I am grateful to those who have included me in the honourable company of Maudsley Lecturers. When you invite a speaker from outside psychiatry, I think you hope to find one who will speak from his own central interest and experience in a way which will illuminate your own. After some inner debate, I decided that I would try to justify that expectation, even though my experience may seem remote from yours. I hope none the less that what I have to say may have some relevance to some of the sciences on which you rely, perhaps even to your profession.

Introduction

The concept of hypochondriasis, and particularly its nosological position, is far from clear, and there is still a great deal of controversy as to whether or not there exists a condition of primary or essential hypochondriasis. Many of the historical and theoretical ramifications are reviewed in another paper (Kenyon, 1964). The object of the present paper is to give an account of the clinical findings in a large series of patients in order to evaluate some of the hypotheses put forward in the literature, and especially to determine if there is sufficient evidence to delineate a separate group suffering from primary hypochondriasis only. There is a dearth of well-documented case series published, although studies based on the investigation of a group of patients have been made by Gillespie (1928, 1929), Brown (1936), Katzenelbogen (1942), Alarcon (1956), Shirvaikar (1957), Greer (1961) and Ladee (1961). However, none of these attempt any sort of comparison with a “control” series, as is done in the present investigation, nor in most cases are numbers sufficiently large for drawing valid conclusions.

In a series of neurotic twins who are being systematically studied by the Genetics Unit at the Maudsley Hospital, two pairs have been of particular interest.† Both had identified with each other to an extreme degree, yet only one of each pair had a psychiatric illness requiring extensive in-patient treatment. They illustrate the fact that identification can be a feature in monozygotic twins, yet does not necessarily lead to concordance for emotional disturbance.

The constellation of symptoms which is termed depersonalization is often as perplexing to the doctor as to the patient. It is more easily diagnosed than defined, and much of the controversy over its nosological position can be attributed to this vagueness of outline. Saperstein (1949) reviewed the historical development of the concept and concluded that the essential feature is the experience of a sense of strangeness or unreality to the individual of his personality, his body or the external environment. Other symptoms of cerebral dysfunction, such as perceptual distortion of the body image, déjà vu experiences, olfactory and auditory hallucinations, metamorphopsia, autoscopy and a disordered time sense, are frequently, but not necessarily, associated (Antoni, 1946; Roth, 1959). The difficulty of expressing unusual subjective events in words gives rise to descriptions remarkable for their rich and often bizarre metaphor (e.g. Lewis, 1934; Bockner, 1949; Roth, 1959). Saperstein (1949) and Bird (1958) emphasize the “as if” qualification of these accounts, which distinguishes them from the delusional experiences of depression and schizophrenia.

During the past decade so many psycho tropic drugs have been produced that the psychiatrist is often faced with a bewildering choice; for some mental disorders no fewer than a dozen preparations claim to remove or alleviate the symptoms. The work of La Verne (1962, 1963) and Jacobsen (1963) has been of considerable value in providing a “compendium of psychopharmacological agents”—a comprehensive classification of psychiatric drugs to assist the prescriber. Nevertheless, there are seldom any clear or universally accepted indications within a class (e.g. antidepressives or antipsychotics) why one drug should be prescribed rather than another. Many preparations share a common basic chemical formula, such as the phenothiazines, and/or a common biochemical function, like the monoamine oxidase inhibitors. The manufacturers themselves, anxious to cover every therapeutic possibility, suggest such a wide range of possible indications that their product often becomes a broad spectrum panacea, inviting increasing scepticism from the physician and concealing any potential advantage it may have for alleviating a particular symptom. Since personal experience determines choice more positively than any number of published reports, the psychiatrist gives most new products an informal trial, but tends to settle down with a limited few of proved usefulness and empirically confirmed indications. This is not a particularly efficient method for obtaining one's personal range of chemotherapeutics, but it is the one most generally used in practice. Its disadvantage lies in the idiosyncratic nature of some drugs, which may work well in one patient but ineffectively, or even adversely, in the next. On the basis of a few short and unsatisfactory trials, sometimes of only one, a potentially useful preparation may be discarded in favour of an older well-tried alternative which may be less therapeutically effective in the long run.

A new series of compounds thought to have some of the properties of major tranquillizers has recently been synthesized (Archer et al., 1962). One of these, oxypertine (Fig. 1) has been made available to us under its code name, WIN.18, 501. Pharmacological studies have shown oxypertine to have tranquillizing, anti-adrenergic and hypotensive properties (Wylie and Archer, 1962).

Despite the advent of the stimulant phenothiazines—effective, sometimes, when older dimethyl compounds fail—a proportion of chronic schizophrenics continue to resist treatment with both types of drug, and also fail to respond to intensive nursing regimes designed to combat the effects of institutionalization. These patients constitute a major therapeutic problem.

