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T HE general problems of psychiatric research are not dissimilar from other fields of medical research succinctly presented in the Report of the Special Committee on Medical Research appointed by the Government of Canada.' Thus, it is scarcely necessary to expand upon the importance of fresh discoveries to enable the medicine we teach to be that of today and tomorrow rather than yesterday. The model of the active, enthusiastic investigator is one that cannot be mimicked by a mere pedagogue. In addition, the inadequacy of support, in respect of personnel, space, equipment, maintenance and security, is common to both medicine and psychiatry. Their dissimilarities arise from the special problems inherent in the study of psychological as compared to physiological processes. In any type of research, the emotional involvement of the human investigator is a factor for which appropriate controls may be desirable. In psychiatric investigation, often both the observer and the observed are subject to emotional interaction. As the committee on research of the Group for the Advancement of Psychiatry has suggested, these problems are not as central in other types of information-gathering situations, such as, say, observing a clock to determine the time it reports.2 If the common problems in psychiatric research actually involved a process like reading a clock, it would be necessary to consider not only the possibility of the time being misread, but also these additional possibilities: (1) that the frequency with which the dock is consulted may modify the time it reports; (2) that the time the clock is expected to show may modify the time it actually reports; (3) if the observer dislikes the clock (let us say, from an esthetic viewpoint), it will report time differently than if he is fond of it; (4) if the observer sends someone else to consult the clock, it will report differently; and (5) that the time indicated by other docks adjacent to the one being consulted, or the position of this dock relative to other clocks, might influence the time the dock in question reports. In delineating one of the core problems of psychiatric research, it is important to say that proper experimental design may control for these very necessary interactions and not necessarily produce control of them. Nevertheless, such considerations do raise the question of the relation of psychiatry to basic sciences. There has been a suggestion in the past that psychiatry can only prove itself by
Based on a paper presented to the Medical Research council, Third Meeting of the Advisory Committee on Co-ordination and Broad Medical Research Policy, Ottawa, April 16-17, 1962. From the Departments of Psychiatry and Psychology, Queen's University, Kingston, Ont. Professor of Psychiatry. tAssociate Professor of Psychology.

ABSTRACT A study involving correlations between personality and the fasting serum cholesterol level of normal volunteers on a fat-free diet was used to illustrate techniques of clinical investigation in psychiatry. Precise data were not quoted, but the procedure was described to show how behavioural studies differ from biological ones. Somatotyping (no significant correlation), excretion of catecholamines under stress (raised with high cholesterol levels) and classical conditioning (no significant correlation) were used as examples of simple biological functions. These were contrasted with trait ratings where one observer predicted cholesterol levels with a high degree of accuracy and another with a low and unreliable one, It seemed that the most important trait being rated was "aggressiveness", and this was probably differentially elicited by the two observers, the one male and authoritarian, the other female and permissive. Such an interaction distorted the information obtained to a degree seldom seen in other data-gathering situations. Estimated and actual achievement on a competitive pin-ball game failed to show significant correlations with other traits. Questionnafres on the attitudes of the subjects' mothers suggested some correlation between severity of training and aggressivity. The techniques of personality investigation described embraced behavioural observations which, it was suggested, were ifi-taught in existing undergraduate medical curricula.

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mized if the area of such endeavours were merely operationally defined. An extreme point of view with regard to psychology has been put forward by Mayer-Gross, Slater and Roth,3 who say: "It would be absurd to maintain that psychology can be to psychiatry what physiology has been to medicine, not only because the claim would be exaggerated but also because it implies that psychiatry and medicine are mere cousin sciences." Inglis4 has produced a countercriticism to this argument which suggests that although at present it might be absurd to claim that psychology can in practice stand in such a relation to psychiatry, there is no absurdity in principle. He points out that even if psychology has little in the way of systematic content to offer in relation to psychiatric problems (and he later produces evidence suggesting that this in itself is not entirely true), nevertheless psychology as a science of behaviour would still have important contributions to make to these problems in terms of its method. He uses as a further illustration of the fact that methodology may often precede content, the example of Pasteur who, when he first investigated difficulties in the production of beetroot alcohol, was unable to bring to bear upon these problems any systematic substantive knowledge of bacteriology. At that time, this was a science whose content he still had to invent. He was, however, able to apply to these problems methods which he had developed as a crystallographer of considerable genius and ingenuity. This method provided both the foundation and content for bacteriology as a biological science. 'So, too, in psychiatry it would seem that we must turn to the methods of the perhaps newer behavioural or social sciences. In this area, we immediately meet the problem that these disciplines have not yet established as firm a set of findings and concepts of indixbitable use in psychiatry as those provided 'by physiology for medicine. Thus, it is true to say that in comparison with other fields, psychiatry does not have a strong research tradition which is oriented to systematic empirical investigation of important problems. At the same time, there is a need for immediately
applicable working formulations whidh in turn offer

