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The Patients Psychiatrists Dislike See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/19932548 Personality disorder: The patients psychiatrists dislike ARTICLE in THE BRITISH JOURNAL OF PSYCHIATRY · AUGUST 1988 Impact Factor: 7.99 · DOI: 10.1192/bjp.153.1.44 · Source: PubMed CITATIONS READS 183 83 2 AUTHORS, INCLUDING: Glyn Lewis University of London 515 PUBLICATIONS 19,434 CITATIONS SEE PROFILE Available from: Glyn Lewis Retrieved on: 04 February 2016 Personality disorder: the patients psychiatrists dislike G Lewis and L Appleby The British Journal of Psychiatry 1988 153: 44-49 Access the most recent version at doi:10.1192/bjp.153.1.44 References Article cited in: http://bjp.rcpsych.org/cgi/content/abstract/153/1/44#otherarticles Reprints/ To obtain reprints or permission to reproduce material from this paper, please write permissions to [email protected] You can respond http://bjp.rcpsych.org/cgi/eletter-submit/153/1/44 to this article at Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article or click here Downloaded bjp.rcpsych.org on July 11, 2011 from Published by The Royal College of Psychiatrists To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/subscriptions/ 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 likely management 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 difficult and less deserving of care compared with control subjects who were not. The PD cases were regarded as manipulative, attention-seeking, annoying, and in control of their suicidal urges and debts. PDtherefore appears to be an enduring pejorative judgement rather than a clinical diagnosis. It is proposed that the concept be abandoned. Personality disorder is an established clinical diagnosis, achieve elsewhere―(Howard,1985).Although ICD-9 surviving in both ICD-9 (World Health Organization, (World Health Organization, 1978) has changed the 1978) and DSM-.III (American Psychiatric Associa name to asthenic, the concept of inadequate PD lion, 1980). In 1974, Shepherd & Sartorius concluded: remains unchanged: “¿aweakinadequate response “¿Despitediagnosticimprecision and terminological to the demands of daily life―(World Health confusion it is indisputable that some working concept Organization, 1978). of psychopathic personality is essential for the practice Among allthis controversy, there is, surprisingly,one of clinical psychiatry―. area of relative agreement; that personality disorder is A number of criticisms have been made of the not a mental illness(Lewis, 1974).Although Henderson concept of personality disorder (PD). Firstly, it is an (1939)and Cleckley(1976)regard PD as an illness,there unreliable diagnosis, in part due to rather vague has recently been an increasing consensus distinguishing definitions (e.g. Kreitman et a!, 1961; Walton & PD from illness.Even Walton (1978),who has criticised Presly, 1973; Lewis, 1974), and remains so, despite PD, wrote “¿ThePersonalityDisorders.. take the attempts at greater precision, for instance in DSM form of recurrent disturbance in relationships with III (American Psychiatric Association, 1980;Meilsop other people and is not a form of illness―. eta!, 1982). Secondly, the concept of personality that Many authorities have found mental illnessdifficult underlies this clinical term has been increasingly to defme (Lewis, 1953;Wootton, 1959;Kendell, 1975b; abandoned by most social psychologists (e.g. Mischel, Farrell, 1979). However, one aspect of the concept 1968), who cite evidence showing that people do not is that the mentally ill are seen as less responsible and behave similarly in different situations. less in control of their actions. Weiner (1980) has But there is a more serious criticism in the literature, argued that the inference that someone is ‘¿incontrol' that personality disorder is a derogatory label that may is an important determinant in whether that person result in therapeutic neglect (Gunn & Robertson, is given help. His subjects were more likely to help, 1976). Kendell (1975a), in his influential monograph and were more sympathetic to, someone who on diagnosis, says “¿itistrue that several of our appeared ill (uncontrollable) than someone who diagnostic terms, like hysteric and psychopath, have appeared drunk (controllable). Thus, distinguishing acquired pejorative connotations even among psychia PD patients from those with mental illness could lead trists―.Although this argument is usually applied to to lack of sympathy and blame because of judgements antisocial PD, it is relevant to many of the other that their actions are under control. categories. For instance, Parry (1978) writes of This study was both an empirical test of whether alcoholics with personality disorder “¿theyareof course, PD is a pejorative term, and an examination of totally unreliable and their protestations are rapidly the hypothesis that patients labelled as PD are shown to be shallow insincerities―.Hysterical