Eating disorders are heterogeneous disorders characterised by a maladaptive drive to lose weight and, for the most part, by extreme fear of weight gain and overvaluation of thin body image. Calorie restriction, overexercise and purging behaviours put some sufferers at high risk of physical morbidity and mortality. Mental preoccupations interfere with social, professional and general quality of life. Patients’ defensive secrecy and compulsivity can make it hard to diagnose and treat such disorders despite the suffering they involve. Integrated medical and psychiatric intervention can save life and safely improve nutrition. Behavioural support – with family and carer involvement when appropriate – can counter the dysregulation that leads to vicious cycles of restriction–binge–purge, helping patients develop new skills to regulate emotion without weight losing. In the future, exciting developments in neuroimaging, neurosurgery and pharmacology may lead to ways to make the brain more responsive to therapy. Insights into risk factors may also improve preventive strategies in a climate of highly sophisticated international electronic communication.

There has long been considerable individual variation in the regimes for managing acutely disturbed patients, in terms of the drugs used, routes of administration and the dosages given. We all tend to learn from ‘accepted’ practice in the units in which we train, and the lack of good-quality controlled trials, published in leading and accessible journals, compounds the problem. Given the importance of this issue, when concerns about sudden death in the context of high dose regimes are generating considerable publicity (for example, MIND is calling for a blanket ban on dosages greater than those given in the BNF), the need for rigorous research has never been greater. Guidelines have, however, become established in a number of units, and this clear summary by Macpherson et al is therefore to be welcomed.

Psychiatry is the branch of medicine concerned with the diagnosis, treatment and study of psychological disorders. The role of the psychiatrist evolves to reflect developments in medicine, science and society. The scientific knowledge base required for the practice of psychiatry changes from generation to generation, but many of the fundamental principles of practice remain essentially unchanged. We attempt here to identify some of these (relatively unchanging) principles and explore their relevance to contemporary psychiatry. In particular, we focus on the work of some of the more reflective physicians of history (e.g. Sir Robert Hutchison, Sir William Osler) in order to identify and interpret principles of medical practice outlined in the 19th and 20th centuries and we explore the relevance of these conceptual frameworks to the practice of psychiatry in the 21st century.

The Royal College of Psychiatrists' guidelines for the psychotherapy training of trainee psychiatrists include a supervised case experience in supportive psychotherapy. There is, however, a lack of clarity over the concept of supportive psychotherapy and how this might be taught and supervised, and this may discourage trainers from offering formal clinical supervision in this modality. In this article we briefly describe the history of supportive psychotherapy, the various ways in which it has been conceptualised, and some of the research in the area. We discuss the case for training and make practical suggestions for how this experience might be offered by consultant psychiatrists in an everyday psychiatric setting.

As we age, there are characteristic changes in our thinking, reasoning and memory skills (referred to as cognitive ageing). However, variation between people in the timing and degree of change experienced suggests that a range of factors determine individual cognitive ageing trajectories. This narrative review considers some of the lifestyle factors that might promote (or harm) cognitive health. The focus on lifestyle factors is because these are potentially modifiable by individuals or may be the targets of behavioural or societal interventions. To support that, the review briefly considers people's beliefs and attitudes about cognitive ageing; the nature and timing of cognitive changes across the lifespan; and the genetic contributions to cognitive ability level and change. In introducing potentially modifiable determinants, a framing that draws evidence derived from epidemiological studies of dementia is provided, before an overview of lifestyle and behavioural predictors of cognitive health, including education and occupation, diet and activity.

In this article we re-examine the conclusions of our article on advance statements in adult mental healthcare that was published in 2010 in the light of new literature published in the intervening decade. We explore the results of studies on the implementation and effectiveness of advance statements in adult mental health services, and then summarise recommendations for legislative changes from the Independent Review of the Mental Health Act 1983 that are relevant for England and Wales.

Mental disorder and criminality are separate entities but some people with a mental disorder commit criminal offences and some criminals have a mental disorder. Before 1800 there was no separate category of mentally disordered offenders (referred to as criminal lunatics until 1948) in UK legislation. The provision of facilities for mentally disordered offenders in Britain and Ireland overlapped with, but was also separate from, provision for the mentally ill generally. The interface between general and forensic psychiatry is an area of tension and of collaboration. To understand how contemporary general and forensic psychiatry interact, it is useful to have an understanding of how factors have evolved overtime.

Studies of utilisation of psychiatric services have shown that between 4 and 18% of medical students annually identify themselves as ‘impaired’ (Dickstein et al, 1990). An unknown number of students may be ill but do not seek help – they soldier on through classes and clinics not realising that their sleep disturbance, worry, vague pains, flagging spirits, failing grades or increasing use of alcohol represent symptoms of strain and possible psychiatric disorder. Some suspect or know that they are ill but the stigma of accepting mental illness or seeking professional help is so profound that they suffer silently.

The internet provides access to what is often a bewildering array of medical knowledge on mental health, some (but not all) of which is evidence based. As well as information for clinicians, there has been a dramatic increase in the variety and quality of information available for patients and carers. In this article we discuss the advantages and limitations of the types of information available, with suggested sites and strategies for assessing their relative merits.

