The post-traumatic stress disorder (PTSD) diagnosis encompasses heterogeneous presentations, many of the diagnostic criteria are not trauma-related and almost all PTSD symptoms are common to several psychiatric diagnoses. Flashbacks are the only symptom unique to PSTD. However, the absence of a consensus definition of flashbacks means that this term means different things to different people, causing misunderstanding and miscommunication, and presumably affecting treatment. This Refreshment discusses how flashbacks are defined in DSM-5-TR and ICD-11 (essentially, as reliving/re-experiencing when awake) and briefly describes the dual representation theory's account of flashbacks. In discussing what flashbacks are and are not, it aims to promote improved understanding, assessment and diagnosis of PTSDs.

Primary hyperparathyroidism (PHPT) is the presence of hypercalcaemia with an elevated or inappropriately normal parathyroid hormone level. In clinical psychiatry this is often detected on routine blood investigations. This article aims to help mental health professionals understand the relevance of PHPT to psychiatry and offers some guidance about further management of patients presenting with this endocrine abnormality in mental health settings. PHPT can be associated with both mental and physical health problems in some individuals, making it a crucial diagnosis that should not be overlooked.

Paediatric functional gastrointestinal disorders (P-FGIDs) are common, affecting up to 25% of children worldwide. They are characterised by chronic abdominal pain and/or altered bowel habits without an underlying disease pathology. P-FGIDs are often associated with co-occurring anxiety and depression across all ages and treating P-FGIDs may provide an opportunity to develop a young person's wider emotion regulation capacities. Using a fictitious case vignette, we outline the range of psychosocial and biomedical treatments for the disorder and the need for an integrated and holistic approach. We propose that by intervening early and enabling children to be curious about, rather than fearful of, their bodily sensations, clinicians may be able to alter harmful illness trajectories in both pain and psychiatric domains.

Quality improvement (QI) is an evidence-based approach to analysing and improving healthcare systems. QI's success has led it to become a required competency expected of medical professionals in several countries. However, much of the QI literature to date has not focused on mental health. Moreover, many psychiatrists have no formal training in QI. To address this gap, this article introduces key QI concepts, including six dimensions of quality care, the Model for Improvement and plan–do–study–act cycles. Each QI concept is illustrated using a fictitious case study of an out-patient psychiatrist reducing chronic benzodiazepine use in their clinic.

Until recently, statistical consultants did not have to worry about being replaced by artificial intelligence. There was no statistical analogue to ‘Dr Google’ before ChatGPT arrived on the scene. Although ChatGPT (most of the time) adequately responds to basic queries such as the assumptions of different statistical tests or summarises relevant manuals on statistical software providing clear instructions with point-and-click software such as SPSS, there are many important aspects of statistical consulting that ChatGPT does not cover. This tutorial article is about these aspects: a summary of what statistical consulting is, its purpose and possible settings during the empirical research cycle, the role and responsibilities of the consultant and the client, how to ensure a good consulting experience, how to prepare for a consulting session, typical questions and more. The article was written for researchers who are considering contacting a statistician for the first time and aims to facilitate a good and fruitful consulting experience for all parties involved.

This article examines the complex phenomenon of self-harm, exploring its motivations, theoretical underpinnings and the intricate transference and countertransference reactions that arise in clinical settings. It aims to integrate psychiatric understanding with contemporary theories of the impact of trauma on both the body and the mind, to deepen the knowledge of self-harm and increase the effectiveness of treatment approaches. The article argues for a nuanced view of self-harm and emphasises the need for compassionate, well-informed care. By addressing the psychodynamics of self-harm, the article seeks to improve therapeutic outcomes and foster an empathetic and effective clinical response. Fictitious case studies are used to illustrate these concepts, demonstrating the critical role of early attachment experiences and the challenges faced by healthcare providers in management.

Metabolic dysfunction is an established phenomenon in people with severe mental illness (SMI), and it has a higher prevalence than in the general population. It is associated with increased morbidity and mortality, and effective recognition and management are essential to enable good psychiatric care. Despite widespread awareness of this disparity for several decades, health outcomes continue to worsen, highlighting the need for more effective preventive and treatment measures. This article outlines the risk factors that contribute to metabolic dysfunction in this population, including genetic, environmental and pharmacological factors, and considers underlying metabolic pathophysiological processes as part of SMI itself. To aid discussions with patients, recognition and interpretation of metabolic risk factors are outlined, together with mitigating strategies. Novel areas of uncertainty are discussed, including the use of a ketogenic diet. This article advocates use of the term ‘metabolic psychiatry’, to increase awareness of the significant overlap between psychiatric illness and metabolic dysfunction.

