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10.1192/bjp.153.1.44Access the most recent version at doi: 1988 153: 44-49 The British Journal of Psychiatry

  G Lewis and L Appleby  

Personality disorder: the patients psychiatrists dislike  

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British Journal of Psychiatry (1988), 153, 44—49

Personality Disorder: The Patients Psychiatrists Dislike

GLYN LEWISand LOUISAPPLEBY

A sample of psychiatrists was asked to read a case vignette and indicate likelymanagement and attitudes to the patient on a number of semantic-differential scales.Patients given a previous diagnosis of personality disorder (PD)were seen as more difficultand less deserving of care compared with control subjects who were not. The PD caseswere regarded as manipulative, attention-seeking, annoying, and in control of their suicidalurges and debts. PDtherefore appears to be an enduring pejorative judgement rather thana clinical diagnosis. It is proposed that the concept be abandoned.

Personality disorder is an established clinical diagnosis,surviving in both ICD-9 (World Health Organization,1978) and DSM-.III (American Psychiatric Associalion, 1980). In 1974, Shepherd & Sartorius concluded:“¿�Despitediagnostic imprecision and terminologicalconfusion it is indisputable that some working conceptof psychopathic personality is essential for the practiceof clinical psychiatry―.

A number of criticisms have been made of theconcept of personality disorder (PD). Firstly, it is anunreliable diagnosis, in part due to rather vaguedefinitions (e.g. Kreitman et a!, 1961; Walton &Presly, 1973; Lewis, 1974), and remains so, despiteattempts at greater precision, for instance in DSMIII (American Psychiatric Association, 1980;Meilsopeta!, 1982). Secondly, the concept of personality thatunderlies this clinical term has been increasinglyabandoned by most social psychologists (e.g. Mischel,1968), who cite evidence showing that people do notbehave similarly in different situations.

But there is a more serious criticism in the literature,that personality disorder is a derogatory label that mayresult in therapeutic neglect (Gunn & Robertson,1976). Kendell (1975a), in his influential monographon diagnosis, says “¿�itis true that several of ourdiagnostic terms, like hysteric and psychopath, haveacquired pejorative connotations even among psychiatrists―.Although this argument is usually applied toantisocial PD, it is relevant to many of the othercategories. For instance, Parry (1978) writes ofalcoholics with personality disorder “¿�theyare of course,totally unreliable and their protestations are rapidlyshown to be shallow insincerities―.Hysterical PD insome accounts is a parody of supposed femininecharacteristics (Chodoff & Lyons, 1958). Inadequatepersonality disorder, the term itself a critical judgement, has been described as an “¿�addictionto help―,and further that “¿�younginadequate women maybecome prolific producers of children with whom theyseek unsuccessfully the kind of intimacy they cannot

achieve elsewhere―(Howard, 1985).Although ICD-9(World Health Organization, 1978) has changed thename to asthenic, the concept of inadequate PDremains unchanged: “¿�aweak inadequate responseto the demands of daily life― (World HealthOrganization, 1978).

Among all this controversy, there is, surprisingly, onearea of relative agreement; that personality disorder isnot a mental illness(Lewis, 1974).Although Henderson(1939)and Cleckley(1976)regard PD as an illness,therehas recently been an increasing consensus distinguishingPD from illness.Even Walton (1978),who has criticisedPD, wrote “¿�ThePersonality Disorders.. . take theform of recurrent disturbance in relationships withother people and is not a form of illness―.

Many authorities have found mental illnessdifficultto defme (Lewis, 1953;Wootton, 1959;Kendell, 1975b;Farrell, 1979). However, one aspect of the conceptis that the mentally ill are seen as less responsible andless in control of their actions. Weiner (1980) hasargued that the inference that someone is ‘¿�incontrol'is an important determinant in whether that personis given help. His subjects were more likely to help,and were more sympathetic to, someone whoappeared ill (uncontrollable) than someone whoappeared drunk (controllable). Thus, distinguishingPD patients from those with mental illness could leadto lack of sympathy and blame because of judgementsthat their actions are under control.

This study was both an empirical test of whetherPD is a pejorative term, and an examination ofthe hypothesis that patients labelled as PD arethought to be more in control of their actions.A sample of psychiatrists was given different shortcase vignettes and then asked to complete a questionnaire assessing their attitudes towards the case.Using vignettes in this way allowed us to controlfor possible confounding variables, and forced thepsychiatrists to use their stereotypes of PD tocomplete the questionnaire.

