Psychological Medicine, 1975, 5, 89-95
Influence of psychiatric training, medical qualification, and paramedical training on the rating of abnormal behaviour J. R. M. COPELAND.i M. J. KELLEHER, A. J. GOURLAY, 2 and A. M. R. SMITH From the USI UK Diagnostic Project, Institute of Psychiatry, De Crespigny Park, London
SYNOPSIS The psychiatric ratings, using the In-Patient Multi-dimensional Psychiatric Scale, of (1) a group of over 200 psychiatrists from the British Isles, (2) third year psychology students, (3) trainee sister tutors, (4) general practitioners attending a postgraduate course in psychiatry, and (5) a group of new registrars at the Maudsley Hospital, were compared. The first hypothesis, that, whereas the non-psychiatrists would rate similar levels of symptoms, the psychiatrists would tend to rate lower than other professional groups, was upheld. The second, that the pattern or profile of symptoms as shown by the IMPS syndromes would differ little between the groups, was also upheld. The third hypothesis, that because of their special training in the recognition of symptoms, psychiatrists would tend to show greater intra-group agreement on the levels of symptoms than the other groups, was not upheld. Some possible reasons for the findings are discussed. The importance for a screening schedule, designed to be used by non-psychiatrists for the detection of psychiatric illness, of the finding that non-psychiatrists rate higher levels of symptoms than psychiatrists, is also discussed. abnormal behaviour according to a standard definition so that it is characterized as a symptom; and (4) recognizing from the resulting collection of symptoms a pattern which is characteristic of a particular syndrome or illness. This is the logical sequence of diagnosis, although with experience it is likely that the diagnostician short-cuts this process to some extent by developing a 'picture' of an illness in his mind which he then uses after the manner of an Identikit. It has been shown repeatedly that psychiatrists tend to form an opinion of a patient's diagnosis in the first few minutes of an interview (Kendell, 1973). During the rest of the interview they may merely seek to confirm the diagnosis by searching for supporting evidence. Steps (3) and (4) are peculiar to the psychiatrist and a study of the way psychiatrists in the British Isles and North America differ among 'Address for correspondence: Dr. J. R. M. Copeland, themselves in their choice of diagnostic terms, US/UK Diagnostic Project, Institute of Psychiatry, De the naming of abnormal behaviour using techCrespigny Park, Camberwell, London S.E.5. 2 nical terms, and the quantitative assessment of Present address: University of Southampton.
This paper describes a study of the ratings of abnormal behaviour made by audiences of psychiatrists and other medically and non-medically qualified raters. The levels and profiles of symptoms rated by the different groups and their intra-group agreement are compared. The expertise of a medical practitioner lies mainly in the areas of diagnosis, prediction of outcome, and treatment of illness. The ability to diagnose a type of illness depends on a number of preliminary steps which may be summarized briefly as (1) the initial perception of the patient's behaviour; (2) a judgement as to how far that behaviour departs from the observer's concept of normality—that is, whether it is pathological, bearing in mind the patient's environment at the time and his intellectual and cultural background; (3) applying a technical term to the
89
90
/. R. M. Copeland, M. J. Kelleher, A. J. Gourlay, and A. M. R. Smith
that behaviour has already been made by the US/UK Diagnostic Project (Copeland et al., 1971; Kendell et al., 1971; Sharpe et al., 1974). Steps (1) and (2), however, the ability to recognize abnormal behaviour, are an important part of the function of both medical and paramedical staff if cases suitable for treatment are to be recognized and referred at an early stage of the illness. The experiment described here was also of practical importance to the Diagnostic Project in developing a screening schedule to be given by trained non-psychiatrists for the recognition of psychiatric illness in the community. HYPOTHESES
The second: 'that the pattern or profile of symptoms as shown by the IMPS (In-Patient Multi-dimensional Psychiatric Scale) syndromes would differ little between the groups'. It seemed unlikely that the observation of behaviour and its recording in non-technical language would show differences between the groups. It was possible, however, that the psychiatrists might rate higher levels of symptoms thought to be important for the patient's diagnosis. Because of their special training in the recognition of symptoms, it was expected that psychiatrists would tend to show greater intragroup agreement on the levels of syndromes recorded than the other groups. This formed the third hypothesis.
