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Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial
Eur Psychiatry 2000 ; 15 Suppl 1 : 7-10 © 2000 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S0924933800004983/FLA
ORIGINAL ARTICLE
Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial P. Tyrer*, C. Manley, E. Van Horn, D. Leddy, O.C. Ukoumunne Department of Public Mental Health, Division of Neuroscience and Psychological Medicine, Imperial College School of Medicine, Paterson Centre, 20 Wharf Road, London W2 1PD, UK
Summary – One hundred fifty-five (77%) of 201 participants recruited in a trial of intensive vs standard case management of patients with recurrent psychotic illness had their personality status measured before treatment and were followed up for two years. The primary outcome was the total number of days spent in psychiatric hospitalisation in the two years following randomisation. Thirty-three (21%) of the patients had a personality disorder and their duration of hospital stay (105 days) was greater than in those without personality disorder (56 days). There was weak evidence that intensive case management more effective in reducing the duration of care in those with personality disorder than in those without personality disorder. © 2000 Éditions scientifiques et médicales Elsevier SAS costs / outcome / personality disorder / schizophrenia / trial
INTRODUCTION Although there are several studies that have measured personality status in severe mental illness, particularly in schizophrenia [3, 5, 9], there are conflicting views about the importance of personality disorder in determining outcome. Ever since the publication of the Danish adoption studies [11] the concept of personality disorder as part of the schizophrenic spectrum (extending from schizotypal personality traits at one extreme to unequivocal schizophrenic syndromes at the other) has been prominent and has been given neuropharmacologicalas well as genetic support [12]. There is also suspicion that the presence of schizotypal personality disorder may adversely effect outcome in schizophrenia [3]. Work in this area is handicapped by difficulties in assessing personality disorder in those with severe mental illness because of the distortion created by condi* Correspondence and reprints
tions that distort reality and retrospective recall. However, this subject is likely to become of greater importance as it has implications for both resource allocation and prediction of outcome [7]. In view of this we decided to assess personality status in a study in which intensive (one caseworker per 10-15 patients) and standard (one case worker per 30-35 patients) case management were compared in a randomised controlled trial and outcome determined two years later [16, 17]. METHOD The UK700 study was a randomised controlled trial carried out between 1994 and 1998 to compare the efficacy of intensive and standard case management in patients with recurrent psychotic disorder (mainly schizophrenia). The rationale and detailed methodology of the UK700 study are reported elsewhere [16].
8
P. Tyrer et al.
Seven hundred and eight psychotic patients from four centres in the UK (Manchester Royal Infirmary, St Charles’ and St Mary’s Hospitals, St George’s Hospital and the Maudsley Hospital in London) were allocated to either intensive or standard case management between February 1994 and April 1996 and followed up for two years. Recruitment to the study was either at the point of discharge from hospital or as outpatients. Assessments were carried out at baseline, one year and two years after randomisation. The primary outcome was the number of days spent in a psychiatric hospital over the two-year period. Clinical and functional change, quality of life, met and unmet needs and patient satisfaction were recorded by instruments at baseline and follow-up and used as secondary outcomes. These included the Comprehensive Psychopathological Rating Scale (CPRS) [1], the Disability Assessment Schedule (DAS) [4] to measure social disability, the Camberwell Assessment of Needs (CAN) [10] and the Lancashire Quality of Life Profile [8]. Satisfaction with mental health services was measured using the Patient Satisfaction Questionnaire [14], with higher scores on the scale indicating greater dissatisfaction. Health service use data were collected prospectively for each patient during the two-year study period. Information was also recorded on the use of staffed accommodation, prison and police custody. All unit costs were for