It is time to improve clinical approaches to faith in mental healthcare, particularly in psychotherapy. Understood as a psychological trait, faith has potentially great personal salience and introduces socially desirable biases into human reasoning. Therapies may have faith-informed components, either explicitly, or (as with some forms of mindfulness) implicitly, which may modify the patient's faith as well as producing symptomatic change. In this narrative review, the ethics of faith's inclusion in therapy is briefly appraised. The psychology of faith is discussed, and a model of the influence of the practitioner's faith on therapeutic choice is presented. Finally, faith-informed approaches to practice, including their impact on therapeutic effectiveness, are considered and recommendations made for their optimal implementation.

Baillon et al’s Cochrane review included 430 participants with agitation in dementia from five randomised controlled trials. Overall, the reviewers found that valproate was no better than placebo for the treatment of agitation in people with dementia; however, the quality of the studies included was very variable. Adverse effects and events were higher in the treatment group compared with the controls, although these finding were largely based on low-quality data with incomplete reporting; thus, valproate's safety profile is of concern. This review demonstrates that there is insufficient evidence to change current treatment guidelines.

A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.

This article examines the concept of moral responsibility in psychopathy. In doing so it shows how philosophical ideas can be used to help approach a complex issue in psychiatry. Building on a fictitious case, we explore two arguments: the exempting view, which proposes that psychopaths lack any ability to function as moral agents; and the mitigating view, which concedes that there are impairments in moral understanding in psychopathy, but takes these to be insufficient to be completely exempting, instead concluding that such individuals are at least partially morally responsible. Typically, clinicians (and the courts) are more comfortable with a mitigating view, whereas philosophers tend to extol an exempting view. Through discussion of the case, we illustrate the value that philosophy brings to clinical psychiatry and the ways in which psychiatry can enrich philosophical debate.

There is a debate in psychiatry regarding whether it is better to use neo-Kraepelinian diagnostic categories or unitary models of psychosis in clinical practice. This article argues that clinicians should use either model as appropriate for the case in question, along with the conceptual framework used in the clinical management of psychosis without a clear biological cause. It first explores the values involved in the development of psychiatric classification systems, the purpose of classification and how we reached the current DSM/ICD and unitary models of psychosis. It then describes a diagnostic approach in which the choice of model should depend on the case in question, and offers a diagnostic protocol to guide the decision.

In 1951 Asher described chronic factitious disorder characterised by dramatic presentations, histories and recurrent admissions. Asher initially described three types of presentation – acute abdominal (laparotamophilia migrans), haemorrhagic (haemorrhagia histrionica) and neurological (neuropathica diabolica). Factitious disorder is now included in both DSM–IV and ICD–10. Numerous case reports exist but the evidence base for effective management strategies remains relatively sparse. It is an uncommon disorder most often encountered in liaison psychiatry that remains difficult to manage and characteristically stimulates strong countertransference reactions in the teams involved. Psychiatric involvement remains vital in such cases although poor engagement is often a significant obstruction. As an illustration, we present a vignette based on case of a previously unreported variant of the neurological category involving Guillain-Barré syndrome.

Partial agonists of dopamine receptors are used in combination with full antagonists in treating psychosis, either to mitigate side-effects or in the hope of increasing effectiveness. We examine how combinations may affect the occupancy of D2/D3 dopamine receptors and explore how these can explain the outcomes in the light of the dopamine hypothesis of psychosis. The combinations considered here are from published studies combining aripiprazole with amisulpride, with risperidone in people with hyperprolactinaemia and with olanzapine to mitigate weight gain. We discuss possible worsening of symptoms by the addition of a partial agonist or switching. We also examine the potentially adverse interaction with a full antagonist such as haloperidol given during a subsequent relapse to control severe agitation.

This commentary questions a Cochrane review that examined whether first-rank symptoms are a useful diagnostic tool for differentiating schizophrenia from other psychotic disorders. It concludes that first-rank symptoms are not particularly accurate in this role, although they might be useful initial screening questions in community surveys or waiting-room screening.

