needs of prisoners and at avoiding giving spurious labels to large numbers of "normal" criminals. Criminality and substance misuse were recorded independently and the diagnosis of personality disorder reserved for those with other evidence of disordered functioning. We did not find the subcategories in the ICD (ninth revision) useful in describing inmates with personality disorder as most of the inmates (over 80%) showed pronounced features of two or more subcategories. Axis II of DSM-III-R suffers from a similar problem, assigning several labels to one patient. This phenomenon has been called comorbidity but can best be regarded as reflecting the unsatisfactory state of existing classifications of personality disorder. Despair over the diagnosis of personality disorder has led some professionals to reject the diagnosis' and others to reject patients who have been given the diagnosis. We adopted Lewis's view that the diagnosis is problematic but indispensable in referring to a group of patients who show profound psychiatric disturbance but do not fit readily into other categories of mental illness.4 The inmates we identified stood out from their peers by virtue of their mental state or behaviour. Usually the interviewee, other inmates, prison officers, and doctors shared our view that their personality problems were of a nature and severity that warranted psychiatric attention. More time or information may have yielded more cases, but we would claim a degree of face validity. A comprehensive psychiatric service for prisoners would have to take these inmates into account. Deciding which diagnosis is primary depends on the purpose for which the question is asked. Our criterion in compiling table II was the provision of services: which problem would dictate the immediate management of the patient? It represents an oversimplification of the reality of
psychiatric practice. A MADEN
Department of Forensic Psychiatry, Institute of Psychiatry, Loindon SE5 8AF I Guze SB. Criminalliv and psychiatric disorders. New York: Oxford University Press, 1976. 2 1)ell S, Robertson G. Sentenced io hospital: offenders in Broadmoor. Oxford: Oxtord University Press, 1988. (Maudslev monograph No 32.) 3 Lewis G, Appleby L. Personality disorder: the patients psychiatrists dislike. Brj Psych 1988;153:44-9. 4 Lewis A. Psychopathic personality: a most elusive category.
involved other specialists; and one involved a general practitioner. It must be emphasised, however, that some persons reported the opposite -for example, that general practitioners took care of them in a more heedful way than previously. Different kinds of episodes of discrimination were reported, but particularly common was the refusal to give the requested health service (37 episodes). If these findings are confirmed in other prospective studies the health authorities should consider intervening with practitioners who are not following the ethical rules of their profession. UMBERTO TIRELLI VINCENZO ACCURSO MICHELE SPINA EMANUELA VACCHER AIDS Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
Delamothe T. America worries about contagion. BMJ 1991302: 1418. (15 June.)
General practitioners' access to x ray services
SIR,-Dr N E Early states, "It might be pertinent to ask radiologists how many referrals they reject (as a proportion of the total) from junior hospital staff, consultant hospital staff, non-fundholding general practitioners, and fundholding general practitioners."' I do not have any figures for the number of referrals rejected but can assure him that general practitioners are not the only group of doctors being asked to reduce the number of requests for examinations. We have achieved a considerable reduction in the numbers of preoperative chest radiographic examinations and of contrast examinations of the urinary tract that we perform. Hospital doctors as well as general practitioners are being asked to reduce their requests for x ray
Department of Psychiatry, Charing Cross and Westminster Medical School,
Child sexual abuse
T S BROWN
Bradford Royal Infirmary,
Bradford, West Yorkshire BD9 6RJ I Early NE. General practitioners' access to x ray services.
1991;303:122. (13 July.)
