The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

We now recognise that withdrawal symptoms from antidepressants are common, and can be severe and long-lasting in some people. Many withdrawal symptoms overlap with symptoms of anxiety or depression, making it difficult to distinguish withdrawal from relapse. We describe how their onset soon after dose reduction, the association of psychological with physical symptoms, their prompt response to reinstatement, and their typical ‘wave’ pattern of onset, peak and resolution can help distinguish withdrawal symptoms from relapse. We also examine evidence that suggests that antidepressant withdrawal symptoms are misdiagnosed as relapse in discontinuation studies aimed at demonstrating the ability of antidepressants to prevent future relapse (relapse prevention properties). In these discontinuation studies people have their antidepressants stopped abruptly, or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.

Women patients suffer from a range of mental disorders similar to those that men may experience. However, there are some striking differences in the prevalence of specific disorders, and in their presentation and management. Some mental illnesses only occur in women. It seems that women patients may have a different experience of treatment, a consequence of differences in their needs and also of the way that health professionals perceive those needs. These differences are embedded in the wider cultural milieu in which we live. There are particular issues for women patients in relation to, for example, childhood sexual abuse, rape and domestic violence. At present, tools to measure needs of individual patients are generally not gender specific.

The management of delirium requires careful consideration of the potential value both of pharmacological interventions and of a range of non-drug strategies. Although placebo-controlled studies of delirium treatment are lacking, less robust evidence can still inform practice. This review makes the case for more active management of delirium on the basis of recent studies of prevention, early identification and treatment both during an episode and managing the aftermath in survivors. A drug-treatment algorithm for delirium advising how drug treatments can be tailored to the specific needs of individual patients is described.

The risk of suicide is higher during the period immediately following discharge from in-patient psychiatric care than at any other time in a service user's life. Demographic and clinical risk factors for suicide in this period are similar to those for suicide at other times and may not be specific enough to enable identification of those at greatest risk. Epidemiological studies suggest that factors related to service organisation and delivery (e.g. social support and continuity of care) are also important in the aetiology of suicide following hospital discharge. Interventions aimed at helping people in the period immediately following discharge from in-patient care have been developed. Although the effect of these interventions on suicidal behaviour has not been examined, available evidence suggests that efforts to increase patients' confidence and level of social support may be of value.

In this article, we offer an account of how various psychological therapies address dysfunctional mentalisation and identify pitfalls of therapy that could lead to an impasse or even to negative consequences associated with psychological treatment. Some practical recommendations follow from our model, particularly in relation to the careful monitoring of the intensity of the patient's attachment and the use of interventions aimed at promoting mentalising.

This article presents evidence for the efficacy of psychosocial interventions for people with dementia and their carers. The evidence base is not yet robust enough to clearly suggest which interventions are most suited for which environment. However, from our literature review there appears to be reason to use music therapy, aromatherapy, life story work, animal-assisted therapy and post-diagnosis/carer support work. We focus on both the traditional outcome measures of behavioural and psychological symptoms of dementia (BPSD) and the more difficult to measure, but equally important, person-centred outcomes of nonpharmacological interventions, as their properties are distinctly different from those of pharmacological agents.

Globalisation means crossing borders. It is a complex, large-scale social phenomenon that presents to mental health services both challenges and opportunities. These relate to the increased cultural diversity of service users and service providers; the effects of migration on mental health; and the implementation of international protocols in relation to training, policy and education. In the aftermath of 11 September 2001 in the USA, the relationship between large-scale social change and mental health has also focused attention on the concepts of anomie and social capital. An explicit return to the principles of biopsychosocial psychiatry and a positive engagement with globalisation will advance the development of effective, evidence-based models of care appropriate to the changing needs of patients.

We discuss the complicated nature of communication between people from different cultural groups, perhaps using a second language. We focus on the fact that mental health practitioners and service users often have in common neither their cultural backgrounds nor their explanatory models of illness. Communication even in a shared language can be less than optimal as words carry multiple meanings. Consequently, consultations that involve culturally grounded explanatory models of illness challenge the professional. We give examples showing that reconciling different explanatory models during the consultation is a core task for psychiatrists and mental health practitioners working in multicultural settings.

Both antidepressants and psychological treatments are effective in the management of late-life depression. Nevertheless, there remains a considerable challenge to improve the prognosis for depression in older people. Endlessly increasing the range of antidepressants does not seem to be the answer, so attention is turning to new combinations of treatments and new ways of delivering care and improving treatment uptake. Collaboration between specialist and primary care, case management and multifaceted interventions are currently the most exciting prospects. There is good evidence for the role of both medication and psychological treatment in keeping the patient well after recovery.

