader point of view. No longer is it reckoned sufficient to enumerate the psychic symptoms and to label the case accordingly. In the scientific journals it is not unusual to find the statement that a certain case does not fit into any division of our present-day classification. It is recognised that to describe a case as an atypical example of a disease is equivalent to saying that some factor has escaped our notice, or is one we cannot explain; that ætiology, from the psychogenic as well as the pathogenic point of view, must be considered, and that bodily and nervous symptoms may be as much a part of the illness as are the psychic; in fact, these last are often merely a symbol expressing some change in the function of an organ outside the brain.

In July, 1927, at a British Medical Association meeting, in the Obstetrics and Gynæcology Section, G. I. Strachan dealt with the mental side of the hygiene of menstruation. He made the statements that in cases where menstruation was influenced in mental disease it was usually in the direction of excess, and moreover he had found no justification for the text-book statement that insanity was usually accompanied by amenorrhœa. A study of the more important text-books of psychiatry reveals a paucity of information on the subject, and this has stimulated me to collect any facts which have bearing on this interesting problem.

In recent years research into mental disorders has tended to become more and more the study of the pathology of the living. The advance of biochemistry has contributed in great measure to this practice. Although bacteriological research has, in recent years, been more extensively undertaken in connection with focal infection, it has, in the opinion of most, yielded disappointing results. The study of focal infection by bacteriological methods alone will not, I am afraid, lead us very far. Endeavour should be made to correlate its local and remote effects in disordered hæmopoiesis, disordered metabolism and disordered endocrines in relation to the internal economy of the patient. In mental disease especially this implies a knowledge of the individual's potentialities that have been predestined by heredity, and later moulded by environment—factors which largely determine the psychopathic tendencies of every one of us. The bacteriological researches of Ford-Robertson and McRae (1) strongly suggest that in mental disorders we are confronted by bacteria of a special type, which as chronic infective agents can probably only adapt themselves to a certain group of the general community having a neurotoxic susceptibility. If, then, we are to make further progress in this direction, we must search for and apply new methods of bacteriological technique, study our results, and attempt to correlate cause and effect. In this relation I shall refer to special methods which are an elaboration of my father's work, the value of which time and experience may prove. In spite of the great importance of the biochemical researches of recent years, I think it will be agreed that some of us, especially those who are clinicians, feel disappointed that so far they have not given us as much indication for scientifically applied treatment as we had hoped. May I suggest that the explanation for this is two-fold. Firstly, in forming the basis of any research the present tendency is to take mental disorders in groups, for example, dementia præcox, which has a wide range of symptoms and between which and other groups it is difficult to draw a line of demarcation. It seems to me that our knowledge of the somatic factors underlying mental disorder is as yet so limited that attempts to continue on these lines will lead us only hesitatingly along the path of progress. Are we not still at the stage where our efforts should be concentrated more on the individual as a problem in pathology which, when solved as far as our knowledge permits, can be correlated in the future with his or her psychogenic group? The second point is that in many instances our scientific work tends to run in too narrow channels; thus it must be frequently lacking in the invaluable support of parallel knowledge in other branches of laboratory and clinical experience. The most obvious example is the lack of adequate collaboration between the biochemist and bacteriologist. I know of no two sciences that can be welded together so opportunely. This combination can be taken a stage further: active and intelligent co-operation with the clinician and X-rays and therapeutic specialists should be sought to enable us to appreciate better the intricate problems we have to face. Some of you may, with reasonable grounds, accuse me of theorizing, and I should at this stage like to mention that before I attempted to put these considerations into practice in cases of mental disorder, I had had the opportunity of carrying out exactly similar lines of research on some hundreds of non-mental patients in hospital and private practice. The majority of them were cases obscure in ætiology and symptomatology. This scientific survey proved to me at least the value of comprehensive work on the individual, and how it enabled one to diagnose and treat many cases with some hope of success. During my two years at Wantage House (the new acute hospital attached to St. Andrew's), I have attempted to carry out what this experience has taught me, with the added advantage that the patients have been under my personal care. Further, there has been every facility for dental and general X-ray diagnosis, and, lastly, ample scope for treatment. The success of such a scheme is only possible by organization and the team spirit, and in this I have been singularly fortunate. The cases I am bringing to your notice are 4 out of some 120 which have been subjected to comprehensive overhaul. I will try to emphasize the salient features in each and correlate them with the mental disorder presented. In this way you can judge for yourselves if we have learnt anything that may in the future lead to a clearer conception of what may underlie at least some forms of mental disorder.

The Final Revision of the Classification of Mental Disorders by the Clinical Psychiatry Sub-Committee was passed at the meeting held on February 23, 1932.

It is a common experience in the investigation of mental disorders that glycosuria is frequently found, thus indicating a tendency in such cases to a faulty carbohydrate metabolism. With the exception of epilepsy, this occurrence of glycosuria has been noted in most mental conditions. Intermittent glycosuria is met with in general paralysis (Kraepelin) (1); Bond (2) and Strauss (3) note it in about 10per cent.of their cases. In dementia prócox Schultze and Knauer (4) did not observe glycosuria in the apathetic form of hebephrenia, but often found it to occur with catatonic excitement. With other observers (see Allers (5)) they record the marked association of glycosuria with depressed states, while its occurrence in mania was infrequent except in markedly excited and resistive cases.

In availing myself of the invitation kindly extended to me by the Institute for the Scientific Treatment of Delinquency of speaking to you on “The Treatment of Mental Disorders and Mental Deficiency in Continental Criminal Law “, I have no intention to abuse this privilege by criticizing the corresponding English law or by making suggestions for its improvement. For the latter task I feel myself neither competent nor authorized, as I am only too well aware that every important legal change is dependent upon many considerations which the foreign observer—though possibly conversant with the external facts—can appreciate only inadequately. What I may safely do, however, is to summarize some outstanding features of modern continental law and to add a few personal experiences concerning the legal system under which I worked for nearly a quarter of a century. I intend to deal first with problems of insanity (including temporary insanity caused by drunkenness), secondly with other forms of mental disorders and with mental deficiency.

INTELLIGENT planning for an integrated public health attack on mental disorders demands adequate epidemiological information. A variety of facts is needed. What is the extent of the problem-that is, how many are affected? What are the characteristics of the mentally ill as a group and as compared to the rest of the population with respect to such factors as age, sex, race, and occupation? How does mental illness develop in the individual and what factors explain its distribution in the population? What are the psychological, physiological, and socioeconomic factors that may be related to cause and course of the illness?

There are in the wards of every mental hospital numbers of persons who for long periods of time exhibit profound disorders of emotion. Thus, we note the fixed depression of the melancholic, the boisterous exuberance of the manic, and the mechanical indifference of the primary dement.