HIV and discrimination
Complications of pregnancy and delivery and psychosis in adult life
SIR,-Although there is much emphasis on the discrimination carried out by the United States with the travel restrictions on foreigners with HIV infection,' very little is officially known on the discrimination carried out by health workers against people with HIV infection either in or outside of the United States. In Italy we conducted a prospective study to evaluate this phenomenon. A coded questionnaire was distributed to all outpatients and inpatients of the AIDS unit of our institution. Informed consent had been obtained and questionnaires were anonymous. Between 30 May and 7 August 1991, 86 subjects filled in the questionnaire. Sixty three used intravenous drugs (48 men and 15 women), 11 were heterosexuals (five men and six women), nine were homosexual men, and three were men without known risk factors for HIV infection. Among these persons, 84 were HIV positive; the two others were HIV negative but at high risk of HIV infection. Of the 34 reporting episodes of discrimination by health workers in public or private Italian institutions, eight reported more than one episode. Twenty three of the 42 episodes involved dentists; seven involved surgeons; six involved internists; four
SIR,-Do obstetric complications constitute a risk factor for later schizophrenia? From the results of their national follow up study Dr D John Done and colleagues conclude that they do not.' Their study is impressive, with large numbers and elegant statistical analyses. But is their conclusion justified? Two aspects of the study give cause for concern: the statistical power and the clinical factors used to define risk. With an overall sample size of some 16000 the issue of statistical power might seem irrelevent. Yet, as the authors themselves hint, the final number of under 50 cases of schizophrenia may well be too small to test adequately the hypothesis in question. Obstetric complications in general probably confer in the order of a twofold increased risk of later schizophrenia.2 This is not a large effect in comparison with that of familial risk factors, for example. The analyses of the subgroup of patients with high risk showed that all the groups with psychosis, including schizophrenia, but not those with neurosis had an odds ratio of stillbirth or neonatal death of between 1-4 and 2 4. The wide confidence intervals on these figures testify to the small sample sizes and may well
explain the inability to show a significant effect. The second problem is the choice of clinical variables used to define obstetric risk. A model that includes only one variable, the prescription of drugs, as indicating the condition of the baby must be interpreted with the greatest caution. Understanding of neonatal physiology at that time was poor, and drug treatments were empirical-for instance, the main indication for treatment with nikethamide (Coramine) was impending death from any cause, and most babies dying in hospital would have received this as a last resort. It thus makes little sense to include this as an independent predictor of neonatal death. Increased rates of obstetric complications in the histories of patients with affective psychosis, as well as schizophrenia, compared with neurotic patients have been shown before.' One way in which the authors might examine further the issue of obstetric risk and later schizophrenia is to look for an inverse correlation between calculated risk and age at onset of the illness. Several previous studies have reported that obstetric complications predict an earlier onset, and if this can be shown not to be the case in the reported sample it will strengthen the authors' conclusions that no link between obstetric risk and later schizophrenia has been shown, London W6 8RP ANN STEWART Department in Paediatrics, University College and Mliddlesex School of Medicine, London V'C1 E 6JJ 1 Donc DJ, Johnstone EC, Frithi CI), Giolding J, Shepherd PM, Crow TJr. Complications of pregnancy and delivery its relation to psychosis in adult life: data from the British perinatal mortality survey sample. B.MJ 1991;302:1576-80. ( 29 June.: 2 Lewis SW. Congenital risk factors for schizophrenia. I'syvchol Mtd 1989;19:5-13. 3 Lewis SW, M\urray RMi. Obstetric complication, neurodevelopmental deviance, and risk of schizophrenia. .7 Psvchiatr Res 1987;21:413-2 1.
SIR,-Dr Brendan McCormack's editorial on sexual abuse and learning disabilities drew attention to an important problem affecting the lives of children and adults who are unable to speak for themselves because of severe communication or cognitive impairments, or both.' The inadequate protection provided by current law is particularly worrying.
There is one aspect of the author's discussion of diagnosis, however, that needs clarification. Dr McCormack emphasised the difficulty of recognising that sexual abuse is occurring and mentioned the presence of "sexualised behaviour, temper tantrums, and challenging behaviour" as pointers. Unfortunately, the latter two features are very common in conditions in the spectrum of autistic disorders; they arise from the characteristic severe impairments of understanding of social interaction and the rules governing social behaviour. "Sexualised behaviour" in the form of masturbation in public is also frequently seen. If the author's recommendation that "such behaviour should always give rise to suspicion of abuse in an adult with learning disabilities" is adopted uncritically then this would involve a large proportion of people with autistic conditions. If it is assumed that the parents or other carers are at fault, this would add immeasurably to the stress of looking after those with communication problems and socially inappropriate behaviour. I have recent experience of three such cases in which parents were unjustly accused solely because of the behaviour of their autistic children-classic examples of the difficulty of proving a negative. Autistic children and adults are, of course, potentially vulnerable to all kinds of abuse. The
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fact that they have disturbed behaviour whether or not they have been abused makes diagnosis even more difficult. The point I wish to make is that special care should be taken when assessing the significance of the behaviour pattern in people with impairments of social interaction and communication. LORNA WING Nationial Autistic Society, London NW2 SRB I MN1cCormack B. Sexual abisec and lcarning disabilities. B13M7 1991;303:143-4. (20 Julv.)
