Robin Downie provides useful reminders of the broad basis of medical practice. This should encourage the sort of ‘engaged attention’ that he describes – the sort of attention needed to appreciate works of art. But what else is going on in a clinical encounter (as in a work of art)? This commentary suggests that real communication is to be understood in dramaturgical terms as occurring between actors in real time and space. It involves shared understandings, which require empathy but which depend on something ineffable to do with our standing as human beings in the world.

‘Drug-centred’ prescribing in psychiatry has been proposed as a new and better approach than the current ‘disease-centred’ alternative. It targets symptoms most important to the patient using the concept that psychotropics act indirectly by altering normal functioning. I contend that it is a straw man: psychiatrists already use ‘drug-centred’ prescribing, applying their knowledge of a drug's pharmacological profile and evidence base to treat each patient's symptoms, not their diagnostic classification. Furthermore, there is no compelling evidence that psychotropics act by altering ‘normal’ functioning: rather, they have diverse effects on different mental states.

Psychosis is a complex presentation with a wide range of factors contributing to its development, biological and environmental. Psychosis is a feature present in a variety of psychiatric disorders. It is important for clinicians to keep up to date with evidence regarding current understanding of the reasons psychosis may occur. Furthermore, it is necessary to find clinical utility from this knowledge so that effective primary, secondary and tertiary preventative strategies can be considered. This article is the first of a three-part series that examines contemporary knowledge of risk factors for psychosis and presents an overview of current explanations. The articles focus on the psychosis risk timeline, which gives a structure within which to consider key aspects of risk likely to affect people at different stages of life. In this first article, early life is discussed. It covers elements that contribute in the prenatal and early childhood period and includes genetic, nutritional and infective risk factors.

The artist Arshile Gorky played a central role in the development of Abstract Expressionism during the 1940s. Born in Armenia, his early figurative works recall a childhood of persecution by Ottoman Turks, a period during which he suffered a number of significant losses. The painting The Artist and His Mother (c. 1926–1936) is based on a photograph showing the 7-year-old Gorky with his mother, 7 years before she starved to death during the Armenian Genocide. This article explores the early experiences that haunt this painting and the difficulties Gorky struggled with during his adult life as an immigrant to the USA – factors that contribute to an understanding of his suicide in 1948.

The media offers opportunities for psychiatrists to communicate with a wide and varied audience, thereby influencing the views of the public and policy makers on mental health issues. There are many different types of media outlet, including daily news media, documentary makers, specialist media, features and comment, and new media. The Science Media Centre is an independent press office that aims to help ensure that the views of scientists, clinicians and researchers are heard in the UK national news media when their area of expertise hits the headlines. In the news media, journalists work to tight time frames and often focus on sensational and controversial topics, presenting challenges for those wanting to engage. For experts to work effectively with the news media it helps to understand more about the way the media works and how to develop necessary skills. Psychiatrists who do work successfully with the media can help ensure that the public receive accurate information about mental health problems, and gain an appreciation of the importance of research in the field and a better understanding of the role of the psychiatrist.

In recent years, there has been growing recognition of the significant incidence of child abuse and neglect in the population, and of its adverse effect on the development of children and their mental and physical health. This awareness has led, especially following the implementation of the Children Act 1989, to an increased demand for psychiatric assessments of children for the courts by social services, solicitors, guardians adlitem and the courts themselves. There has been some reluctance to take up this work, for two main reasons. First, there has been concern that these time-consuming assessments will result in a shift of resources away from treatment, thus having an adverse impact on the balance of child mental health services. In some areas, the need has been recognised within the commissioning and contracting processes. Provision has been increased accordingly, acknowledging that it is part of the responsibility of the health authorities to assist the local authorities in this way.

We describe the case of a child presenting with what initially appeared as a pervasive developmental disorder (ICD F84.1) associated with, and in our view, induced by, schizophrenic illness in the mother. Important issues are raised for both adult and child psychiatry, in particular that the failure of the Mental Health Act (1983) to address the mother's needs adequately, left the child vulnerable to her untreated illness.

The category ‘somatoform disorders' was introduced comparatively recently in DSM–III and thereafter in ICD–10: it is the umbrella term currently favoured to cover a heterogeneous group of interrelated and overlapping syndromes, which have been given many names over the years. All these syndromes have in common the process of somatisation: that is, the presence of physical symptoms unexplained by physical disease, with variable degrees of distress and loss of function, about which the patient consults doctors.