44

45PERSONALITY DISORDER

Method Case 6

Information as for case 2 was given, except that theword “¿�man―in the opening sentence was changed to“¿�solicitor―.

Questionnaire

The questionnaire consisted of 22 semantic differentials,with a 6-point scale, designed to elicit one aspect of theassessment or management of the case. Some of the itemsplaced more emphasis on practical management issues (e.g.antidepressant prescription, psychotherapy referral), butmost asked directly about attitudes to the patient (e.g. likelyto annoy, attention-seeking, etc.). A full list is given inTable I. The semantic differentials were scored so that ahigher score represented responses that were more rejectingor that indicated lack of active treatment. For instance, aresponse at the end of the scale “¿�overdosewould be anattention-seeking act―scored 6 and a response at the end“¿�overdosewould be a genuine suicidal act―was scored 1.Each subject was asked to complete the questionnaire andthen choose a diagnosis from a list of depression, anxiety,adjustment reaction, drug dependence, personality disorder,and neurasthenia.

Results

Characteristics of the sample

Of the sample, 72% (173 of 240) returned completedquestionnaires and a further 9% (22) refused to participate,

usually complaining that there was insufficient clinicalinformation on which to base judgements. Overall it wasa very experienced sample, with a mean of 16.5 yearspsychiatric practice.

Previous diagnosis of personality disorder

The principal experimental concern was to see whether theprevious diagnosis of personality disorder affected thepsychiatrists' attitudes. Preliminary analysis illustrated thatall statistically significant differences between the casesdepended on the presence or absence of the PD diagnosis,so cases 1 and 4 were combined as group PD (n = 58) andthe remainder, receiving cases 2, 3, 5, and 6 were combinedas group NoPD (n= 115).

The means of group PD were higher (i.e. more critical)than those of NoPD on all but I of the 22 items as shownin the first two columns of Table I. Individual one-wayanalyses of variance showed a significant difference betweengroups PD and NoPD on 16 of the 22 semantic differentials.The F ratios of these one-way analyses are in column 3 ofTable I.

These results confirm the hypothesis: when psychiatristswere given a previous diagnosis of personality disorder, theirattitudes to the patient were less favourable. This occurredirrespective of whether they were informed of our interestin unfavourable attitudes towards PD (case 4). Furthermore, PD had a much more powerful effect on theseattitudes than did sex and class.

Sample

Psychiatrists (240), who lived in England, Wales, orScotland, were randomly selected from the membership listof the Royal College of Psychiatrists (approximately 12%of total; Department of Health and Social Security, 1987).Those who were described as registrars, who were retired, orwere listed as being child psychiatrists, were excluded fromthe sample (but several child psychiatrists were included inthe sample because they were not listed as such). Subjectswererandomlyallocatedone of the sixbrief casehistories,which they were asked to read before completing andreturning an accompanying questionnaire. They were toldthat we were interested in how experience influenced thepractice of psychiatrists, and were asked to provide detailsabout previous qualifications and experience in psychiatryand in other specialties. The real purpose of the study wasexplained only to those receiving case 4 (see below).

Case histories

The six case histories differed from each other in only oneor two particulars. Each history contained the informationwhich a general practitioner's (OP's) letter might provideabout a depressed patient. The amount of information wasdeliberately restricted, to encourage subjects to drawinferences based on pre-existing attitudes.

The first case history was as follows:“¿�A34-year-old man is seen in out-patients. He complains

of feeling depressed, and says he has been crying on hisown at home. He is worried about whether he is havinga nervous breakdown, and is requesting admission. He hasthought of killing himself by taking an overdose of sometablets he has at home. He has taken one previous overdose,2 years ago, and at that time he saw a psychiatrist who gavehim a diagnosis of personality disorder. He has recentlygone into debt and is concerned about how he will repaythe money. He is finding it difficult to sleep and his OPhasgivenhimsomenitrazepam.He thinksthesehavehelpeda little and is reluctant to give them up.―

The other cases were modified from the first as follows:

Case 2

No previous diagnosis was mentioned.

Case 3

Previous diagnosis was given as depression.

