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Among patients admitted to psychiatric hospitals are some who are discharged undiagnosed. It can be expected that psychiatric patients, as patients in other medical specialties, who do not meet the criteria for any of the established diagnostic groups, will be considered as undiagnosed until the course of their illness and clinical picture makes the diagnosis evident. The undiagnosed patients are a diagnostic and therapeutic challenge. Because in a space of five years, 256 patients left undiagnosed, it was felt that this group merited investigation.

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In a previous report records were studied of 256 in-patients who were discharged as undiagnosed, i.e. in-patients who at the time of discharge did not have a definable psychiatric illness (Welner, Liss, Robins and Richardson, 1972). In that study it was shown that when rigorous criteria for psychiatric research (Feighner, Robins, Guze, Woodruff, Winokur and Munoz, 1972) were used 68 per cent of these patients met the criteria for an established psychiatric disorder. It was concluded that: (1) The chart review diagnoses for a population of undiagnosed patients consisted of a variety of established psychiatric disorders and the population was not homogeneous. (The chart review diagnosis is a diagnosis obtained by review of the patients' hospital records and evaluating the information by using diagnostic criteria for psychiatric disorders.) (2) The most efficient way to arrive at a diagnosis was by structured rather than conventional narrative interview. This study is a follow-up study of these patients and attempts to evaluate the validity of the chart review diagnosis. A concordance between the chart review diagnosis and follow-up diagnosis supports the above conclusions. The follow-up study also served to establish diagnosis in patients who had too few symptoms initially to meet the criteria for a diagnosis.

In a previous study (Liss, Welner and Robins, 1973), the hospital records of 212 patients who received a diagnosis of personality disorder other than antisocial personality were studied. The clinical information about these patients was used to arrive at an established psychiatric diagnosis based upon the rigorous diagnostic criteria designed for research (Feighner, Robins, Guze, Woodruff, Winokur, and Munoz, 1972). In 118 cases (56 per cent) the clinical symptoms and the course of the disorder met the required diagnostic criteria for one or more of the established psychiatric diagnoses. The remaining 94 patients (44 per cent) had too few symptoms to meet these criteria.

A diagnosis of personality disorder is commonly used in psychiatry. It is generally agreed to refer to a disorder manifested by limited adaptive flexibility and certain relatively fixed ineffectual modes of behaviour (Ausubel, 1961; Brody and Lindbergh, 1967; DSM II, 1968; Noyes and Kolb, 1958; Schneider, 1950; Small, Small, Alig and Moore, 1970; Walton, Foulds, Littman and Presly, 1970). However, of twenty or more different types of personality disorders only antisocial personality has been differentiated by rigorous criteria as a distinct diagnostic entity (Robins, 1967; Feighner, Robins, Guze, Woodruff, Winokur and Munoz, 1972; Robins, 1966).

One-hundred-and-one-patients diagnosed initially as personality disorder (other than antisocial per sonality) and whose records had been reviewed were followed up (90 per cent follow-up). Using rigorous diagnostic criteria, there was consistent agreement and continuity of diagnoses between the follow-up and the record study. As in the record study, there was no correlation between the personality disorder diagnosis and the diagnosis by criteria. The patients in this study were divided into five groups: Group I (undiagnosed, too few symptoms), Group II (affective