In this commentary, some aspects of the context of this diagnosis are considered. It is suggested that avoidant/restrictive food intake disorder (ARFID) is principally a reconfiguration of existing problems. However, it is also stressed that we still need to develop treatments that help patients and their families, given the expectation that has been fuelled by the promotion of the new diagnostic scheme. In developing those therapies, we should not forget that we previously had a number of psychosocial treatment approaches that were helpful for such children when their problems were labelled differently.

Working with people who have criminal convictions for endangering others is certainly challenging. The place of psychiatric or psychological intervention is still uncertain but for some people, for example those who have a background of physical or sexual abuse, it seems reasonable to provide them with access to interventions that seem to benefit those who do not have such convictions. The dangerous and severe personality disorder (DSPD) system provides an environment to do this. However, if it is ever to be successful in enabling future safe community placements, it has to address issues of stigmatisation.

This article offers a selective review of memory and of issues relevant for a psychiatrist thinking about memory in a forensic context. It considers the development of our knowledge of memory, some of the ways in which memory can be erroneous and some evidence that this fallibility may sometimes be overstated. It concludes with a section on good practice in psychiatric assessment and in medico-legal work, looking at memory assessment, malingering/exaggeration and guidance for expert witnesses.

Research that should change clinical practice is often ignored for years. Fifty-five new trials are reported in medicine every day. Psychiatrists need to have some way to sift, digest and act on new research to benefit their patients. This article outlines the key elements of evidence-based psychiatry in an attempt to address these needs. Initially, an evidence-based approach is about asking an answerable question, searching for the evidence and then critically appraising the available information for its validity and relevance. The fourth step involves integrating the evidence with clinical expertise and the patient's values. The whole idea is to improve real-life patient care. This article outlines a number of the tools needed to overcome some of the common problems that psychiatrists face when trying to find and use published research results to help solve patients' problems.

We offer a contemporary review of studies of the offspring of parents with bipolar disorder and explore the clinical characteristics of these populations. We discuss how different methodological approaches may influence study findings and may explain some of the heterogeneity in the results reported. We also highlight some of the environmental risk factors that may increase the likelihood of transition from an ‘at-risk’ or high-risk state to bipolar disorder. Last, we briefly discuss the implications of study findings for early intervention strategies and comment on such issues as genetic counselling and primary and early secondary prevention programmes.

The use of portfolios has rapidly expanded in recent years and is now relevant to a number of different aspects of professional practice in medicine in general and psychiatry in particular, including training, appraisal and revalidation as well as continuing professional development. In this article I will examine the background of important changes and new trends in medical education on which the increasing use of portfolios is based, their potential value as learning and assessment tools, and some of the challenges and dilemmas associated with their use.

Eating disorders encompass physical, psychological and social pathologies that increase health risk. Anorexia nervosa has the highest mortality of any psychiatric disorder, but patients are not always managed by specialist eating disorders services and the duty of care sometimes falls to the general psychiatrist. This article is an aide-memoire for assessing and managing physical risk in patients with anorexia nervosa.

Although medical experts are valued in the administration of justice, the cases in the UK of Meadow and others, including most recently Pool, have all contributed to understandable anxiety on the part of doctors who carry out court work. This article uses an in-depth analysis of these cases and details of some other medical regulatory cases to draw out some lessons for potential medical expert witnesses. Although the most recent judgment in Pool leaves a number of unanswered questions, steps are identified that may be taken to reduce the risk of regulatory investigation by the General Medical Council.

Keeping up to date with the best evidence on treatment interventions is an essential part of clinical practice, but it can seem an overwhelming task for busy clinicians. Systematic reviews and meta-analyses provide a useful and convenient summary of knowledge and form an essential part of an evidence-based approach to clinical practice. However, these reviews vary in methodology and therefore in the quality of the recommendations they provide. Clinicians need to feel confident in their skills of critical appraisal, so that they can assess the relative merits of systematic reviews. In this article we discuss the strengths and limitations of different types of evidence synthesis to enable the reader to feel more confident in assessing the scientific information to use in clinical practice.

A good medical history is an essential starting point in ensuring that the physical health needs of people with severe mental illness are addressed. Psychiatrists have an important role in helping to tackle the general ill health, excess of undiagnosed physical illness and reduced survival rates among their patients. To do this they need to use their medical training, communication skills and regular contact with patients. Assessments should include family history, past and current physical health, medication, lifestyle, healthcare and physical symptoms. Some groups of patients will need more detailed assessments.

At most, 15% of patients in Western countries remain free of relapse after their first episode of schizophrenia (Crow et al, 1986). Like many chronic illnesses, schizophrenia can be controlled by appropriate treatment, but there may be a gradual deterioration over time. This encompasses problems such as loss of self-care, communication and community skills; negative symptoms of poverty of affect and ideation; cognitive impairment; behaviour problems such as aggression; and poorly controlled positive symptoms.