Case 4

Information as for case 1wasgiven,but the subjectsweretold that we were interested in the labelling effect of certainpsychiatric diagnoses and were asked not to let themselvesbe influenced by previous labels.

Case 5

Information as for case 2 was given, except that the patientwas female.

Group/meansOne-wayTwo-wayanovaanova(F

ratios)StatementaboutpatientPDNoPDGroupDiagnosisManipulating

admission3.412.7514.2***4.6***Unlikelyto arousesympathy3.502.61l5.0***2.8*Taking

an overdose would beattention-seeking3.673.187.l**6.4***Shouldbe discharged from out-patientfollow-up2.051.657.0**1.5Wouldnot like to have in one'sclinic2.962.457.2**2.0Poses

difficult managementproblem3.892.9519.2***2.0Likelytoannoy3.142.597.0**2.9*Unlikely

toimprove2.542.0013.7***3.6**Causeof debts under patient'scontrol4.364.043@9*1.4Not

mentallyill3.672.969.8**9@4***Casedoes not merit NHStime3.002.675@3*2.7*Unlikely

to completetreatment3.762.6142.9***3.8**Unlikelyto comply withadvice/treatment3.452.6921.6***3.8**Suicidalurges under patient'scontrol3.483.182.73.1*Likely

to become dependent onone4.093.940.21.0Conditionnotsevere3.603.1210.3**45***Admissionnotindicated4.033.413.62.2Not

a suiciderisk3.443.074@3*4.l**Doesnot require sicknesscertificate3.002.443.83.6**Dependent

onbenzodiazepines3.263.140.91.9Psychotherapyreferral notindicated3.543.550.01.5Antidepressants

not indicated3.773.126.6*5.8***

GroupPDGroupNoPDNumber

ofcasesMean

ofvariables(s.e.m.)Number

ofcasesMean

ofvariables

(s.e.m.)Depression

Personality disorderAnxiety stateAdjustment reactionNeurastheniaDrug dependence25

73

16203.03

(0.11)3.48 (0.18)3.88 (0.30)3.76 (0.36)3.07 (0.36)

—¿�64

489212.59

(0.07)3.30 (0.37)3.27 (0.09)3.09 (0.18)3.61 (0.97)3.0

46 LEWISAND APPLEBY

TABLE IMeans and results of analysis of variance

*p<005; **p<001; ***p<()()()jANOVA = analysis of variance; PD = personality disorder; NoPD = no personality disorder.

HighervaluesindicategreateragreementwithStatement;therewasa 6-pointscalebetweenthe twostatementsof thesemanticdifferential.

Diagnosis made by respondents: d.f. = 3; P< 0.001; Table II). Because of this relationship,Its relationship to attitudes two-way analyses of variance were performed, entering the

group effect first. This allowed us to examine the effectsAt the end of the semantic differential, the psychiatrists of diagnosis independent of the group effect. The resultswere asked to make a provisional diagnosis. Sixty-three per are shown in the fourth column of Table I.cent made a diagnosis of depression. The respondents in The mean values (Table II) show that the diagnosis ofGroup PD were more likely than those in Group NoPD depression was associated with the least-criticalattitudes.to make the diagnosis of adjustment reaction (x2= 14.4; Personality disorder, adjustment reaction, and anxiety had

TABLE IIThe relationship between the diagnosis made by the psychiatrists and their attitudes to the case

The significantsemanticdifferentialitemshavebeensummedfor each subjectand the meansfor eachdiagnostic group are given here. Higher values indicate more critical attitudes (see Table I).

Item234Correlat5ion

(r)67891.Not

mentallyill0.400.350.190.400.230.270.250.282.Takinganoverdose0.510.280.390.310.310.410.30would

beattentionseeking3.Manipulating

admission0.270.370.360.360.230.104.Causeof debtsunder0.310.040.140.230.21patient's

control5.Suicidalurgesunder0.120.290.170.19patient's

control6.Shouldbedischarged0.290.250.06from

out-patientfollowup7.Case

does notmerit0.250.24NHStime8.Unlikely

toarouse0.37sympathy9.Likely

to annoy

47PERSONALITY DISORDER

higher scores than depression, but the small sample sizemakes it impossible to say whether there were any realdifferences between these diagnoses. Table II gives anoverall picture of the results, obtained by calculatingthemeans of the sum of the significant variables in eachdiagnostic category.

