Traditionally, delusions have been viewed as false, unshakeable beliefs which arise out of internal morbid processes and are out of keeping with a person's educational and cultural background (Hamilton, 1978). Primary delusions appear to arise without understandable cause, and secondary delusions appear more understandable in relation to the prevailing affective state or cultural climate (Sims, 1995), for example. However, during the cognitive therapy process we would expect that even primary delusions might become more understandable as the patient's life history and belief profile are gradually disclosed.

This article is an overview of developments in psychopathy and their application to children and adolescents. A key question is whether or not psychopathy is stable throughout the lifespan. Some characteristics indicate phenotypic similarities with adult psychopathy, and current instruments appear to be measuring similar constructs across the age ranges. Although the literature on developmental aspects of psychopathy in young people is limited, a number of instruments have been designed to measure the construct. These tools appear to have reasonable construct, concurrent and predictive validity, but we cannot yet recommend their routine use in clinical practice or in the criminal justice system, given the limited evidence base on their predictive validity. At best, they should be viewed as a means of subtyping potentially high-risk groups with a view to treatment planning.

Bipolar disorder is a complex disorder of mood and behaviour that requires a multimodal treatment approach. In the past 10 years there has been growing interest in psychoeducational interventions delivered as adjuncts to conventional management. Several studies have tested the effectiveness of psychoeducational treatments delivered in a variety of formats. In this article we assess the evidence for the efficacy of these interventions and consider the likely future role of structured psychoeducational treatments in clinical practice.

Recent developments in UK government policy have highlighted the unmet needs of people with dual diagnosis (comorbidity of substance misuse and psychiatric disorder, particularly severe mental illness). Advances in assessment techniques and diagnostic practice have informed the treatment of comorbidity and improved its outcome. There is growing evidence for the effectiveness of psychosocial interventions such as motivational interviewing and cognitive–behavioural therapy, mostly from US studies. However, within the secondary care provided by addiction and general psychiatric services there are serious implementation barriers related to service organisation, staffing levels, training and – most importantly – the difficulties of engaging people with severe mental illness and comorbid substance misuse in treatment. The evidence for the effectiveness of psychosocial treatments and models of service is reviewed and challenges for optimal practice in the UK are highlighted.

Depression, as a heterogeneous collection of disorders, is likely to include subgroups that are more genetic in origin. In common with other neuropsychiatric disorders such as schizophrenia, Alzheimer's disease and Huntington's disease, earlier age at onset in depression is associated with higher genetic loading and poorer long-term outcome. Adolescents and young adults with depression are also at high risk of developing a bipolar illness. This article reviews depressive illnesses that occur for the first time in adolescence and young adulthood. Case studies are used to discuss atypical presentations and the evolving concept of bipolar-spectrum disorders.

The need for specific psychiatric services for women has been debated by many practitioners involved in care delivery and management of women with differing degrees of mental health problems.

Acute mental disturbance associated with physical illness is well described in early medical literature, but it was not until 1 AD that Celsus coined the term ‘delirium’ (Lindesay, 1999). Although delirium has many synonyms that are applied in particular clinical settings (Box 1), all acute disturbances of global cognitive functioning are now recognised as ‘delirium’, a consensus supported by both ICD–10 (World Health Organization, 1992) and DSM–IV (American Psychiatric Association, 1994) classification systems. Delirium is a complex neuropsychiatric syndrome that typically involves a plethora of cognitive and non-cognitive symptoms, resulting in a broad differential diagnosis dominated by mental disorders. Psychiatrists' skills in assessing cognitive function and psychopathology, coupled with their knowledge of psychotropic agents, make them well suited to improving detection, coordinating management and facilitating research into this understudied disorder.

