CNS Drugs

, Volume 6, Issue 4, pp 315–330 | Cite as

Antipsychotic-Induced Extrapyramidal Symptoms

Role of Anticholinergic Drugs in Treatment
  • Thomas R. E. Barnes
  • Mike A. McPhillips
Adverse Effects


Acute extrapyramidal symptoms (EPS), specifically the motor syndromes of parkinsonism, acute akathisia and acute dystonia, are among the most common adverse effects of antipsychotic medication. They produce physical disability and subjective distress, interfere with psychosocial and occupational adjustment, confound the clinical assessment of psychiatric symptoms, and lead to poor compliance with medication.

Parkinsonism, akathisia and dystonia can also be chronic conditions in patients receiving long term antipsychotic treatment. However, the most common movement disorder seen in such patients is tardive dyskinesia. The presence of the obvious movements of this condition can stigmatise patients. In the more severe cases, disability may be directly related to the particular movements, with interference with mobility, respiration, speech, eating, difficulty swallowing and possibly an increased risk of choking.

To tackle acute EPS, the clinician will need to consider modifying the dosage of conventional antipsychotics or switching to a new antipsychotic that has a lower liability for these problems. If adjunctive drug therapy is considered necessary, the choice will depend partly on the particular extrapyramidal syndrome exhibited by the patient and partly on the adverse effect profiles of the possible treatments.

Anticholinergic (i.e. antimuscarinic) agents are widely used in psychiatric practice to treat and prevent EPS. However, there are hazards with these drugs, including a risk of abuse and toxic confusional states, anticholinergic adverse effects (such as dry mouth, blurred vision, tachycardia, constipation, and urinary hesitation and retention) and cholinergic rebound phenomena on withdrawal. In the light of these problems, it has been recommended that anticholinergic agents are not routinely administered for the prophylaxis of EPS, unless there is a history of acute dystonia or known susceptibility to these antipsychotic-induced motor phenomena. Indeed, the evidence from published studies supports the value of anticholinergic drugs as treatment for EPS rather than for prophylaxis.

Despite the efficacy of anticholinergic drugs, not all EPS are equally responsive to this treatment. The tremor and rigidity of parkinsonism are reliably relieved by these agents. However, this syndrome is known to abate spontaneously over time. After 3 months, the majority of patients initially requiring treatment with anticholinergics can have this therapy withdrawn without a relapse of parkinsonian symptoms. Therefore, anticholinergics should be periodically withdrawn to test the need for their continued prescription.

Acute dystonic reactions are also effectively treated with anticholinergic drugs. In severe cases, intravenous or intramuscular administration can provide relief in minutes. The place of anticholinergics in the treatment of tardive dystonia is less clear, as only a proportion of patients will show any benefit.

Anticholinergics also have an uncertain reputation in both acute and chronic akathisia, being of limited efficacy. Acute akathisia may respond best to anticholinergics if it is accompanied by parkinsonism, in which case both syndromes may improve.

Anticholinergic drugs are not effective in alleviating tardive dyskinesia. The evidence suggests that these agents can sometimes worsen the movements, and when discontinued, a modest improvement may be seen in a proportion of patients exhibiting this condition. However, it has not been established that patients receiving antiparkinsonian medication in addition to antipsychotic medication are at a greater risk of developing tardive dyskinesia.