There have been many evaluations of the use of chlordiazepoxide in mental illnesses, most of these concerned with its use in the reduction of anxiety. The majority of the papers have emanated from North America and have reported in “open” investigations that the drug is of value in reducing anxiety. Other papers from Britain, Australia and the European Continent have also described the results of similar treatment. Of the British contributions, only two of eight (Jenner et al., 1961; Gore and McComisky, 1961) describe results of placebo-controlled trials. A recent annotation concerning chlordiazepoxide (1961) observed that most of the trials had not involved the use of placebo. Furthermore, as chlordiazepoxide is a drug very much more expensive than a barbiturate, it was considered that more placebo-controlled investigations were desirable.

The social adjustment of individuals is studied from different viewpoints by psychiatrists and sociologists. The psychiatrist is concerned with the malfunctioning personality (and with normal function toward which patients must be assisted); the sociologist is concerned with the functioning social system. The basic reference of both disciplines is to the individual and the individual's adaptation in his social group.

In our previous paper (Humphrey and Ounsted, 1963) we found that the symptoms and behaviour problems of children adopted in early infancy resembled those of children reared by their own parents. A significant trend appeared only among children adopted after the age of 6 months, who were more prone to anti-social conduct. But the proportion of adopted children referred to the Park Hospital for Children over a four-year period (2·9 per cent.) was more than double the corresponding estimate for the general population. It is tempting to attribute at least part of this excess to the relatively large number of delayed adoptions in our sample, of whom 34 out of 80 (43 per cent.) were aged 6 months or more at the time of placement.

The only previous studies are referred to in Mental Hospitals at Work (Jones, 1962) and it is stated, “In recent years some attempts have been made, though to our knowledge none have been published, to estimate the amount of time which psychiatrists in mental hospitals actually spend in the care of patients”. In our opinion the topic of medical staffing has received little official recognition. Our own assessments are explained in this article with a view to finding some sort of base line and general agreement.

Although much effort has gone into the description and classification of schizophrenic behaviour patterns, little attempt has been made to detail the course of the disorder. The present paper is an effort to trace the effects of chronicity on perception by use of a cross-sectional method. The specific tasks were selected to maximize autochthonous factors in perception. At the same time a demonstrable sensitivity to emotional states was desired, since changes in the schizophrenic condition are often considered reflections of reaction to stress. A wide enough area of behaviour was encompassed so that a general pattern, if one emerged, could be considered typical of perception as a whole.

How useful to the psychiatrist are subjective complaints by a patient?

The question of objective appraisal was reviewed by Harris (1938, 1954) in connection with follow-up studies, initially of in-patients, and latterly of day-patients, at the Maudsley Hospital.

Hamilton and Salmon (1962) and Hamilton (1964) have investigated the effect upon male chronic schizophrenics, inter alios, of the following regimes: (a) working in a hospital industrial workshop, (b) occupational therapy and (c) no specific activity (the first study only). Hamilton (1964), considering both studies, concludes that the results “may be said to weight the available evidence in favour of the superiority of Workshop Therapy”. Certain points should be raised in connection with this conclusion.

In 1957 Professor Buscaino and the author reported the effect of intraperitoneal injection in mice of material from schizophrenic patients (1). The material was obtained from urine by treatment with activated charcoal and elution (2). These results have recently been confirmed by Fujita and Ging (3) who also found a characteristic toxic action of material from schizophrenic patients. Further work (4) showed that direct application to the cerebral cortex of the unanaesthetized rabbit of urinary material from schizophrenics caused the appearance of regular high voltage waves. The material obtained from the urine of controls, when applied to the cortex in the same concentration, did not have the same effect (5).

Kishimoto (1958) reported quantitative and qualitative peculiarities in the absorption spectra of body fluids in schizophrenia, and considered that there were abnormalities in the oxidation of adenine through hypoxanthine and xanthine to uric acid.

We have previously demonstrated, in small groups of patients receiving either electric convulsive treatments or imipramine therapy, changes in calcium metabolism associated with recovery from states of depression (5, 7). Other investigators have also reported somewhat unusual changes in calcium physiology among depressed patients or during the administration of antidepressant therapies. These include low cerebrospinal fluid calcium levels (4), changes in blood calcium during electric convulsive treatments (10), and alterations in bound and ionized fractions of blood calcium during imipramine therapy (3). It is the purpose of this report to describe and discuss the changes in urinary calcium excretion in the relatively large series of patients we have now acquired.

Many attempts have been made to measure some of the changes in various bodily functions that occur during the course of a depressive illness. These changes (and their responses to drugs) have been used in investigations that try to correlate such changes with the clinical syndromes of “endogenous” and “reactive” depressions (10). No reliable and valid correlations have, however, yet been found (4, 5).