This article reports the results of a synthesis of qualitative research articles about lay perspectives on prescribed psychotropic medicines. It updates and elaborates on a model of medicine-taking developed by Pound and colleagues. In this model, the concept of resistance refers to the various ways in which people take prescribed medicines while trying to minimise their intake. The synthesis included 12 papers published since 1992. The findings are presented at the societal level, in terms of the social meanings of mental health problems and medication, and at the individual level; the latter covers active engagement and lay evaluation, as well as the outcomes of evaluation, including the doctor–patient relationship. Although it can be difficult to achieve in the current clinical environment, there is much scope for developing more concordant relationships with patients in relation to prescribing and using psychotropic medicines.

This paper will describe the increasingly important role of the community psychiatric nurse (CPN) in the treatment and management of people with schizophrenia, and draw attention to new training programmes which have a focus on skills acquisition in evidence-based methods. However, before describing the way in which these programmes of training improve CPN skills, it is worth examining the history of community psychiatric nursing.

There has been a resurgence of interest in the role of childhood trauma in the aetiology of psychosis. In this review, recent findings on the association between childhood trauma and a continuum of psychotic symptoms are presented. Evidence of the association between specific childhood trauma subtypes and psychotic symptoms is examined, with a brief discussion of some current hypotheses about the potential mechanisms underlying the associations that have been found. Some practice implications of these findings are also highlighted.

Diversion from custody is a policy supporting the removal of people with mental disorders from the criminal justice system to hospital or a suitable community placement where they can receive treatment. There are three principal reasons why such a policy is necessary. First, when those with mental disorders fall through the net of psychiatric services they tend to gravitate towards the criminal justice system; second, the standard of health care provided in prison is, generally speaking, poor; and third, because prison health care centres are not recognised as hospitals for the purposes of the Mental Health Act (MHA) 1983, treatment for mental disorder cannot be given against a prisoner's will unless this can be justified under common law.

The concept of borderline personality disorder (BPD) seems to include, almost by definition, the idea that people described by the term are difficult to help. The broad picture portrayed by the diagnostic criteria (Box 1) is likely to be familiar to most clinicians and to cause the hearts of many to sink. A core issue for those with BPD is difficulty of relationship, and this will inevitably – even especially – include clinical and therapeutic relationship. It is all too common for distress to be met with much therapeutic effort but for little to change. Indeed, there is often a nagging sense that attempts at treatment may be making matters worse. The care of people with BPD presents an important challenge to mental health services. At the individual level, the patient continues to be at risk and to suffer and the clinician feels frustrated. At the service level, substantial resources may be expended to little apparent benefit.

Up to a third of patients with schizophrenia develop treatment resistance. Clozapine has been established as the most effective antipsychotic medication for treatment-resistant schizophrenia. However, it is significantly underutilised in this population. Possible reasons include clinicians' lack of experience with the drug and negative attitudes towards it. African-Caribbean patients are less likely to be treated with clozapine compared with their White counterparts and more likely to have treatment discontinued due to perceived risk of agranulocytosis. This paper discusses the current evidence relating to the underuse of clozapine and factors responsible for this.

Attention-deficit hyperactivity disorder (ADHD) is a commonly diagnosed childhood psychiatric disorder. Debate over its diagnostic validity, aetiology, presentation and treatment has extended from the clinical to the public domain. As children with ADHD diagnoses reach adulthood there is increasing interest in ‘adult ADHD’. Cohorts followed up show poorer outcomes as adults than do controls. Self-referred adults, sometimes relatives of children with ADHD, are also of interest regarding adult ADHD. Innovative work is being done examining issues of aetiology, treatment, outcomes and comorbidity in these groups, but heterogeneity among those diagnosed with ADHD and changes in classification systems and diagnostic criteria over time complicate comparison of research findings. The diagnostic validity of adult ADHD remains uncertain and needs further study.

This article outlines the majority of the adverse physical effects that have been described secondary to the consumption of alcohol at levels above recommended sensible limits. These conditions are cited according to the organ system they belong to. Only brief descriptions are provided because of the vastness of this topic. The underlying pathophysiology of tolerance and withdrawal is touched upon as this is of relevance to the psychiatrist. Definitions of the terms used describing alcohol misuse, and sensible upper limits of alcohol consumption are also mentioned.

