Baan was referring to the underdeveloped world, or the ‘third world’ as it is often called. This review is concerned with psychiatry in a small part of it—Sub-Saharan Africa—that part of the African continent inhabited by black Africans. At the time of writing, the term is used more specifically to describe independent black Africa, excluding South Africa—hence a bloc of cultures and sub-cultures with ethnic, economic, religious and customary patterns very different from those of the continents of Europe and North America where the bulk of current data and theory about psychiatric disorders has been obtained and expanded. In view of such major differences in factors long thought to influence the occurrence and nature of psychiatric illnesses, the patterns of these disorders in Sub-Saharan Africa are important in clarifying theories about psychiatric disease despite the paucity of adequate research carried out to date.

My choice of subject for this Memorial Lecture is one which I hope would have been approved of by the late Dr. Shorvon, who must have often applied his great therapeutic acumen to the treatment of anxious patients. I intend to present neither a compendious review of some aspect of anxiety nor a catalogue of recent research work. Rather, I shall outline some conceptual and practical problems met in investigating an emotion. Such problems have occupied medical men and also many philosophers, psychologists and theologians. I shall outline the types of anxiety, using the term loosely, and then attempt a scientific analysis ending with some speculative model-making.

Sedatives such as barbiturates, benzodiazepines and alcohol are valuable reducers of anxiety, but their effects do not endure for long after the drug has been metabolized and excreted. Phobics often become able to enter their phobic situation under the influence of sedatives, but as the drug effect wears off they begin to escape from the situation once more. This might be a form of drug-dissociative behaviour. In animal experiments, behaviour learned in the sedative drugged state often fails to transfer to the undrugged state (Miller, 1964). However, this effect might be more pronounced during the phase of peak drug effect than during the phase when the drug effect is wearing off. In rats, exposure to the phobic situation during slow withdrawal of sedative drugs was found to be effective in extinguishing conditioned avoidance responses (Sherman, 1967). That more lasting behavioural changes can follow treatment given both in the drug and in the non-drug state is suggested by evidence adduced by Baum (1971); he found that, in rats, avoidance behaviour which was learned both in the alcohol and in the non-drug state was more resistant to extinction than avoidance acquired in a non-drug state alone. The same might apply to approach behaviour in human phobics.

Oxypertine (Integrin, Winthrop Laboratories) is a phenylpiperazine derivative unrelated to the phenothiazines or benzodiazepines. It has powerful anti-psychotic properties demonstrated in early trials and reviewed by Skarbek and Jacobsen (1965).

It has been found that young people suffering from school phobia, particularly those of secondary school age in Britain, tend to be the youngest in their family (Hersov, 1960; Smith, 1970). This paper reports an investigation carried out in an attempt to confirm and extend this observation. A hundred school-phobic youngsters admitted to Highlands, a psychiatric in-patient unit for adolescents, were looked at from the point of view of order in the sibship; in this respect they were compared with 91 non-school-phobic children suffering from neurotic or conduct disorders admitted to the same hospital unit and with 127 randomly selected normal secondary school children stratified for age, sex and social class. The state of excessive dependency which appears to exist between mothers and their children in school phobia, even in early adolescence (Berg and McGuire, 1971) may be partly due to the circumstance of the affected individual being a younger child in the family.

In the search for environmental causes of mental disorder, the epidemiologist looks for an association between the disorder and some environmental factor. The significance of such an association can only be determined by a comparison of the patient population with a control population. Ideally, die control population will be the general population from which the patients have been drawn, but because this often presents great technical difficulties an alternative is to compare one diagnostic group with another. Sound conclusions cannot, however, be drawn from such a comparison unless it is known how far the diagnostic groups differ for factors which influence, or are thought likely to influence, the association being studied. Such factors, of which age- and sex-distribution are the most obvious, will often include social and cultural status. Cultural status—at least in so far as this may be equated with religion and country of birth—can be allowed for by confining the comparison to patients of a particular religion and place of birth. As regards social status, it is the patient's background rather than his present condition which seems important; for on the one hand present social status will be varyingly influenced by the type and severity of disorder, and on the other hand a person's general social behaviour and attitude (in as far, at least, as these are associated with the sort of social factors which psychiatrists have commonly studied) are more likely to stem from the type of upbringing he had than from his recent experiences.

A review of some of the literature concerned with the aetiology of homosexuality shows that certain variables, in particular those involving the relationship between the homosexual and his parents, differ between studies involving populations of neurotic homosexuals and those concerned with non-psychiatric populations. Investigators concerned with the former group (Bieber et al., 1962; O'Connor, 1964; West, 1955), have placed emphasis on the importance of the mother-child relationship, having found this to be abnormally intense in the case of many homosexuals. On the other hand, a well controlled study by Bene (1965), involving a non-psychiatric population of homosexuals, revealed no difference between her homosexual and heterosexual groups as regards maternal overprotection. Her findings caused her to place more emphasis on the father-child relationship.

