Personality disorder

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5276 (Published 10 September

2013)
Cite this as: BMJ 2013;347:f5276

 CME
 Personality disorders

 Child and adolescent psychiatry

 Child and adolescent psychiatry (paedatrics)

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1. Linda Gask, professor of primary care psychiatry1,

2. Mark Evans, consultant psychiatrist in psychotherapy2,
3. David Kessler, senior lecturer3
Author Affiliations

1. Correspondence to: L Gask Linda.Gask@manchester.ac.uk

Summary points
 People with personality disorder have a persistent pervasive abnormality
in social relationships and functioning
 Personality disorder is associated with high service use and excess
medical morbidity and mortality
 Diagnosis of personality disorder along a single dimension of severity is
a major change from traditional categorical approaches
 Depression, anxiety, substance use, suicidal behaviour, and suicide are
all more common in these patients; comorbid mental health problems are more
difficult to treat and have poorer outcomes
 General principles of management include consistency, reliability,
encouraging autonomy, and the sensitive management of change
 Specialist treatments with evidence of effectiveness in borderline
personality disorder include dialectical behaviour therapy, mentalisation based
treatment, transference focused therapy, cognitive analytic therapy, and
schema focused therapy

Most non-psychiatrists are aware of the diagnosis of personality disorder but

rarely make it with confidence. In the past, this diagnosis came with a tacit
admission that not much can be done, but there is now increasing evidence
that treatment can be effective. Epidemiological studies show that 4-12% of
the adult population have a formal diagnosis of personality disorder; if milder
degrees of personality difficulty are taken into account this is much
higher.1 People carry the label of personality disorder with them, and this can
influence their care when they come into contact with services, including
mental health providers. GPs also carry the clinical responsibility for their
patients with personality disorder, and this can be challenging over the long
term. This article aims to review the current evidence for the diagnosis and
treatment of personality disorder.
Sources and selection criteria
We searched Medline, the Cochrane Database of Systematic Reviews,
Clinical Evidence, and the database of the Centre for Reviews and
Dissemination using the search term “personality disorder”. We focused mainly
on systematic reviews, meta-analyses, high quality observational studies, and
randomised controlled trials published in the past five years. We also
consulted our own reference archives and expert contacts.

What is personality disorder?

The exact definition of personality disorder is open to debate and differs
between the two main diagnostic systems used for mental health problems,
ICD (International Classification of Diseases) and DSM (Diagnostic and
Statistical Manual of Mental Disorders). Temperamental differences between
children can be seen from a very young age and probably have a large
inherited component. “Personality” refers to the pattern of thoughts, feelings,
and behaviour that makes each of us the individuals that we are. This is
flexible and our behaviour differs according to the social situations in which we
find ourselves.
People with personality disorder seem to have a persistent pervasive
abnormality in social relationships and social functioning in general.2 More
specifically, there seems to be an enduring pattern of perceiving, relating to,
and thinking about the outside world and the self that is inflexible, deviates
markedly from cultural expectations, and is exhibited in a wide range of social
and personal contexts. People with personality disorder have a more limited
range of emotions, attitudes, and behaviours with which to cope with the
stresses of everyday life.
Personality disorder is viewed as different from mental illness because it is
more persistent throughout adult life, whereas mental illness results from a
morbid process of some kind and has a more recognisable onset and time
course.3 A cohort study found good rates of remission in people with borderline
personality disorder (78-99% at 16 year follow-up), but remission took longer
to occur than in people with other personality disorders and recurrence was
more common.4Evidence from two randomised controlled trials also suggests
that most people with this disorder will show persistent impairment of social
functioning even after specialist treatment.5 6

Why is personality disorder important?

People with personality disorders experience considerable distress, suffering,
and stigma. They can also cause distress to others around them.

Epidemiological research has shown that comorbid mental health problems,

such as depression, anxiety, and substance misuse, are more common in
people with personality disorder,7 are more difficult to treat, and have worse
outcomes. One systematic review found that in depression, personality
disorder is an important risk factor for chronicity.8 Two recent narrative reviews
of the epidemiological literature concluded that personality disorder is also
associated with higher use of medical services, suicidal behaviour and
completed suicide, and excess medical morbidity and mortality, especially in
relation to cardiovascular disease.9 10 One systematic review found an
association with violent behaviour.11

How is personality disorder diagnosed?

The two major diagnostic systems in psychiatry have taken very different views
on how to revise their classification of personality disorder. There has been
growing criticism of a purely categorical approach that requires a decision as
to whether a person meets criteria for paranoid, borderline, or antisocial
personality disorder. Considerable overlap exists between categories, which
do not take into account the wide variation in impairment seen in everyday
practice, and reinforce the stigma associated with the diagnosis. There has
been debate about whether a dimensional approach using scores for
personality traits or applying a simple measure of severity of disorder would be
an improvement. The recently published fifth edition of DSM (DSM-5) has left
the previous categorical classification unchanged,12 although an alternative,
more complex, classification that was rejected before publication is also
included in a later section. The eleventh revision of ICD (ICD-11) is still in
preparation,13 but recent publications propose a dimensional approach using
five levels of severity. A criticism of this approach has been that the diagnosis
of borderline personality disorder, which has considerable clinical utility, is lost.
The diagnosis is in some sense a misnomer because the primary category to
which the condition was thought to be borderline was schizophrenia, and this
is no longer the case. However, it is still possible to describe borderline
personality disorder using a combination of traits (figure⇓).

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Summary of differences between Diagnostic and Statistical Manual of Mental
Disorders, fifth edition (DSM-5) and latest available information about
international classification of diseases, 11th revision (ICD-11) for diagnosis of
personality disorder
Controversy remains about diagnosing personality disorder in adolescence,
not least because of the current pejorative nature of the diagnosis. Referral to
a specialist is recommended for suspected cases.

What do we know about the causes of

personality disorder?
As with other mental health problems, personality disorders are probably the
result of multiple interacting genetic and environmental factors. There is
growing evidence for a genetic link, with results from twin studies suggesting
heritability of personality traits and personality disorders ranging from 30% to
60%.14 A narrative review of epidemiological studies also suggests that family
and early childhood experiences are important, including experiencing abuse
(emotional, physical, and sexual), neglect, and bullying.10

How is personality disorder managed

and treated?
Across the range of personality disorders, there is still little evidence for what
treatments are helpful. An exception to this is borderline personality disorder,
for which there is now a growing evidence base, and (to a lesser extent)
antisocial personality disorder. National Institute for Health and Care
Excellence (NICE) guidelines have now been produced for both of
these.15 Unusually for people with personality disorder, those with a borderline
diagnosis tend to seek treatment, whereas those with antisocial personality
disorder and other categories tend to be reluctant to commit to treatment. In
view of the prevailing evidence, we will focus this section on the general
management and specific treatment of these two categories.