the financial year 1997/1998 and future costs were discounted at a rate of 6% [18]. The total cost of care over two years was analysed as a secondary outcome. Personality status was assessed by the ICD-10 version of the Personality Assessment Schedule [6, 13]. This records all the ICD-10 personality groups and can also be used to score the overall severity of personality disorder into three levels – personality difficulty, simple personality disorder and diffuse (complex) personality disorder – together with no personality disorder [15]. STATISTICAL ANALYSIS The outcome at two years of patients with either a simple or diffuse (complex) personality disorder was compared to other patients using the t-test. Potential differential benefits of intensive case management between those with and without personality disorder were assessed using tests of interaction. Regression analysis was used to implement the interaction tests. For all analyses besides hospitalisation and costs of care, differences in outcome were adjusted for the corre-
sponding baseline scores. Bootstrap methods [2] were used to check the validity of the findings when analysing the hospitalisation and cost of care variables, which were heavily skewed. The bootstrap technique allows parametric statistics to be applied correctly to skewed data. As there were no marked differences from the bootstrap results, the t-test and regression results are reported in the tables. RESULTS One hundred fifty-five (77%) of the 201 patients seen at the St Mary’s/St. Charles’ centre had their personality status assessed, 102 of these assessments were with the subject and the other 53 with an informant. In all instances the reasons for non-assessment were the inability or refusal of the patient to be interviewed or the absence of a suitable informant. Table I shows the number and percentage of subjects with a personality disorder on each of the ICD10 personality groups. The most common disorders occurred in the anxious, paranoid and histrionic groups. Thirty-three (21%) of the patients who had their personality status measured were classified as having either a simple or diffuse personality disorder overall, and 56 (36%) had an overall classification of personality difficulty (table II). The demographic profile of patients with personality disorder was similar to that of other patients (table III). Table IV summarises the two-year outcome by personality disorder status. After two years those with personality disorder on average had spent nearly twice as long in hospital than those with no personality disorder (mean 105 days vs 56 days; P = 0.02), though Table I. Number (% of 155 subjects) with each ICD10 personality type. Personality type (ICD-10 equivalent) Paranoid Schizoid Dissocial and antisocial Impulsive Borderline Histrionic Anankastic or obsessivecompulsive Anxious Dependant
No disorder Difficulty
Disorder
N (%)
N (%)
N (%)
121 (78 %) 147 (95 %) 144 (93 %) 133 (86 %) 135 (87 %) 131 (85 %) 131 (85 %)
24 (15 %) 8 (5 %) 11 (7 %) 18 (12 %) 16 (10 %) 15 (10 %) 22 (14 %)
10 (6 %) 0 (0 %) 0 (0 %) 4 (3 %) 4 (3 %) 9 (6 %) 2 (1 %)
109 (70 %) 31 (20 %) 15 (10 %) 123 (79 %) 23 (15 %) 9 (6 %)
N = 155. Eur Psychiatry 2000 ; 15 Suppl 1 : 7–10
9
Influence of personality on outcome of severe mental illness
there was no significant difference with respect to the total cost of care over two years. Of the other outcomes only satisfaction levels differed significantly between the personality groups, with the disorder group having lower levels of dissatisfaction (mean 15.9 vs 17.7; P = 0.02). The results of tests of interaction effect between personality status and case management status are summarised in table V for the hospitalisation and total cost of care over two-year outcomes. There was weak evidence that intensive case management is more beneficial for patients with personality disorder than those without, in terms of reducing the number of days spent in psychiatric hospitalisation. Intensive case management reduced days spent in hospital for personality disorder patients by a mean 110 days compared to just 21 days for patients without personality disorder. There
Table II. Overall classification of personality status. Classification No personality disorder Personality difficulty Simple personality disorder Diffuse personality disorder TOTAL
N
%
66 56 25 8 155
42.6 36.1 16.1 5.2 100
Table III. Demographic characteristics by personality disorder status. Variable Age Percentage female Percentage Black Caribbean
Disorder N = 33
No disorder N = 122