Despite extensive research and a vast literature, the diagnosis of schizophrenia remains primarily a clinical decision based upon the presence of some agreed-upon symptom complex. Laboratory studies and special testing procedures have not yet demonstrated their utility in establishing diagnosis in this syndrome. While it is easy to cite studies of diagnostic difficulty (Beck, 1962), it is also apparent that when clinicians state they are ‘certain of the diagnosis' or agree to utilize pre-established diagnostic stereotypes, the diagnostic agreement frequently achieves an 80 per cent reliability (Beck, 1962; Hordern et al., 1968). Clinicians the world over tend to identify gross symptoms in similar ways. However, they may ascribe varying significance to similar symptom complexes and may even use similar symptom constellations to arrive at different diagnoses (Saenger, 1968; Sandifer et al., 1968). There seems to be general agreement on the major symptoms found in schizophrenia (Cooper, 1967; Beck et al., 1962; Hordem et al., 1968); however, diagnostic agreement on subtypes, and on admixtures of paranoid symptoms and depression is much more difficult to achieve (Cooper, 1967; Morgan et al., 1968; Lorr and Klett, 1968; Hordem et al., 1968). The present study attempts to formalize the apparent commonality of clinical features which together establish a diagnosis of schizophrenia through the development of a valid and reliable checklist of symptoms.

An interview with the patient is the main method of examination in the functional psychoses, following which the diagnosis is made. This diagnosis is fundamental in communicating about the patient, in clinical discussions between psychiatrists or in comparing research results. It is essential that the diagnosis should be reliable and valid. Kreitman (1961) has defined reliability as the amount of agreement between psychiatrists examining the same patient, or a comparable series of patients. He also argues that the frame of reference of the examiner should be that of general clinical psychiatry. It should also avoid personality traits in psychiatrists which are associated with different kinds of orientation (Kreitman, 1961). Another problem, that of nomenclature, may turn out to be an argument about the choice of labels. These problems are of great concern to the clinical psychiatrist and are made worse by weaknesses in interview techniques. It is important to look for improvements, and the present study examines the reliability and validity of the In-patient Multidimensional Psychiatric Scale (I.M.P.S.). This is a scale for rating psychotic syndromes following an interview with the patient. These syndromes have been established by repeated factor analyses (Lorr and Klett, 1967). The initial work was based on psychotic American patients, but similar factor syndromes appear from studies of psychotics in other countries (Lorr and Klett, 1968, 1969a, 1969b).

Tests involving the arrangement of pictures to tell a story have long been included among tests of intellectual ability. First devised by De Croly (1914), one or more items of this type have appeared in a number of experiments and standardized tests; and the Wechsler intelligence scales (1944, 1955) include a Picture Arrangement subtest consisting of six or eight items ranging in length from three to six pictures. However, apart from its possible use for psychiatric interpretation (e.g. Wechsler, 1958; Ch. 10) its specific value as a component of the scale has not been established. Some critics, suggesting that the test has a low reliability, are inclined to omit it from short forms of the Wechsler scales; yet test-retest reliabilities of about 0.65 (Wechsler, 1958) are similar to those of Arithmetic and Object Assembly, which are rarely omitted. Perhaps a more cogent reason for its omission is uncertainty as to what ability the test measures. Wechsler (1958) suggests that it shows the subject's ability to ‘comprehend and size up a total situation’; and that, as all the stories concern human activities, it may be a measure of social intelligence and awareness. Identification of the ability or abilities involved by factor analysis is also inconclusive: the test does not show significant association with Picture Completion, the other pictorial subtest in the Wechsler scale; and in different analyses it has shown associations with a Memory factor or with a factor described as ‘freedom from distractibility’.

During World War II psychiatric screening to exclude ineffective soldiers from active duty consisted of interviews of three to six minutes duration. These interviews were described as successful by Bloomberg and Hyde (1), and by Leavitt (2). But six years later Bloomberg admitted that induction screening had proved ineffective, and suggested continuous observation for the first six months of military service to separate those who would adjust from those who would not (3). This concept of prolonged observation was supported by the wartime findings of Egan et al. (4) and Aita (5). Egan's group examined the records of 2,054 men who had been psychiatrically rejected on the basis of a short interview, but who later served; 79.4 per cent rendered satisfactory service. Aita's five-year follow-up showed that of 100 soldiers considered borderline on interview 21 per cent failed to render satisfactory service and of 100 considered satisfactory 5 per cent failed. If the questionable risk hundred had been rejected the Army would have lost 49 average and 30 outstanding soldiers. It seemed, therefore, more profitable for the Army to risk retaining ineffectives than to attempt to weed them out completely on the basis of brief psychiatric interviews.