In psychiatric and psychotherapeutic practice, ‘boundaries' delineate the personal and the professional roles and the differences that should characterise the interpersonal encounters between the patient/client and the professional. Boundaries are essential to keep both parties safe. The author outlines the various types of boundary violation that can arise in clinical practice, their consequences (both clinical and legal), how professionals can avoid them and how health care institutions might respond, should they occur. He concentrates on sexual boundary violations, because these have been the subject of most empirical study.

Antisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. Informed by this developmental perspective, we provide a framework for the management and treatment of adults with antisocial personality disorder, highlighting the importance of creating a safe setting and recommending adaptations of therapeutic technique to facilitate the engagement of this ‘treatment-rejecting’ patient population. We conclude with an outline of the current government policy on the treatment of high-risk offenders with personality disorder.

Although the physical health of doctors is largely better than that of the general population, they continue to have high levels of stress, depression and substance misuse. These aspects of mental ill health are particularly elevated in psychiatrists, and in a number of studies psychiatrists have also been found to be those doctors most likely to face disciplinary proceedings. This article explores the individual and organisational causes of these problems and the ways they may interact within the psychiatrist's work role, and suggests a variety of possible interventions to improve the mental health of doctors in psychiatry.

I explore implementation of the National Institute for Clinical Excellence's clinical guidelines for schizophrenia at an individual practitioner level and at an organisational level. Integrating effective individual and team approaches into a systematic organisational approach with collaborative working between managers, clinicians and service users will be essential to successful implementation and is likely to require a strong lead from senior clinicians. Implementation is likely to be best achieved through a sense of ownership of the guidelines and a process that borrows from their spirit, which emphasises collaboration, building on the strengths and good practice already present. Although full implementation will require additional resources, current resources must be employed effectively. The task of implementation is immense, however, and in some areas resource deficiencies and other structural problems might present insurmountable obstacles.

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

This commentary aims to support and elaborate on some of the specific issues raised by Dein & Woodbury-Smith. Although I agree with many of their comments, I believe that the role of neuropsychological and sensory impairments, as well as dysfunctional coping strategies among individuals with an autism-spectrum disorder who offend, need to be expanded from a psychological perspective. In my experience, the assessment of these factors plays a crucial role in guiding opinions on mental capacity, individual interventions, risk assessment and management. Elements of psychopathy in autism also require clarification. It could be argued that by understanding these issues, any attempts at social inclusion and preventing offending will be more successful.

Of the many interactions with psychotropic drugs, a minority are potentially hazardous. Most interactions are pharmacodynamic, resulting from augmented or antagonistic actions at a receptor or from different mechanisms in the same tissue. Most important pharmacokinetic interactions are due to effects on metabolism or renal excretion. The major enzymes involved in metabolism belong to the cytochrome P450 (CYP) system. Genetic variation in the CYP system produces people who are ‘poor’, ‘extensive’ or ‘ultra-rapid’ drug metabolisers. Hazardous interactions more often result from enzyme inhibition, but the probability of interaction depends on the initial level of enzyme activity and the availability of alternative metabolic routes for elimination of the drug. There is currently interest in interactions involving uridine diphosphate glucuronosyltransferases and the P-glycoprotein cell transport system, but their importance for psychotropics has yet to be defined. The most serious interactions with psychotropics result in profound sedation, central nervous system toxicity, large changes in blood pressure, ventricular arrhythmias, an increased risk of dangerous side-effects or a decreased therapeutic effect of one of the interacting drugs.

Depression in schizophrenia has been a neglected field for some time, but much evidence exists as to the common occurrence of affective disturbance in so-called non-affective psychosis. Depression is related to poor outcome in terms of functional recovery, relapse rate and suicide, and there is increasing evidence that it also precedes the onset of first-episode psychosis for many individuals. This article reviews recent steps forward in the evidence base for depression in schizophrenia in terms of prevalence, importance, assessment and treatment implications, with the aim of providing useful information for practising psychiatrists.

Cinema is at once a powerful medium, art, entertainment, an industry and an instrument of social change; psychiatrists should neither ignore nor censor it. Representations of psychiatrists are mixed but psychiatric treatments are rarely portrayed positively. In this article, five rules of movie psychiatry are proposed, supported by over 370 films. Commercial and artistic pressures reduce verisimilitude in fictional and factual films, although many are useful to advance understanding of phenomenology, shared history and social contexts in psychiatry. Acknowledging some negative representations, three areas are explored where cinema gets it mostly right: addictions, bereavement and personality disorder. Although there are excellent representations of psychosis on film, film-makers have more often portrayed it violently – ultimately demonising people as psychokillers in more than 100 films cited. When people with mental illness are stigmatised through stereotypes, examining unwelcome depictions can uncover important truths. Psychiatrists' engagement with film will ensure professional and artistic gains.

This article reviews the current literature regarding treatments for smoking cessation in both the general population and in those with mental health problems. The gold-standard treatment for the general population is pharmacotherapy (nicotine replacement therapy, bupropion or varenicline) coupled with individual or group psychological support. This is also effective in helping people with mental illness to reduce or quit smoking, but care must be taken to avoid adverse medication interactions and to monitor antipsychotic medication in particular as cigarette consumption reduces.