mean (SD) 37.1 (9.1) 40.4 (11.8) % 45.5 % (15/33)40.2 % (49/122) % 12.1 % (4/33)18.0 % (22/122)
was no significant interaction between case management status and personality disorder status on cost of care over two years and the other two-year outcomes. DISCUSSION The results indicate the importance of personality status in severe mental illness and suggest that the routine assessment of personality status is important for planners and those involved in delivery of psychiatric services. The results of interaction analyses weakly indicate that greater input into the care of these patients might have a positive effect on outcome in a way that is not shown with similar patients without personality disorder. However, the numbers of patients in the subgroups are small and these interaction results should be interpreted with some caution. Although the difficulties in assessing personality disorder in psychotic patients are considerable [19], the importance of making these assessments is important for both clinical and economic reasons. The failure to improve outcome in psychotic patients is often assumed to be due to treatment resistance or poor compliance with medication. Our data suggest that a more common explanation could be co-morbid personality disorder and that attention should be paid to treating this rather than the persistent focus on the mental state disorder. REFERENCES 1 Åsberg M, Montgomery SA, Perris C, Schalling D, Sedvall G. A comprehensive psychopathological rating scale. Acta Psychiat Scand 1978 ; Suppl 271 : 5-29. 2 Efron B, Tibshirani RJ. An introduction to the bootstrap. London: Chapman and Hall; 1993. 3 Fenton WS, McGlashan TH. Risk of schizophrenia in character disordered patients. Am J Psychiatry 1989 ; 146 : 1280-4. 4 Jablensky A, Schwartz R, Tomov T. WHO collaborative study
Table IV. Two-year outcome by personality disorder status. Variable Days in hospital Costs of care (£) CPRS score Quality of Life score No. of unmet needs (CAN) DAS score Patient (dis)satisfaction
Mean (sd) Mean (sd) Mean (sd) Mean (sd) Mean (sd) Mean (sd) Mean (sd)
Disorder
N
No disorder
N
105.1 (156.2) 21677 (21873) 30.0 (19.3) 4.37 (0.79) 3.31 (3.67) 1.14 (0.94) 15.9 (2.7)
31 31 28 24 26 26 20
56.4 (87.7) 20766 (17694) 20.6 (14.8) 4.44 (0.80) 3.16 (2.85) 0.95 (0.67) 17.7 (4.9)
114 114 104 89 103 98 83
* Two subjects missing on patient’s satisfaction from the no disorder group. Eur Psychiatry 2000 ; 15 Suppl 1 : 7–10
Difference (disorder – no disorder)* Estimate 95 % CI P-value 48.7 910 9.43 –0.07 0.15 0.19 –1.87
6.3 –6556 2.77 –0.43 –1.16 –0.13 –4.14
91.1 8377 16.10 0.29 1.47 0.51 0.41
0.02 0.81 0.006 0.70 0.82 0.24 0.11
10
P. Tyrer et al.
Table V. Number of days spent in hospital and cost of care over two years by personality disorder status and case management status. Outcome
Personality disorder status
Case management status Intensive
N
Standard
Difference (Intensive - Standard) N
Estimate
95 % Confidence Interval interaction
Days in hospital, mean (sd)
0.06 No disorder Disorder
46.4 (84.2) 23.6 (35.8)
59 8
67.1 (90.8) 133.4 (172.1)
55 –20.7 23 –109.8
–53.2 –236.5
11.7 16.9
Total cost of care (£), mean (sd)
0.27 No disorder Disorder
5 6 7 8
9 10
11 12
P-value of
20339 (17650) 14090 (10987)
59 8
21225 (17891) 24316 (24203)
of impairments and disabilities associated with schizophrenic disorders: a preliminary communication. Objective and methods. Acta Psychiat Scand 1980 ; 285 : 152-63. McGlashan T. The Chestnut Lodge follow-up study. ii: Longterm outcome of schizophrenia and affective disorders. Arch Gen Psychiatry 1984 ; 41 : 586-601. Merson S, Tyrer P, Duke P, Henderson F. Inter-rater reliability of ICD-10 guidelines for the diagnosis of personality disorders. J Pers Dis 1994 ; 8 : 89-95. Oldham JM. Personality disorders: current perspectives. JAMA 1994 ; 272 : 1770-6. Oliver JP, Huxley PJ, Priebe S, Kaiser W. Measuring the quality of life of severely mentally ill people using the Lancashire Quality of Life Profile. Soc Psychiat Psychiat Epidem 1991 ; 32 : 76-83. Peralta V, Cuesta MJ, de Leon J. Premorbid personality and positive and negative symptoms in schizophrenia. Acta Psychiat Scand 1991 ; 84 : 336-9. Phelan M, Slade M, Thornicroft G, et al. The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry 1995 ; 167 : 589-95. Rosenthal D, Wender PH, Kety SS, Welner J, Schulsinger F. The adopted-away offspring of schizophrenics. Am J Psychiatry 1971 ; 128 : 307-11. Siever LJ, Davis KL. A psychobiologic perspective on the personality disorders. Am J Psychiatry 1991 ; 148 : 1647-58.