PD in thought to be more in control of their actions. some accounts is a parody of supposed feminine A sample of psychiatrists was given different short characteristics (Chodoff & Lyons, 1958). Inadequate case vignettes and then asked to complete a question personality disorder, the term itself a critical judge naire assessing their attitudes towards the case. ment, has been described as an “¿addictiontohelp―, Using vignettes in this way allowed us to control and further that “¿younginadequatewomen may for possible confounding variables, and forced the become prolific producers of children with whom they psychiatrists to use their stereotypes of PD to seek unsuccessfully the kind of intimacy they cannot complete the questionnaire. 44 PERSONALITY DISORDER 45 Method Case 6 Information as for case 2 was given, except that the Sample word “¿man―inthe opening sentence was changed to Psychiatrists (240), who lived in England, Wales, or “¿solicitor―. Scotland, were randomly selected from the membership list of the Royal College of Psychiatrists (approximately 12% Questionnaire of total; Department of Health and Social Security, 1987). Those who were described as registrars, who were retired, or The questionnaire consisted of 22 semantic differentials, were listed as being child psychiatrists, were excluded from with a 6-point scale, designed to elicit one aspect of the the sample (but several child psychiatrists were included in assessment or management of the case. Some of the items the sample because they were not listed as such). Subjects placed more emphasis on practical management issues (e.g. wererandomlyallocatedone of the sixbrief casehistories, antidepressant prescription, psychotherapy referral), but which they were asked to read before completing and most asked directly about attitudes to the patient (e.g. likely returning an accompanying questionnaire. They were told to annoy, attention-seeking, etc.). A full list is given in that we were interested in how experience influenced the Table I. The semantic differentials were scored so that a practice of psychiatrists, and were asked to provide details higher score represented responses that were more rejecting about previous qualifications and experience in psychiatry or that indicated lack of active treatment. For instance, a and in other specialties. The real purpose of the study was response at the end of the scale “¿overdosewouldbe an explained only to those receiving case 4 (see below). attention-seeking act―scored 6 and a response at the end “¿overdosewouldbe a genuine suicidal act―wasscored 1. Each subject was asked to complete the questionnaire and Case histories then choose a diagnosis from a list of depression, anxiety, The six case histories differed from each other in only one adjustment reaction, drug dependence, personality disorder, or two particulars. Each history contained the information and neurasthenia. which a general practitioner's (OP's) letter might provide about a depressed patient. The amount of information was deliberately restricted, to encourage subjects to draw Results inferences based on pre-existing attitudes. The first case history was as follows: Characteristics of the sample “¿A34-year-oldman is seen in out-patients. He complains Of the sample, 72% (173 of 240) returned completed of feeling depressed, and says he has been crying on his questionnaires and a further 9% (22) refused to participate, own at home. He is worried about whether he is having usually complaining that there was insufficient clinical a nervous breakdown, and is requesting admission. He has information on which to base judgements. Overall it was thought of killing himself by taking an overdose of some a very experienced sample, with a mean of 16.5 years tablets he has at home. He has taken one previous overdose, psychiatric practice. 2 years ago, and at that time he saw a psychiatrist who gave him a diagnosis of personality disorder. He has recently Previous diagnosis of personality disorder gone into debt and is concerned about how he will repay the money. He is finding it difficult to sleep and his OP The principal experimental concern was to see whether the hasgivenhimsomenitrazepam.Hethinksthesehavehelped previous diagnosis of personality disorder affected the a little and is reluctant to give them up.― psychiatrists' attitudes. Preliminary analysis illustrated that The other cases were modified from the first as follows: all statistically significant differences between the cases depended on the presence or absence of the PD diagnosis, Case 2 so cases 1 and 4 were combined as group PD (n = 58) and the remainder, receiving cases 2, 3, 5, and 6 were combined No previous diagnosis was mentioned. as group NoPD (n= 115). Case 3 The means of group PD were higher (i.e. more critical) than those of NoPD on all but I of the 22 items as shown Previous diagnosis was given as depression.
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