way cannot really be checked in any other way, and those who ask for such checks merely reveal their own personal deficiencies. He points out that when this ideology is put so baldly, few psychiatrists would agree with it; but he also suggests that we might do well to consider the extent to which such beli&fs do in fact influence both training and research in the field. In fact, it has become perhaps a popular pastime, if not sport, to point out what is wrong with psychiatric research. Ruesch6 has underlined the equation of power and money which has operated to the detriment of wisdom and sapiential influence, so that academic values become blurred by those of the business and political world. He has also very rightly pointed to the distortion introduced by language. So many of the concepts current in behaviour are expressed by words with differing meanings in everyday life and other fields. This has perhaps led to the development of a condensed and distorted language which may, through professional jargon, do violence to the facts and seriously handicap the work of the investigator. If more attention were paid to the denotative meaning of psychiatric language, perhaps this confusion might be reduced. Such denotation can, of course, involve several "levels" of discourse.
Behaviour can be studied in many ways and at different levels. Firstly, at the central or cerebral level we have got beyond the stage of regarding the brain as a large "jelly bag" and now understand it better as a series of organs linked together

in differing associations by networks involving a hierarchy of functions.7 This level would be more
the responsibility of the neurophysiologist or neuropharmacologist. Thus, single cell electrode studies are proceeding in animals, and measurement of evoked cortical potentials in humans. The response to stimulation or drugs can thus be elicited. The study of autonomic response, regarding the brain

some approach to treatment. These conditions favour quick and often premature closure on many basic questions. In time, it may easily he forgotten that many of these "answers" are unverified hypotheses: they come to be treated as established fad.2 Hamburg5 has caricatured this approach by suggesting that the views of such a psychiatrist might be that now, after all these many thousands of years, the forces of human behaviour and the principles by which one acts are understood. In addition, the
only way to learn anything important about 'human

behaviour is by doing what we always do, namely, conduct psychotherapy, which incidentally happens to provide us with a good living and social position. Moreover, the understanding we arrive at in this

or parts of the brain as a neuro-humor, can also be measured. The end products of such endocrine activity may be collected and analyzed from body fluids. At present, however, we are somewhat limited by our technical achievements to urinary estimations. Classical and operant conditioning techniques may also be used as measures of response. At a more peripheral level, that of verbal behaviour, an analysis of language in both its formal content and interaction in interview may be made.8'0 Similarly, verbal reports through questionnaires of attitudes may be elicited. At a third level, social behaviour in the responses between individuals, their performance in reality situations, or their response to reward or punishment may be assessed. Clinical psychiatric investigation may span a similar range. To illustrate such an approach, an investigation of the relation of personality to cholesterol metabolism will be used as an example.