What are the basic principles of managing

personality disorders?
When working with people with all types of personality disorder, it is important
to explore treatment options in an atmosphere of hope and optimism, building
a trusting relationship with an open non-judgmental manner. Services should
be accessible, consistent, and reliable, bearing in mind that many people will
have had previous experiences of trauma and abuse. Consideration should be
given to working in partnership, helping people to develop autonomy, and
encouraging those in treatment to be actively involved in finding solutions to
their problems.

Managing borderline personality

disorder
Consider borderline personality disorder in a person presenting to primary care
who has repeatedly self harmed and shown persistent risk taking behaviour or
marked emotional instability. Primary care doctors should aim to help manage
patients’ anxiety by enhancing coping skills and helping patients to focus on
the current problems. Techniques for doing this include looking at what has
worked in the past, helping patients to identify manageable changes that will
enable them to deal with the current problems, and offering follow-up
appointments at agreed times. When a patient with borderline personality
disorder presents to primary care in crisis, it is important to assess the current
level of risk to self and others.

People with this disorder require special attention when managing transitions
(including changes to and endings of treatment) given the likelihood of intense
emotional reactions to any perceived rejection or abandonment.

Referral to specialist mental health services can be useful to establish a

diagnosis. Also consider referral when a patient with this disorder is in crisis,
when levels of distress and risk of self harm or harm to others are increasing.

Specialist treatment
The past 20 years have seen increased emphasis on understanding the
underlying problems, symptoms, and states of mind of people with borderline
personality disorder and an accompanying development of specific treatments
to target them (box).

Psychological treatments with the current best

evidence for borderline personality disorder
Dialectical behaviour therapy
Developed as a modified version of cognitive behavioural therapy, it also
incorporates the concept of “mindfulness” drawn from Buddhist philosophy.
The treatment focuses on emotional regulation, distress tolerance, and
interpersonal effectiveness through individual therapy, group skills training, and
telephone coaching.

Mentalisation based treatment

An adaption of psychodynamic psychotherapy grounded in attachment theory,
which emphasises improving patients’ ability to “mentalise”—that is, to
understand their own and other people’s mental states and intentions. The
treatment is delivered in a twice weekly individual and group therapy format or
as part of daily attendance at a treatment centre.

Transference focused therapy

A form of psychodynamic psychotherapy derived from Otto Kernberg’s theory
of object relations, which describes contradictory internalised representations
of self and others. It focuses intensely on the therapy relationship and is
delivered as twice weekly individual sessions aimed at the integration of split
off aspects of the personality.

Cognitive analytic therapy

Brief focused therapy that integrates ideas from psychoanalytic object relations
theory and cognitive behavioural therapy. A collaborative therapy that uses
diagrams and letters to help people to recognise and revise confusing patterns
and mental states, it is delivered individually over 24 weeks with follow-ups.

Schema focused therapy

A development of cognitive behaviour therapy founded by Jeffrey Young,
which blends elements of Gestalt therapy, object relations, and constructivist
therapies. It identifies and modifies dysfunctional patterns (schemata) made up
of patients’ memories, feelings, and thoughts about themselves and others. It
is usually delivered as once or twice weekly individual therapy.

Dialectical behaviour therapy is a modified version of cognitive behavioural

therapy that also uses the concept of “mindfulness” drawn from Buddhist
philosophy. Several randomised controlled trials focusing mainly on women
who repeatedly self harm have shown reductions in anger, self harm, and
attempts at suicide.16
People with borderline personality disorder are less able than the general
population to “mentalise;” that is, to understand their own and other people’s
mental states and intentions. Randomised controlled trials of mentalisation
based treatment, which focuses on improving mentalising capacity, have
shown reduced suicidal behaviour and hospital admissions, as well as an
improvement in associated symptoms.6 17 Other therapies, all with trial
evidence of effectiveness in reducing borderline symptoms are schema
focused therapy,18 19 transference focused therapy,20 and cognitive analytic
therapy.21 In addition to improving core symptoms, schema focused therapy
improved psychological functioning and quality of life; transference focused
therapy improved psychosocial functioning and reduced inpatient admissions;
and cognitive analytic therapy improved interpersonal functioning and overall
wellbeing and led to a reduction in dissociation (splitting of the personality).
A systematic review of randomised trials identified two other treatments with
evidence of effectiveness in this group of patients. The first, problem solving
for borderline personality disorder, is an integrated treatment that combines
cognitive behavioural elements, skills training, and intervention with family
members. It can reduce borderline symptoms and improve impulsivity—the
tendency to experience negative emotions and global functioning.22 The
second, manual assisted cognitive treatment, aimed at reducing deliberate self
harm, was successful in a study of patients with borderline personality disorder
who self harm.23

Effective management and care coordination

Specialist treatments are not generally available in the community, and it may
be difficult to motivate people struggling with chaotic lifestyles and unstable
support systems to engage with them. Evidence is emerging that well
structured general psychiatric management can be as effective as branded
specialised treatments when delivered under research conditions.5 In this
randomised trial, general psychiatric management involved case management
and weekly individual sessions using a psychodynamic approach that focused
on relationships and management of symptom targeted drugs.
Good care coordination within a community mental health setting is key to
stabilising patients, some of whom may later receive more specialist
interventions. Indeed, the type of therapy may not be important, but rather that
management is consistent, reliable, encourages autonomy, and is sensitive to
change. Management should be systematic and preferably manualised
(guided by a “manual” for the therapist with a series of prescribed goals and
techniques to be used during each session or phase of treatment) to provide a
clear model for patient and therapist to work with. This helps the mental health
professional to deal with common clinical problems, such as self harm and risk
of suicide, by talking with the patient about any precipitants to unmanageable
feelings, giving basic psychoeducation about managing mood states, and
encouraging problem solving and the sharing of risk and responsibility. In
addition, close attention should be paid to any emerging problems in the
therapeutic alliance.24

Are there any drug treatments available for

borderline personality disorder?
There is no clear evidence for the efficacy of drugs for the core borderline
symptoms of chronic feelings of emptiness, identity disturbance, and
abandonment. Some randomised trials have shown benefits with second
generation antipsychotics, mood stabilisers, and dietary supplements of
omega-3 fatty acids,25 but these are mostly based on single studies with small
sample sizes and are not recommended by NICE.15 Antidepressants may be
helpful only in the presence of coexisting depression or anxiety.

