This article discusses the aetiology of both simple and complex post-traumatic stress disorders (PTSDs) in terms of attachment theory, and points out the similarities between the diagnosis of complex PTSD and of borderline personality disorder. Case vignettes illustrate an outline of the assessment and treatment of the psychobiological symptoms of PTSD informed by attachment research.

Psychiatric out-patient services originated in the early-20th century to enable triage of new referrals to the asylum in order to differentiate between treatable and untreatable cases. They evolved to provide community follow-up of patients discharged from hospital and assessment of those newly referred to psychiatric services. Non-attendance at out-patient appointments represents an enormous waste of clinical and administrative resources and has potentially serious clinical implications for those who are most psychiatrically unwell. The place of out-patient clinics in modern community mental health services is explored with reference to the reasons for, and clinical and cost implications of, missed appointments. An alternative model is described that incorporates recent UK government guidance on the roles and implementation of community mental health teams, liaison with primary care and new roles for consultant psychiatrists.

We review the various functional cognitive disorders (FCDs) – complaints about memory function or another cognitive process in the absence of relevant neuropathology. These are increasingly coming to the attention of psychiatrists and neurologists and FCD encompasses some newly recognised conditions in addition to classic types such as pseudodementia and psychogenic amnesia. The clinical features, neuropsychological findings and treatment are presented and discussed.

The General Medical Council suggests that leadership skills are a core requirement for all doctors. The NHS Institute for Innovation and Improvement goes further, stating that doctors have not only an intrinsic leadership role but also a responsibility to contribute to the effective running of healthcare organisations. The Medical Leadership Competency Framework (MLCF) outlines a structure with domains, elements and competency outcomes, all of which are clearly spelled out with examples and methods of learning for different stages of a medical career. The revised curriculum for postgraduate training in psychiatry contains many aspects of the MLCF, both complementing and supplementing its emphasis on the development of personal qualities and skills. This article highlights this approach and describes how the development of leadership and management skills fits with the current structures for training in psychiatry.

Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castle et al (1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

Many psychiatric in-patients report boredom. Such complaints may appear trivial, but this literature review by a clinical librarian suggests that boredom is more complex than may initially appear and relates to wider areas of importance for in-patient psychiatric teams. Boredom may relate to the internal experience of meaning, which itself encompasses meaningful relationships and roles and a sense of control. Although meaningful therapeutic activities are vital, mental health professionals should focus on the internal as well as the external dimensions of boredom. Medications, particularly dopamine antagonist antipsychotics, may be a contributing factor. This article highlights the benefits of the clinical librarian role in synthesising research in mental health. Research can illuminate psychiatric practice in a more holistic way than purely by applying 'scientific' evidence in the practice of ‘biological’ psychiatry.

Cannabis use is more common among people with severe mental illness than in the general population. It has detrimental effects on the course of the illness, physical health and social life of users, as well as being a financial burden on health services. It is important to understand why some people with severe mental illness continue to use cannabis, despite experiencing its effects on their condition. This article reviews research on the scale of cannabis use by such patients, the effects on the course of their illness, possible reasons to explain why they use it, and how they can be assessed in clinical settings, as well as providing some assessment tools to measure various characteristics related to cannabis use.

Palliative care is the active, total care of patients whose disease is not responsive to curative treatment. Psychological problems such as depressive illness, anxiety, delirium, problems coping and body image disturbances are common in the palliative care setting, although they are often missed. A full assessment of these patients should take into account physical, emotional and spiritual factors; therapeutic work should include the patient's family. Pharmacological (antidepressants, anxiolytics and antipsychotics) and cognitive–behavioural treatments are often effective in allaying distress in this group of patients, and can improve coping skills and quality of life. Liaison psychiatrists have a role in teaching palliative care staff to recognise psychiatric disorders. A number of case studies are presented to illustrate these points.

Harm in talking therapies, and in healthcare professionals’ relationships with patients generally, has received little attention in comparison with harm by medication and other treatments. There has been little research into causes, types and effects. Professionals behave as if it does not happen and tend to react defensively to complaints. We believe that it is essential for professionals to understand the potential for harm and evaluate their actions in order to make them safer. This article defines harm in the therapeutic context, discusses its prevalence and then focuses on adverse idealising transference: the adverse effects that may arise when a patient transfers idealising feelings onto the professional.

Benzodiazepines are still widely prescribed in psychiatry, mainly for the treatment of anxiety-related disorders. This is not because they are only taken by a hard core component of patients who are addicted and do not need them; it is because they remain the most effective and rapid acting of all drug treatments. Strategies for practitioners to use them more confidently are described.

