76 BRITISH MEDICAL JOURNAL 8 JULY 1978

13 Stroobandt, R, Fagard, R, and Amery, A, American Heart Journal, 1973,86, 781.

14 Thurston, H, and Swales, J D, Lancet, 1976, 2, 930.15 Beevers, D G, et al, Kidney International, 1976, 8, S181.16 Woods, J W, et al, New England J'ournal of Medicine, 1976, 294, 1137.1 Veterans Administration Cooperative Study Group, J3ournal of the

American Medical Association, 1967, 202, 1028.18 Veterans Administration Cooperative Study Group, J7ournal of the

American Medical Association, 1970, 213, 1143.19 Berglund, G, et al, Lancet, 1978, 1, 1.20 Wilhelmsen, L, British Medical3Journal, 1978, 1, 1348.

Is schizophrenia a psychosis or aneurosis ?

Schizophrenia is classed as one of the psychoses; if asked to saywhich symptoms were chiefly responsible for the incapacitymost doctors would probably cite such conventional psychoticmanifestations as delusions and hallucinations. These arecertainly prominent in the acute stage, but schizophrenia isusually a chronic disorder, and a recent study' suggests that inchronic schizophrenia the symptoms that cause the most handi-cap and present the most intractable management problems arethose usually termed neurotic.

Cheadle and colleagues' studied 190 schizophrenics treatedfor an average of 12 years mainly in the community (144 hadhad no admissions in the previous year) and found that worrying,social unease, tension, depression, lack of energy, and irritabilitywere far commoner than delusions and hallucinations. Moreimportant, patients with high neurotic scores seemed to havemore difficulties with work and social life than those withpsychotic symptoms.The average age of these patients was about 45, but barely

a quarter were working, and isolation was common. Most ofthe men (690o) had never married. Of the women, by contrast,6800 had married; but over half had later become divorced orseparated. Many patients who did not actively complain aboutisolation seemed to be leading a restricted and unrewardingexistence. Thoreau's belief that "most men lead lives of quietdesperation" may not generally be true, but it accuratelydescribes the plight of many schizophrenics.

Cheadle et al seemed surprised by the high prevalence andseriousness of neurotic problems, but perhaps it is not sounexpected. Delusions and hallucinations need not be a majorhandicap if the patient does not talk about them. "If you can'tbe sane, try to be discreet" is still sound advice for psychoticpatients. Paranoid schizophrenics in particular may appearremarkably "normal" if they keep off their paranoid hobby-horse and may find little difficulty in staying married andemployed. What cannot be so easily hidden is the social in-competence which is evident so often in schizophrenia and whichcreates such problems in getting and keeping both jobs andfriends. These negative symptoms are not only a serious handi-cap but, unlike the positive ones, they do not readily respondto the neuroleptic drugs which are of such value in reducing thenumber and frequency of exacerbations.Taken with other studies showing the poor quality of schizo-

phrenic life,2 these findings raise further questions about theappropriateness of "community care" for patients whose mainproblem is the lack of precisely those social skills which arenecessary for living in an ordinary community. Indeed, thewhole concept is coming under increasing challenge4; criticshave suggested that before the mental hospitals are emptiedit would have been prudent to find out whether or not thecommunity does, indeed, care. There is a strong possibility thatit does not, although Bennett5 rightly warns against dogmatism."A good hospital is better than a poor hostel .... A good familyenvironment is better than a poor hospital. . . Universaldenunciation of any one type of setting is likely to be harm-ful. . . ."

The study by Cheadle et all also fuels another perennialpsychiatric controversy-namely, the utility of our conceptsof neurosis and psychosis with their different and sometimescompeting meanings. Psychosis, in particular, when notsynonymous with schizophrenia, is used variously to implyseriousness, an endogenous quality, and the presence of delu-sions; while neurosis can imply a lesser disorder, an aetiologybased on environment or personality, and the preservation ofcontact with reality. Words so accommodating and flexible areof dubious scientific value. Furthermore, some of these impliedmeanings are misleading. Amphetamine psychosis has a goodprognosis; obsessive compulsive neurosis a bad one. Neuroticbehaviour may be a manifestation of organic brain disease,and Sims6 has shown that neurosis has a substantial mortality.Any symptom requires a context to be of use in diagnosis or

treatment. Backache has very different connotations in cancerand influenza. It would be unfortunate if a well-intentionedemphasis on the neurotic symptoms of schizophrenics merelygained them the sort of dismissive attitude which is commonlyencountered by the ordinary run of neurotic patients.

1 Cheadle, A J, Freeman, H L, and Korer, J R, BritishJournal of Psychiatry,1078, 132, 221.

2 Brown, G W, Birley, J L T, and Wing, J K, British Journal of Psychiatry,1972, 121, 241.

3 Wing, J K, and Creer, C, Schizophrenia at Home. London, Institute ofPsychiatry, 1974.

Hawks, D, British Journal of Psychiatry, 1975, 127, 276.Bennett, D, British Journal of Psychiatry, 1978, 132, 209.

6 Sims, A, Lancet, 1973, 2, 1072.

Maternal alcohol consumption andbirth weight

The effects of the mother's alcohol consumption on the fetusbecame known in the early part of this century,' but the subjectwas then ignored until the description of infants with the "fetalalcohol syndrome." Animal studies had already suggested thatintrauterine growth retardation often resulted from chronicexposure to alcohol,;-7 but only within the last decade has thesubject been resuscitated: for example, Ulleland et al8 studied12 infants delivered to 11 alcoholics and found 10 small forgestational age.

Is there any intake of alcohol that is safe for the fetus?Unfortunately the data so far published have not providedenough detail to answer this question. A prospective study inFrance9 found that women who consumed the equivalent of400 ml or more of wine a day during pregnancy had a significantexcess of perinatal deaths, fetal growth retardation, and lowplacental weight. The French authors, however, made noattempt to exclude any chronic alcoholics, so that a small groupof very heavy drinkers could have biased their results.

Furthermore, results are always confounded by the fact thatwomen who drink tend also to smoke. A prospective studyby Little'0 therefore identified 66 women with an average dailyconsumption of at least 35 ml of absolute alcohol before con-ception. For each of these cases they chose three controls,matched for smoking habits: one with a low intake of alcohol(less than 3 5 ml/day) and two with an intermediate intake(3 5 ml to 34 ml/day). They found a significant negative associa-tion between birth weight and the amount of alcohol consumedin late pregnancy. The regression equation indicated that foreach 35 ml of absolute alcohol consumed in later pregnancythe mean birth weight would be reduced by 160 g; this estimate,however, was based on only 20 women who drank 35 ml or moreat this time. It is curious that in the whole sample of 264singleton infants only seven (2-71') weighed less than 2500 g.

Only one study," in the United States, has partitioned thedata adequately and examined the incidence of prematurity.