Managing antisocial personality disorder

The treatment of people with antisocial personality disorder will be facilitated
by working within a clearly described care pathway because a diverse range of
services are often be involved. The pathways should specify likely helpful
interventions at each point and should enable effective communication
between clinicians and organisations. Locally agreed criteria should be
established to facilitate transfer between services with shared objectives and a
comprehensive assessment of risk. Services should consider establishing
multiagency antisocial personality disorder networks that actively involve
service users. Once established, they can play a central role in training, the
provision of support and supervision to staff, and the development and
maintenance of standards.15
Although it may not be appropriate or possible to provide specific therapeutic
interventions for antisocial personality disorder in primary care, GPs still need
to offer treatment for patients with comorbid disorders in line with standard
care. In doing so, GPs should be aware that the risk of poor adherence,
misuse of drugs, and drug interactions with alcohol and illicit drugs is
increased in this group. It may be helpful to liaise closely with other agencies
involved in the care of these patients, including the criminal justice system and
drug support workers. Local schemes are available in primary care in the UK
for the management of patients who have been violent or threatening towards
their GPs or other primary care staff. Assessment of risk in primary care should
include history of violence, its severity, and precipitants; the presence of
comorbid mental disorders; use of alcohol and illicit drugs and the potential for
drug interactions; misuse of prescribed drugs; current life stressors; and
accounts from families or carers if available.

Specialist treatments
Robust evidence for the effectiveness of specific psychological interventions in
antisocial personality disorder is currently lacking.26 However, NICE guidelines
suggest the use of group based cognitive and behavioural interventions that
focus on the reduction of offending and other antisocial behaviour.15 Particular
care is needed in assessing the level of risk and adjusting the duration of
programmes accordingly. Participants will need to be supported and
encouraged to attend and complete programmes. People with dangerous and
severe personality disorder will often come through the criminal justice system
and will require forensic psychiatry services. Treatments (including anger
management and violence reduction programmes) will essentially be the same
as above but will last longer. Staff involved in such programmes will require
close support and supervision.

Are there any drug treatments available for

antisocial personality disorder?
No specific drugs are recommended for the core symptoms and behaviours of
antisocial personality disorder (including aggression, anger, and
impulsivity).27Drugs may be considered for the treatment of comorbid
disorders.

Other treatments
Therapeutic communities, which provide a longer term, group based, and often
residential approach to therapy, have a long history in the treatment of
personality disorder, but there is no evidence for their effectiveness. In the UK,
the Department of Health set up pilot projects for management of personality
disorder in 2004-05. One of these, the Service User Network model, offers
community based open access support groups for people with personality
disorder, with service users engaged in the design and delivery of the
service.28 Analysis of routine data, together with a cross sectional survey,
showed that the service attracted a large number of people with serious health
and social problems and that use of the service was associated with improved
social functioning and reduced use of other services. Nidotherapy (nest
therapy) is a new treatment approach for people with mental illness and
personality disorder, which involves manipulation of the environment to create
a better fit between the person and his or her surroundings, rather than trying
to change a person’s symptoms or behaviour. Evidence from a systematic
review in which only one study met inclusion criteria showed an improvement
in social functioning and engagement with non-inpatient services.29

What are the problems in everyday

practice?
Personality disorder affects the doctor-patient relationship. Misunderstandings
and even angry reactions are not uncommon and consistency, clarity, and
forward planning are all important in managing the relationship. The diagnosis
of personality disorder should never be given to a patient whom the doctor
simply finds “difficult.” There is evidence of a disparity between a formal
diagnosis of personality disorder achieved using a research interview and the
diagnoses made by GPs.30However, it is important to be aware that a diagnosis
of comorbid personality disorder is a possibility in patients who do not respond
to treatment or seem particularly difficult to manage. A simple eight item
screening interview (standardised assessment of personality: abbreviated
scale) is useful in this respect.31 It is useful to have clear management plans in
place to deal with recurring patterns of crisis, with agreement between GP,
specialist mental healthcare, and the service user about potential options for
managing likely problems, possible sources of support and advice, and when
to urgently refer to specialist care.
Efforts need to be made to challenge stigma and unhelpful attitudes of
healthcare professionals,32 develop professional skills in understanding and
managing difficult encounters with challenging patients,33 34 and promote
engagement in psychological therapy if it is likely to be helpful. However,
people with comorbid substance misuse may face problems in accessing
psychological therapies (some services do not offer them to these people),
specialist therapies may not be locally available, and barriers persist in
accessing mental healthcare for people with personality disorder in the UK
despite policy guidance to the contrary.35
No patient should be excluded from mental health services because he or she
has a personality disorder, nor should the incorrect notion that personality
disorder is all pervasive and immutable be used to deny people access to
valuable therapeutic interventions.
 A patient’s perspective
Before therapy I just did not know what was going on in my head. One thing
always seemed to affect another: the inability to hold down a job, getting into
debt, relationship problems, constantly blaming others, and wondering what
the hell was wrong with me.

My GP was becoming concerned and I willingly accepted a referral to the local

psychotherapy department. When I was told that I probably had borderline
personality disorder and that a service was available for people with this
disorder it was an enormous relief.

The therapy has been ongoing and has enabled me to feel safe and contained
within it. This has helped me to be more open with my therapist and to make
sense of my difficult childhood and adolescence and how this has affected my
present condition.

The things that create a better life for people are jobs, relationships, and
security. However, for people with personality disorder these are the very
situations that can often trigger symptoms. Therapy can show different
directions: one you have always known and another way. New ways, however,
can also bring new problems.

It makes me aware that I need to be kind to myself and that healing is an

ongoing process.