The four main Indian religions – Hinduism, Buddhism, Jainism and Sikhism – have several shared concepts about self and suffering, which are salient to the world-view of the followers of these faiths. Understanding the concepts of mind, self and suffering in these faiths can help clinicians build better rapport and gain deeper understanding of the inner world of patients of these faiths. This article highlights the broad cultural and religious beliefs of these groups, with the hope that increased knowledge among clinicians might lead to better therapeutic engagement.

The central role of medication in the treatment of attention-deficit hyperactivity disorder (ADHD) in children and adolescents is the focus of controversy once more. Questions about the safety and appropriateness of medication have arisen both within and without the medical community. This coincides with the disappointing results for long-term ADHD treatment, illustrated recently by the first major outcome study to be published. Clinicians have had to contend with a number of public health scares following on from the actions of drug regulatory bodies, in addition to misinformation and misunderstanding from the media. Ironically, this comes at a time when we have an ever-widening range of medications and formulations available to us, and better-quality studies to inform treatment decisions. The recently published National Institute for Health and Clinical Excellence guidelines address some of these issues and provide a welcome summary and reference point for beleaguered clinicians.

Once a formal diagnosis of gender dysphoria is established and comorbid disorders addressed, it is the role of the gender specialist to facilitate treatment according to agreed goals. This article reviews the treatment of gender dysphoria, including psychotherapy, and how eligibility and readiness for surgery are assessed. It considers issues facing transgender individuals detained in prison or psychiatric hospital, the factors that affect patients' satisfaction with gender reassignment surgery and how the specialist can ensure a satisfactory outcome.

Delusional infestation (delusional parasitosis) is a relatively rare condition but it has been of interest to a wide range of professionals, including entomologists, zoologists and dermatologists, as patients predominantly seek help from specialties other than psychiatrists. The illness requires a multidisciplinary approach and a strong bond of trust between the treating clinician and the patient to ensure the best possible outcome. This article discusses how clinicians in all specialties should approach patients presenting with the disorder and outlines differential diagnosis and associated laboratory tests. It considers the evidence base for treatment and the success of psychodermatology clinics that provide a ‘neutral setting’ for consultation to address the problem of patients’ non-engagement. Such clinics are few, and there is a need to develop disease-specific pathways in primary care and hospital settings to improve prognosis.

This article brings together the psychiatric and psychoanalytic views of mental illness to deepen the understanding of mental disorder. The intention is to bring to the fore the importance of loss and mourning in clinical practice. Looking for the loss event that underpins the disorder helps determine therapeutic treatment options and increases the chance of authentic therapeutic engagement and recovery. The article summarises theory about the mourning process and discusses the relationship of loss and pathological mourning to mental illness. Fictitious case vignettes developed from years in psychiatric practice are used to illustrate how this relates to clinical practice and formulation.

The principles of primacy of patient welfare, patient autonomy and social justice are fundamental to medical and psychiatric professionalism. Medical professionalism is also about encouraging and celebrating good practice. As a set of values and behaviours on the one hand, and relationships with patients, carers and other stakeholders on the other, the implicit contract between psychiatry and society needs to be renegotiated regularly. Serious threats to medical professionalism in the past 30 years have led to the demoralisation of professionals. Learned helplessness and a perceived loss of autonomy have been recognised as important factors in the ‘loss’ of professionalism. Psychiatry as a profession needs to identify its core attributes, skills and competencies. Professionalism should allow individuals to set and maintain their own standards of care.

Deliberate self-harm remains a common problem in the United Kingdom, with rates in the order of 250–300 per 100 000 per year (Hawton & Fagg, 1992). Since the suicide rate in the 12 months after hospital attendance for deliberate self-harm is around 1% (Hawton & Fagg, 1988), each year approximately 2–3 per 100 000 of the population die by suicide within a year of attending hospital with a non-fatal episode of deliberate self-harm. This is about a quarter of the overall suicide rate of 11 per 100 000. There is therefore an easily definable group at risk of suicide who should be the focus of a suicide prevention strategy.

Alzheimer's disease pathology accumulates years before the onset of clinical symptoms and has been termed ‘preclinical dementia’. Biomarkers have been developed to detect this pathology – namely, brain amyloid deposition and markers of neurodegeneration. In this article we describe these biomarkers and review the evidence for their clinical use in predicting risk both in the cognitively ‘normal’ and in those who already have established cognitive decline. We also discuss the limitations and ethical considerations of these tests and consider whether we should start incorporating Alzheimer's disease biomarkers into clinical practice. We find that, because many cognitively healthy people will have Alzheimer's pathology, and it is not clear whether this does help predict future risk of Alzheimer's disease, diagnosing preclinical dementia carries numerous ethical implications and is currently not being advocated outside research settings.