Although the diagnosis of depression was associated withmore favourable attitudes overall, a previous diagnosis ofPD (GroupPD) stillresultedin morecriticalattitudes,evenwhen the psychiatrists' own diagnosis was depression(Table II). This result was confirmed by the analysis ofvariance, for there was only one semantic differential thatshowed a significant group by diagnosis interaction, the item“¿�manipulatingadmission―(F= 2.89; P<0.05) and evenhere, the mean of subjects who diagnosed depression ingroup PD (mean = 3.00) was still higher than those in groupNoPD (mean= 2.55; t = 2.74;P<0.0l). The vast majorityof the attitudes showedno such interaction and it is clearthat the group effect of previous diagnosis was independentof the effect of the ‘¿�current'diagnosis made by thepsychiatrists. It indicates that PD still had an effect onattitudes even though it was not the psychiatrists' owndiagnosis.

The diagnosis of adjustment reaction was commoner inthe group that had been given a previous diagnosis of PD,and adjustment reaction was associated with more criticalattitudes. This suggeststhat adjustment reaction could bea diagnosis applied to depressivesymptoms in those whosefundamental disturbance is seen as of the personality ratherthan due to illness.

The more-experienced psychiatrists had less-criticalattitudes on a number of items, e.g. “¿�annoying―,“¿�notmentally ill―,“¿�conditionnot severe―.Such cross-sectionaldata though, could reflect changes in medical educationrather than experience.

Perception of control and personality disorder

The correlations between individual items provide someconfirmation of the suggested link between mental illnessand control (Table III). “¿�Notmentally ill―was correlatedwith items implying the patient had control over his or herbehaviour (items 2—5in Table III). Weiner's (1980) modelalso predicts that perceived control should be associatedwith lack of sympathy (items 8 and 9) and so make it lesslikely that the psychiatrist would consider helping (items6 and 7). Of the correlation coefficients in Table III, 31of 36 are significant at the 5% level.

Discussion

This study supports the view that psychiatrists formpejorative, judgemental, and rejecting attitudestowards those who have been given a diagnosis ofpersonality disorder. Patients previously labelled aspersonality disordered were seen as manipulative,difficult to manage, unlikely to arouse sympathy,annoying, and not deserving NHS resources. Psychiatrists viewed them as uncompliant, not acceptingadvice, and having a poor prognosis. They were morelikely to be discharged from follow-up examination,and suicide attempts were seen as attention-seekingrather than ‘¿�genuine'.Requests for admission werethought to be manipulative, and the patients werejudged less mentally ill, and their problems lesssevere.

At the end of the questionnaire, the subjects wereasked to make their own diagnosis; analysis of theresults indicated that these attitudes to PD were

TABLE IIICorrelations between selected items

1.Ifr>0.15,thenP<O.05;ifr>0.25thenP<0.00l.

48 LEWIS AND APPLEBY

apparent regardless of the psychiatrists' own diagnosis. One cannot argue therefore, that the featuresshown above are the real features of personalitydisorder.

The results show that the past diagnosis of PD wasmore important in determining these attitudes thansex, class, and giving a previous diagnosis ofdepression. Informing the respondents of our mainexperimental concerns did not affect attitudes.

Methodological issues

Case vignettes have been used in previous studies ofdecision-making by psychiatrists (Mayou, 1977) andphysicians (O'Toole et a!, 1983). This methodallows a fully controlled experimental study, andusually produces results consistent with behaviouralobservations (e.g. Weiner, 1980). Although a casevignette does not provide as much information asa clinical interview, it cannot create attitudes that donot already exist.

Unambiguous semantic differentials are an acceptedmethod of measuring attitudes. The validity of thescales is supported by the results, for instance, thatpsychotherapists were more likely to refer for psychotherapy, and biological psychiatrists were more likelyto prescribe antidepressants. Attitudes are an important determinant of behaviour (e.g. Nisbett & Ross,1980) and an important area of study in their ownright, particularly in psychiatry, where rejecting andpejorative attitudes would be noted by patientsbecause of non-verbal cues, although the psychiatrists' overt behaviour might be unchanged.

Categories of personality

The case vignette used here did not specify a categoryof PD nor provide any information that mightsupport any particular PD diagnosis. This is consistent with the practice of many psychiatrists, who usethe term without subdividing PD into categories.