Adis International Limited Clozapine Dystonia Antipsychotic Drug Tardive Dyskinesia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Barnes TRE. Movement disorder associated with antipsychotic drugs: the tardive syndromes. Int Rev Psychiatry 1990; 2: 355–66CrossRefGoogle Scholar
  2. 2.
    Farde L, Nyberg S, Oxenstierna G, et al. Positron emission tomography studies on D2 and 5-HT2 receptor binding in risperidone-treated schizophrenic patients. J Clin Psychopharmacol 1995; 15Suppl. 1: S57–63Google Scholar
  3. 3.
    Bonner TI. The molecular basis of muscarinic receptor diversity. Trends Neurosci 1989; 12: 148–51PubMedCrossRefGoogle Scholar
  4. 4.
    Eglen RM, Reddy H, Watson N. Selective inactivation in muscarinic receptor subtypes. Int J Biochemistry 1994; 26 (12): 1357–68CrossRefGoogle Scholar
  5. 5.
    Tune L, Coyle JT. Serum levels of anticholinergic drugs and impaired recent memory in chronic schizophrenic patients. Am J Psychiatry 1982; 139: 1460–2PubMedGoogle Scholar
  6. 6.
    Modell JG, Tandon R, Beresford TP. Dopaminergic activity of the antimuscarinic antiparkinsonian agents. J Clin Psychopharmacol 1989; 9: 347–51PubMedCrossRefGoogle Scholar
  7. 7.
    Chouinard G, Annable L, Ross-Chouinard A, et al. A five year prospective longitudinal study of tardive dyskinesia: factors predicting appearance of new cases. J Clin Psychopharmacol 1988; 8: 21S–6SPubMedCrossRefGoogle Scholar
  8. 8.
    Gerlach J, Casey DE. Tardive dyskinesia. Acta Psychiatr Scand 1988; 77: 369–78PubMedCrossRefGoogle Scholar
  9. 9.
    Singh MM, Kay SR. A comparative study of haloperidol and chlorpromazine in terms of clinical effects and therapeutic reversal with benztropine in schizophrenia. Psychopharmacologia 1975; 43: 103–13PubMedCrossRefGoogle Scholar
  10. 10.
    Crow TJ, Frith CD, Johnson EC, et al. The influence of anticholinergic medication on the extrapyramidal and anti-psychotic effects of neuroleptic drugs in the treatment of acute schizophrenia. Biol Psychiatry 1981; 16: 790–2Google Scholar
  11. 11.
    Johnstone E, Crow T, Ferrier N, et al. Adverse effects of anticholinergic medication on positive schizophrenic symptoms. Psychol Med 1983; 13: 513–27PubMedCrossRefGoogle Scholar
  12. 12.
    Woody GE, O’Brien CP. Anticholinergic toxic psychosis in drug abusers treated with benztropine. Compr Psychiatry 1974; 15: 439–42PubMedCrossRefGoogle Scholar
  13. 13.
    Mac Vicar K. Abuse of antiparkinson drugs by psychiatric patients. Am J Psychiatry 1977; 134: 809–11Google Scholar
  14. 14.
    Smith JM. Abuse of the antiparkinson drugs: a review of the literature. J Clin Psychiatry 1980; 41: 351–4PubMedGoogle Scholar
  15. 15.
    Crawshaw JA, Mullen PE. A study of benzhexol abuse. Br J Psychiatry 1984; 145: 300–3PubMedCrossRefGoogle Scholar
  16. 16.
    Aguilera L, Martinez-Bourio R, Cid C, et al. Anaphylactic reaction after atropine. Anaesthesia 1988; 43: 955–7PubMedCrossRefGoogle Scholar
  17. 17.
    Gardos G, Cole JO, Tarsy D. Withdrawal syndrome associated with antipsychotic drugs. Am J Psychiatry 1978; 135: 1321–4PubMedGoogle Scholar
  18. 18.
    Jellinek T, Gardos G, Cole JO. Adverse effects of antiparkinson drug withdrawal. Arch Gen Psychiatry 1981; 35: 483–9Google Scholar
  19. 19.
    Chouinard G, Bradwejn J, Annable L, et al. Withdrawal symptoms after long-term treatment with low-potency neuroleptic drugs. J Clin Psychiatry 1984; 45: 500–2PubMedGoogle Scholar
  20. 20.
    George V, Castot A, Bidault I. Existe-t-il un syndrome de sevrage specifique aux antiparkinsoniens dopaminergiques? Therapie 1987; 42: 339–41PubMedGoogle Scholar