There seemed no good evidence to suppose that the psychiatric ratings of doctors with no special psychiatric experience should vary in any way from that of other professional groups with PARTICIPANTS similar lack of experience. It was to be expected, Three main professional groups were chosen for however, that psychiatrists trained and experi- comparison, (1) those medically qualified and with enced in the assessment, diagnosis, treatment, psychiatric training, (2) those medically qualified but without psychiatric training, and (3) those not and follow-up of psychiatric patients would medically qualified and without psychiatric training. differ from other professional groups without It was considered important to choose groups which this experience in either or both the overall level would be expected to have sufficient interest in the of psychiatric symptoms rated and the profiles rating of psychiatric patients to ensure their enthusiof those symptoms, for a particular patient. It astic participation. Group (1) consisted of 211 was not clear in which direction this difference psychiatrists working in the British Isles, who had would be shown. On the one hand, it might be already been invited to participate in a previous argued that psychiatrists, having been sensitized study. They had been gathered by holding rating by their training and experience to the recog- sessions in some of the major British and Irish nition of psychiatric symptoms, would recognize training centres (Edinburgh, Glasgow, Manchester, more symptoms and rate them more highly. On Birmingham, Belfast, Dublin, and London). All the other hand, it could equally be argued that possessed a diploma in psychological medicine and such training and experience would lead to a had had at least four years' psychiatric experience. (2) A group of hospital doctors was chosen, 35 more critical and economical approach to the Maudsley new registrars who were about to embark recognition of symptoms and that their wider on a postgraduate course at the Maudsley Hospital experience of the extremes of human behaviour and the Institute of Psychiatry. These raters had would lead them to accept a wider range of been gathered as part of a prospective study of behaviour as normal. Previous work had shown the effects of teaching on symptom ratings by that raters trained at the Maudsley Hospital psychiatrists-in-training (Kelleher, 1974). Less than tended to rate lower than their fellows; therefore, half of these (15) had any previous postgraduate it might be expected that, if the intensive psychiatric experience and fewer still had received Maudsley training had more than simple face any consistent teaching. As part of the same group, validity, psychiatrists would rate lower levels of a sample of non-hospital doctors represented by 18 general practitioners attending a postgraduate course symptoms than other professional groups. at the Institute of Psychiatry was chosen. These The first hypothesis was formulated: 'that general practitioners were self selected for the course; whereas the non-psychiatrists would rate similar some confessed to having no knowledge of psylevels of symptoms, the psychiatrists would tend chiatry, hence their attending the course, others found to rate lower than the other professional groups'. it interesting and wished to revise their knowledge.
Psychiatric training and the rating of abnormal behaviour In interpreting the results for this group, the very selective nature of the sample must be borne in mind. (3) There were two non-medically qualified groups. One, a group of 51 trainee sister tutors in London, had extensive experience of the handling of patients in general, but, unlike the doctors, they were comparatively unconcerned with diagnosis and follow-up. Their overall intelligence was considered to be on a par with the other groups. Only nine of them had any postgraduate experience in psychiatric nursing. The second non-medically qualified group was made up of 54 third year psychology students from a college of the University of London. They had no previous experience in assessing patients. INSTRUMENT
The Lorr In-Patient Multi-dimensional Psychiatric Scale (IMPS), the instrument used in the study (Lorr and Klett, 1967), comprises a series of 89 ratings of abnormal behaviour in which each item is briefly defined in non-technical terms. The rater is asked to compare the patient with the normal person, and to rate him on a nine-point scale for each item. The results can be quickly analysed according to the methods developed by Lorr, in which the items are grouped into 'syndromes', and standardized according to Lorr's normative data. These syndromes, originally derived by factor analysis, are approximations to conventionally accepted clinical symptom groups, and are satisfactory for detecting consistent differences in the levels of ratings of abnormal behaviour. The ten syndromes or groups of symptoms are:
91
intended to elicit the principal symptoms of the present mental state. It was not intended to be a complete case presentation, and no additional history was supplied. Mrs. A, the subject interviewed, was a woman with many severe symptoms that could be described as both schizophrenic and affective; in her case the affective symptoms were suggestive of a mixed manic-depressive type. At one time she felt 'wonderfully happy', but said that something was causing her to dance and sing and move her left leg. Messages were passed to her over the television, and from time to time people had laughed at her because she must be in hell. She felt dirty and nasty and thought she might have died as a child, and might therefore be no longer alive. She displayed a number of neurotic symptoms and gave a history of previous treatment for depression. RESULTS
1. Excitement (EXC), which covers hurried, loud speech, elevated mood, and over-activity 2. Hostility (HOS) 3. Paranoid ideas (PAR), covering ideas and delusions of persecution 4. Grandiosity (GRN), including boasting and ideas and delusions of grandeur 5. Perceptual distortions (PCP), covering hallucinations 6. Intrapunitiveness (INP), with mainly depressive symptoms, guilt, and self-depreciation 7. Retardation (RTD), including slowness of both movement and speech 8. Cognitive disorientation (DIS)—that is, disorientation in time and place 9. Motor-abnormalities (MTR), including abnormal and excessive movements 10. Conceptual disorganization (CNP), disturbances of thought and language.