Tips for non-specialists

 Consider personality disorder in people who are difficult to engage and
do not respond to treatment—for example, those who do not respond to
treatment for depression
 Try to maintain a consistent and non-judgmental approach even when
“under fire” from a person who is emotionally aroused or wound up
 It is more important to recognise the general problem of an enduring
pattern of difficulty in a wide variety of social contexts, and a limited repertoire
of coping skills, than to diagnose a particular subtype of personality disorder
 Make plans for crisis management, especially recurrent crises, such as
repeated self harm or threats of self harm
 Explore possible therapeutic avenues with specialist care; don’t let the
label be a reason for not referring
 Additional educational resources
Resources for healthcare professionals
 National Institute for Health and Care Excellence guidance for borderline
and antisocial personality disorders:
 http://guidance.nice.org.uk/CG78
 www.nice.org.uk/CG77
 Personality Disorders (www.personalitydisorder.org.uk/)—Resources
from the national personality disorder programme, which supported
improvements in the treatment of personality disorders across the health and
social care workforce
 Balint Society (http://balint.co.uk/)—Membership of the Balint group
provides a space to think about those encounters that leave health
professionals feeling drained, puzzled, or stuck
Resources for patients and service users
 MIND (www.mind.org.uk/mental_health_a-
z/8028_personality_disorders)—Free leaflet on personality disorders, with tips
on self help
 Royal College of Psychiatrists
(www.rcpsych.ac.uk/expertadvice/problemsdisorders/personalitydisorder.aspx)
—Free leaflet with advice for patients, families, and friends
 Emergence (www.emergenceplus.org.uk)—Useful information for
service users, carers, and professionals (need to register)
Questions for future research
 Can early intervention in childhood reduce the risk of developing
personality disorders?
 Can we reliably and usefully screen for personality disorder in primary
care?
 Would implementation of action plans for crisis management in primary
care make a difference?
 How can we improve access to psychological therapy for people with
personality disorder?
 What is the optimal length of time that psychological therapy for
personality disorder should last?
 Can we reliably and effectively implement general psychiatric
management more widely in mental healthcare for people with borderline
personality disorder?
 Can we develop more useful generic guidelines for personality disorder?
 Will application of a dimensional approach to diagnosis (as in
International Classification of Diseases, eleventh revision) change attitudes to
the diagnosis of personality disorder?

Notes
Cite this as: BMJ 2013;347:f527

Guidelines
Recognition, assessment and
treatment of social anxiety
disorder: summary of NICE
guidance
BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2541 (Published 22 May 2013)
Cite this as: BMJ 2013;346:f2541

 Guideline summaries
 Anxiety disorders (including OCD and PTSD)

 Child and adolescent psychiatry

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1. Stephen Pilling, director, professor123,

2. Evan Mayo-Wilson, senior research associate123,
3. Ifigeneia Mavranezouli, senior research fellow in health economics123,
4. Kayleigh Kew, systematic reviewer4,
5. Clare Taylor, senior editor5,
6. David M Clark, professor6
7. On behalf of the Guideline Development Group
Author Affiliations
1. Correspondence to: S Pilling s.pilling@ucl.ac.uk
 Accepted 16 April 2013

Social anxiety disorder is one of the most persistent and common of the
anxiety disorders, with lifetime prevalence rates in Europe of 6.7% (range 3.9-
13.7%).1 It often coexists with depression, substance use disorder, generalised
anxiety disorder, panic disorder, and post-traumatic stress disorder.2 It can
severely impair a person’s daily functioning by impeding the formation of
relationships, reducing quality of life, and negatively affecting performance at
work or school. Despite this, and the fact that effective treatments exist, only
about half of people with this condition seek treatment, many after waiting 10-
15 years.3 Although about 40% of those who develop the condition in
childhood or adolescence recover before adulthood,4 for many the disorder
persists into adulthood, with the chance of spontaneous recovery then limited
compared with other mental health problems.
This article summarises the most recent recommendations from the National
Institute for Health and Care Excellence (NICE) on recognising, assessing,
and treating social anxiety disorder in children, young people, and adults.5

Recommendations
NICE recommendations are based on systematic reviews of the best available
evidence and explicit consideration of cost effectiveness. When minimal
evidence is available, recommendations are based on the Guideline
Development Group’s experience and opinion of what constitutes good
practice. Evidence levels for the recommendations are given in italic in square
brackets.

Principles for working with all people with

social anxiety disorder
 When a person is first offered an appointment, provide clear information
in a letter about:
o -Where to go on arrival and where they can wait (offer the use of a
private waiting area or the option to wait elsewhere—for example, outside
the service’s premises)
o -Location of facilities available at the service (for example, the car
park and toilets)
o -What will happen and what will not happen during assessment
and treatment.
When the person arrives for the appointment, offer to meet them or alert them
(for example, by text message) when their appointment is about to begin.
[Based on the experience and opinion of the Guideline Development Group
(GDG) and on evidence reviewed in two recent NICE guidelines on mental
health6 7 ]
 Offer to provide treatment in settings where children and young people
and their parents or carers feel most comfortable—for example, at home or
in schools or community centres. [Based on the experience and opinion of
the GDG]

Identification of adults with possible social

anxiety disorder
 Ask the identification questions using the two-item generalised anxiety
disorder scale (GAD-2)8 in line with NICE guidance6, and if social anxiety
disorder is suspected:
o -Use the three-item mini-social phobia inventory (Mini-SPIN)9 or
o -Consider asking the following two questions: Do you find yourself
avoiding social situations or activities? Are you fearful or embarrassed in
social situations?
If the person scores 6 or more on the Mini-SPIN or answers yes to either of the
two questions above, refer for or conduct a comprehensive assessment for
social anxiety disorder.

[Based on a systematic review of assessment tools and the experience and

opinion of the GDG]

Identification of children and young people

with possible social anxiety disorder
Professionals in primary care and education and in community settings should
be alert to possible anxiety disorders in children and young people, particularly
those who avoid school, social or group activities, or talking in social
situations, or are irritable, excessively shy, or overly reliant on parents or
carers. Consider asking the child or young person (or their parents or carers)
about their feelings of anxiety, fear, avoidance, distress, and associated
behaviours, to help establish if social anxiety disorder is present, using the
following statement and questions:
 “Sometimes people get very scared when they have to do things with
other people, especially people they don’t know. They might worry about doing
things with other people watching. They might get scared that they will do
something silly or that people will make fun of them. They might not want to do
these things or, if they have to do them, they might get very upset or cross.”
Then ask:
o -“Do you/does your child get scared about doing things with other
people, like talking, eating, going to parties, or other things at school or with
friends?”
o -“Do you/does your child find it difficult to do things when other
people are watching, like playing sport, being in plays or concerts, asking or
answering questions, reading aloud, or giving talks in class?”
o -“Do you/does your child ever feel that you/your child can’t do
these things or tries to get out of them?”
[Based on the experience and opinion of the GDG]
If the child or young person or parents or carers answer “yes” to one or more
of the questions consider a comprehensive assessment for social anxiety
disorder. [Based on the experience and opinion of the GDG]

Comprehensive assessment for children,

young people, and adults
 Obtain a detailed description of the person’s current social anxiety and
associated problems and circumstances including:
o -Feared and avoided social situations, and what they are afraid
might happen in social situations (for example, looking anxious, blushing,
sweating, trembling, or appearing boring)
o -Anxiety symptoms
o -View of self
o -Safety seeking behaviours
o -Anticipatory and post-event processing
o -Occupational, educational, financial, and social circumstances in
adults
o -Family circumstances and support, friendships and peer groups,
educational and social circumstances in children and young people
o -Medication, alcohol, and recreational drug use.
[Based on the experience and opinion of the GDG]
Delivering interventions for children, young
people, and adults
All interventions should be delivered by competent practitioners. Psychological
interventions should be based on the relevant treatment manual(s), which
should guide their structure and duration. Practitioners should consider using
competence frameworks developed from the relevant treatment manual(s) and
for all interventions should receive regular, high quality, outcome informed
supervision; use routine sessional outcome measures; and monitor treatment
adherence and practitioner competence (for example, using video and audio
recordings, and external audit and scrutiny if appropriate). [Based on a
systematic review of assessment tools and the experience and opinion of the
GDG]