Supervised community treatment (SCT) is one of the most prominent amendments to the Mental Health Act 1983. It has divided opinion among health professionals and introduces significant powers not previously available in England and Wales. This article considers how SCT fits into the established legislative framework and how it may affect the care delivered by mental health practitioners.

An editorial in The Lancet two decades ago (Lancet, 1981) described the contemporary practice of electroconvulsive therapy (ECT) in Britain as “a shameful state of affairs”. It concluded that, “if ECT is ever legislated against or falls into disuse it will not be because it is an ineffective or dangerous treatment; it will be because psychiatrists have failed to supervise and monitor its use adequately”.

The pace of development and implementation of good information management systems has been disappointingly slow and the potential benefits of using patient information for secondary purposes have not been fully realised. The secondary use of patient data might be at the level of individual practitioners or teams, or at a local-service, regional or national level. Using patient data for purposes other than direct patient care requires an understanding of the principles of case-mix, standards for recording data, the limits of accuracy of data collected in routine practice and of the principles of data security and confidentiality. The alternatives to secondary use of information are to manage the mental health service without information about the people who use it or to gather this information through channels that run in parallel to the process of clinical care.

Homelessness has long been associated with high rates of psychosis, alcohol and substance misuse, and personality disorder. However, psychiatric services in the UK have only recently engaged actively with homeless people. This article provides some background information about homelessness and mental illness and describes the elements of inclusion health and some of the models of service for homeless people that have been established over the past 30 years.

‘Digital’ is an omnipresent yet often vague, misunderstood or feared topic in health services. There are many current and potential gains for individual patients and local populations, clinicians and organisations through optimisation of digital technologies. We argue that understanding the various aspects of digital psychiatry is an essential contemporary need. This is the first of two articles on the subject, exploring the gains and challenges of virtual/online assessments, including ethical considerations and the use of virtual reality and electronic prescribing.

We describe the importance of relational factors in prescribing practices and discuss how they may influence treatment outcomes. Although relational factors play a part in every clinician–patient interaction, they are particularly relevant when managing patients with complex emotional needs. We discuss how relational prescribing can add value when incorporated into standard practice. We introduce psychodynamic theory principles, and we suggest a framework to facilitate reflection and support decision-making when clinicians are faced with complex prescribing decisions.

This article is aimed at organisers of courses for the Royal College of Psychiatrists' membership examinations (MRCPsych) and College tutors preparing trainees for the MRCPsych. Running revision courses requires planning and a good deal of work but should be possible for most MRCPsych preparation courses. The theoretical background of assessments is explained. An overview of the type of examination used in the MRCPsych is provided and advice as to how trainees can best prepare for them given. Advice is given on the recruitment and retention of examiners for mock clinical exams, how to deal with simulated patients and what equipment is useful to buy for the use of trainees. We also explain how trainees can practice for the written papers and how feedback is best given to them. The new MRCPsych formal examination and workplace-based assessment programme are also discussed.

This article discusses the definition, nature and origins of clinical errors and potential means of prevention. The relationship between clinical errors and medical negligence is examined, as are the characteristics of litigants and events that prompt litigation. Legal aspects of medical negligence are outlined and clinical situations most commonly associated with negligence claims are described. Probably no more than 1 in 7 adverse events in medicine results in a negligence claim and the factors that predict whether patients will resort to litigation include a prior poor relationship with the clinician and the feeling that they are not being kept informed. The actual rate of negligence claims in psychiatry is unknown, but it is rising. Clinicians must therefore be aware of the risks and of which areas of practice are most risky.

Engaging patients in first-episode psychosis services is critical in maximising the effect of early intervention and establishing a framework for longer-term treatment. Biopsychosocial assessments determine a working diagnosis and inform evidence-based treatment. Atypical antipsychotics should be used at doses that maximise therapeutic benefit and adherence while minimising side-effects. Patients are helped to construct a narrative of their illness, including a shared understanding of the contribution of biological and environmental risks, and early warning signs. Common comorbid conditions, including depression, suicidal ideation, substance misuse and anxiety, should be addressed. Management of comorbid borderline and antisocial personality disorders is difficult; their nexus with psychosis is discussed. Cognitive–behavioural therapy is a mainstay of treatment, with specific interventions developed for problems typical in first-episode presentations. Core psychosocial interventions include psychoeducation, vocational and educational support, family interventions and multimodal group programmes.

This article outlines the changes to psychotherapy training for psychiatrists proposed in the Royal College of Psychiatrists' new specialist training curriculum. There is some debate about whether this curriculum should be taken up in its present form because of the limitation of resources to implement it. I describe the effect of taking the College at its word that psychotherapy training should be mandatory and the improvement this has already brought about in psychotherapy training on the Exeter and South Devon training rotations. I also discuss what will be required to implement the new requirements.

The term ‘dymorphophobia’ – derived from the Greek dysmorphia, meaning ugliness (expressly of the face) – was first coined by Morselli in the late-19th century. He described a subjective feeling of a physical defect which the patient feels is noticeable to others, although his appearance is within normal limits. Dysmorphophobia first appeared in the US psychiatric nosology (as an atypical somatoform disorder) in 1980, with the publication of DSM–III (American Psychiatric Association, 1980). However, the term was subsequently criticised both because the condition does not represent a phobia as such, and also because the use of the term had become so broad and imprecise (see Munro & Stewart, 1991).