SIR,-Dr Andrew J Wiener,' in commenting on my editorial on the long term effects of child sexual abuse,2 first constructs a straw man of his own making by claiming that my argument against child sexual abuse depends entirely on its propensity to inflict long term harm, then demolishes this thesis to his own satisfaction. I agree that child sexual abuse is an evil irrespective of its long term consequences. In condemning a social evil there is no need to medicalise it by claiming that it causes illness. On the other hand, some social ills-for example, unemploymentprobably do contribute to morbidity and mortality and surely it is permissible to point this out. Dr Wiener rightly raises the possibility that the same social and family factors that predict adult psychopathology may also predict vulnerability to sexual abuse. We are preparing for publication data showing that the sexual abuse itself contributes to adult psychopathology independently of the disrupted and deprived background which enhances the risks of being abused. The law on sexual contact with children could be changed tomorrow and some moral convulsion could conceivably alter the public's attitude to the sexual use of children, but such contact would almost certainly go on producing immediate and long term psychological and emotional damage to those children. Child sexual abuse is in my opinion a medical problem as well as a moral and legal problem, and the clear recognition of this, far from "stunting" our view of the rights of children, as asserted by Dr Wiener, provides information essential for their protection. PAUL MULLEN
Department of Psychological Medicine, University of Otago,
Dunedin, New Zealand 1 Wiener AJ. Consequences of child sexual abuse. BMJf 1991;303: 415. (17 August.) 2 Mullen PE. The consequences of child sexual abuse. BM7 1991;303:144-5. (20 July.)
Availability of cadaver organs for transplantation SIR,-In discussing the availability of cadaver organs for transplantation Dr David J Hill and colleagues question whether current clinical criteria are sufficiently exhaustive to ensure that all brain stem function has permanently ceased. They further claim that in North America theatre staff are concerned that ventilated, beating heart donors are not truly dead when operations to remove organs begin and that the same anxieties exist in the United Kingdom, including among anaesthetists. In support of this contention they quote our review of the management of multiple organ donors as stating that anaesthetists both anaesthetise and paralyse brain stem dead donors. This is misleading. Hypertension and tachycardia are not unusual during organ retrieval, and because of the importance of maintaining haemodynamic stability at this time, we suggested that glyceryl
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trinitrate, nitroprusside, or isoflurane (a volatile anaesthetic agent that is a potent vasodilator) could be used if necessary to control these responses.Explanations for these haemodynamic changes have included intact spinal reflex arcs between afferent pain fibres and sympathetic efferent nerves, humoral responses after adrenal stimulation, and residual brain stem function.' Although apparently some anaesthetists are more comfortable if volatile anaesthetic agents are administered during organ retrieval, the vast majority consider that the use of such agents other than to control potentially harmful tachycardia and hypertension is illogical for brain stem dead donors.4 It is also recommended that somatic motor reflexes, similarly mediated at a spinal level, should be controlled with a muscle relaxant simply to facilitate surgery. The presence of these reflex haemodynamic and motor responses to surgical stimulation and the need to control them during organ retrieval do not in our view invalidate the current clinical criteria for diagnosing irreversible damage to the brain stem and thereby establishing that there is no prospect of the patient recovering. A C TIMMINS C J HINDS
Anacsthetic laboratory, St Bartholomew's Hospital, London EC IA 7BE I Hill D)J, Evans 1)W, (Gresham GA. Availability of cadaver organs for transplantation. BMJ 1991303:312. (3 August.) 2 Timmins AC, Hinds CJ. M\lanagement of the multiple-organ donor. Current OpiniOn in Anaestheszology 1991;4:287-92. 3 Wetzel RC, Setzer N, Stiff JL, Roberts MC. Hemodynamic responses in brain dead organ donor patients. Anesth Analg 1985;64: 125-8. 4 Bodenham A, Park GR. Care of the multiple organ donor. Intensive Care Med 1989;15:340- 8.