  21. 21.
    Bermanzohn PC, Siris SG. Noncompliance with antiparkinsonian medications in neuroleptic-treated schizophrenic patients: three cases of an unreported phenomenon. J Clin Psychiatry 1994; 55: 488–91PubMedGoogle Scholar
  22. 22.
    Drachman DA. Memory and cognitive function in man: does the cholinergic system have a specific role? Neurology 1977; 27(8); 783–90PubMedCrossRefGoogle Scholar
  23. 23.
    Kopelman MD, Corn TH. Cholinergic ‘blockade’ as a model for cholinergic depletion: a comparison of the memory deficits with those of Alzheimer-type dementia and the alcoholic Korsakov syndrome. Brain 1988; 111Ft 5: 1079–110PubMedCrossRefGoogle Scholar
  24. 24.
    Hitri A, Craft RB, Fallon J, et al. Serum neuroleptic and anticholinergic activity in relation to cognitive toxicity of antiparkinsonian agents in schizophrenic patients. Psychopharmacol Bull 1987; 23: 33–7PubMedGoogle Scholar
  25. 25.
    Baker LA, Cheng LY, Amara IB. The withdrawal of benztropine mesylate in chronic schizophrenic patients. Br J Psychiatry 1983; 143: 584–90PubMedCrossRefGoogle Scholar
  26. 26.
    Pullen GP, Best NR, MacGuire J. Anticholinergic drug abuse: a common problem? BMJ 1984; 289: 612–3PubMedCrossRefGoogle Scholar
  27. 27.
    Wells BG, Marken PA, Rickman LA, et al. Characterizing anticholinergic abuse in the community. J Clin Psychopharmacol 1989; 9: 431–5PubMedCrossRefGoogle Scholar
  28. 28.
    Leipzig RA, Mendelowitz A. Adverse psychotropic drug-drug interactions. In: Kane JM, Lieberman JA, editors. Adverse effects of psychotropic drugs. New York: The Guilford Press, 1992: 13–76Google Scholar
  29. 29.
    Tonda ME, Guthrie SK. Treatment of neuroleptic-induced movement disorders. Pharmacotherapy 1994; 14: 543–60PubMedGoogle Scholar
  30. 30.
    Leon JD, Simpson GM. Assessment of neuroleptic-induced extrapyramidal symptoms. In: Kane JM, Lieberman JA, editors. Adverse effects of psychotropic drugs. New York: The Guilford Press, 1992: 218–34Google Scholar
  31. 31.
    Farde L, Nordstrom AL, Wiesel FA, et al. Positron emission tomographic analysis of central D1 and D2 dopamine receptor occupancy in patients treated with classical neuroleptics and clozapine. Arch Gen Psychiatry 1992; 9: 538–44CrossRefGoogle Scholar
  32. 32.
    Lavin MR, Rifkin A. Prophylactic antiparkinson drug use: I. Initial prophylaxis and prevention of side effects. J Clin Pharmacol 1991; 31: 763–8PubMedGoogle Scholar
  33. 33.
    Ebel H. Therapy of neuroleptic-induced extrapyramidal movement disorders. Neurol Psychiatry Brain Res 1994; 2: 140–51Google Scholar
  34. 34.
    Lake CR, Casey DE, McEvoy JP, et al. The ‘pros’ and ‘cons’ of anticholinergic prophylaxis. Psychopharmacol Bull 1986; 22: 981–4PubMedGoogle Scholar
  35. 35.
    Winslow RS, Stiller V, Coons DJ, et al. Prevention of acute dystonic reactions in patients beginning high-potency neuroleptics. Am J Psychiatry 1986; 143: 706–10PubMedGoogle Scholar
  36. 36.
    Boyer WF, Bakalar NH, Lake CR. Anticholinergic prophylaxis of acute haloperidol-induced acute dystonic reactions. J Clin Psychopharmacol 1987; 7: 164–6PubMedGoogle Scholar
  37. 37.
    Keepers GA, Casey DE. Prediction of neuroleptic-induced dystonia. J Clin Psychopharmacol 1987; 7: 342–5PubMedCrossRefGoogle Scholar
  38. 38.
    Arana GW, Goff DC, Baldessarini RJ, et al. Efficacy of anticholinergic prophylaxis for neuroleptic-induced acute dystonia. Am J Psychiatry 1988; 145: 993–6PubMedGoogle Scholar
  39. 39.