Suicide is a complex issue that is sparking increasingly more debate in contemporary society. There is need for an open discussion on the concept of rational suicide, specifically in relation to psychiatric disorders, so as to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients. To be able to conduct such a discussion in an objective manner, we must first be made aware of the potential prejudices that we harbour on the topic of suicide as a result of our societal and historical background. A historical and philosophical approach to the topic, through careful examination of the topic of suicide in the texts of Plato, helps create such an awareness.

Clinicians trained in cognitive–behavioural therapy (CBT) are frequently not trained to work with dreams. Given the high prevalence and impact of nightmares and bad dreams, empowering CBT therapists to effectively work with these sleep phenomena is crucial to improve therapeutic outcomes. This article briefly outlines a cognitive–behavioural model of dreams and reviews some clinical guidelines for directly and indirectly addressing nightmares and bad dreams in CBT practice.

In response to an article on recent advances in the use of ECT for depression, this commentary supports earlier and more extensive use of the treatment. It challenges the belief that ECT is associated with a higher risk of cognitive deficits and mortality and points out its rapid effect compared with antidepressant medication. It calls for clinicians to remain up to date regarding ECT and consider its opportune use in severe depression.

Socratic questioning is at the core of collaborative clinical communication, with a wide array of applications in behavioural medicine and psychotherapy. This brief article describes the process of therapeutic Socratic questioning, illustrates its clinical applications in therapy and provides a brief update on its recent developments.

The National Service Framework for Mental Health (NSF–MH), published by the Department of Health in 1999, set an ambitious 10-year agenda for improving mental healthcare for working-age adults in England, based on seven quality standards covering all major services. The NSF–MH was supported by a series of other policy documents published by the government. This article illustrates a means of modelling the government's policy for adult mental health services to produce figures for the necessary services, staffing and financial resources required to meet the policy objectives. The findings of a report recently published by the Sainsbury Centre for Mental Health, which undertook a detailed assessment of what needs to be done to deliver these standards in terms of service provision, staffing and funding, is summarised and its implications examined.

Eye movement desensitisation and reprocessing (EMDR) is a psychological therapy that addresses trauma, stress and emotional distress. It has been successfully used in the management of various psychiatric disorders. This article shows that it may also be safely used to manage the psychological distress arising from a variety of physical health conditions and in so doing, reduce the illness burden from conditions such as various cancers, traumatic childbirth, tokophobia, pre-eclampsia, myocardial infarction, haemodialysis in end-stage renal disease, and acute postoperative pain. It can be a stand-alone treatment for hyperemesis gravidarum and tinnitus. The article examines the rationale and evidence for its use in these conditions and suggests areas where more research is needed. Adding EMDR therapy to the range of available interventions in general hospitals has the potential to improve the health and well-being of patients in these settings.

The goal of psychoanalytic psychotherapy with a distressed child is to alter the child's psychic structure and function. The technique is based on the same theory as adult psychoanalytic psychotherapy (see Box 1). The unconscious is central, as is the interpretation of defence, resistance, transference, working through and the reconstruction of earlier life. It differs from adult psychotherapy in that the child's age and level of development are at all times central to the work. In young children the focus of interpretation is on free play, while with adults it is free association of ideas. In the treatment of adolescents a combination of techniques, both adult and pre-adolescent, are used, while for late adolescents the technique is basically adult technique with attention to issues relevant to that stage of the life cycle.

The widespread nature of child sexual abuse is increasingly recognised and in the public domain following high-profile cases. Children and vulnerable people need protecting from such abuse. At the heart of the dilemma facing clinicians is the need to feel supported by the legislative framework to maintain confidentiality and use their clinical discretion in the best interests of their patients, ensuring that they receive the help they need, but also protecting others at risk. There are compelling arguments both for and against strengthening legislation to improve child protection.

For decades society has recognised that children are vulnerable and so it has sought to protect them. However, similar legal protection for adults who may be equally vulnerable has been neglected. The incremental introduction of legislation and reports in the UK, along with guidelines on good practice, now afford adults safeguarding procedures similar to those for children. This article offers a practical overview of these developments. In addition, it highlights some of the dilemmas that face practitioners in this evolving arena, as legislation and policy do not anticipate the diverse scenarios in which mental healthcare professionals may be involved. Decisions made can be subject to legal challenge, so it is important that psychiatrists understand their role as well as the role of their organisation in this complex area.