55 –887 23 –10226
–7485 –28494
5711 8042
13 Tyrer P. Personality Assessment Schedule PAS-I (ICD-10 version). In: Personality disorders: diagnosis, management and course, 2nd ed.. Oxford: Butterworth-Heinemann; 2000. p. 160-80. 14 Tyrer P, Remington M. Controlled comparison of day hospital and out-patient treatment for neurotic disorders. Lancet 1979 ; i : 1014-6. 15 Tyrer P, Johnson T. Establishing the severity of personality disorder. Am J Psychiatry 1996 ; 153 : 1593-7. 16 UK700 Group, Creed F, Burns T, Butler T, Byford S, Murray R, Thompson S, et al. Comparison of intensive and standard case management for patients with psychosis: rationale of the trial. Br J Psychiatry 1999 ; 174 : 74-8. 17 UK700 Group, Burns T, Creed F, Fahy T, Thompson S, Tyrer P, White I. Intensive versus standard case management for severe psychotic illness: a randomised trial. Lancet 1999 ; 353 : 2185-9. 18 UK700 Group, Byford S, et al. Costs of care in intensive versus standard case management for severe psychotic illness: a randomised controlled trial. Br J Psychiatry 2000 ; (in press). 19 Van Horn E, Manley C, Ukoumunne OC, Leddy D, Cicchetti D, Tyrer P. Problems in developing an instrument for the rapid assessment of personality status. Eur Psychiatry 2000 ; 15 Suppl 1 : 29-33.
Eur Psychiatry 2000 ; 15 Suppl 1 : 7–10
ORIGINAL ARTICLE
Personality abnormality in severe mental illness and its influence on outcome of intensive and standard case management: a randomised controlled trial P. Tyrer*, C. Manley, E. Van Horn, D. Leddy, O.C. Ukoumunne Department of Public Mental Health, Division of Neuroscience and Psychological Medicine, Imperial College School of Medicine, Paterson Centre, 20 Wharf Road, London W2 1PD, UK
Summary – One hundred fifty-five (77%) of 201 participants recruited in a trial of intensive vs standard case management of patients with recurrent psychotic illness had their personality status measured before treatment and were followed up for two years. The primary outcome was the total number of days spent in psychiatric hospitalisation in the two years following randomisation. Thirty-three (21%) of the patients had a personality disorder and their duration of hospital stay (105 days) was greater than in those without personality disorder (56 days). There was weak evidence that intensive case management more effective in reducing the duration of care in those with personality disorder than in those without personality disorder. © 2000 Éditions scientifiques et médicales Elsevier SAS costs / outcome / personality disorder / schizophrenia / trial
INTRODUCTION Although there are several studies that have measured personality status in severe mental illness, particularly in schizophrenia [3, 5, 9], there are conflicting views about the importance of personality disorder in determining outcome. Ever since the publication of the Danish adoption studies [11] the concept of personality disorder as part of the schizophrenic spectrum (extending from schizotypal personality traits at one extreme to unequivocal schizophrenic syndromes at the other) has been prominent and has been given neuropharmacologicalas well as genetic support [12]. There is also suspicion that the presence of schizotypal personality disorder may adversely effect outcome in schizophrenia [3]. Work in this area is handicapped by difficulties in assessing personality disorder in those with severe mental illness because of the distortion created by condi* Correspondence and reprints
tions that distort reality and retrospective recall. However, this subject is likely to become of greater importance as it has implications for both resource allocation and prediction of outcome [7]. In view of this we decided to assess personality status in a study in which intensive (one caseworker per 10-15 patients) and standard (one case worker per 30-35 patients) case management were compared in a randomised controlled trial and outcome determined two years later [16, 17]. METHOD The UK700 study was a randomised controlled trial carried out between 1994 and 1998 to compare the efficacy of intensive and standard case management in patients with recurrent psychotic disorder (mainly schizophrenia). The rationale and detailed methodology of the UK700 study are reported elsewhere [16].
