This article discusses a cognitive–behavioural therapy (CBT) approach to the treatment of medically unexplained symptoms that is based on the ‘five areas’ model of CBT. We describe a typical course of therapy and some of the common problems encountered during treatment. Emphasis is placed on the practical management of these conditions, and the focus is on symptoms as opposed to cause. We believe that this approach is widely applicable and could be used in a large range of settings to tackle these debilitating conditions. In writing this article we intended to provide an overview of patients with medically unexplained symptoms. The article would be of interest to staff within liaison psychiatry departments looking to set up a medically unexplained symptoms service and general psychiatry teams who may have contact with patients presenting with somatic symptoms. Psychiatric teams without access to a liaison department may also find this article interesting.

There has been considerable progress in recent years in developing psychosocial interventions for people who experience persistent psychotic symptoms. However, it is sometimes difficult to generalise these findings into routine clinical practice. Long-term, psychodynamically informed, supportive psychotherapy is a valuable approach for working with individuals for whom current psychosocial interventions are ineffective or where unhelpful team reactions are obstacles to care. Its principles are used to inform a multiaxial formulation, which is shared with the treatment team and guides treatment, promoting good-quality comprehensive routine care. The benefits of this approach can best be seen at the individual case level using a subsequent multiaxial reformulation.

Pregnancies in women with serious mental illness are high risk and such women are also less likely to engage in the recommended health screening for women of reproductive age. Hence, reproductive health issues are important aspects of physical healthcare that should be assessed in women accessing mental health services. Pregnancy planning and management are crucial in reducing risk of relapse in women with affective disorders, and psychiatrists should acquaint themselves with the screening programmes and reproductive and sexual health services in their area and encourage their patients' uptake of these. Clinicians should be aware of the reproductive impact of medications and the needs of specific groups of women.

This review examines whether the diagnosis of dissociative identity disorder (DID) could be used to support a defence of ‘not guilty by reason of insanity’ (NGRI, or the insanity defence). The problem is that DID has doubtful validity and can easily be malingered. However, the diagnosis is listed in standard psychiatric manuals. If accepted as valid, DID would have problematic forensic implications.

This article describes the establishment of a clinician as a referral coordinator to manage referrals into a typical mental health service for older adults. The referral coordinator model, which include risk assessment at the point of referral and accurate comprehensive collection of referrer data, is compared with other traditional and more recent models of referral management. The importance of thorough collation of clinical information to produce a preliminary risk assessment and the stages of development of an algorithm as a core requirement to guide the coordinator and ensure consistency over time are described. An initial analysis of local referrer data and trends over a period of 3 years is presented to emphasise the educational opportunities offered by taking control of referral management.

Hostage situations differ greatly – in the aims and goals of the hostage-takers, the frequency and intensity of maltreatment, the type and quality of conditions, the duration of captivity, and the processes by which they are ultimately resolved and concluded. Although there is a paucity of research-based data about hostage reactions, clinical management, and outcome, there are general descriptive accounts in the medical and popular literature. A number of key texts are highlighted in the references, and examples of different conditions are briefly summarised in Box 1.

At present, the treatment options for Alzheimer's disease are largely symptomatic giving rise to temporary remissions in cognitive decline or the amelioration of troublesome behavioural and psychological symptoms. However, as more is becoming known about the molecular biology of Alzheimer's disease, there is a clear movement to treatments directed towards disease modification. Disease modification is now a realistic option and its importance is highlighted by the fact that a delay in the progression of the disease by just five years would halve the disease prevalence. Ultimately, however, drug therapy based on the molecular biology of Alzheimer's disease will be preventive. These treatment strategies are still in their infancy, but our understanding of the processes requiring therapeutic manipulation is improving at a dramatic rate.

In recent decades the professional life of the psychiatrist has become increasingly difficult. Several reports have highlighted the problems, which lead to disenchantment, low morale, sick leave, anxiety, depression and even early retirement (Ramirez et al, 1996; Kendell & Pearce, 1997; Pattani et al, 2001). Changes in the National Health Service (NHS), the difficulties in daily practices, the climate of litigation and the culture of blame have all contributed to an atmosphere where lack of empathy and appreciation has become the norm.

Teaching methods to help students appreciate the value of psychodynamic formulation and to become more skilled in producing formulations are described. These are closely related to the four levels of our model formulation, each level corresponding to a set of competencies through which students should normally progress. Accurate diagnosis of a student's current capabilities and needs is crucial to effective teaching. Teaching methods at each level are illustrated through detailed reference to a case example. The usefulness of small-group discussion for assimilating clinical material within a clear framework is emphasised throughout.