Delirium frequently occurs among hospital in-patients, with significant attributable healthcare costs. It is associated with long-term adverse outcomes, including an eightfold increased risk of subsequent dementia. The purpose of this article is to inform clinicians of the best practices for spotting, stopping and treating delirium and provide guidance on common challenging clinical dilemmas. For spotting delirium, suggested screening tools are the 4 ‘A's Test (in general medical settings) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Prevention is best achieved with multicomponent interventions and targeted strategies focusing on: (a) avoiding iatrogenic causes; (b) brain optimisation by ensuring smooth bodily functioning; (c) maintaining social interactions and normality. Non-pharmacological approaches are the first line for treatment; they largely mirror prevention strategies, but the focus of empirical evidence is on prevention. Although sufficient evidence is lacking for most pharmacological approaches, an antipsychotic at low doses for short durations may be of utility for highly distressing or high-risk situations, particularly in hyperactive delirium, but only as a last resort.

Qualitative research methods, defined as the collection and analysis of non-numerical data to understand concepts and experiences, are often used to inform mental health practice and policies. When utilising qualitative research methods, it is important that the researcher uses an explicit theoretical framework to guide the study. A theoretical framework informs how researchers engage with a topic or problem, report on their work with participants, describe key concepts and address assumptions within the research questions and procedures. In this article, we describe the basic concepts underpinning three of the most commonly used frameworks in mental health research: positivism, interpretivism and critical realism. We also describe how these theoretical frameworks may guide the qualitative process, including the theoretical and methodological approaches chosen and the ways in which these theoretical frameworks can be applied in practice. To enhance understanding of these frameworks, we include examples of how such frameworks can be used in qualitative mental health research.

This article discusses sceptical arguments about measurement scales. Measurement scales are part of a promising agenda of openness, transparency and patient and public involvement (PPI) in medical research, but have received critical, sometimes hostile attention from anthropologists. This is because scales repackage localised cultural assumptions about distress as something universal and pan-human and have the capacity to reshape people's interior lives in unhelpful, possibly harmful ways. We take as an example the Patient Health Questionnaire-9 (PHQ-9). Use of the PHQ-9 is currently mandated by major funders. But its history suggests flawed PPI and a lack of openness. The article suggests a constructive role for anthropology in mental health research, using ethnographic evidence and theory to show how, although they have their uses, mental health scales should not be regarded as inert or harmless.

Lunatic Asylums, published 130 years ago, is a fascinating insight into how these institutions were managed in the late Victorian era. This brief article considers what it reveals about the zeitgeist of the time and the book's author, the remarkable Charles Mercier.

Medical dramas such as Grey's Anatomy influence young people's career aspirations, creating unrealistic expectations. This article examines the gap between these portrayals and the reality of medical practice, highlighting challenges such as rigorous training and high stress. Using Italy's ‘numero chiuso’ (‘closed number’) system as a case study, it addresses the global issue of intense competition in medical school admissions. The article advocates for realistic education and better support to prepare future healthcare professionals.

Domestic abuse – abusive behaviour perpetrated by an adult towards another adult to whom they are personally connected (e.g. partners, ex-partners or family members) – damages mental health, increases mental health service use and challenges clinical management. Training and guidance for mental health professionals on identifying and responding to patients exposed to domestic abuse are available, but there has been less development of resources for mental health professionals in identifying, assessing and responding to perpetrators of domestic abuse. In this article, we describe a framework for responding to domestic abuse perpetration in clinical settings in general adult mental health services, aimed at improving practice. This could support mental health professionals in sensitive enquiry and assessment for domestic abuse perpetration, and guide appropriate responses, as part of routine training and continuing professional development.

Although most people experiencing psychosis are not violent, a diagnosis of a psychotic disorder is associated with an increased likelihood of violence. Some progress has been made in delineating the nature of this association, but it remains unclear whether specific types of psychotic experience make a specific contribution to the propensity for violence. Just as the phenomenological approach has produced a fuller understanding of psychotic experiences (that can inform improved aetiological and interventional frameworks), the authors assert that such an approach (with its closer attention to the full extent of the patient's subjectivity) has the potential to advance our understanding of the relationship between psychosis and violent behaviour in a way that has clinical applicability. This article examines this potential by overlaying approaches to the phenomenology of psychosis with a framework for the subjectivity of violence to demonstrate how a fuller explanatory formulation for violent behaviour can be derived.