We outline benefits and problems of introducing internet-based approaches (e.g. e-learning, social networking) into journal clubs. We also look at potential risks to the continuing existence of clubs posed by the changing health economy and the move in psychiatry from clinical medicine to community care. Overall, we are optimistic for the journal club's survival.

With the arrival of clinical governance, psychiatrists working for the National Health Service (NHS) can no longer work in isolation, and commitment to both clinical effectiveness and continuing professional development (CPD) is expected and likely to become mandatory. Clinical governance gives clinical effectiveness a high priority within NHS organisations, both at primary and secondary care levels, together with clearer lines of accountability.

Self-determination theory has been offered as a potential theoretical framework for recovery. It has been argued that a concept as wide-ranging as recovery seems likely to require a number of theoretical frameworks, including self-determination theory, which appears to be particularly applicable to the clinical and social dimensions of this concept. With its emphasis on social competence and environmental support, self-determination theory may be particularly useful as a framework for considering recovery in client groups with higher levels of service need associated with disability or risk.

Anthony Winston reviews and describes current perspectives on the aetiology of borderline personality disorder, covering areas such as the role of traumatic factors, attachment theory and self-psychology. The author links these to the psychopathology of the borderline patient who experiences difficulties such as regulation of affect, impulse control and cognitive capacity to both think and reflect. The psychological function of splitting is considered along with other defence mechanisms as having adaptive potential for the borderline patient. Winston describes in a helpful way the links between human development, psychodynamics and psychopathology as he reveals some of the more recent contributions to the field of BPD. At the beginning of his article, he emphasises the problems encountered when attempting to treat or manage patients with BPD. He centres these difficulties on the counter-transference of the clinician, pointing out how such feelings can “all too easily be transformed into therapeutic nihilism”. His article can easily be read as an attempt to counter such a state of mind and he appears to try to generate a more hopeful if not optimistic outlook. In doing so, I fear that he goes beyond his own account of the research evidence for the effectiveness of treatment. Such enthusiasm or optimism can readily be understood as a reactive polar opposite to nihilism or pessimism. I would like to consider further Winston's statements germane to this aspect of his article and raise for further discussion some other ideas which extend beyond the narrower confines of aetiology and psychological therapy.

Psychopathology is an integral part of the theory and practice of psychiatry. This commentary explores the importance of psychopathology, especially with regard to clinical practice. The concept of lifeworld is introduced as an important component of attributing meaning to a person's experience of mental disorder. It is also argued that the advance of neuroscience does not preclude the importance of psychopathology.

This article examines how madness is depicted in the work of Dostoyevsky. It gives a brief account of Dostoyevsky's life before looking at the many ways in which he portrayed insanity. It suggests that he provided a sophisticated and complex picture of mental illness which has relevance for how contemporary clinicians conceive of psychiatric illness.

Making effective use of psychotherapy can be difficult for patients and their doctors, for a number of reasons. First, the term ‘psychotherapy’ itself is unsatisfactory, used by some people to indicate a particular type of psychotherapy (usually psychodynamic), and by others to embrace all forms of psychological treatment. When we use the term ‘medication’ we usually add a qualifying adjective (e.g. antidepressant or antipsychotic medication) and it is helpful to do so in psychotherapy (e.g. dynamic therapy, cognitive therapy, etc.).

Formal communication skills training is the norm at UK medical schools, and evidence is mounting that it is effective in a number of domains, including patient satisfaction and shared decision-making, leading to improved treatment adherence. However, applying these models in mental health settings is challenging, despite the fact that positive therapeutic relationships and an ability to actively manage consultations are the cornerstone of psychiatric practice. Communication skills training is still too often regarded as better suited to physical health consultations than more complex psychiatric interviews. Here, it is considered why this might be, with reference to the one eligible randomised controlled trial identified in this systematic literature review.

Email is a major means of communication in healthcare and it facilitates the fast delivery of messages and information. But email's ubiquity has brought challenges. It has changed the way we get things done, and working days can be dictated by the receipt and reply of multiple email messages, which drown out other priorities. This article examines email's advantages and disadvantages and, with a focus on healthcare professionals, examines what individuals and organisations can do to ensure email works for us, rather than – as can seem the case – the other way around.

This paper has two objectives: to review some aspects of the law of confidentiality in the health care field and to evaluate how the law of confidentiality impacts on the processes of child protection.