Interventions for adults with social anxiety

disorder
First line treatment
 Offer adults individual cognitive behavioural therapy (CBT) that has
been specifically developed to treat social anxiety disorder (based on the
Clark and Wells model or the Heimberg model5). [Based on a systematic
review, network meta-analysis, and an economic model]
 Do not routinely offer group CBT in preference to individual CBT.
Although there is evidence that group CBT is more effective than most other
interventions, it is less clinically and cost effective than individual CBT.
[Based on a systematic review, network meta-analysis, and an economic
model]
Second line treatments
 For adults who decline CBT and wish to consider another psychological
intervention, offer CBT based, supported self help.[Based on a systematic
review, network meta-analysis, and an economic model]
 For adults who decline cognitive behavioural interventions and express
a preference for a drug intervention, discuss their reasons for declining
cognitive behavioural interventions and try to resolve any concerns. [Based
on the experience and opinion of the GDG and on a systematic review,
network meta-analysis, and an economic model]
 If the person wishes to proceed with a drug intervention, offer a selective
serotonin reuptake inhibitor (escitalopram or sertraline). Monitor carefully for
adverse reactions. [Based on a systematic review, network meta-analysis,
and an economic model]
Third line treatments
 For adults who decline cognitive behavioural interventions and drug
treatment, consider short term, psychodynamic psychotherapy specifically
developed for social anxiety disorder. However, bear in mind the more
limited clinical and cost effectiveness of this intervention. [Based on a
systematic review, network meta-analysis, and an economic model]
The components of the recommended psychological therapies for adults can
be found in the full NICE guideline.5

Interventions for children and young people

with social anxiety disorder
 Offer individual or group CBT focused on social anxiety. Consider
involving parents or carers for effective delivery of the intervention,
particularly in young children. [Based on a systematic review and meta-
analysis]
The components of the recommended psychological therapies for adults can
be found in the full NICE guideline.5
 Do not routinely offer drug interventions to treat social anxiety disorder in
children and young people. [Based on a systematic review and meta-
analysis]

Overcoming barriers
The guideline deals with several potential barriers to people seeking treatment
for social anxiety disorder: people may think that the social anxiety is part of
their personality and cannot be changed (or, in the case of children, that they
will grow out of it); they may fear negative evaluation by healthcare
professionals if they disclose their problem; even after presentation, the
disorder may not be recognised by healthcare professionals, especially in
primary care.10 The guideline advises healthcare professionals to be aware of
barriers to people seeking treatment, and on how to identify the disorder in all
age groups and how services can make themselves more accessible. It also
recommends effective treatments and seeks to help commissioners identify
the services that should be made available.
Further information on the guidance
Factors prompting the development of this guideline include the poor
recognition and inadequate assessment of social anxiety disorder and the
limited awareness or availability of treatments despite the existence of
effective psychological and drug interventions. Social anxiety disorder is
under-recognised in primary care,10particularly when it coexists with
depression. Often the depressive episode may be identified but the underlying
and more persistent social anxiety disorder is not. The early age of onset
means that recognition of social anxiety disorder in educational settings is
important and may bring early and lasting benefits to children, but it is
challenging to achieve this without accurate identification and clear referral
pathways.
Methods
This guideline was developed by the National Collaborating Centre for Mental
Health using NICE guideline methods (www.nice.org.uk/guidelinesmanual).
The guideline review process involved comprehensive and systematic
literature searches to identify relevant evidence for the clinical and economic
reviews, with critical appraisal of the quality of the identified evidence. Results
of intervention studies were compared using pairwise and network meta-
analysis. Results of the network meta-analysis were used to inform an
economic model. A multidisciplinary team of healthcare professionals from
psychiatry, psychology, and general practice and service user and carer
representatives (forming the GDG) was established to review the evidence
and develop the subsequent recommendations. The guideline then went
through an external consultation with stakeholders. The GDG considered the
stakeholders’ comments, reanalysed the data where necessary, and modified
the guideline as appropriate.
NICE has produced three different versions of the guideline: a full version; a
summary version known as the “NICE guideline”; and a version for children,
young people, and adults with social anxiety disorder, their parents and carers,
and the public. All these versions, as well as a pathway, are available from the
NICE website. Updates of the guideline will be produced as part of NICE’s
guideline development programme.

Areas for future research

 What methods are effective in improving uptake of and engagement with
interventions for adults with social anxiety disorder?
 What is the best way of involving parents in the treatment of children
and young people with social anxiety disorder at different stages of
development?
 What is the clinical and cost effectiveness of specific CBT for children
and young people with social anxiety disorder compared with generic
anxiety focused CBT?
  What is the clinical and cost effectiveness of individual and group CBT
for children and young people with social anxiety disorder?
 What is the clinical and cost effectiveness of combined psychological
and drug interventions compared with either intervention alone in treating
adults with social anxiety disorder?

Notes
Cite this as: BMJ 2013;346:f2541

 Mental health

Doctors accessing mental-health

services: an exploratory study
1. Josephine Stanton1,
2. Patte Randal2
+Author Affiliations
1. 1Child and Family Unit, Auckland Healthcare, Auckland Mail
Centre, Auckland, New Zealand
2. 2Rehabilitation Psychiatry, Buchanan Rehabilitation Centre,
Auckland Healthcare, Auckland Mail Centre, Auckland, New
Zealand
1. Correspondence to
Dr Josephine Stanton; josephines@adhb.govt.nz
 Received 3 November 2010
 Accepted 2 February 2011
 Published 23 February 2011

Abstract
Objective To develop a more in-depth understanding of how doctors do and
do not access mental healthcare from the perspectives of doctors themselves
and people they have contact with through the process.
Design Qualitative methodology was used with semistructured interviews
transcribed and analysed using Grounded Theory. Participants were 11
doctors with experience as patients of psychiatrists, four doctor and four non-
doctor personal contacts (friends, family and colleagues) and eight treating
psychiatrists.
 Results Participants described experiencing unrealistic expectations and a
harsh work environment with poor self care and denial and minimisation of
signs of mental health difficulties. Doctor contacts described particular difficulty
in responding effectively to doctor friends, family and colleagues in need of
mental healthcare. In contrast, non-doctor personal contacts were more able
to identify and speak about concerns but not necessarily to enable accessing
adequate mental-health services.
Conclusions Three areas with potential to address in supporting doctors'
accessing of appropriate healthcare have been identified: (1) processes to
enable doctors to maintain high standards of functioning with less use of
minimisation and denial; (2) improving the quality and effectiveness of informal
doctor-to-doctor conversations about mental-health issues among themselves;
(3) role of non-doctor support people in identifying doctors' mental-health
needs and enabling their access to mental healthcare. Further research in all
these areas has the potential to contribute to improving doctors' access to
appropriate mental healthcare and may be of value for the general population.