Complex post-traumatic stress disorder (CPTSD) was adopted as a new diagnosis in ICD-11. Trauma-focused cognitive–behavioural therapy (CBT) is effective in treating PTSD but with CPTSD being a recently defined diagnosis, the evidence for its effectiveness in that disorder is not as clear, but it is still promising. This article reviews the diagnosis, psychopathology and some key differential diagnoses, and looks at the two CBT approaches that are currently used in clinical practice: the phase-oriented approach and the unimodal approach. The key aims of this article are to clarify the concept of CPTSD, its differentiation from borderline personality disorder and prominent comorbidities, how it develops and how CBT is used to treat it.

Post-traumatic stress disorder (PTSD) is a complex, heterogeneous mental health problem that can be challenging to identify, assess, understand, diagnose and treat. This article provides an overview and critique of key topics, literature and principles to inform comprehensive and meticulous assessment of PTSDs. Although expert witnesses are the target audience, this article will have relevance for identifying, assessing, understanding and diagnosing PTSDs in all clinical contexts. A range of topics relevant to assessment are discussed, including: the complex relationship between trauma and PTSDs; DSM-5-TR PTSD and ICD-11 PTSD and complex PTSD diagnoses and the similarities and differences between them; the clinical presentation of PTSDs; psychological models of PTSDs; how to approach assessment and differential diagnosis; the impact of PTSD on neuropsychological abilities and functioning (disability); causation, reliability and assessing PTSDs when this is being considered as a legal defence; evidence-based interventions (medication, psychological therapy, when is the ‘right time’ for therapy, contraindications); and prognosis (if untreated, how long therapy/change takes). Given ongoing debate, the article proposes that trauma exposure is best defined in future iterations of the DSM and ICD as exposure to one or more psychologically threatening or horrific experiences that are overwhelming.

To make a valid will, a person should be able to understand the nature and consequences of doing so, the extent of their estate and the claims others may have on it. No disorder of mind should be present that would affect their testamentary decisions, and clinicians are therefore often asked to give an opinion on whether a person has testamentary capacity. This article discusses the legal issues involved, with reference to UK case law (in particular, the legal test of Banks v Goodfellow (1870)), and outlines the requirements of testamentary capacity assessment (including retrospective assessments), the clinician's responsibilities when requested by a solicitor to make an assessment of capacity (‘the golden rule’) and what they might expect if appearing in court to give expert witness regarding testamentary capacity. Fictitious case studies are presented illustrating certain points in testamentary capacity assessment.

Clinical guidelines recommend avoiding the use of medications to manage personality disorder. In clinical practice, however, substantial amounts of medication are used. In this article, we summarise the recommendations of guidelines published in various countries in the past 15 years. We review the evidence from randomised controlled trials and recent reviews, discuss the discordance between guidance and clinical practice and give recommendations on what a clinician should consider if they choose to prescribe in cases of severe disturbances in mood or behaviour despite the lack of evidence.

This article reviews some of the various shorter cognitive tests that are available. They vary in complexity, time taken to administer them and what specific neurocognitive domains they assess. They range from screening tests such as the Mini-Cog to more detailed measures such as the Montreal Cognitive Assessment or the Mini-Mental State Examination. The Addenbrooke's Cognitive Examination is more comprehensive and covers attention, memory, verbal fluency, language and visuo-spatial function. The article suggests areas of cognition that may be related to the six competencies assessed in the determination of fitness to plead and to stand trial.

The article reviews some basic statistical concepts used in medicine, including the mean, standard deviation, sensitivity and specificity. Using this background the authors describe how these can be applied to cognitive tests, taking the Montreal Cognitive Assessment (MoCA) as an example. Two different approaches to using the MoCA in diagnosing dementia are considered: one using a fixed cut-off score, the other taking account of normative data about the effects of age and educational level on MoCA scores. It is recommended that clinicians assessing cognitive function should not rely on a fixed cut-off score, but where possible compare the patient's result with those of people of comparable age and educational background, although normative data of this kind are not always available.