Psychiatry has had a significant influence on both Hollywood and world cinema. In turn, psychiatrists' fascination with psychiatric themes in films has inspired scores of books and bibliographies about films and psychiatry. Advances in medical education have led to the development of core-competency-based curricula for both undergraduate and postgraduate students. Learning objectives underpin such competencies. However, teaching competencies in the workplace is hampered by practical and ethical issues, especially in the case of psychiatric patients. Medical educationalists have found films to be a useful teaching tool with their larger-than-life vivid portrayals. In this article we demonstrate, with examples, the use of films and discrete film clips to achieve specific learning objectives that can be incorporated easily into most undergraduate and postgraduate teaching programmes in psychiatry.

Supervision is a key feature of professional development in a wide range of professions. The Royal College of Psychiatrists, in its ‘Statement on approval of training schemes for basic specialist training for the MRCPsych’ (available on request from the Postgraduate Educational Services Department of the Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG) dictates that each basic specialist trainee should have a “protected hour per week” with his or her educational supervisor. This time should belong “exclusively” to the trainee and be “for the benefit of the trainee”. The Higher Specialist Training Handbook (Royal College of Psychiatrists, 1998) also emphasises the central importance of supervision as part of higher training for specialist registrars. Training consultants are expected to be “readily available” to trainees, and to provide a “regular, weekly, timetabled supervision session”. Supervision is obviously perceived by those responsible for standard-setting in psychiatry as a key activity. However, there is a marked lack of clarity as to what constitutes good and effective supervision and there are often few opportunities for learning how to supervise. Hayes (1996) writes about research supervision but his comments are equally applicable to other forms of supervision. He suggests that quality supervision, where it exists, is often by accident rather than by design. It is likely to have been acquired experientially and not without some past hurt to either supervisor or supervised or both. He argues that too much attention has been paid to the quality control of supervision and not enough to quality assurance, with insufficient attention paid to all the possible roles of a supervisor and the key personal attributes necessary to fulfil these roles.

Polypharmacy and the risks of long term use of antipsychotic medications point toward the need for identifying practices for deprescribing in psychiatry. The following article gives a brief overview of key points around deprescribing antipsychotic medications in psychiatry, including identifying risks and benefits, considerations around timing, and steps involved.

Avoidant/restrictive food intake disorder (ARFID) was a new diagnosis in DSM-5 and is due to be included in ICD-11. However, confidence in making the diagnosis seems to be low among clinicians. Furthermore, there is no national consensus on care pathways for ARFID and therefore patients tend to be managed across core child and adolescent mental health services, specialist eating disorder services and paediatric services. If not adequately treated, ARFID can result in stunted growth, nutritional deficiency and impaired psychosocial functioning. Research and guidelines for managing this disorder are scarce, owing to low rates of diagnosis. This article aims to improve clinician confidence in the use of ARFID as a diagnosis and explores current consensus on treatment approaches, in order to progress future service planning for this complex and diverse patient group.

Young offenders with a learning disability may encounter a variety of different psychiatrists, most of whom do not claim any particular expertise in helping them. Child and adolescent psychiatrists, learning disability psychiatrists and forensic and prison psychiatrists may all see young offenders referred to them who have a learning disability –that is, ‘mental retardation’ as defined in ICD–10 (World Health Organization, 1992) (Box 1). Many of these psychiatrists do not see such referrals as a core part of their role, and perhaps because of this, surprisingly little is known about this group of young offenders. They frequently fall into the borderlands between different types of service provision, and as a result can become marginalised. This is of particular concern since recent work has suggested that young offenders with a learning disability may have substantial mental health needs. This article aims to summarise what is known about this group and describe how some of their mental health needs might be met.