In 1899, Maudsley wrote:

Recent research confirms that a range of psychological problems and psychiatric disorders are common in people with diabetes. Such problems are important not only because of the suffering caused, but also because of their impact upon the management and outcome of the diabetes itself. This article reviews the psychosocial impact of diabetes and its treatment, describes the range of psychological problems and psychiatric disorders which commonly occur in people with diabetes, and outlines the role of the psychiatrist in the recognition and management of these clinical problems.

Eye movement desensitisation and reprocessing (EMDR) was described by Shapiro (1989a,b) as a new method for treating post-traumatic stress disorder (PTSD). In May 1987, while walking in the park, Shapiro noticed that her own disturbing thoughts changed then disappeared “without any conscious effort” (Shapiro, 1995) when they had been temporally paired with diagonal upward to and fro eye movements. Over the next six months Shapiro worked with approximately 70 people to develop a procedure based on the temporal pairing of distressing images and thoughts with various eye movements. Shapiro began to develop strategies to unblock stalled emotional processing, which was initiated by EMDR in non-patients. She successfully tried the method on a Vietnam veteran suffering from severe PTSD and then embarked upon a trial of EMDR on a mixed group of victims of rape, molestation and Vietnam combat trauma. Initially, EMDR achieved wide recognition as a new breakthrough treatment for PTSD. This was, in part, because of very positive early reports (e.g. Wolpe & Abrams, 1991), but also because the EMDR effect appeared to occur with unprecedented speed, often in cases of PTSD that had previously resisted treatment by many other methods over a long period.

The present case study describes a typically complex clinical presentation of chronic post-traumatic stress disorder (PTSD) suffered by a Second World War veteran and advises on multi-disciplinary out-patient management extending to acute hospital care. Limited symptomatic impact of psychological and psychopharmacological therapies is discussed, and related to patient reports of satisfaction with therapeutic outcome.

The number of in-patient beds for psychiatric treatment in America has declined dramatically over the past 40 years. Public and private policies have encouraged an extremely short-term, crisis-stabilisation model of treatment. This is true on both general and subspecialty units. As a result, readmissions have increased, emergency rooms are crowded, and many patients end up homeless or incarcerated in the criminal justice system. These changes have created a public health crisis in America, and are the greatest challenges that American psychiatry faces today.

Attention-deficit hyperactivity disorder (ADHD) is an established diagnosis in children but there is a lack of agreement about its validity as a distinct entity in adults. Literature suggests that between one-third and two-thirds of children diagnosed with ADHD continue to manifest symptoms into adulthood. An adult diagnosis should be done on the basis of a thorough assessment, structured and semi-structured clinical interview, and with a complete understanding of the symptoms that manifest in adults. This may be supplemented by the use of rating scales. We present a review of the literature covering aetiology, clinical presentations, diagnostic evaluation and management of ADHD in adults.

One-third of our lives is spent asleep, but the reasons why we sleep are not yet fully understood. Sleep is a state of inactivity accompanied by a loss of awareness and a markedly reduced responsiveness to environmental stimuli. When a recording is made of an electroencephalogram (EEG) and other physiological variables such as muscle activity and eye movements during sleep (a technique called polysomnography) a pattern of sleep consisting of five different stages emerges. This pattern varies from person to person, but usually consists of four or five cycles of quiet sleep alternating with paradoxical (active) sleep, with longer periods of paradoxical sleep in the latter half of the night. A representation of these various stages over time is known as a hypnogram, and one of these derived from a normal control subject is shown in Figure 1. The quiet sleep is divided further into four stages, each with a characteristic EEG appearance, with progressive relaxation of the muscles and slower, more regular breathing as the deeper stages are reached. Most sleep in these deeper stages occurs in the first half of the night.

In a recent Round the Corner, Mitchell commented on a Cochrane Review of exercise therapy for chronic fatigue syndrome (CFS). One of the trials included in that review, and discussed by Mitchell, was the PACE trial. In this month's Round the Corner we are publishing a response we received from authors of the PACE trial (Chalder, White & Sharpe), together with Mitchell's reply. Ed.

The relationship between psychiatrists and psychotherapists is a complicated one. It has become no easier as mental health services have come under increasing strain over recent years, with pervasive bureaucratisation and the introduction of market forces. I aim in this article to elucidate the roles that a psychodynamic psychotherapy service can play as an integral part of a general psychiatric service in addition to its specialist treatment functions. I also explore some of the reasons why psychotherapy and general psychiatric services are still not fully integrated, thus failing to provide the most effective range of treatments and enhance the effectiveness of mental health staff in all settings in the delivery of those treatments.