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not differentiate the two groups. The trait ratings of the first psychiatrist, who was a female, yielded a mean correlation with cholesterol of 0.047, a value which was not signfficantly different from zero. Indeed, the standard deviation of these correlation coefficients was also not signfficantly different from the chance value to be expected around the true value of zero. In striking contrast, however, the correlations derived from the second psychiatrist, a male, as a group, were highly significant. The average correlation coefficient was 0.428, a value which would occur by chance less frequently than 1 in 100,000. Of the 31 individual ratings made, 11 were significantly correlated with cholesterol level at the 5% level or better. He rated the students with high cholesterol as being more verbally and physically hostile, having more hostile attitudes, being more aggressive, more socially driving, more ambitious, expressing more physical sexuality, having more need of social achievement, sublimating more, being more inflexible, more rebellious and more dominant. This psychiatrist was also highly successful at predicting the actual cholesterol level. The point biserial correlation between his judgment of high and low and the level as measured was 0.58, significant at beyond the 1% level. The fact that a number of traits as rated by one psychiatrist was signfficantly related to cholesterol, did not prove that all these traits were independent. In fact, it seemed highly likely that all these trait ratings were referring to a single psychological characteristic. An inspection of the results suggested clearly that the main trait which is associated with high lipid level is probably aggressiveness. This, in fact, proved to be the case. This unreliability of the rating of traits of the first psychiatrist illustrated the clock analogy. Thus, while it might have been possible that she was not sensitive to certain traits, it was more likely that the most important one of aggressiveness was not elicited in the presence of a female who had a nonauthoritarian role in the university, in contrast to the highly authoritarian role of the male psychiatrist involved. 6. Social Relationships In one of the studies the students with high and low cholesterol levels were grouped separately and .a sociometric test of preference was made. Although it is not easy to score such sociometric results, they suggested that the high cholesterol group was less cohesive than the low one. It was predicted that the high cholesterol students would have a higher initial level of aspiration than the other subjects and also that this would be increased under socially competitive conditions. They were asked to predict their performance on a labyrinth pinball game, both under unstressed individual situations and later under highly coin-

petitive group ones. No significant difference was found by this test. The difficulty of this task, involving a high degree of manual dexterity, may have reduced its validity for this purpose. There are, however, certain simple social "games" which may be adapted to provide more sensitive measurements of such traits. It is, for example, possible to program machines so that it appears that two subjects are actually playing against each other, whereas the responses are built in so as to produce behaviour in the face of standard, controlled degrees of co-operation and competition 7. Influence of Family Upbringing It was predicted that there would be a relation between observed personality traits and parental upbringing. Accordingly, an extensive attitude questionnaire, which was based upon the empirical Harvard study described in Patterns of Child Rearing by Sears, Maccoby and Levin,'2 was sent to mothers of volunteer subjects. The mothers were asked for their present attitudes and were not asked to estimate what these had been when their children were small. It was, however, realized that the questionnaire was unlikely to reveal validly such matters as consistency of parental attitudes. Also, such answers would not necessarily coincide with what the subjects remembered their upbringing to have been. This questionnaire was concerned with matters of maternal warmth and acceptance of the child, degree of breast feeding, patterns of weaning, severity of bowel training, the permissiveness or strictness of the parent and the degree of punishment involved in training. It consisted of 78 questions, all on a 5-point scale. Five possible answers to each item were described, and the respondents were told to check the one most closely resembling their own opinion. In a preliminary analysis the five traits correlating most highly with cholesterol level were correlated with the six maternal attitudes thought to be most likely related to the handling of instinctual drives. Signfficant but low positive correlations between punishing or restricting attitudes and aggressiveness were obtained. Unfortunately, it is difficult to assess retrospectively how adults were actually brought up as children. It was assumed that if the mothers of these adults were asked how they had brought up their children, they would be unable to recall the details and they would tend to distort their responses in the direction of their present beliefs. They were asked, therefore, merely to give their present attitudes towards child-rearing practices. Nevertheless, because of the unreliability of attitude questionnaires in general and the possibility of change of mothers' attitudes over the years, we were left with doubts about the validity of the results. These samples suggested to us that we might extend the study of child-rearing attitudes to young

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mothers who were actually raising young children in order to see if they were related over a period of time to the personality traits actually developing in these children. Such an ongoing study has already been embarked upon. It is certainly germane to the question of child rearing, which, although a matter of great importance, has seldom been submitted to systematic study. It has rather been a field of speculation, at best informed, and at worst harmfully ignorant.
COMMENT

In this way, our experimental method tried to link up a chain of causality which led from concepts of genetic endowment embodied in physical structure, cerebral excitation and inhibition, as illustrated in hormonal excretion and through conditioning, into one of more complex mechanisms, namely repression or sensitization. A further degree of complexity is introduced by the rating scales, self concepts, and observer concepts, derived from personality theory, which in turn progresses to social relations and organization derived initially, probably, from the family influence. By such means, it is hoped that some link-up between biological and social studies can be forged as a contribution to the original problem, namely the genesis of coronary heart disease. We might suggest that a combination of a certain genetic endowment, in the sense of high appetitive drive, becomes, in certain persons, an internal stressor resulting in high social competition, high levels of catecholamines, which in turn mobilize the unesterified fatty acids which, through a change of liver synthesis, may lead to high cholesterol levels. This may be one of the important substrates of later coronary occlusion. In this way the wheel is full circle so that the outward expression of behaviour in turn is mediated through inner cellular or network activities that in turn are sensitive to internal messages, be they hormonal or neuronal.
CONCLUSION