Figure 1 shows the mean IMPS syndrome profiles derived from the ratings of Mrs. A for (1) the 211 psychiatrists from the British Isles, (2) the 51 student sister tutors, and (3) the 54 third year psychology students. It can be seen that for these three groups, the first and second hypotheses are generally upheld. Figure 2 compares the three medically qualified groups for the same IMPS syndrome profiles derived from the ratings of Mrs. A: (1) the 211 psychiatrists are shown once again on this figure for comparison, (2) the 35 Maudsley new registrars, and (3) the small sample (18) of general practitioners. It will be seen that for these three groups both hypotheses were partially upheld, in so far as the mean ratings for the psychiatrists were consistently below those of the Maudsley new registrars, and in six IMPS syndromes out of 10 were below those of the general practitioner group, although the latter differences did not reach significance. Of the 10 syndromes the psychiatrists rated the lowest of all the groups on five, hostility,* intrapunitiveness,* motor-abnormalities,* retardation,* and conceptual disorganization, and next to lowest on perceptual distortion.* However, the general practitioners also rated low levels on the syndromes, coming lowest of all on three, excitement, perceptual distortion* and paranoid ideas,* and next to lowest on four,
One videotaped interview was used, lasting approximately 40 minutes. It was unstructured and
'Significance equal to or less than 005 against at least two other groups.
J. R. M. Copeland, M. J. Kelleher, A. J. Gourlay, and A. M. R. Smith
92
A 70-
w 60
50
40
EXC
HO5
PAR
GRN
PC P
INP
RTD
DIS
MTR
CNP
FIG. 1. Inpatient multidimensional psychiatric scale mean symptom profiles for psychiatrists from the British Isles, student Psychiatrists from the British Isles (n =211). sister tutors, andthirdyear psychology students {patient Mrs. A.). Student sister tutors («=57). —.—.—.—Third year psychology students (n=54).
70
/\
60
50-
40-
FIG. 2. Inpatient multidimensionalpsychiatric scale mean symptom profiles for psychiatristsfrom the British Isles, Maudsley new registrars, and sample of general practitioners (patient Mrs. A.). Psychiatrists from the British Isles (n=211). ———Maudsley new registrars (n=35). Sample of general practitioners (n = 18).
grandiosity, intrapunitiveness, retardation,* and motor-abnormalities. If these two groups are taken together—that is, the two medically qualified groups with the longest clinical experience of assessing patients—between them they rate lowest on eight of the 10 syndromes. This con-
trasts with the two non-medically qualified groups taken together, the sister tutors and the psychology students who between them scored the highest levels of all the groups for seven of the ten syndromes, excitement, hostility, grandiosity,* perceptual distortion,* intrapunitiveness,*
Psychiatric training and the rating of abnormal behaviour
retardation,* and motor-abnormalities.* The Maudsley new registrars hold a central position. The psychiatrists and general practitioners differ strikingly on two syndromes. If it is true that a low level of rating of abnormal behaviour indicates a willingness to accept a wide range of behaviour as normal, the psychiatrists appear the most willing to accept 'hostility' as normal behaviour and the general practitioners the least. Of course, the psychiatrist's training is directed towards helping him to understand and cope with the hostility displayed by patients. More striking still is the general practitioners' tolerance of paranoid behaviour and the psychiatrists' relative intolerance (P< 0-001). If the psychiatrists are accepted as a standard, this group of general practitioners tended to undervalue this symptom. The overall shape of the symptom profiles for all five groups are roughly similar to one another. The syndromes were compared using the method of Greenhouse and Geisser (1959). This is a method for analysing such profiles by using a traditional univariate analysis of variance approach, and gives tests for differences in the overall mean levels of the group profiles. Excluding the sample of general practitioners, the differences between the profiles of the nonpsychiatrists and the psychiatrists for level of symptoms reached significance (P
Influence of psychiatric training, medical qualification, and paramedical training on the rating of abnormal behaviour J. R. M. COPELAND.i M. J. KELLEHER, A. J. GOURLAY, 2 and A. M. R. SMITH From the USI UK Diagnostic Project, Institute of Psychiatry, De Crespigny Park, London