    Goff DC, Arana GW, Greenblatt DJ, et al. The effect of benztropine on haloperidol-induced dystonia, clinical efficacy and pharmacokinetics: a prospective, double-blind trial. J Clin Psychopharmacol 1991; 11: 106–12PubMedGoogle Scholar
  40. 40.
    Manos N, Lavrentiadis G, Ckiouzepas J. Evaluation of the need for prophylactic antiparkinsonian medication in psychotic patients treated with neuroleptics. J Clin Psychiatry 1986; 47: 114–6PubMedGoogle Scholar
  41. 41.
    Rifkin A, Quitkin F, Kane JM, et al. Are prophylactic antiparkinson drugs necessary? Arch Gen Psychiatry 1978; 35: 483–9PubMedCrossRefGoogle Scholar
  42. 42.
    World Health Organization, Heads of centres collaborating in WHO co-ordinated studies on biological aspects of mental illness. Prophylactic use of anticholinergics in patients on long-term neuroleptic treatment: a consensus statement. Br J Psychiatry 1990; 156: 412Google Scholar
  43. 43.
    McClelland HA, Blessed G, Bhate S, et al. The abrupt withdrawal of antiparkinsonian drugs in schizophrenic patients. Br J Psychiatry 1974; 124: 151–9PubMedCrossRefGoogle Scholar
  44. 44.
    Orlov P, Kasparian G, Dimascio A, et al. Withdrawal of antiparkinson drugs. Arch Gen Psychiatry 1971; 25: 410–2PubMedCrossRefGoogle Scholar
  45. 45.
    Simpson GM, Angus JWS. A rating scale for extrapyramidal side-effects. Acta Psychiatr Scand 1970; 212: 11–9CrossRefGoogle Scholar
  46. 46.
    Raleigh FR. Reducing unnecessary antiparkinson medication in antipsychotic drug therapy. J Am Pharm Assoc 1977; NS17: 101–2Google Scholar
  47. 47.
    Johnson DAW. Prevalence and treatment of drug-induced extrapyramidal symptoms. Br J Psychiatry 1978; 132: 27–30Google Scholar
  48. 48.
    Silver H, Geraisy N, Schwartz M. No differences in the effect of biperiden and amantadine on parkinsonian and tardive dyskinesia-type involuntary movements: a double-blind crossover placebo-controlled study in medicated chronic schizophrenic patients. J Clin Psychiatry 1995; 56: 167–70PubMedGoogle Scholar
  49. 49.
    Mindham RHS. Assessment of drug-induced extrapyramidal reactions and of drugs given for their control. Br J Clin Pharmacol 1976; Suppl.: 395–400CrossRefGoogle Scholar
  50. 50.
    Comaty JE, Janicak MD, Rajaratnam J, et al. Is maintenance antiparkinsonian treatment necessary? Psychopharmacol Bull 1990; 26: 267–70PubMedGoogle Scholar
  51. 51.
    Manos N, Gkiouzepas J, Logothetis J. The need for continuous use of antiparkinson medication with chronic schizophrenic patients receiving long-term neuroleptic therapy. Am J Psychiatry 1981; 138: 184–8PubMedGoogle Scholar
  52. 52.
    Klett CJ, Point P, Caffey E. Evaluating the long-term need for antiparkinsonian drugs by chronic schizophrenics. Arch Gen Psychiatry 1972; 26: 375–9CrossRefGoogle Scholar
  53. 53.
    Leegood H, Barnes TRE, Liddle PF. The effects of abrupt procyclidine withdrawal in a chronic schizophrenic inpatient population - a double-blind study [abstract]. Psychiatr Bull 1991; 15 Suppl. 4: 92Google Scholar
  54. 54.
    Barnes TRE. Comment on the WHO consensus statement. Br J Psychiatry 1990; 156: 413–4PubMedCrossRefGoogle Scholar
  55. 55.
    Van Putten T, May PRA. ‘Akinetic depression’ in schizophrenia. Arch Gen Psychiatry 1978; 35: 1101–7PubMedCrossRefGoogle Scholar
  56. 56.
    Barnes TRE, McPhillips MA. How to distinguish between the neuroleptic-induced deficit syndrome, depression and disease-related negative symptoms in schizophrenia. Int Clin Psychopharmacol 1995; 10Suppl. 3: 115–21PubMedGoogle Scholar
  57. 57.
    Siris SG. Adjunctive medication in the maintenance treatment of schizophrenia and its conceptual implications. Br J Psychiatry 1993; 163Suppl. 22: 66–78Google Scholar