8
P. Tyrer et al.
Seven hundred and eight psychotic patients from four centres in the UK (Manchester Royal Infirmary, St Charles’ and St Mary’s Hospitals, St George’s Hospital and the Maudsley Hospital in London) were allocated to either intensive or standard case management between February 1994 and April 1996 and followed up for two years. Recruitment to the study was either at the point of discharge from hospital or as outpatients. Assessments were carried out at baseline, one year and two years after randomisation. The primary outcome was the number of days spent in a psychiatric hospital over the two-year period. Clinical and functional change, quality of life, met and unmet needs and patient satisfaction were recorded by instruments at baseline and follow-up and used as secondary outcomes. These included the Comprehensive Psychopathological Rating Scale (CPRS) [1], the Disability Assessment Schedule (DAS) [4] to measure social disability, the Camberwell Assessment of Needs (CAN) [10] and the Lancashire Quality of Life Profile [8]. Satisfaction with mental health services was measured using the Patient Satisfaction Questionnaire [14], with higher scores on the scale indicating greater dissatisfaction. Health service use data were collected prospectively for each patient during the two-year study period. Information was also recorded on the use of staffed accommodation, prison and police custody. All unit costs were for the financial year 1997/1998 and future costs were discounted at a rate of 6% [18]. The total cost of care over two years was analysed as a secondary outcome. Personality status was assessed by the ICD-10 version of the Personality Assessment Schedule [6, 13]. This records all the ICD-10 personality groups and can also be used to score the overall severity of personality disorder into three levels – personality difficulty, simple personality disorder and diffuse (complex) personality disorder – together with no personality disorder [15]. STATISTICAL ANALYSIS The outcome at two years of patients with either a simple or diffuse (complex) personality disorder was compared to other patients using the t-test. Potential differential benefits of intensive case management between those with and without personality disorder were assessed using tests of interaction. Regression analysis was used to implement the interaction tests. For all analyses besides hospitalisation and costs of care, differences in outcome were adjusted for the corre-
sponding baseline scores. Bootstrap methods [2] were used to check the validity of the findings when analysing the hospitalisation and cost of care variables, which were heavily skewed. The bootstrap technique allows parametric statistics to be applied correctly to skewed data. As there were no marked differences from the bootstrap results, the t-test and regression results are reported in the tables. RESULTS One hundred fifty-five (77%) of the 201 patients seen at the St Mary’s/St. Charles’ centre had their personality status assessed, 102 of these assessments were with the subject and the other 53 with an informant. In all instances the reasons for non-assessment were the inability or refusal of the patient to be interviewed or the absence of a suitable informant. Table I shows the number and percentage of subjects with a personality disorder on each of the ICD10 personality groups. The most common disorders occurred in the anxious, paranoid and histrionic groups. Thirty-three (21%) of the patients who had their personality status measured were classified as having either a simple or diffuse personality disorder overall, and 56 (36%) had an overall classification of personality difficulty (table II). The demographic profile of patients with personality disorder was similar to that of other patients (table III). Table IV summarises the two-year outcome by personality disorder status. After two years those with personality disorder on average had spent nearly twice as long in hospital than those with no personality disorder (mean 105 days vs 56 days; P = 0.02), though Table I. Number (% of 155 subjects) with each ICD10 personality type. Personality type (ICD-10 equivalent) Paranoid Schizoid Dissocial and antisocial Impulsive Borderline Histrionic Anankastic or obsessivecompulsive Anxious Dependant