Evidence for the effectiveness of treatment or secondary prevention of psychotic illness such as schizophrenia is often disappointing. This situation reflects our limited understanding of the aetiology of psychosis. There is good evidence that both genetic and environmental factors are implicated but the precise identity of these is unclear. Cannabis use is one candidate as a possible, modifiable environmental influence on both incidence and prognosis of psychosis. Evidence supporting this candidature is exclusively observational, and its strength has perhaps been overestimated and problems related to its interpretation underestimated by some. Nevertheless the possibility that cannabis does cause psychosis remains. Because of this, and because there are other good public health reasons to prevent cannabis use, interventions targeting use need to be evaluated. This evaluation, along with other imaginative approaches to future research, is needed to further our understanding of the determinants of mental illness and how we can most effectively improve the population's mental health.

Internet gaming disorder (IGD) is a condition in which the individual is preoccupied with playing online video games and unable to regulate this behaviour, resulting in adverse physical and psychological consequences. Although there is some debate about whether IGD is an addiction or a coping mechanism, global evidence indicates that the condition is increasing in prevalence with recent advances in technology and its higher penetration into routine life. Male children and adolescents located in East Asian countries are at higher risk than others in the world. Attention-deficit hyperactivity disorder, depression and anxiety are typically associated with IGD. Given the continuing ambiguity regarding the diagnosis and screening tools for the disorder, it has become all the more relevant for mental health practitioners and academics to attend to this condition and develop evidence-based treatments. This review summarises both the existing evidence for the disorder and the debates that surround it.

In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.

Dissociative identity disorder (DID) is as real as any other psychiatric disorder but has been over-diagnosed by gullible clinicians, especially in forensic settings. Its classification has been poor, but the new ICD-11 classification, especially of partial DID, should help research and practice.

In clinical psychiatry, it is common to see pregnant and postpartum patients who express excessive anxiety and concerns about pregnancy or childbearing. This implies the need to distinguish between symptoms that could be considered to be an expected reaction to the situation, the diagnosis of an anxiety disorder or the presence of pregnancy-related (pregnancy-specific) anxiety. The last presents as a specific clinical phenomenon, identified in the literature as concerns exclusively linked to the situation of pregnancy or childbirth. In this article I review key points in the differential diagnosis of perinatal anxiety and its impact on both the pregnancy and the baby, as well as aspects of detection and diagnosis. I also give a brief summary of possible management approaches and treatments.

Personality disorder is likely to be common in late life, but our ignorance is such that, at present, we can only speculate about its frequency and importance. The only firm evidence we have is that antisocial personality features tend to be attenuated in older age and obsessional and detached features accentuated. Differentiating personality change following organic disease from personality disorder requires more attention as it is important for good clinical management.

The relationship between childbirth and serious mental illness has been known since the time of Ancient Greece. It was first described in the psychiatric literature by Esquirol and later by his pupil Marcé in 1857. A substantial number of women become mentally ill, often for the first time, following childbirth. There are few events associated with such a measurable and predictable risk to mental health as childbirth, with its nine months warning. Despite this, there is little awareness amongst general psychiatrists of the predictable and manageable risk that faces many of their female patients should they become pregnant, nor of the risks that mentally ill mothers may pose for their children.

The prime duty of specialist mental health services is to provide effective care to often non-compliant and unstable severely mentally ill (SMI) patients. Society expects such care to be humane and effective, but also demands that the severely ill are closely supervised to minimise risk to the public. Sadly, specialist services all too often fail on both counts. In part, this is due to the sheer complexity of care that is needed, going far beyond purely medical or therapeutic interventions. SMI patients have profound difficulties accessing and using everyday services and opportunities. Negative symptoms of apathy, self-neglect and low motivation, coupled with irrational beliefs and compounded by inadequately resourced and tightly rationed provision of social care, require mental health care services to be constantly active across areas of both medical and social provision. Services that ignore the importance of long-term, integrated care do so at their peril. A steady stream of disasters has been blamed on a lack of communication and coordination between agencies (Spokes, 1988; Ritchie et al, 1994), and follow-up studies of SMI patients managed by traditional hospital out-patient services repeatedly note a mismatch between levels of need and service uptake, with the least needy consuming the greater amount of service (Goering et al, 1984; Melzer et al, 1991).

Criticism of the biomedical model of psychiatry that regards mental illness as brain disease has been labelled ‘anti-psychiatry’. Critical psychiatry arises out of so-called anti-psychiatry, but has additional roots in transcultural psychiatry, its alliance with psychiatric user/survivor groups, and the methodological critique of the neuroscientific basis of mental health problems and psychiatric treatment effectiveness. It is not opposed to psychiatry as such and argues for a person-centred shift for practice and research. This article discusses how a more truly biopsychosocial model, which critiques the biomedical model to produce a more relational practice, is needed not only for psychiatry but also for medicine in general.