SYNOPSIS The psychiatric ratings, using the In-Patient Multi-dimensional Psychiatric Scale, of (1) a group of over 200 psychiatrists from the British Isles, (2) third year psychology students, (3) trainee sister tutors, (4) general practitioners attending a postgraduate course in psychiatry, and (5) a group of new registrars at the Maudsley Hospital, were compared. The first hypothesis, that, whereas the non-psychiatrists would rate similar levels of symptoms, the psychiatrists would tend to rate lower than other professional groups, was upheld. The second, that the pattern or profile of symptoms as shown by the IMPS syndromes would differ little between the groups, was also upheld. The third hypothesis, that because of their special training in the recognition of symptoms, psychiatrists would tend to show greater intra-group agreement on the levels of symptoms than the other groups, was not upheld. Some possible reasons for the findings are discussed. The importance for a screening schedule, designed to be used by non-psychiatrists for the detection of psychiatric illness, of the finding that non-psychiatrists rate higher levels of symptoms than psychiatrists, is also discussed. abnormal behaviour according to a standard definition so that it is characterized as a symptom; and (4) recognizing from the resulting collection of symptoms a pattern which is characteristic of a particular syndrome or illness. This is the logical sequence of diagnosis, although with experience it is likely that the diagnostician short-cuts this process to some extent by developing a 'picture' of an illness in his mind which he then uses after the manner of an Identikit. It has been shown repeatedly that psychiatrists tend to form an opinion of a patient's diagnosis in the first few minutes of an interview (Kendell, 1973). During the rest of the interview they may merely seek to confirm the diagnosis by searching for supporting evidence. Steps (3) and (4) are peculiar to the psychiatrist and a study of the way psychiatrists in the British Isles and North America differ among 'Address for correspondence: Dr. J. R. M. Copeland, themselves in their choice of diagnostic terms, US/UK Diagnostic Project, Institute of Psychiatry, De the naming of abnormal behaviour using techCrespigny Park, Camberwell, London S.E.5. 2 nical terms, and the quantitative assessment of Present address: University of Southampton.
This paper describes a study of the ratings of abnormal behaviour made by audiences of psychiatrists and other medically and non-medically qualified raters. The levels and profiles of symptoms rated by the different groups and their intra-group agreement are compared. The expertise of a medical practitioner lies mainly in the areas of diagnosis, prediction of outcome, and treatment of illness. The ability to diagnose a type of illness depends on a number of preliminary steps which may be summarized briefly as (1) the initial perception of the patient's behaviour; (2) a judgement as to how far that behaviour departs from the observer's concept of normality—that is, whether it is pathological, bearing in mind the patient's environment at the time and his intellectual and cultural background; (3) applying a technical term to the
89
90
/. R. M. Copeland, M. J. Kelleher, A. J. Gourlay, and A. M. R. Smith
that behaviour has already been made by the US/UK Diagnostic Project (Copeland et al., 1971; Kendell et al., 1971; Sharpe et al., 1974). Steps (1) and (2), however, the ability to recognize abnormal behaviour, are an important part of the function of both medical and paramedical staff if cases suitable for treatment are to be recognized and referred at an early stage of the illness. The experiment described here was also of practical importance to the Diagnostic Project in developing a screening schedule to be given by trained non-psychiatrists for the recognition of psychiatric illness in the community. HYPOTHESES
The second: 'that the pattern or profile of symptoms as shown by the IMPS (In-Patient Multi-dimensional Psychiatric Scale) syndromes would differ little between the groups'. It seemed unlikely that the observation of behaviour and its recording in non-technical language would show differences between the groups. It was possible, however, that the psychiatrists might rate higher levels of symptoms thought to be important for the patient's diagnosis. Because of their special training in the recognition of symptoms, it was expected that psychiatrists would tend to show greater intragroup agreement on the levels of syndromes recorded than the other groups. This formed the third hypothesis.
