The practice of brief psychotherapy is a distillate of the active ingredients in longer-term work but with the addition of two special elements: limited time and therapist activity in formulating a focus and focusing on it. Typically, patient and therapist work together over 10 to 25 sessions in weekly meetings. In very brief dynamic psychotherapy (VBDT), the time frame is shrunk to fewer than 10 sessions, sometimes just a single session; the constraint means that there is less room for corrective manoeuvre in order to achieve the therapeutic task of maximum benefit and minimum harm in the time available. To do this well requires knowledge, skill and sensitivity. In this paper, special attention is paid to a ‘three-plusone’ intervention (brief intervention and followup (BRF)) that has been tested in a randomised controlled trial (RCT).

The neurological deficits in sensory and motor function in schizophrenia have been described using a confusing variety of terms, reflecting their uncertain relevance and significance to psychosis. In this article we explore the nature of neurological abnormalities in psychosis, describe their assessment and suggest their potential relevance for clinician and patient. We propose that the assessment of neurological abnormalities and extrapyramidal side-effects should figure in the assessment of any patient with psychosis, particularly at illness onset. Furthermore, we suggest that neurological abnormalities can inform prognostic predictions and help to identify patients with more complex future care needs.

It is obvious that learning is an essential part of all successful educational processes, including continuing professional development (CPD). Yet learning can be hard work, especially for the mature adult, and being able to recognise the nature of some of its intrinsic difficulties is likely to be helpful. In educational circles today, it is recognised that engaging experienced or senior people in the educational process of CPD is often difficult.

Taking hostages has a long history as a method, with variable effectiveness, of securing concessions from individuals, organisations and governments. More recently, it has become a popular tactic among terrorist organisations. Although the resilience of individuals should never be underestimated, there is evidence that being taken hostage can have enduring effects, particularly on children. Individuals vary in how they cope with such an experience, both during and subsequent to it. The literature demonstrates that the research base is limited, and many important questions remain to be answered. Hostage-taking is an area of clinical and scientific interest. Apart from the need to establish the most effective post-incident interventions for individual hostages and their families, there are opportunities to develop further insights into the dynamics and effects of unequal power relationships.

There are many similarities in the experience and approach of general practitioners (GPs) and psychiatrists. GPs may spend some time in psychiatric posts before settling down as principals in their own practice, while some psychiatrists are members of both their own College and the Royal College of General Practitioners. Although there is great potential benefit for patients in this symbiotic relationship, GPs and psychiatrists work in different settings that require different techniques and time-scales. The professional work of both specialities has been profoundly affected by the National Health Service (NHS) reorganisation of the early 1990s. GPs have developed new relationships not only with psychiatric colleagues, but also with professionals of other disciplines such as psychologists, social workers and counsellors.

In value-based healthcare (VBHC) value is defined as outcomes that matter to patients divided by the cost of achieving these outcomes. Value is measured for discrete medical conditions across the whole cycle of care. Data on the value achieved by different providers is openly shared. Providers increase value using quality improvement (QI) techniques to improve outcomes, reduce costs or both. Patients or commissioners choose the provider achieving the greatest value. Units should compete regionally or nationally. There are challenges to implementing such ideas in the mental health services in the UK. However, measuring outcomes, understanding costs and using QI to drive up value may be possible without adopting the complete model that has developed in the context of a North American and acute hospital healthcare system.

Tardive dyskinesia is a common iatrogenic neurological and neurobehavioural syndrome associated with the use of antidopaminergic medication, especially antipsychotics. Prior to the introduction of the newer antipsychotics in the 1990s, it was one of the major areas of psychiatric research but interest waned as the new drugs were reputed to have a reduced liability to extrapyramidal adverse effects in general, a claim now discredited by numerous pragmatic research studies. Early small-scale short-term prevalence studies were presented as evidence to support the assumption that patients on the newer drugs did indeed have a lower prevalence of tardive dyskinesia but recent large-scale review of studies with patients exposed for longer suggest that things have not changed. This article presents a clinical overview of a complex and varied syndrome in terms of its phenomenology, epidemiology and risk factors; a companion article will consider treatment. This overview aims to highlight tardive dyskinesia once again, especially to practitioners who have trained in an environment where this was considered mainly in historical terms.

Drug treatments play an important role in the treatment of child and adolescent psychiatric disorders. However, there is often a long delay before research findings are translated into clinical practice; furthermore, changes in clinical practice outstrip the available evidence. This paper focuses on current issues and research findings on the pharmacological treatment of attention-deficit hyperactivity disorder (ADHD) and affective disorders. Clinical findings from a US study of the treatment of ADHD with extended-release stimulants and non-stimulants, and the development and use of clinical guidelines are discussed. Clinical trials of selective serotonin reuptake inhibitors for early-onset depression, approaches to managing treatment-resistant depression and guidance on the drug treatment of early-onset mania are considered.

This second of two articles on the ‘typical’ (‘first-generation’) antipsychotics covers non-phenothiazines: thioxanthenes (flupentixol and zuclopenthixol), butyrophenones/diphenylbutylpiperidines (including one-time world market-leader haloperidol, and pimozide) and sulpiride, for many years the only substituted benzamide available in the UK. Several tolerability issues ascribed specifically or more frequently to older antipsychotics are also discussed.