No disorder Difficulty
Disorder
N (%)
N (%)
N (%)
121 (78 %) 147 (95 %) 144 (93 %) 133 (86 %) 135 (87 %) 131 (85 %) 131 (85 %)
24 (15 %) 8 (5 %) 11 (7 %) 18 (12 %) 16 (10 %) 15 (10 %) 22 (14 %)
10 (6 %) 0 (0 %) 0 (0 %) 4 (3 %) 4 (3 %) 9 (6 %) 2 (1 %)
109 (70 %) 31 (20 %) 15 (10 %) 123 (79 %) 23 (15 %) 9 (6 %)
N = 155. Eur Psychiatry 2000 ; 15 Suppl 1 : 7–10
9
Influence of personality on outcome of severe mental illness
there was no significant difference with respect to the total cost of care over two years. Of the other outcomes only satisfaction levels differed significantly between the personality groups, with the disorder group having lower levels of dissatisfaction (mean 15.9 vs 17.7; P = 0.02). The results of tests of interaction effect between personality status and case management status are summarised in table V for the hospitalisation and total cost of care over two-year outcomes. There was weak evidence that intensive case management is more beneficial for patients with personality disorder than those without, in terms of reducing the number of days spent in psychiatric hospitalisation. Intensive case management reduced days spent in hospital for personality disorder patients by a mean 110 days compared to just 21 days for patients without personality disorder. There
Table II. Overall classification of personality status. Classification No personality disorder Personality difficulty Simple personality disorder Diffuse personality disorder TOTAL
N
%
66 56 25 8 155
42.6 36.1 16.1 5.2 100
Table III. Demographic characteristics by personality disorder status. Variable Age Percentage female Percentage Black Caribbean
Disorder N = 33
No disorder N = 122
mean (SD) 37.1 (9.1) 40.4 (11.8) % 45.5 % (15/33)40.2 % (49/122) % 12.1 % (4/33)18.0 % (22/122)
was no significant interaction between case management status and personality disorder status on cost of care over two years and the other two-year outcomes. DISCUSSION The results indicate the importance of personality status in severe mental illness and suggest that the routine assessment of personality status is important for planners and those involved in delivery of psychiatric services. The results of interaction analyses weakly indicate that greater input into the care of these patients might have a positive effect on outcome in a way that is not shown with similar patients without personality disorder. However, the numbers of patients in the subgroups are small and these interaction results should be interpreted with some caution. Although the difficulties in assessing personality disorder in psychotic patients are considerable [19], the importance of making these assessments is important for both clinical and economic reasons. The failure to improve outcome in psychotic patients is often assumed to be due to treatment resistance or poor compliance with medication. Our data suggest that a more common explanation could be co-morbid personality disorder and that attention should be paid to treating this rather than the persistent focus on the mental state disorder. REFERENCES 1 Åsberg M, Montgomery SA, Perris C, Schalling D, Sedvall G. A comprehensive psychopathological rating scale. Acta Psychiat Scand 1978 ; Suppl 271 : 5-29. 2 Efron B, Tibshirani RJ. An introduction to the bootstrap. London: Chapman and Hall; 1993. 3 Fenton WS, McGlashan TH. Risk of schizophrenia in character disordered patients. Am J Psychiatry 1989 ; 146 : 1280-4. 4 Jablensky A, Schwartz R, Tomov T. WHO collaborative study
Table IV. Two-year outcome by personality disorder status. Variable Days in hospital Costs of care (£) CPRS score Quality of Life score No. of unmet needs (CAN) DAS score Patient (dis)satisfaction
Mean (sd) Mean (sd) Mean (sd) Mean (sd) Mean (sd) Mean (sd) Mean (sd)
Disorder
N
No disorder
N
105.1 (156.2) 21677 (21873) 30.0 (19.3) 4.37 (0.79) 3.31 (3.67) 1.14 (0.94) 15.9 (2.7)
31 31 28 24 26 26 20
56.4 (87.7) 20766 (17694) 20.6 (14.8) 4.44 (0.80) 3.16 (2.85) 0.95 (0.67) 17.7 (4.9)
114 114 104 89 103 98 83
* Two subjects missing on patient’s satisfaction from the no disorder group. Eur Psychiatry 2000 ; 15 Suppl 1 : 7–10
Difference (disorder – no disorder)* Estimate 95 % CI P-value 48.7 910 9.43 –0.07 0.15 0.19 –1.87