There is clear evidence of increased medical comorbidity and related mortality in people with severe mental illness, despite numerous guidelines for managing medical conditions in this population. This article assesses inequalities in medical treatment and preventive healthcare received by psychiatric patients compared with the general population. It considers whether the medical care provided is adequate and whether published guidelines improve it. Mental health specialists, general practitioners and hospital specialists appear to deliver poorer than average medical care for this vulnerable population. Implementation of physical healthcare guidelines is incomplete and the guidelines must be matched with resources to address this deficit.

There is evidence pointing to a bias in the application of the Mental Health Act 1983 (which is in force in England and Wales). One study found that Black people on in-patient units were four times more likely to have been compulsorily admitted than White people. Furthermore, it has been shown that compulsory admissions to secure units are 2.9–5.6 times higher for Black than for White patients. Any understanding of this bias necessitates an examination of the attitudes of mental health professionals towards Africans and African–Caribbeans. Here we discuss possible contributory factors and examine a number of initiatives that have been instituted in order to tackle this problem.

The classification of depression has been debated for decades. The introduction of operational criteria and the category of major depression were significant advances in the 1970s. However, the validity of the major depression category is controversial. The article highlights the limitations of using severity criteria and cross-sectional evaluation to diagnose depression. It recommends the classic typologies (melancholia, dysthymia and adjustment disorder) for clinical presentations of depression, highlighting the need to use longitudinal clinical patterns and context for diagnosis. Major depression owes its success to its loose definition, to the subordinate status of adjustment disorders and dysthymia and to the mechanistic application of the diagnostic hierarchy and criteria. There is a need to focus more on the context of depression (stress, coping and support) and to reduce the medicalisation of distress.

Machines will replace therapists and counsellors. This was the confident prediction made a decade ago. In this article, I discuss the inherent limitations of machines as conversationalists that have prevented the prediction from coming true. Machines can, however, be exploited to assist therapy and I consider the following digital tools: test administration; managing procedural, symptom-relieving cognitive–behavioural therapies; providing virtual environments for immersive behavioural therapies and for e-learning; and assisting training through automated discourse analysis and the use of cognitive maps.

Auditory hallucinations (voices) are the most common symptom in schizophrenia, occurring in 70% of those with the diagnosis. A proportion respond to antipsychotic medication, but despite adequate concordance with prescribed medication, voices may still remain. Voice hearers often inadvertently activate coping strategies that maintain the symptoms and linked distress. Assessment can identify ineffective strategies. Effective strategies can then be initiated, starting with distraction to reduce distress in the short term and leading to focusing approaches that give an improved understanding of voice maintenance. This article describes how to recognise voice hearers' ineffective coping strategies and how to teach effective approaches that are a crucial catalyst in the recovery process.

Multicultural societies offer a significant challenge to mental health services. Different groups have different rates of illness, illness models, ideas of what a suitable pathway of care is and what suitable care looks like. Trying to set up services to meet all these needs can be difficult. There may need to be modifications in clinical practice, service configuration and the way services are commissioned. Ethnic minority communities face complex problems and, consequently, strategies to deal with them can be complex, requiring support from the non-statutory sector, social services and other branches of medicine. Service development often needs research, staff training, race-equality schemes and sufficient funding to make change possible. I offer here a scheme for considering how to think through service development in this area as well as introducing the government strategy, Delivering Race Equality.

The recruitment and retention crisis in UK nursing puts many reforms outlined in recent health policies at risk. Increasing bureaucratisation of health care, unattractive working conditions, poor pay and the emotionally exhausting nature of the work are associated with high rates of burnout and workplace violence. Some nurses prefer agency work, some leave because they cannot reconcile a caring role with working in the NHS. It seems that health care has become emotionally distant and the profession's longstanding attachment to caring through interpersonal relationships has been overridden by a high-technology, fast-track system of care management. To retain the principles and ethos of nursing at the centre of health developments, attention must be given to the micro-environments in which nurses work.

Psychotic disorders in adolescence are uncommon, but often mark the beginning of a lifetime of contact with mental health services. They pose a challenge and anxiety to sufferers, to their families and to professionals involved in assessment and treatment. Accurate and early diagnosis, coupled with appropriate treatment, is essential to minimise secondary handicaps. However, their rarity means that professionals are frequently unfamiliar with some aspects of presentation or management and that appropriate service provision is not readily available (e.g. admission directly into an in-patient bed in an age-appropriate environment). A lack of age-appropriate provision may also mean that adult psychiatrists are occasionally called on to manage and treat a younger teenager presenting with a psychotic disorder.

Self-harm in adolescents is common and is increasing. It can present to professionals as a symptom of major mental health disturbance or it can form part of a cultural ‘norm’. This article reviews current knowledge about self-harm in 12- to 18-year-olds. Definitions of self-harming behaviour, epidemiological and aetiological factors, risk assessment and management of self-harming in various settings are discussed in terms of pragmatic clinical approaches and evidence-based practice.