Article summary
Article focus
 Doctors' accessment of adequate mental healthcare is less than optimal.

 Family and community contacts have an important role in accessing

mental healthcare.

 Our understanding of the processes related to doctors accessing mental

healthcare can be improved by exploring perspectives of doctor patients, their
support people and treating psychiatrists.

Key messages
 Doctors' unrealistic expectations of themselves and associated
minimisation and denial of a range of self care needs may function as a barrier
to accessing mental healthcare.

 Addressing how doctors respond to other doctors in informal

conversations indicating mental healthcare needs may be helpful in improving
access to care.

 Non-doctor support people may have a valuable role in enabling doctors

to access appropriate mental healthcare.
 All these areas need further research.

Strengths and limitations of this study

 This is the first study of its kind and generates new insights in an
important area.

 Because of challenges in recruiting doctors with experience as patients

of psychiatrists, a hard-to-reach group, the sample is small and not broadly
representative.

Introduction
Living in a culture where doctors are seen as healthy people who treat sick
patients creates a paradox for a doctor moving into a patient role. Accordingly,
many doctors do not make use of usual channels for accessing
healthcare1 and continue to treat themselves despite guidelines to the
contrary.2 Much expert opinion about barriers to healthcare for doctors is
available in the literature, but the quality of the data available is limited.3
Moving into the role of a patient with psychological illness has been described
as particularly challenging.4 There is increasing concern about doctors' mental
health and effectiveness in accessing mental-health services.5–7
Out of this concern, a literature documenting, researching and recommending
interventions for medical students and doctors is emerging.8–11 The research
base is limited. Individual case information has been made
available.12 13 Questionnaire surveys provide important information about
attitudes,14 15 but the depth and complexity they are able to contribute to our
understanding are limited. We need more understanding about how doctors do
and do not access mental healthcare. This is likely to be helpful in addressing
barriers to healthcare for doctors. Moreover, Kay et al3 point out similarities
between doctors and the general population in accessing mental healthcare.
Thus, increasing understanding of barriers for doctors accessing mental
healthcare may have implications for the wider population. Likewise, research
in the general population has demonstrated the importance of family and
community contacts in facilitating access to mental-health services.16 So, we
need more understanding of how this may also be important for doctors.
The aim of this paper is to develop a more in-depth understanding of how
doctors do and do not access mental healthcare from the perspectives of
doctors themselves and people they have contact with through the process.

The data presented in this paper are drawn from a more wide-ranging
multiperspective qualitative study on doctors as patients of psychiatrists.
Participants
Recruitment was challenging. We sought information-rich participants, doctors
with experience as a patient of a psychiatrist who were fluent in English and
had capacity to consent. We approached seven doctors who were known to
one or other of the researchers through personal or collegial contact as having
had experience as patients of psychiatrists. Five agreed to participate. Formal
channels such as the Medical Council and support providers to doctors
declined to participate because of concerns about confidentiality. One of the
researchers (PR) had been involved in developing an informal support network
for doctors with mental-health issues, and three potential participants were
identified via this role. Two agreed to participate. She also put out an invitation
to participate in the study to members of a currently developing local internet
site for peer support for doctors. One member specifically declined, and there
were no other responses. Two were identified and referred to the researchers
by other participants. One self-identified to the researchers following listening
to a presentation of preliminary data. One was referred by a treating
psychiatrist.

Eleven doctors, five men and six women, were interviewed. The age range
was 32–54. The number of years since graduation was 5–28 years. Diagnoses
identified by the doctors themselves were Depression, Psychotic Depression,
Bipolar Disorder, Generalised Anxiety Disorder, Brief Psychotic Episodes,
Bipolar disorder with a differential diagnosis of Schizophrenia, Borderline traits
and Poly Substance Dependence.

Nine were working in clinical medicine at the time of the interview, five as
specialists. Six were working in psychiatry, two as specialist psychiatrists and
four as generalists with a special interest in psychiatry. One was working in
General Practice. At the time of initial identification of mental-health needs,
only two were working in psychiatry. Six were working in General Practice, two
were in specialist training positions, one was a house surgeon, one was a
student, and one was a specialist. The range of time off work owing to illness
was up to 2 years.

Psychiatrists with experience of treating doctors as patients were recruited

separately. Eleven were approached. They were selected by the researchers
to provide a range of orientations and practice type. Three declined interview.
Eight were interviewed. The range of years since qualification as a psychiatrist
was 12–39 years. Estimated numbers of doctors treated ranged from 8–12 to
60–70. All had private-practice experience, and most, but not all, of their
experience of treating doctor–patients had been in the private sector.
Eight contact people (friends, family or colleagues) were identified by the
doctors with experience as patients. Four of these were themselves doctors,
two of whom had also been recruited as doctors with experience as patients of
psychiatrists. In total, 25 participants were interviewed.

Procedure
Participants were interviewed individually by the two researchers together for
one or two interviews of up to 90 min each. The interviews were initially open.
The participant was invited to choose a place to begin. Most told their story.
This part of the interview was not time-limited, and a second interview was
scheduled when needed. Participants were encouraged to range broadly over
their experience, with prompts such as, ‘Can you tell us more about that?’
Questioning in the interview was focused towards bringing forward the
experiences, thoughts, values, etc of the participant—for example, ‘How did
you decide to …?,’ ‘How did you experience/understand that?,’ ‘What were
your hopes/fears when you …?’

A tentative checklist of relevant issues was developed initially from published

personal accounts, personal and clinical contact with doctors with mental-
health issues, and seminars for psychiatrists treating doctors. This was revised
and developed in accord with ongoing data analysis of interviews. Most issues
were covered in the open part of the interview. If not, they were specifically
enquired about. Issues from the checklist relevant to this paper were
identifying and managing vulnerability, other people knowing, identifying
mental illness (what helped and hindered this?), decision to access care (how
was this made?), finding/choosing a psychiatrist, talking to colleagues, friends,
family, etc, stigma, and worry about and experience of the Medical Council.

Ethical approval was obtained from the Ministry of Health Ethics Committee
(No AKY/04/12/344).