The present study therefore extends Gunn &Robertson's (1976) assertion on the label ‘¿�psychopath' to the overall term of personality disorder that“¿�whatis conveyed. . . is that the patient is difficultand probably unpleasant―; although it does notexclude the possibility that some types of personalitydisorder are less damning than others.

Personality disorder and mental illness

How has a term, which appears at first sight to bringtogether a group of deviant types of behaviour, cometo be a derogatory label? We argue here, withsupportive evidence from the study, that the answer

lies in the assumption that PD is not a mental illness,and the consequent attributions of control.

The PD patients were judged less mentally ill, andwere seen as being in control of their debts andsuicidal urges. They were thought to be manipulatingand attention-seeking, both expressions implyingcontrol of behaviour. Perceived control and absenceof ‘¿�illness'were also significantly correlated with lackof help-givingand sympathy, consistent with Weiner's(1980) model.

Sociologists (e.g. Scheff, 1963) usually think ofmental illness as a stigmatising label, but for thepsychiatrists in this study it was associated withfavourable attitudes. This does not imply that thereis no stigma to mental illness; rather that ‘¿�abnormal'behaviour may be relatively excused if attributed tomental illness. For a psychiatrist, someone who ismentally ill requires professional help, including thesympathy and acceptance that doctors are expectedto provide.

Although mental illness is a concept without rigidboundaries (Farrell, 1979), doctors appear to distinguish between those that are ill and those that arenot. Furthermore, the unreliability of the PD diagnosis suggests that the rules employed are arbitrary.This view would be ethically acceptable, althoughscientifically dubious, if its only consequence werea caring, sympathetic attitude to those whosebehaviour fell within the illness boundary. However,this study demonstrates that patients receiving anon-illness, PD diagnosis may be rejected and viewedwith therapeutic pessimism even when they havepsychiatric symptoms. Those labelled as personalitydisordered appear to be denied the benefits of beingregarded as ill, but also denied the privilege of beingregarded as ‘¿�normal'.

In clinical practice, judgements are frequentlymade on whether a patient is in control of his or heractions, and so responsible for them. For example,if a patient considered ill breaks a window, his actionmay automatically be attributed to his illness; he istherefore not responsible and is not blamed. For thepatient thought to have a PD, there may be anequivalent automatic assumption: he is responsibleand deserves blame for his actions.

Each case vignette described the same symptomsand so the effect of the PD label on attitudes wasseen to override the patient's complaints It has beensuggested that those diagnosed as personality disordered are less likely to receive treatment fordepression despite having depressive symptoms(Slavney & McHugh, 1974; Thompson & Goldberg,1987). Here, prescription of antidepressants and outpatient follow-up examination was less likely ingroup PD. The PD label appears to reduce the

49PERSONALITY DISORDER

importance attributed to symptoms, perhaps byproviding alternative explanations: for instance, thatthe patient is attention-seeking or manipulative, thattheir symptoms are less genuine.

Conclusion

This study adds to the criticism of the personalitydisorder diagnosis. We have suggested that becauseitisseen as distinctfrom mental illness,itimplies

control and responsibility, and encourages rejection.Most seriously, it leads to pejorative attitudes.

We suggest that the clinical diagnosis of personality disorder has no justification and should beabandoned. No physicist would claim that an electronwas any more worthwhile than a positron, but psychiatrists appear to prefer one diagnosis to another. Ascientific classification loses credibility if it containsvalue judgements or moral statements. A classification based on symptoms should be more reliable, andencourage a sympathetic approach to treatment.

Acknowledgements

The projectwas fundedby theBethlemRoyaland MaudsleyHospitals.We thankallthosewho returnedquestionnaires,andDr Graham Dunn forinvaluablestatisticalhelp.

References

AMERICAN PSYCHIATRIC ASSOCIATION (1980) Diagnostic and Statis

tical Manual of Mental Disorders (3rd edn) (DSM—III).WashingtonDC: APA.

CHODOFF, P. & Lyous, H. (1958) Hysteria, the hysterical

personalityand hystericalconversion.AmericanJournalofPsychiatry, 114, 734—740.

CLECKLEY,H. (1976) The Mask of Sanity (5th edn). St Louis:C. V. Mosby.

