People with learning disabilities form only a small part of the general population, but because of their many special needs, they require the provision of specialist health services. National statistics on the prevalence of learning disabilities are poor, but it has been estimated that 160 000 people in England and Wales have severe or profound learning disabilities (Audit Commission, 1987).

This article is about the management of eating disorders in which binge eating is a prominent feature. These disorders include bulimia nervosa, the most common eating disorder, and ‘binge eating disorder’, a provisional new diagnosis included in DSM–IV. In addition, binge eating is seen in anorexia nervosa and in many atypical eating disorders.

Public health has traditionally been concerned with the primary prevention of disease, either by eliminating its causes or by enhancing host resistance. Clean water supplies, efficient sewage and rubbish disposal, and refrigeration of food have largely eliminated the micro-organisms responsible for a wide range of infectious diseases, while anti-smoking campaigns have reduced mortality from cancer of the lung and coronary heart disease. Immunisation programmes have had a similarly dramatic effect on the incidence of many bacterial and viral diseases. Indeed, they have completely eliminated smallpox, and the polio virus seems likely to follow it into oblivion.

Treatment of trauma has been already covered in this journal (Adshead, 1995) and elsewhere (Davidson, 1992; Kleber & Brom, 1992; Wilson & Raphael, 1993). However, there are situations where the trauma can become extensive and chronic, sometimes called Type II trauma (Terr, 1991), necessitating additional therapeutic considerations. Such situations are not uncommon in the world today, frequently occurring during wars that are typically ‘low-intensity’ conflicts involving poor, Third World countries. It has been estimated that there have been over 150 such wars since 1945, in which 90% of all casualties are civilians. According to Summerfield (1996), what predominates is the use of terror to exert social control, if necessary by disrupting the social, economic and cultural structures. The target is often population rather than territory and psychological warfare is the central element. Atrocities, including civilian massacres, reprisals, bombing, shelling, mass displacements, disappearances and torture are the norm. The consequences for mental health, not to mention the social, economic, cultural and other costs, can be substantial.

Antisocial behaviour is the most common reason for referral to child mental health services. It is also a clinical problem of considerable importance, because there is a marked tendency for it to persist, and the long-term outcome includes antisocial personality disorder and criminality. Furthermore, effective treatments are now available, although not yet widely used in Britain.

Sexual offences account for just under 1% of all notifiable offences and have been increasing over the past decade (Home Office, 1993). However, the official statistics on rape prevalence grossly underestimate the extent of the problem; many cases of non-consensual intercourse are not reported or prosecuted; about one-third of reported serious sexual offences are ‘no crimed’ by the police, and many rape offences are reduced to lesser charges through the practice of plea bargaining. Only a small minority of alleged rapists are eventually convicted and receive a custodial sentence (Gregory & Lees, 1996).

The category ‘somatoform disorders' was introduced comparatively recently in DSM–III and thereafter in ICD–10: it is the umbrella term currently favoured to cover a heterogeneous group of interrelated and overlapping syndromes, which have been given many names over the years. All these syndromes have in common the process of somatisation: that is, the presence of physical symptoms unexplained by physical disease, with variable degrees of distress and loss of function, about which the patient consults doctors.

In 1981 the condition that was later to be known as the acquired immune deficiency syndrome (AIDS) was described, and in 1983 its causative agent, the human immunodeficiency virus 1 (HIV-1), was isolated. The past 15 years have led to a growing awareness of the global nature of the epidemic and, in parallel with it, to the recognition of its medical, socioeconomic and psychological consequences. In the UK, almost 12 000 AIDS cases have been reported since 1982, and more than 25 000 cases of HIV-1 infection have been identified since 1984. Most cases of AIDS and HIV-1 have been in the Thames Regions, and it is expected that this geographical pattern will continue until the end of the decade.

The early treatment of newly diagnosed schizophrenia has ramifications for the future psychiatric and social well-being of the patient. Changes in care structures and care delivery mechanisms, in addition to financial constraints and outcome targets, provide an additional incentive to ensuring that any intervention is both successful and cost-effective.

This paper will address the ways in which all of us as doctors respond to the impact of illness in patients. The constructs used are psychoanalytic and the experience comes from running a psychological service for doctors for the past seven years. In line with the Nuffield Hospitals Report (1996) it is a service funded by the Regional Postgraduate Medical Dean.

The proportion of children affected by chronic illness is relatively high, approximately 10–12%. For these children, there is no available cure and the best that medical care can currently offer is relief from symptoms and the opportunity to participate in normal life as far as possible. Epidemiological work suggests that many of the children experience relatively few restrictions on everyday life, but about 1–2% of the total population of sick children have more severe conditions (Gortmaker & Sappenfield, 1984).

Those who work with older adults will inevitably find themselves working with families. Indeed assessment of an older person is often difficult if members of their family and social network are not involved. Referrals to social and psychiatric services are often precipitated by family changes. Ratna & Davis (1984) described 142 consecutive referrals to a community old age psychiatry service and found retirement, family conflict, departure of or illness of a carer, or bereavement precipitated 60% of referrals. Thus, work with older adults will often necessitate work with families, although it may not be seen in those terms.

The human search for tranquillity has embraced the use of numerous substances of which alcohol is probably the most widely used. Alcohol acts in part by facilitating neurotransmission at γ-aminobutyric acid (GABA) synapses and until recently the pharmacological treatment of anxiety was based principally on drugs that produce similar actions on this neurotransmitter and its receptor complex (Cowen & Nutt, 1982) (Box 1).

Studies of utilisation of psychiatric services have shown that between 4 and 18% of medical students annually identify themselves as ‘impaired’ (Dickstein et al, 1990). An unknown number of students may be ill but do not seek help – they soldier on through classes and clinics not realising that their sleep disturbance, worry, vague pains, flagging spirits, failing grades or increasing use of alcohol represent symptoms of strain and possible psychiatric disorder. Some suspect or know that they are ill but the stigma of accepting mental illness or seeking professional help is so profound that they suffer silently.

There are many similarities in the experience and approach of general practitioners (GPs) and psychiatrists. GPs may spend some time in psychiatric posts before settling down as principals in their own practice, while some psychiatrists are members of both their own College and the Royal College of General Practitioners. Although there is great potential benefit for patients in this symbiotic relationship, GPs and psychiatrists work in different settings that require different techniques and time-scales. The professional work of both specialities has been profoundly affected by the National Health Service (NHS) reorganisation of the early 1990s. GPs have developed new relationships not only with psychiatric colleagues, but also with professionals of other disciplines such as psychologists, social workers and counsellors.