  58. 58.
    Hogarty GE, McEvoy JP, Ulrich RF, et al. Pharmacotherapy of impaired affect in recovering schizophrenic patients. Arch Gen Psychiatry 1995; 52: 29–41PubMedCrossRefGoogle Scholar
  59. 59.
    Kane JM, Woerner M, Sarantakos S. Depot neuroleptics: a comparative review of standard, intermediate and low-dose regimens. J Clin Psychiatry 1986; 47 Suppl.: 30–4Google Scholar
  60. 60.
    Swett CJ. Drug-induced dystonia. Am J Psychiatry 1975; 132: 532–4PubMedGoogle Scholar
  61. 61.
    Burke RE. Neuromuscular effects of neuroleptics: dystonia. In: Kane JM, Lieberman JA, editors. Adverse effects of psychotropic drugs. New York: Guilford Press, 1992: 189–200Google Scholar
  62. 62.
    Angus JWS, Simpson GM. Hysteria and drug-induced dystonia. Acta Psychiatr Scand 1970; 212: 52–8CrossRefGoogle Scholar
  63. 63.
    Rupniak NMJ, Jenner P, Marsden CD. Acute dystonia induced by neuroleptic drugs. Psychopharmacology 1986; 103: 138–9Google Scholar
  64. 64.
    Addonzio G, Alexopolous GS. Drug-induced dystonia in young and elderly patients. Am J Psychiatry 1988; 145: 869–71Google Scholar
  65. 65.
    Ayd FJ. A survey of drug-induced extrapyramidal reactions. JAMA 1961; 175: 1054–60PubMedCrossRefGoogle Scholar
  66. 66.
    Stern TA, Anderson WH. Benztropine prophylaxis of dystonic reactions. Psychopharmacology 1979; 61: 261–2PubMedCrossRefGoogle Scholar
  67. 67.
    British Medical Association and the Royal Pharmaceutical Society of Great Britain. British national formulary. No. 31. London: British Medical Association and The Pharmaceutical Press, 1996 MarGoogle Scholar
  68. 68.
    Burke RE, Fahn S, Jankovic J, et al. Tardive dystonia: late-onset and persistent dystonia caused by antipsychotic drugs. Neurology 1982; 32: 1335–46PubMedCrossRefGoogle Scholar
  69. 69.
    Sachdev P. Risk factors for tardive dystonia: a case control comparison with tardive dyskinesia. Acta Psychiatr Scand 1993; 88: 98–103PubMedCrossRefGoogle Scholar
  70. 70.
    Friedman JH, Kuraski LT, Wagner RI. Tardive dystonia in a psychiatric hospital. J Neurol Neurosurg Psychiatry 1987; 50: 801–3PubMedCrossRefGoogle Scholar
  71. 71.
    Yassa R, Nair V, Dimitry R. Prevalence of tardive dystonia. Acta Psychiatr Scand 1986; 73: 629–33PubMedCrossRefGoogle Scholar
  72. 72.
    Marsden CD, Quinn NP. The dystonias. BMJ 1990; 300: 139–44PubMedCrossRefGoogle Scholar
  73. 73.
    Jankovic J, Schwartz K. Botulinum toxin injection for cervical dystonia. Neurology 1990; 40: 277–80PubMedCrossRefGoogle Scholar
  74. 74.
    Anderson TJ, Rivest J, Stell R, et al. Botulinum toxin treatment of spasmodic torticollis. J R Soc Med 1992; 85: 525–9Google Scholar
  75. 75.
    Safferman A, Lieberman JA, Kane JM, et al. Update on the clinical efficacy and side effects of clozapine. Schizophr Bull 1991; 17: 247–61PubMedCrossRefGoogle Scholar
  76. 76.
    Friedman JH. Clozapine treatment of psychosis in patients with tardive dystonia. Mov Disord 1994; 9: 321–4PubMedCrossRefGoogle Scholar
  77. 77.
    Barnes TRE. Neuromuscular effects of neuroleptics: akathisia. In: Kane JM, Lieberman JA, editors. Adverse effects of psychotropic drugs. New York: Guilford Press, 1992: 201–17Google Scholar
  78. 78.
    Braude WM, Barnes TRE, Gore SM. Clinical characteristics of akathisia: a systematic investigation of acute psychiatric inpatient admissions. Br J Psychiatry 1983; 143: 139–50PubMedCrossRefGoogle Scholar
  79. 79.
    Sachdev P, Kruk J. Clinical characteristics and predisposing factors in acute drug-induced akathisia. Arch Gen Psychiatry 1994; 51: 963–74PubMedCrossRefGoogle Scholar