DEPARTMENTOF HEALTHANDSOCIALSECURITY(1987) Medical anddentalstaffingprospectsintheNHS inEnglandandWalesin1986. Health Trends, 19, 1—7.

FARRELL, B. A. (1979) Mental illness: a conceptual analysis.

Psychological Medicine, 9, 21—35.GUNN, J. & ROBERTSON, G. (1976) Psychopathic personality: a

conceptual problem. Psychological Medicine, 6, 631—634.HENDERSON,D. K. (1939) Psychopathic States. New York: W. W.

Norton.HOWARD, C. (1985) The ‘¿�inadequatepersonality'. In Handbook of

Psychiatry, vol. 4. The Neuroses and Personality Disorders (edsG. F. M. Russell& L. A. Hersov).Cambridge:CambridgeUniversity Press.

KENDELL, R. E. (1975a) The Role of Diagnosis in Psychiatry.Oxford: BlackwellScientificPublications.

—¿� (1975b) The concept of disease and its implications for

psychiatry. British Journal of Psychiatry, 127, 305—315.KREITMAN, N., SAINSBURY, P., MORRISSEY, J., TOWERS, J. &

SCRIVENER, J. (1961) The reliability of psychiatric diagnosis.

JournalofMentalScience,107,887—908.LEWIS,A. (1953) Health as a social concept. British Journal ofSociology,4,109—124.

—¿� (1974) Psychopathic personality: a most elusive category.

Psychological Medicine, 4, 133-140.MAYOU, R. (1977) Psychiatric decision making. British Journal of

Psychiatry,130,374—376.MELLSOP, G., VARGHESE, F., JOSHUA, S. & HICKS, A. (1982) The

reliability of axis II of DSM—III. American Journal of

Psychiatry,139,1360—1361.MISCHEL, W. (1968) Personality and Assessment. New York:

Wiley.NISBETr, R. & RosS, L. (1980) Human Inference: Strategies and

Shortcomings of Social Judgement. Englewood Cliffs, NJ:Prentice Hall.

O'TooLE, R., TURBETr, P. & NALEPKA,C. (1983) Theories,professional knowledge and diagnosis of child abuse. In TheDark Side of Families: Current Family Violence Research (edsD. Finkelhor, R. J. Gellis, 0. T. Hottaling & M. A. Straus).BeverlyHills: Sage.

PARRY, R. A. (1978) Alcoholism. In Companion to PsychiatricStudies(2ndedn)(edsA. Forrest,J.Afleck& A. Zealley).Edinburgh: Churchill Livingstone.

SCHEFF,T. J. (1963) The role of the mentally ill and the dynamicsof mental disorder. Sociometry, 26, 436—453.

SHEPHERD, M. & SARTORIUS, N. (1974) Personality disorder andthe ‘¿�InternationalClassification of Diseases'. PsychologicalMedicine, 4, 141—146.

SLAVNEY, P. R. & MCHUGH, P. R. (1974) The hystericalpersonality: a controlled study. Archives of General Psychiatry,30, 325—329.

THOMPSON,D. J. & GOLDBERG,D. (1987) Hysterical personalitydisorder: the process of diagnosis in clinical and experimentalsettings.BritishJournalof Psychiatry,150,241—245.

WALTON, H. J. (1978) The psychoneuroses. In Companion toPsychiatric Studies (2nd edn) (eds A. Forrest, J. Affleck & A.Zealley). Edinburgh: Churchill Livingstone.

—¿� & PRESLY, A. S. (1973) Use of a category system in the

diagnosis of abnormal personality. British Journal of Psychiatry,122, 259—268.

WEINER, B. (1980) A cognitive (attribution)-emotion-action model

of motivated behaviour: an analysis of judgements of help giving.Journalof Personalityand SocialPsychology,39, 186—200.

WOOl-rON, B. (1959) Social Science and Social Pathology. London:George Allen.

WORLD HEALTh ORGANIZATION (1978) Mental Disorders: Glossary

& Guide to their Classification in Accordance with the NinthRevision of the International Classification of Diseases (ICD-9).Geneva:World Health Organization.

5Glyn Lewis, MA, MSc, MRCPsych,Research Worker, General Practice Research Unit; Louis Appleby, BSc,MRCP, MRCPsych,Clinical Lecturer, Department of Psychiatry, Institute of Psychiatry, De Crespigny Park,London SE5 8AF

*Correspondence