Despite much research, environmental influences that can be said to cause a schizophrenic illness remain elusive. When the effects of an (often prolonged) prodromal syndrome are taken into account, the first episode appears to come from nowhere. However, over the past couple of decades a number of factors have emerged that can be argued to influence, and not merely reflect, the illness onset. The possible effects of season and geography of birth, urbanisation, immigration, substance misuse, prenatal influenza, famine and other stresses, and obstetric complications are summarised. These varied findings, often of small effect and borderline significance, present a challenge to clinicians attempting to make sense of their patients' life experiences. Any hard conclusions still depend largely on how one formulates the illness.

We present a narrative review of evidence-based treatment for obsessive–compulsive disorder (OCD), covering first-line pharmacological treatment, augmentation strategies, approaches for treatment-refractory OCD and the management of OCD in special populations (children and adolescents, pregnant and breast-feeding women, and elderly people).

Terrorism is a complex problem that is highly relevant in contemporary society, underscoring the need for greater understanding as well as cross-disciplinary and international research in this area. Controversies surround potential associations between mental illness and terrorism, many due to the limited and conflicting existing research, and mental health professionals’ duties to their patients versus society and the state. In this article, we review the literature, discuss clinical implications and the role of psychiatrists in anti-terrorism efforts. We also propose a simplified framework that may be incorporated into clinical practice to screen for potential terrorist tendencies.

The purpose of this review is briefly to consider the biological basis of depression and to attempt to illustrate how antidepressants produce their beneficial effects by correcting these abnormalities.

The forensic psychiatry of learning disability is a subspeciality which exists on the ‘borderlines’ between other areas. It takes in information from forensic psychiatry, learning disability, child and adolescent psychiatry, psychology, genetics and pharmacology to name but a few.

Clozapine remains underutilised as the only antipsychotic for treatment-resistant schizophrenia, despite liberal National Institute for Health and Clinical Excellence guidelines for its consideration. Bearing in mind its monitoring requirements and poor tolerability, suggestions are made for patients who fail to improve on other antipsychotic drugs. Clozapine may be offered to apparently unsuitable patients, although this is fraught with difficulty. A realistic appraisal of the alternatives is essential in this situation. Optimising plasma clozapine levels, alongside the use of rehabilitative interventions and adjuncts as necessary, will maximise efficacy, and there are numerous options to minimise side-effects. Clozapine requires a lengthier trial than other antipsychotics and discontinuation should be avoided if possible, as the results are generally very poor. Established successful clozapine treatment can induce substantial functional gains which accrue with time: patients are retained in treatment and relapse is prevented. Such optimal outcomes justify the initial effort expended by all.

The evaluation of treatment effects is important to both the clinician and the patient. However, outcomes in randomised trials are often difficult to apply to the clinic. The number needed to treat (NNT) is one method that facilitates the interpretation of clinical trials in a meaningful way. When combined with the number needed to harm (NNH), the balance between the risks and benefits of a particular treatment can be appreciated. We illustrate the use of these concepts by focusing on recent large pragmatic studies of antipsychotics, including CATIE, EUFEST and CUtLASS.

The UK National Institute for Health and Care Excellence guidance suggests that psychodynamic principles may be used to understand the experiences of people with psychosis. In this article we consider the application of psychodynamic principles in psychotherapy for psychosis, focusing on one particular model: supportive psychodynamic psychotherapy (SPP). We describe this approach with a detailed fictitious case example and discuss how SPP has developed through significant modifications of classical psychoanalytic therapy and the evidence base for it. We consider its overlap with cognitive–behavioural therapy, its advantages and disadvantages, and the arguments for making SPP available as a treatment option in services for psychosis.

Intoxication with alcohol and drugs is commonly associated with criminal offending. The relationship between intoxication and criminal culpability is complex and may be of psychiatric relevance, especially if a mental condition legal defence is being considered. This article outlines the legal issues (such as they apply in England and Wales) of which psychiatrists should be aware when preparing medico-legal opinions about mentally disordered offenders.

Workshops are used in many psychiatric teaching and learning contexts, from undergraduate to continuing professional development. Most psychiatrists have at some time attended a workshop. However, the terms workshop, tutorial and small-group teaching are used indiscriminately. It is therefore important to reflect on what characterises a workshop, the learning theories behind their development and what learning needs workshops best meet. We give an outline of the evidence for workshops in medical education and review the principles governing how to conduct workshops and the use of technology to enhance their delivery. Data collected from an undergraduate psychiatry course delivered in an Irish university are used to illustrate how applying these principles contributes to optimising the use of workshops from both the learners’ and facilitators’ perspective.

Testing for illicit drug use is used in pre-employment checks, the criminal justice system, sports medicine and for screening and confirmatory purposes in patients with physical and mental illnesses. The types of drugs tested for and the methods used vary depending on the indication. This article focuses primarily on blood, urine and oral fluids, which are specimens more commonly used in mental health settings, although hair and sweat are increasingly used in medico-legal cases and in child protection issues. The main drugs and their metabolism are discussed to gain a better understanding of the methods used and for accurate interpretation. Methods to ensure validity during sample collection are explored. False-positive and false-negative tests are common and possible confounders are discussed.