There seemed no good evidence to suppose that the psychiatric ratings of doctors with no special psychiatric experience should vary in any way from that of other professional groups with PARTICIPANTS similar lack of experience. It was to be expected, Three main professional groups were chosen for however, that psychiatrists trained and experi- comparison, (1) those medically qualified and with enced in the assessment, diagnosis, treatment, psychiatric training, (2) those medically qualified but without psychiatric training, and (3) those not and follow-up of psychiatric patients would medically qualified and without psychiatric training. differ from other professional groups without It was considered important to choose groups which this experience in either or both the overall level would be expected to have sufficient interest in the of psychiatric symptoms rated and the profiles rating of psychiatric patients to ensure their enthusiof those symptoms, for a particular patient. It astic participation. Group (1) consisted of 211 was not clear in which direction this difference psychiatrists working in the British Isles, who had would be shown. On the one hand, it might be already been invited to participate in a previous argued that psychiatrists, having been sensitized study. They had been gathered by holding rating by their training and experience to the recog- sessions in some of the major British and Irish nition of psychiatric symptoms, would recognize training centres (Edinburgh, Glasgow, Manchester, more symptoms and rate them more highly. On Birmingham, Belfast, Dublin, and London). All the other hand, it could equally be argued that possessed a diploma in psychological medicine and such training and experience would lead to a had had at least four years' psychiatric experience. (2) A group of hospital doctors was chosen, 35 more critical and economical approach to the Maudsley new registrars who were about to embark recognition of symptoms and that their wider on a postgraduate course at the Maudsley Hospital experience of the extremes of human behaviour and the Institute of Psychiatry. These raters had would lead them to accept a wider range of been gathered as part of a prospective study of behaviour as normal. Previous work had shown the effects of teaching on symptom ratings by that raters trained at the Maudsley Hospital psychiatrists-in-training (Kelleher, 1974). Less than tended to rate lower than their fellows; therefore, half of these (15) had any previous postgraduate it might be expected that, if the intensive psychiatric experience and fewer still had received Maudsley training had more than simple face any consistent teaching. As part of the same group, validity, psychiatrists would rate lower levels of a sample of non-hospital doctors represented by 18 general practitioners attending a postgraduate course symptoms than other professional groups. at the Institute of Psychiatry was chosen. These The first hypothesis was formulated: 'that general practitioners were self selected for the course; whereas the non-psychiatrists would rate similar some confessed to having no knowledge of psylevels of symptoms, the psychiatrists would tend chiatry, hence their attending the course, others found to rate lower than the other professional groups'. it interesting and wished to revise their knowledge.
Psychiatric training and the rating of abnormal behaviour In interpreting the results for this group, the very selective nature of the sample must be borne in mind. (3) There were two non-medically qualified groups. One, a group of 51 trainee sister tutors in London, had extensive experience of the handling of patients in general, but, unlike the doctors, they were comparatively unconcerned with diagnosis and follow-up. Their overall intelligence was considered to be on a par with the other groups. Only nine of them had any postgraduate experience in psychiatric nursing. The second non-medically qualified group was made up of 54 third year psychology students from a college of the University of London. They had no previous experience in assessing patients. INSTRUMENT
The Lorr In-Patient Multi-dimensional Psychiatric Scale (IMPS), the instrument used in the study (Lorr and Klett, 1967), comprises a series of 89 ratings of abnormal behaviour in which each item is briefly defined in non-technical terms. The rater is asked to compare the patient with the normal person, and to rate him on a nine-point scale for each item. The results can be quickly analysed according to the methods developed by Lorr, in which the items are grouped into 'syndromes', and standardized according to Lorr's normative data. These syndromes, originally derived by factor analysis, are approximations to conventionally accepted clinical symptom groups, and are satisfactory for detecting consistent differences in the levels of ratings of abnormal behaviour. The ten syndromes or groups of symptoms are:
91
intended to elicit the principal symptoms of the present mental state. It was not intended to be a complete case presentation, and no additional history was supplied. Mrs. A, the subject interviewed, was a woman with many severe symptoms that could be described as both schizophrenic and affective; in her case the affective symptoms were suggestive of a mixed manic-depressive type. At one time she felt 'wonderfully happy', but said that something was causing her to dance and sing and move her left leg. Messages were passed to her over the television, and from time to time people had laughed at her because she must be in hell. She felt dirty and nasty and thought she might have died as a child, and might therefore be no longer alive. She displayed a number of neurotic symptoms and gave a history of previous treatment for depression. RESULTS
1. Excitement (EXC), which covers hurried, loud speech, elevated mood, and over-activity 2. Hostility (HOS) 3. Paranoid ideas (PAR), covering ideas and delusions of persecution 4. Grandiosity (GRN), including boasting and ideas and delusions of grandeur 5. Perceptual distortions (PCP), covering hallucinations 6. Intrapunitiveness (INP), with mainly depressive symptoms, guilt, and self-depreciation 7. Retardation (RTD), including slowness of both movement and speech 8. Cognitive disorientation (DIS)—that is, disorientation in time and place 9. Motor-abnormalities (MTR), including abnormal and excessive movements 10. Conceptual disorganization (CNP), disturbances of thought and language.