Data analysis
The interviews were transcribed verbatim from recordings by a typist and
reviewed by one of the researchers (JS). Identifying data were removed. A
grounded-theory approach to data analysis was used.17 18 The transcripts
were closely read by each of the researchers individually and independently
coded using the Qualitative Solutions and Research NVIVO computer software
(QSR International, Doncaster, Australia). The two sets of codes and themes
were then extensively and continuously discussed and compared.
Convergence and divergence in accounts were both explicitly sought, with
particular emphasis on exceptions. Emerging themes and higher-level codes
were fed into the ongoing interviewing process. This process was repeated, at
times in part and at times in whole, through the data-collection process. In
returning to the transcripts, the recoding was focused on both confirmation and
disconfirmation of hypotheses, and an evolving analysis of themes. Additional
depth to this process was contributed by comparing and contrasting accounts
from different groups of participants.

Researchers
Both researchers are doctors with decades of experience working in psychiatry
across a range of disorders and service types. One of the researchers has
personal experience of psychosis and depression (PR). Both researchers have
experience as network members of doctors engaging as patients of
psychiatrists and limited experience in engaging with doctors as patients. One
of the researchers is working as a child and adolescent psychiatrist, using
biological as well as psychological approaches and compulsory care (JS). The
other researcher is working psychologically with people with severe and
chronic psychiatric disorder (PR). Both are committed to working creatively
and reflectively, developing strategies for empowering and enabling people
who are using mental-health
services19(http://www.collaborativepsychiatry.com).

Results
Accounts of male and female participants did not generate differences in
coding. Where an indication of gender is used in presenting the data, these
are assigned randomly, irrespective of the gender of the person making the
comment.

Doctors as super people

All of the doctor participants described elements of a culture of unrealistic
expectations of themselves and one another, needing to ‘know everything
about everything’ and not able to make ‘any mistakes.’you have a particular
way that you think that doctors are meant to act … be calm, cool and collected
and … having everything together. … dealing with life and death and being in
control. … putting yourself on the back burner and just fighting for your
patients.

To show vulnerability was to risk losing respect of peers and seniors. Some
described having empathy for a patient in distress being associated with the
risk that you might ‘reveal your own emotions and vulnerability.’
Participants described some variability in the whole heartedness with which
they took up this idea. One described thinking it was, ‘Ok to be vulnerable’ but
you ‘did not show it.’ Another described awareness of a discrepancy between
the expectation that they be ‘kind, caring and compassionate’ towards other
people but ‘not to have that for yourself.’ Another described how medical
students ‘tried to be accepting’ when a class member developed a psychotic
illness. One described awareness of these expectations but not having a
sense, himself, of patients needing to see him as invulnerable.

Pressure in the workplace

Bullying and lack of emotional safety were described in the workplace,
particularly in years following graduation but continuing through later
practice.there was that absolute sense of ‘can't cope, sling your hook, off you
go, you're obviously not made for it, you're obviously not good enough’

Treating psychiatrists spoke of competitiveness, criticism and harshness

among colleagues in medicine from their own experience and listening to other
doctors.

Most doctor participants described not taking care of basic needs such as for
sleep, or even a coffee break. Some described becoming more able to do this
over time.

Maintaining the myth

Some of the participants spoke about how difficult it was to maintain the myth
of being a super-person and the cost of this.I've got this dichotomous view of
myself; at one level I do think I'm very careful and I do generally deal quite well
with patients. [um] But on the other hand if there's any hint of criticism I
suddenly think I'm no good.

Failing to identify signs of illness

Several participants described actively denying and minimising awareness of
difficulties and early signs of illness.I managed to keep convincing myself that I
was quite capable and I managed to convince a lot of other people [doctors]

The commonest response to a perceived difficulty in functioning was to just

‘keep going.’I'd be dragging myself around. I remember at the end of the day I
had to lie down for about an hour before I could drive home.

Initiating help-seeking
Even once the recognition of need for help was acknowledged, the decision to
see a psychiatrist was a last resort for most participants. Several described
self-treating with medication, exercise, relaxation, etc until a point of crisis or
desperation was reached.It was just getting so bad, like I was just, things were
becoming so unmanageable in my life.

Doctor-contact people—friends, colleagues and

family who were also doctors
Six of the eight treating psychiatrists and five of the 11 doctor patients
described experiences as doctor-contact people in addition to the four doctors
identified as contact people. Thus, 15 of the 21 participants who were doctors
described experience as contacts with doctors with mental-health issues. They
were in a range of roles including friend, partner, colleague or supervisor. The
coding of their descriptions of experiences in all these roles overlapped
substantially and therefore were analysed together. There was little overlap
with the descriptions of the 4 non-doctors identified as personal contacts.

Some of the doctors described difficulty in perceiving need for care,

‘particularly mental health’ in doctor friends and colleagues with a tendency to
over or underestimate the seriousness of issues. One participant described
being approached for a prescription for benzodiazapines and feeling ‘off-
guard,’ ‘completely dis-empowered.’wanting to be helpful but … I felt so much
on the defensive being asked for something and not delivering it that I didn't
sort of think, think more broadly … obviously she may be in some sort of
trouble

Another described failing to respond usefully to a phone call from a colleague

asking for information around treatment of depression.I didn't hear the asking
for help in it. … I heard his uncomfortableness. … how I dealt with the
uncomfortableness was to draw away, you know, rather than to step in. And
again it was this fear of stepping in where I wasn't wanted, of his feeling
humiliated because of me finding out about his vulnerability and the fact that
he was a mess.

Several doctors described identifying signs of illness in friends or colleagues

and not speaking about them.I can pick up on an intuitive level that they [other
doctors] are depressed and I struggle to know what to do about it because you
can't sort of say, ‘I've been there and I can see that you're struggling, do you
want to have a little talk to me?’
Participants described finding it hard to know ‘how much to probe’ in a context
which is ‘sort of professional’ and ‘more a social [conversation].’the sense of
paralysis around ‘what the hell do I do?’ and being tied up with just the
complexity of it all.

Some of the doctor contacts described regret at having responded to hearing

experiences described by a doctor friend in terms of symptoms rather than an
example of a range of ordinary experience.As a friend who wasn't trained you
wouldn't see it as a symptom, you'd just go ‘that's [x].’

Some of the doctor patients described how unhelpful it had been when doctor
friends had responded to them by identifying symptoms or recommending
mental health services rather than hearing and responding as to an ordinary
human concern.