Many memorable characters in Western culture could be viewed as having features of autism or Asperger syndrome. In spite of the familiarity of autistic stereotypes such as Star Trek‘s Mr Spock, more completely described characters with autism are still unusual. In recent years there has been a growing interest in autism, mirrored by an increase in depictions of autism in popular works of fiction and autobiography. In this article I will outline the issues that have preoccupied writers and the techniques they have used to demonstrate autistic difference. Some writers have illuminated aspects of the autistic triad of social impairment, abnormalities of language and need for sameness. Other writers have opened our eyes to the autistic world view in its strangeness and richness. Still more have started to examine prejudice, disability rights and the implications of an international autism community. As in other areas of mental health, literature can help inform, entertain and question our attitudes and values.

Caring for people in distress or illness is emotionally draining and physically demanding. This article focuses on the experiences and needs of health service staff as professional carers. It overviews the current circumstances in the UK and links readers to the findings of: the Stevenson/Farmer Review of 2017; the report of the General Medical Council on the state of medical education and practice of 2018; and the British Medical Association survey of doctors and medical students published in 2019. We review the sources of stress that affects healthcare practitioners and introduce the concepts of emotional labour, psychological safety and psychosocial resilience. We draw attention to the vital importance of social support and leadership to protecting healthcare staff. We conclude this review of the topic by outlining a stepped model for actions that aim to: develop staff of healthcare services and help them to thrive at work; support staff who are struggling at work; and intervene to care for staff who are distressed or unwell whether they are continuing to work or not.

Delusional disorder, rare in clinical practice, remains one of the most enigmatic conditions in psychiatry. Linked to schizophrenia spectrum disorders since the mid-20th century, recent work has confirmed 19th-century notions of an aetiology based on attentional biases and personality dimensions. Unfortunately, the literature exists largely as case reports and series, often published as ‘curiosities’, and therefore lacks the rigour of formal diagnosis. This article reviews current thinking on aetiology and epidemiology, considers diagnosis, and reviews recent work on physical and psychological therapies. It concludes that delusional disorder is likely to respond well to treatment with standard antipsychotics, often at low doses, but that adherence and concordance remain particular problems. Cognitive therapy has been shown to be beneficial but is time-consuming and resource-intensive. Selective serotonin reuptake inhibitors may profit further investigation. There remains considerable scope for investigation of this fascinating condition.

The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.

The Disability Discrimination Act, passed by Parliament in 1995, is an important piece of legislation with the potential to protect the employment rights of people with disabilities. It covers people with physical or mental impairments that have a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities. The Act has sections regarding protection from discrimination in employment, in the provision of goods, services and facilities, and in education. These parts of the Act have implications for people working in mental health services when they are considering employment and educational opportunities for service users.

Twenty-four-hour nursed care refers to a model of psychiatric care which in fact varies quite significantly from unit to another. This sort of residential care unit has also been called the “hospital hostel” (Goldberg et al, 1985), “ward in a house” (Wykes & Wing, 1982), “psychiatric nursing home” and in some cases “staffed group home”. Although the unit size, staffing structures and ratios, and the degree of direct management within the National Health Service (NHS) vary, this model of care has some quite specific characteristics, which have been summarised by Shepherd et al (1994) as follows:

Neuroimaging is traditionally divided into structural and functional imaging. Structural imaging looks at brain structure or anatomy and includes computed tomography (CT) and magnetic resonance imaging (MRI). Functional techniques seek to examine the physiological functioning of the brain, either at rest or during activation, and include single photon emission computed tomography (SPECT), positron emission tomography (PET), MRI spectroscopy, functional MRI (fMRI) and encephalographic brain mapping. Although fMRI, MRI spectroscopy and brain mapping are likely to have clinical applications in the near future, the main imaging modalities of current clinical relevance to psychiatrists are CT, MRI and SPECT, which will be the focus of this article.

A genuinely critical and reflective approach to psychiatry can potentiate learning, improve practice and promote personal development. To support this assertion, I attempt to link theory and practice. Following a brief overview of the seminal ideas that permeate the literature on critical thinking, I present three perspectives of reflective practice – those of the psychiatric trainee, the teacher and the practitioner – through examples of reflective exploration of personal experience, under the light of relevant evidence. I conclude with a critique on the limitations of reflective psychiatry.

Lithium is a gold standard maintenance treatment in bipolar affective disorder. It has a narrow therapeutic range, and at higher serum lithium levels there is a risk of adverse effects and toxicity. There are three patterns of lithium intoxication: acute, acute-on-chronic and chronic. We describe risk factors for lithium intoxication, mechanisms of toxicity and clinical symptoms seen in lithium intoxication. We describe both the acute and chronic effects of lithium toxicity. Lithium intoxication may be life-threatening and associated with longer-term sequelae. The management of lithium intoxication involves determining the type of intoxication. We discuss treatment strategies aimed at reducing absorption and increasing elimination of lithium. We discuss clinical indications for extracorporeal methods such as dialysis, which are used to limit the time and degree of exposure of the central nervous system to toxic lithium concentrations. Haemodialysis is the most rapid method of eliminating lithium from the body, but careful monitoring is required. Preventive strategies to mitigate the risk for lithium intoxication are discussed.