Figure 1 shows the mean IMPS syndrome profiles derived from the ratings of Mrs. A for (1) the 211 psychiatrists from the British Isles, (2) the 51 student sister tutors, and (3) the 54 third year psychology students. It can be seen that for these three groups, the first and second hypotheses are generally upheld. Figure 2 compares the three medically qualified groups for the same IMPS syndrome profiles derived from the ratings of Mrs. A: (1) the 211 psychiatrists are shown once again on this figure for comparison, (2) the 35 Maudsley new registrars, and (3) the small sample (18) of general practitioners. It will be seen that for these three groups both hypotheses were partially upheld, in so far as the mean ratings for the psychiatrists were consistently below those of the Maudsley new registrars, and in six IMPS syndromes out of 10 were below those of the general practitioner group, although the latter differences did not reach significance. Of the 10 syndromes the psychiatrists rated the lowest of all the groups on five, hostility,* intrapunitiveness,* motor-abnormalities,* retardation,* and conceptual disorganization, and next to lowest on perceptual distortion.* However, the general practitioners also rated low levels on the syndromes, coming lowest of all on three, excitement, perceptual distortion* and paranoid ideas,* and next to lowest on four,
One videotaped interview was used, lasting approximately 40 minutes. It was unstructured and
'Significance equal to or less than 005 against at least two other groups.
J. R. M. Copeland, M. J. Kelleher, A. J. Gourlay, and A. M. R. Smith
92
A 70-
w 60
50
40
EXC
HO5
PAR
GRN
PC P
INP
RTD
DIS
MTR
CNP
FIG. 1. Inpatient multidimensional psychiatric scale mean symptom profiles for psychiatrists from the British Isles, student Psychiatrists from the British Isles (n =211). sister tutors, andthirdyear psychology students {patient Mrs. A.). Student sister tutors («=57). —.—.—.—Third year psychology students (n=54).
70
/\
60
50-
40-
FIG. 2. Inpatient multidimensionalpsychiatric scale mean symptom profiles for psychiatristsfrom the British Isles, Maudsley new registrars, and sample of general practitioners (patient Mrs. A.). Psychiatrists from the British Isles (n=211). ———Maudsley new registrars (n=35). Sample of general practitioners (n = 18).
grandiosity, intrapunitiveness, retardation,* and motor-abnormalities. If these two groups are taken together—that is, the two medically qualified groups with the longest clinical experience of assessing patients—between them they rate lowest on eight of the 10 syndromes. This con-
trasts with the two non-medically qualified groups taken together, the sister tutors and the psychology students who between them scored the highest levels of all the groups for seven of the ten syndromes, excitement, hostility, grandiosity,* perceptual distortion,* intrapunitiveness,*
Psychiatric training and the rating of abnormal behaviour
retardation,* and motor-abnormalities.* The Maudsley new registrars hold a central position. The psychiatrists and general practitioners differ strikingly on two syndromes. If it is true that a low level of rating of abnormal behaviour indicates a willingness to accept a wide range of behaviour as normal, the psychiatrists appear the most willing to accept 'hostility' as normal behaviour and the general practitioners the least. Of course, the psychiatrist's training is directed towards helping him to understand and cope with the hostility displayed by patients. More striking still is the general practitioners' tolerance of paranoid behaviour and the psychiatrists' relative intolerance (P< 0-001). If the psychiatrists are accepted as a standard, this group of general practitioners tended to undervalue this symptom. The overall shape of the symptom profiles for all five groups are roughly similar to one another. The syndromes were compared using the method of Greenhouse and Geisser (1959). This is a method for analysing such profiles by using a traditional univariate analysis of variance approach, and gives tests for differences in the overall mean levels of the group profiles. Excluding the sample of general practitioners, the differences between the profiles of the nonpsychiatrists and the psychiatrists for level of symptoms reached significance (P