Antepartum haemorrhage and cervical cancer SIR,-I was interested in the comment from the National Maternity Hospital consultants about bleeding in pregnancy among women with carcinoma of the cervix.' The experience of clinical colleagues must always be respected when discussing clinical matters, but so often a small figure variation may be misleading when unusual conditions are being considered. Mr John M Stronge and colleagues quote their experiences of four women with carcinoma of the cervix presenting in pregnancy at 40, 34, 32, and 36 weeks of gestation. All had "substantial haemorrhage." They do not quote any women with carcinoma of the cervix in this time who presented with lesser bleeding. This is against my clinical experience. While preparing the ABC series I searched my memory and could think of eight to 10 women with invasive carcinoma of the cervix in pregnancy, of whom two had moderate bleeding; the rest had considerably less, some having no real bleeding at all but only spotting. When such small series are examined we must turn to published reports; these confirm that many women with invasive carcinoma of the cervix discovered in pregnancy have little bleeding. Many cases, even of invasive cancer, are diagnosed from cytological screening and subsequent colposcopy of women with an abnormal smear; these women do not bleed much and so would weight the figures. In a series collected by Moore and Gusberg of 22 women with invasive carcinoma of the cervix in pregnancy "most had no symptoms"; two had contact bleeding and three had "some bleeding."2 Hence less than 20% of their series could have been scored as having substantial bleeding. Cromer and Hawkin reviewed 20 women with carcinoma of the cervix in pregnancy; four of these had carcinoma in situ and 16 invasive carcinoma.
Seven of those with invasive carcinoma had some bleeding but only one (6%) had severe bleeding.' A bigger series was collected by Hacker et al, who summarised the findings from other sources and ended with 263 women with invasive carcinoma of the cervix out of 579 795 pregnancies. Of these cancers 168 were diagnosed either in the first trimester or in the postpartum period and are not relevant to this discussion. In the remainder, 35% of the women presented with a discharge or no symptoms and 65% had some bleeding. But the range of the duration of the symptom was 2-5-6-1 months (mean 4 5 months)-the bleeding could not have been substantial or someone would have taken some action. In 1906 Bernard Shaw (born as a breech presentation as a district case in The National Hospital) presented Doctor's Dilemma to the world in London.' In the preface to that book he states, "Even trained statisticians often fail to appreciate the extent to which statistics are vitiated by the unrecorded assumptions of their interpreters." GEOFFREY CHAMBERLAIN
St George's Hospital Mledical School, London SW17 ORE 1 Stronge JM, Boyd W, Rasmussen MiJ. Antepartum haemorrhage and cervical cancer. BAIJ 1991;303:249-50. (27 July.) 2 Moore D, Gusberg S. Cancer precursors in pregnancy. Obstet Gvnecol 1959;13:530-8. 3 Cromer J, Hawkin S. Cancer of the cervix and pregnancy. Obstet Gvnecol 1963;22:346-51. 4 Hacker NF, Berek JS, Lagasse LD, Charles EH, Savage EW, Mioore JG. Carcinoma of the cervix associated with pregnancy.
Obstet Gynecol 1982;59:735-46. 5 Shaw B. Ihe doctor's dilemma. London: I'enguin, 1946:61.
Breast carcinomas diagnosed in the 1980s SIR, -Drs H Joensuu and S Toikkanen compared breast carcinomas diagnosed in the 1980s with those diagnosed in earlier decades.' The histological factors compared in the study included a measurement of the mitotic count and an assessment of the overall tumour grade. We have recently shown that a delay in fixation of six hours produces a reduction of about 50% in the number of observable mitotic figures in breast carcinomas.2' In some tumours the decreased mitotic count can result in change in the overall Bloom and Richardson tumour grade and hence prognostic group.' We believe that it is now essential to include details of tissue fixation in any study comparing breast carcinomas on the basis of mitotic counts, particularly if tumour grade and subsequent prognosis are to be discussed. R D START S S CROSS J H F SMITH Department of Histopathology, Northern General Hospital, Sheffield S5 7AU
1 Joensuu H, Toikkanen S. Comparison of breast carcinomas diagnosed in the 1980s with those diagnosed in the 1940s to 1960s. BMJ 1991;303:155-8. (20 July.) 2 Start RD, Flynn MS, Rogers K, Smith JHF. Delayed fixation significantly decreases observed mitotic figures in breast carcinoma. J Pathol 19911163:1 54A. 3 Start RD, Flynn MS, Cross SS, Rogers K, Smith JHF. Is the grading of breast carcinoma affected by a delay in fixation? Virchows Arch [A] (in press).
Mental health needs of Asians SIR,-Dr Tony Dixon reported the results of a survey, conducted by the Confederation of Indian Organisations, of Asians living in Haringey.' I have analysed preliminary findings of a follow up study of a cohort of first generation immigrants from the Indian subcontinent, all of whom were