we still only dimly discern the message of the pattern, it is premature to concentrate all our attention on the molecules of the fibres of the threads. The inescapable conclusion is that the greatest barrier to psychiatric research lies in our educational patterns. As long as the behavioural sciences play little part in the medical school curriculum, there will be no firm ground beneath the feet of the potential young investigator. Long study devoted to the biological sciences may well prepare a medical student for biological exploration: it can scarcely equip him for even the most primitive behavioural observation. His model of investigation will assuredly be fixed in a physical mould. Relevant though this may be to certain problem areas it has undoubtedly led to the risible ideology of "behind every twisted mind there is a twisted molecule". How much profitable new knowledge might we expect in internal medicine from doctors who had received a mere 60 hours of instruction in anatomy, physiology and biochemistry! It would seem that as long as we approach behavioural studies armed with a first-aid course we will reap first-aid results. The challenge to medical education is a clear one.
REFERENCES

1. Canada, Special Committee Appointed to Review Extramural Support of Medical Research by the Government of Canada: Report to the Honourable Gordon Churchill, chairman, the Committee of the Privy Council on Scientific and Industrial Research, November 12, 1959, Queen's Printer, Ottawa, 1959. 2. Group for Advancement of Psychiatry, Committee on Research: Some observations on controls in psychiatric research, Report No. 42, Group for Advancement of Psychiatry, New York, 1959. 3. MAYER-GROSS W., .LATER, E. AND ROTH, M.: Clinical psychiatry: Cassell & Co. Ltd., London, 1954. 4. INGLIS 3.: Psychological Research and Psychiatric Proldems, unpublished data. 5. HAMBURG, D. A.: Arch. Gea. Psijchk&t., 4: 215, 1961. 6. RUESCH, 3.: A.M.A. Arch. Nearol. Pai,chsat., 77: 93, 1957. 7. ELKES, J.: Contribution of neuropharmacology to psychiatry. Paper read at American Psychiatric Association. Regional Research Conference, Montreal, April 1962. 8. PITTENGER, R. E.: Psychi,at. Res. Rep. Amer. Psychiat. A88., No. 8: 41, December, 1957. 9. EisLEa, F. G.: Brit. ,7. Med. Ps.,uchol., 29: 35, 1956. 10. CHAPPLE, E. D.: Genet. P,sychol. Monogr., 22: 3, 1940. 11. INGLIS, 3.: Abnormalities of motivation and "ego-functions", In: Handbook of abnormal psychology, edited by H. 3. Eysenck, Basic Books, Inc., New York, 1961, p. 262. 12. SEARS R. R., MACCOBY E E AND LEvIN, H.: Patterns of child rearing, Row, .Peterson and Co., New York, 1957.

The methodology of one specific study has been used in an attempt to illustrate clinical investigation in the field of psychological medicine and to compare and contrast it with that of physical medicine. Epitomized in the two terms, psychological and physical, is a division springing from their roots, the one more firmly in the behavioural and the other, in the biological sciences. Personality theory may well provide a bridge between the two, spanning both physiological and social parameters. Behaviour can be described in terms of measurable functions, but its complexity cannot be reduced to simplicity without the risk of irrevocable distortion. The procrustean effort that may be applied to fit an emotion into a physiological bed may lead to nothing but meaningless distortion. The pattern of a tapestry can no longer be discerned when the threads are picked apart. When

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO SURGICAL ThEATMENT OF EXOPHTHALMIC GOITRE L6normant thinks that operative mortality is very greatly increased by recommending surgical interference only in advanced oases of exophthidmic goitre, when resistance is seriously impaired. In such cases, even if the patient recovers from the operation, complete retrogression of the symptoms cannot be expected, owing to the fact that secondary degenerative changes have probably already taken place in the thyroid, myocardiurn, and pen-ocular tissues. The length of time during which the patient should be subjected to medical treatment before having recourse to surgery varies, according to different authorities, from six weeks to six months.-Heibert A. Bruce: Canad. Med. Ass. 1., 3: 5, 1913.