Dementia is is stereotypically associated with older people. However, in a significant minority it can affect people in their 40s and 50s, or even younger. Currently there is a lack of awareness, even among healthcare professionals, and there is a dearth of appropriate services for such patients. Despite the attention given to this condition by National Institute for Health and Clinical Excellence guidelines, provision of specialist early-onset dementia services in the UK remains patchy. Carers and patients often find themselves being passed ‘from pillar to post’ between psychiatry and neurology, and also between adult, old age and liaison psychiatry. The responsibility for identifying available and appropriate help is often left with carers. This leads to unnecessary delays, causes undue distress to patients and places an added burden on carers.

The focus of this article is the assessment and management of medically unexplained (‘psychogenic’) amnesia, which we classify here as global or situation specific. Other psychiatric causes for memory disorder and neurological conditions that could cause diagnostic confusion are briefly reviewed, as are forensic aspects of memory complaints. Finally, brain and physiological mechanisms potentially associated with psychogenic amnesia are discussed.

We outline the difficulties in classifying paraphilias as mental disorder and summarise the changes to this diagnostic category in DSM-5. We review the research on the epidemiology and aetiology of paraphilias, and provide guidance on assessment and referral options for general psychiatrists when they encounter patients who may meet diagnostic criteria for a paraphilic disorder. Empirical evidence for effective treatments for paraphilias is limited, and specific treatment services are scarce, particularly for individuals presenting with legal paraphilias or those who are committing paraphilic sexual offences but who have not been convicted.

Both primary and secondary care practitioners often wish to offer their patients access to effective psychosocial interventions, yet the lengthy waiting-lists for specialised psychological or psychotherapeutic services create frustration among both referrers and their patients. There is therefore a need for new ways of accessing such treatments that can be delivered in most psychiatric team settings. For this to be realistic, such delivery must be possible within the time available to most practitioners (10–20 minutes for many consultant psychiatrists). One approach is to offer structured self-help materials.

The recovery approach is much in vogue, initiated by the user movement and embraced by politicians. Users and politicians have a variety of opinions about how it fits with professional psychiatric practice – some view recovery and professional practice as compatible, others view them as mutually exclusive, naming professional practice the ‘medical model’. This editorial explores the relationship between the medical model and the recovery approach. We argue that both have multiple points of similarity, and that applying the medical model to the recovery approach has the potential to significantly influence psychiatric practice.

Psychotic symptoms in elderly people can be seen in a variety of conditions. This article reviews treatment strategies (both pharmacological and non-pharmacological) for such symptoms in schizophrenia and neurodegenerative disorders in this population. Traditionally, antipsychotics have been the most commonly used treatment for psychotic symptoms. Their usefulness in treating schizophrenia, both chronic and late onset, is well established and the atypical antipsychotics, which have a better side-effect profile, are more suitable for elderly people. More recently, there have been increasing concerns about their safety in psychoses due to dementia. The debate about whether an absolute ban on their use is required is still ongoing, but it has highlighted the need for adopting and developing non-pharmacological interventions.

The use of simulated patients in medicine offers students a standardised learning experience and a reproducible way of exploring attitudes and teaching communication skills. This would seem to be particularly relevant to psychiatry with its focus on attitudes and interpersonal skills, but doubts have been raised about the utility of simulated patients in teaching skills such as empathy and the generalisability of this learning to the real world. This, tempered with cost implications, may have limited the use of simulated patients to assessment through objective structured clinical examinations rather than to teaching and to learning. This article examines the educational advantages and disadvantages of the use of simulated patients in psychiatric teaching and argues that their judicious use complements undergraduate and postgraduate training in psychiatry. The article offers practical tips on writing simulated patient scenarios to deliver specific learning objectives and discusses the potential use of novel simulation techniques in psychiatric education.

Most articles on the management of the premenstrual syndrome (PMS) begin by noting that the term “premenstrual tension” was first coined by R. T. Frank in 1931 and “pre-menstrual syndrome” by Greene & Dalton in 1953. However, in 1847, Dr Ernst F. von Feuchtersleben wrote:

‘Mindfulness' has become a popular topic among psychological therapists. This introductory article explains what mindfulness is and how it can be developed, before exploring how it has been incorporated within psychoanalytic and cognitive–behavioural psychotherapies. These reflect general as well as specific presumed therapeutic actions. At present, variations in the way mindfulness is understood, taught and applied mean that it is too early to fully assess its potential. They demonstrate how the use of attention and awareness in therapy cuts across traditional divisions and where mindfulness in therapy is most in need of further investigation.

In 2000, about 350 million adults used the internet and people increasingly take articles from websites to medical appointments. The quality and safety of websites vary widely and some users are reluctant to access mainstream sites. People are vulnerable to misinformation and exploitation: there is evidence that online purchases have caused morbidity and mortality. This paper reviews the current evidence on the dissemination of health information on the internet and the various strategies that are developing to assess and screen site quality. Such strategies include ‘quality assurance’ marking, specially designed search engines, and operational criteria for individuals to apply to sites. It also discusses the medical community's roles and responsibilities in relation to this burgeoning area.