6.3 –6556 2.77 –0.43 –1.16 –0.13 –4.14
91.1 8377 16.10 0.29 1.47 0.51 0.41
0.02 0.81 0.006 0.70 0.82 0.24 0.11
10
P. Tyrer et al.
Table V. Number of days spent in hospital and cost of care over two years by personality disorder status and case management status. Outcome
Personality disorder status
Case management status Intensive
N
Standard
Difference (Intensive - Standard) N
Estimate
95 % Confidence Interval interaction
Days in hospital, mean (sd)
0.06 No disorder Disorder
46.4 (84.2) 23.6 (35.8)
59 8
67.1 (90.8) 133.4 (172.1)
55 –20.7 23 –109.8
–53.2 –236.5
11.7 16.9
Total cost of care (£), mean (sd)
0.27 No disorder Disorder
5 6 7 8
9 10
11 12
P-value of
20339 (17650) 14090 (10987)
59 8
21225 (17891) 24316 (24203)
of impairments and disabilities associated with schizophrenic disorders: a preliminary communication. Objective and methods. Acta Psychiat Scand 1980 ; 285 : 152-63. McGlashan T. The Chestnut Lodge follow-up study. ii: Longterm outcome of schizophrenia and affective disorders. Arch Gen Psychiatry 1984 ; 41 : 586-601. Merson S, Tyrer P, Duke P, Henderson F. Inter-rater reliability of ICD-10 guidelines for the diagnosis of personality disorders. J Pers Dis 1994 ; 8 : 89-95. Oldham JM. Personality disorders: current perspectives. JAMA 1994 ; 272 : 1770-6. Oliver JP, Huxley PJ, Priebe S, Kaiser W. Measuring the quality of life of severely mentally ill people using the Lancashire Quality of Life Profile. Soc Psychiat Psychiat Epidem 1991 ; 32 : 76-83. Peralta V, Cuesta MJ, de Leon J. Premorbid personality and positive and negative symptoms in schizophrenia. Acta Psychiat Scand 1991 ; 84 : 336-9. Phelan M, Slade M, Thornicroft G, et al. The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry 1995 ; 167 : 589-95. Rosenthal D, Wender PH, Kety SS, Welner J, Schulsinger F. The adopted-away offspring of schizophrenics. Am J Psychiatry 1971 ; 128 : 307-11. Siever LJ, Davis KL. A psychobiologic perspective on the personality disorders. Am J Psychiatry 1991 ; 148 : 1647-58.
55 –887 23 –10226
–7485 –28494
5711 8042
13 Tyrer P. Personality Assessment Schedule PAS-I (ICD-10 version). In: Personality disorders: diagnosis, management and course, 2nd ed.. Oxford: Butterworth-Heinemann; 2000. p. 160-80. 14 Tyrer P, Remington M. Controlled comparison of day hospital and out-patient treatment for neurotic disorders. Lancet 1979 ; i : 1014-6. 15 Tyrer P, Johnson T. Establishing the severity of personality disorder. Am J Psychiatry 1996 ; 153 : 1593-7. 16 UK700 Group, Creed F, Burns T, Butler T, Byford S, Murray R, Thompson S, et al. Comparison of intensive and standard case management for patients with psychosis: rationale of the trial. Br J Psychiatry 1999 ; 174 : 74-8. 17 UK700 Group, Burns T, Creed F, Fahy T, Thompson S, Tyrer P, White I. Intensive versus standard case management for severe psychotic illness: a randomised trial. Lancet 1999 ; 353 : 2185-9. 18 UK700 Group, Byford S, et al. Costs of care in intensive versus standard case management for severe psychotic illness: a randomised controlled trial. Br J Psychiatry 2000 ; (in press). 19 Van Horn E, Manley C, Ukoumunne OC, Leddy D, Cicchetti D, Tyrer P. Problems in developing an instrument for the rapid assessment of personality status. Eur Psychiatry 2000 ; 15 Suppl 1 : 29-33.
Eur Psychiatry 2000 ; 15 Suppl 1 : 7–10