One doctor spouse described concern that her being a doctor delayed rather
than facilitated access to care as both she and doctor colleagues avoided
accessing ‘to protect his identity and his career.’Anyone else would have
dialed 111 and the ambulance would have been there and he would have been
admitted

In contrast to the above accounts, one of the doctor colleagues who had felt
unable to be helpful was described by the doctor patient as having been
‘enormously’ helpful in seeing the size of the problem and ‘putting the flag up.’

Several of the doctor-contact people described feeling they had learnt from
these and other experiences and would feel more able to respond effectively in
the future.

Non-doctor-contact people: friends, colleagues and

family who were not doctors
Non-medical network members described identifying difficulties and the need
for help in their partners but not necessarily identifying these as mental
illness.I was aware that she was a bit down and that things weren't right, you
know. The Wordsworth poem; ‘Some natural sorrow, loss, or pain, that has
been, and will be again.’ It felt like that kind of situation to me.

Another described being aware of her partner being ‘grumpy’ and knowing that
something needed to happen but not having the knowledge to identify
depression. Their personal knowledge was overshadowed by the medical
knowledge of their partners leaving them disempowered in this context.[Her
being a doctor] just made it very hard for me to convince her… um… that she
might need help because she's the expert.

Some described feeling that their loved one's concern about confidentiality
impeded accessing care. Some of those who did take an active role in calling
a crisis team or ambulance described difficulty getting an adequate response
and then facing their partner's anger and rejection of what was offered.

Treating psychiatrists
Treating psychiatrists described delays in doctors accessing treatment. They
described most doctor patients as self-referring, some sent by their employer
and some by the Medical Council. Referral via general practitioner was less
usual. They described doctors self-referring in response to concern about their
work performance and associated fear of complaints to the Medical Council
rather than presenting as having a mental illness.

Discussion
Summary of main findings
1. Doctors described having a culture of unrealistic expectations of
themselves and each other.

2. These expectations were associated with denial and minimisation of

need for self care, vulnerability and early signs of illness. In this way,
they formed a barrier to help-seeking.

3. Doctor colleagues, friends and partners, whether recruited as doctor

patients, doctor contacts or treating psychiatrists, described experiences
of considerable difficulty in identifying concerns and speaking about
these to other doctors.

4. Non-doctor personal contacts described being able to identify difficulties

and speak about them but not necessarily to enable effective help-
seeking for the doctor.

Strengths and limitations of study

This is an in-depth study of an information-rich group in an area where more
understanding is acutely needed. Including the perspectives of the doctors
themselves as well as doctors and non-doctors with whom they had contact in
the process has given us the opportunity to generate new insights.
Challenges in recruiting have meant there is a self-selection bias. Most
participants were recruited via personal knowledge or recommendation. In the
current climate, this personal knowledge may be necessary to create the
safety for agreement to participate.

Personal knowledge based on prior relationship with some of the participants

by at least one of the researchers, as well as the openly stated personal
experience of being a patient of a psychiatrist of one of the researchers (PR),
has the potential strength of facilitating trust and enabling openness on the
part of the participants and also of increasing depth of understanding for the
researchers.

Conversely, there is also a potential limitation that the preconceived

understandings, attitudes or values inherent in this personal knowledge could
interfere unhelpfully in the process of engagement with the data. It should be
noted that only one of the participants was well known to both the researchers,
and only one of the researchers (PR) had personal experience of being a
patient of a psychiatrist. Ongoing comparison between the independent data
analyses undertaken by each researcher was used to optimise the potential
usefulness of differences in personal knowledge in enriching the level of
engagement with the data.

Doctors working in psychiatry are over-represented, and doctors currently

working in General Practice under-represented. The small number of non-
doctor personal contact people is of particular significance, as the study
indicated a marked difference in the contribution of doctor and non-doctor-
contact people to doctors accessing mental-health services. This has not
previously been identified.

Relationship of findings to previous research

The culture of unrealistic expectations of doctors described here has been
previously identified.5 12 20 Clearly doctors cannot know everything, cannot be
infallible and will have a range of health issues. Self-perceived medical errors
are associated with distress and a range of negative outcomes for
physicians.21 Unless doctors are able to acknowledge realistic limitations and
vulnerability, they will need to use denial to protect themselves from conscious
awareness of their vulnerability and fallibility, and minimise these to others.
Denial and minimisation have been identified in doctors.22 23 Potential
adverse effects of denial of fallibility were demonstrated by Wu et al.24 They
found that doctors who took responsibility for making an error experienced
more distress but were more likely to engage in constructive remedial
processes. The limited role of intrapersonal denial as a barrier to accessing
mental healthcare is demonstrated by Tyssen et al,25 in that most of the
doctors in their study who described themselves as having had mental-health
problems in the previous year had not sought help for them.
Informal conversations with colleagues have been identified as one of the
ways doctors access healthcare.26 27 The difficulty described in this study by
doctor friends, colleagues and partners in identifying and speaking about
mental-health issues in this context has not previously been demonstrated in
research. That this may be a more widespread phenomenon is indicated by
Thompson et al's4 finding that GPs played down evidence of colleagues
being physically unwell.
There is some research into doctors' descriptions of how they would respond
to hypothetical scenarios. Farber et al28 found physicians were more likely to
say they would report a physician in a hypothetical scenario who was impaired
owing to substance abuse than one who was psychologically or cognitively
impaired. The tendency to report was associated with valuing protecting the
good of society over the rights of the individual. Roberts et al29 found that
medical students described valuing of confidentiality over accessing
appropriate help in responses they described to vignettes of medical students
with serious symptoms and functional impairment. There were no significant
differences in described responses to mental illness, substance abuse or
diabetes.
The idea that non-doctor personal contact people are more able to identify and
speak about mental-health issues in doctors has not been previously reported.
A relationship with a supportive spouse has been described as being
protective with respect to risk of burnout30 31and doctors have described
themselves as more likely to disclose a mental-health issue to a non-doctor
contact than a professional.15

Conclusions
This study indicates three important areas to address and research further in
improving access to mental healthcare for doctors. The first is that of
managing unrealistic expectations in order to support doctors to maintain high
standards of functioning and to acknowledge vulnerability and fallibility to
selves and others in appropriate ways.

The second is that of informal doctor to doctor conversations. It may be that

improving the quality and effectiveness of informal doctor-to-doctor
conversations is an area where a difference can be made in improving doctors'
access to mental-health services. This may also be of significant benefit for
doctors' general health.
 The third area is the potential role of non-doctor contact and support people in
being more readily able, than other doctors, to identify and speak about
mental-health issues with doctors.

These findings could also be important for other groups and the general
population.

Footnotes
 To cite: Stanton J, Randal P. Doctors accessing mental-health
services: an exploratory study. BMJ Open 2011;1:e000017.
doi:10.1136/bmjopen-2010-000017