Most of the excitatory neurotransmission in the central nervous system (CNS) is mediated by the endogenous excitatory amino acids (EAAs) glutamate, aspartate and homocysteine. Most of the endogenous inhibitory neurotransmission is mediated by gamma-aminobutyric acid (GABA). EAAs modulate the firing of almost all neurons in the CNS, as excitatory neurotransmission can result in both neuronal inhibition and excitation. The glutamate system is the best characterised of the EAA systems (Box 1).

The DSM–IV classification of body dysmorphic disorder (BDD) refers to an individual's preoccupation with an ‘imagined’ defect in his or her appearance or markedly excessive concern with a slight physical anomaly (American Psychiatric Association, 1994). An Italian psychiatrist, Morselli, first used the term ‘dysmorphophobia’ in 1886, although it is now falling into disuse, probably because ICD–10 (World Health Organization, 1992) has discarded it, subsuming the condition under hypochondriacal disorder.

Mental health services are increasingly supporting recovery-oriented practice as a basis for service delivery. There is considerable overlap between the values and approaches associated with recovery-based practice and those already endorsed as good psychiatric practice. However, these agreed principles may not be consistently applied and further steps may be needed if the reorientation of the relationship between psychiatrists and people using psychiatric services is to fully reflect recovery principles. This article describes ways in which psychiatric practice could develop, including conceptualising medication as one of many possible recovery tools that a person can actively use to support their well-being, and a range of practices available to professionals to support people in taking up an active stance in relation to medication. It also identifies recovery-supportive practices for when someone is unable to fully participate in decision-making, owing to crisis, loss of capacity or concerns about safety.

We argue that current debates about attention-deficit hyperactivity disorder (ADHD) can be considered afresh using an evolutionary lens. We show how the symptoms of ADHD can often be considered adaptive to their specific environment. We suggest that, from an evolutionary point of view, ADHD symptoms might be understood to result from an ‘evolutionary mismatch’, in which current environmental demands do not fit with what evolution has prepared us to cope with. For example, in our ancestral environment of evolutionary adaptedness (EEA), children were not expected to sit still and concentrate on academic tasks for many hours a day. Understanding ADHD in terms of such a ‘mismatch’ raises significant issues regarding the management of childhood ADHD, including ethical ones. An approach based on the concept of mismatch could provide an alternative to current debates on whether ADHD results from nature or nurture and whether it is under- or over-diagnosed. It would allow clinicians and policy makers to take both the child and the environment into account and consider what might be desirable and feasible, both in society and for specific children, to lessen the mismatch.

Recruitment and retention of psychiatrists is a major concern in commissioning and providing mental health services. With consultant vacancies overall in the UK running at over 12% for many years, current services are stretched and in some areas only locum provision enables them to be maintained. This means that plans to reshape services with new teams, strengthening community-based work, could founder. Most professions within mental health share similar difficulties. The different stages of the career pathway of aspiring psychiatrists, from interested teenagers through to post-retirement consultants, are described. Difficulties at each stage in attracting and retaining the most appropriate people are discussed, and solutions at each point of the career cycle that could add up to a permanently better staffed service and a happier workforce are offered.

Agitation in psychiatric settings, particularly in psychosis, presents a staggering challenge for clinicians, who must both manage the patient's acute symptoms and simultaneously make an accurate diagnosis. Too often, the management of the former confounds the latter. Patients are very often sedated medically, which masks their underlying condition, rendering accurate diagnosis delayed and inherently difficult. Significant data are available regarding both pharmacological and non-pharmacological interventions for agitation that maximise symptom control while minimising confounding side-effects. In this article, a review of the historical evolution of agitation management in psychotic illness is presented, followed by an evidence-based clinical guideline for managing agitation in psychosis in the USA.

Most people with schizophrenia have frequent contact with their families. Therefore, the family should be involved in their relative's treatment and care wherever possible, so that they can contribute to that person's recovery and the family's own needs for information, support and treatment can be addressed. Family psychoeducation refers to a group of structured psychotherapeutic interventions that involve the person with schizophrenia and their family as partners in care. Trained practitioners adopt a collaborative approach to information sharing and provide training in coping, communication and problem-solving skills. This article describes the common principles and techniques of family psychoeducation (FPE), along with the substantial evidence for its benefits for families, especially reduced relapse rates for the person with schizophrenia. Despite recommendations in clinical practice guidelines, FPE is not widely available throughout the world. The current challenge is to address this through systemic approaches to practice change and tiered approaches to family service delivery.

Chronic physical illness is a significant risk factor for psychological symptoms, psychiatric disorder and suicide. Properly targeted cognitive–behavioural therapy (CBT) can improve outcomes for people with chronic physical illnesses. This article looks at practical aspects of the use of CBT as part of the overall medical and psychiatric management of chronic physical illness.

If personality disorder is no longer to be a diagnosis of exclusion it needs a conceptual framework that fits both the symptoms of the illness and the behavioural problems that constitute its current diagnostic criteria. In this article, we suggest that personality disorder is best understood as disorganisation of the capacity for affect regulation, mediated by early attachments. We present evidence for this argument based on both developmental and neurobiological research.

Taking risks is a fundamental part of the human experience that supports personal growth. Therapeutic risk-taking enables patients to make decisions about their level of safety and to pursue goals. Promoting therapeutic risk-taking can be complex. Professionals can experience tension striving for a balance between the interests of the individual and societal pressures to control risk. This article examines therapeutic risk-taking, recognising the challenges to supporting it in practice and debating how they may be overcome.