  80. 80.
    Van Putten T. Why do schizophrenic patients refuse to take their drugs? Arch Gen Psychiatry 1974; 31: 67–72PubMedCrossRefGoogle Scholar
  81. 81.
    Van Putten T, Marder S. Behavioural toxicity of antipsychotic drugs. J Clin Psychiatry 1987; 48: 13–9PubMedGoogle Scholar
  82. 82.
    Ayd FJ. Akathisia and suicide: fact or myth? Int Drug Ther News Lett 1988; 23: 37–8Google Scholar
  83. 83.
    Wilbur R, Kulik AV. Propranolol for akathisia [letter]. Lancet 1983; II: 917CrossRefGoogle Scholar
  84. 84.
    Lipinski JF, Zubenko GS, Cohen BN, et al. Propranolol in the treatment of neuroleptic-induced akathisia. Am J Psychiatry 1983; 141: 412–5Google Scholar
  85. 85.
    Adler L, Angrist B, Peselow E, et al. A controlled assessment of propranolol in the treatment of neuroleptic-induced akathisia. Br J Psychiatry 1986; 149: 42–5PubMedCrossRefGoogle Scholar
  86. 86.
    Friis T, Christensen TR, Gerlach J. Sodium valproate and biperiden in neuroleptic-induced akathisia, parkinsonism and hyperkinesia. Acta Psychiatr Scand 1983; 67: 178–87PubMedCrossRefGoogle Scholar
  87. 87.
    Kruse W. Persistent muscular restlessness after phenothiazine treatment: a report of three cases. Am J Psychiatry 1960; 17: 152–3Google Scholar
  88. 88.
    Marsden CD, Tarsy D, Baldessarini RJ. Spontaneous and drug-induced movement disorders in psychiatric patients. In: Benson DF, Blumer D, editors. Psychiatric aspects of neurological disease. New York Grune and Stratton, 1975: 219–65Google Scholar
  89. 89.
    Sovner R, DiMascío A. Extrapyramidal syndromes and other neurological side-effects of psychotropic drugs. In: Lipton MA, Di Mascio A, Killam KF, editors. Psychopharmacology: a generation of progress. New York: Raven Press, 1978: 1021–32Google Scholar
  90. 90.
    Weiner WJ, Luby ED. Persistent akathisia following neuroleptic withdrawal. Ann Neurol 1983; 13: 466–7PubMedCrossRefGoogle Scholar
  91. 91.
    Barnes TRE, Braude WM. Akathisia variants and tardive dyskinesia. Arch Gen Psychiatry 1985; 42: 874–8PubMedCrossRefGoogle Scholar
  92. 92.
    Gibb WRG, Lees AJ. The clinical phenomenon of akathisia. J Neurol Neurosurg Psychiatry 1986; 49: 861–6PubMedCrossRefGoogle Scholar
  93. 93.
    Kane JM, Smith JM. Tardive dyskinesia: prevalence and risk factors 1959-1979. Arch Gen Psychiatry 1982; 39: 473–81PubMedCrossRefGoogle Scholar
  94. 94.
    Wada Y, Yamaguchi N. The rabbit syndrome and antiparkinsonian medication in schizophrenic patients. Neuropsychobiology 1992; 25: 149–52PubMedCrossRefGoogle Scholar
  95. 95.
    Yassa R, Lai S. Prevalence of the rabbit syndrome. Am J Psychiatry 1986; 143: 656–7PubMedGoogle Scholar
  96. 96.
    Gardos G, Cole JO. Tardive dyskinesia and anticholinergic drugs. Am J Psychiatry 1983; 140: 200–2PubMedGoogle Scholar
  97. 97.
    Kane JM, Woerner M, Borenstein M. Integrating incidence and prevalence of tardive dyskinesia. Psychopharmacol Bull 1986; 22: 254–8PubMedGoogle Scholar
  98. 98.
    Saltz BL, Woerner MG, Kane JM, et al. Prospective study of tardive dyskinesia incidence in the elderly. JAMA 1991; 266: 2402–6PubMedCrossRefGoogle Scholar
  99. 99.
    Kane JM, Jeste DV, Barnes TRE, et al. Tardive dyskinesia: a task force report of the American Psychiatric Association. Washington, DC: American Psychiatric Association, 1992Google Scholar

Copyright information

© Adis International Limited 1996

Authors and Affiliations

  • Thomas R. E. Barnes
    • 1
  • Mike A. McPhillips
    • 1
  1. 1.Department of PsychiatryCharing Cross and Westminster Medical SchoolLondonEngland, UK

Personalised recommendations