The eating disorders of childhood and adolescence lie in the murky waters between those of adulthood anorexia nervosa and bulimia nervosa, and the feeding disorders of childhood. Early-onset eating disorders include anorexia nervosa, on which this article will focus. The younger the patient, however, the more likely he or she is to present an ‘atypical’ picture. Anorexia nervosa and bulimia nervosa have been previously addressed in this journal, by Palmer (1996) and Fairburn (1997). With older adolescents, ideas relevant to adult patients will be appropriate at times. Nevertheless, developmental issues should be borne in mind.

Clinical governance is defined by the government as:

“a framework through which [National Health Service (NHS)] organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish'’ (emphasis not in original) (Department of Health (DOH), 1998).

In this paper I will be discussing the professional duties of psychiatrists. I will argue that there is an ethical tension at the heart of psychiatric practice – between the psychiatrist's professional duties to his or her patient, and what professional duties there might be to protect public safety. It may be of some comfort to clinicians to know that this tension has exercised the best minds for centuries, including thinkers such as Marcus Aurelius nearly 800 years ago (Spruit, 1998).

Supervision is a key feature of professional development in a wide range of professions. The Royal College of Psychiatrists, in its ‘Statement on approval of training schemes for basic specialist training for the MRCPsych’ (available on request from the Postgraduate Educational Services Department of the Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG) dictates that each basic specialist trainee should have a “protected hour per week” with his or her educational supervisor. This time should belong “exclusively” to the trainee and be “for the benefit of the trainee”. The Higher Specialist Training Handbook (Royal College of Psychiatrists, 1998) also emphasises the central importance of supervision as part of higher training for specialist registrars. Training consultants are expected to be “readily available” to trainees, and to provide a “regular, weekly, timetabled supervision session”. Supervision is obviously perceived by those responsible for standard-setting in psychiatry as a key activity. However, there is a marked lack of clarity as to what constitutes good and effective supervision and there are often few opportunities for learning how to supervise. Hayes (1996) writes about research supervision but his comments are equally applicable to other forms of supervision. He suggests that quality supervision, where it exists, is often by accident rather than by design. It is likely to have been acquired experientially and not without some past hurt to either supervisor or supervised or both. He argues that too much attention has been paid to the quality control of supervision and not enough to quality assurance, with insufficient attention paid to all the possible roles of a supervisor and the key personal attributes necessary to fulfil these roles.

Trainees need to gain experience in the psychotherapies, but practical problems in implementing training programmes have made it difficult for many trainees to access the full range of experience.

Improvements over recent decades in acute care of the brain-injured now ensure that all but the most severely injured survive. The legacy of that survival is an increasing number of people with enduring organic mental disorders. Here, I will focus upon the psychiatric sequelae of five types of severe single-insult brain injury: head trauma, subarachnoid haemorrhage, and hypoxic, hypoglycaemic and postencephalitic injury. Thrombotic stroke is a common and important cause of brain injury but the psychiatric consequences have been more extensively studied and are fairly well-known (Robinson & Price, 1982; Starkstein et al, 1987). Damage due to alcohol and associated malnutrition is also well-documented (Jacobson & Lishman, 1987, 1990). Neither will be specifically addressed here, though some of the consequences of brain injury are similar, regardless of cause.

Psychiatric emergencies are common and each case presents particular problems and difficulties. This article focuses on one subset of psychiatric emergencies, that of severe depression, and on the role of and use of antidepressant treatments in these conditions. The clinical situations to be discussed in this article include active suicidality, severe psychomotor retardation (with associated problems of hydration and nutrition), affective psychosis, bipolar depression and behavioural disturbance.

A 19-year-old student, wandering the streets of a Northern city, is picked up at 3am by a taxi driver. The student requests delivery to a fictitious destination. The student recounts to the driver a series of events including abandonment by parents at the age of six in a forest in the West Country, and subsequent adoption by an elderly couple who live in Birmingham. The taxi driver takes the student to the central police station, where, after a brief interview, sectioning under the Mental Health Act 1983 takes place.

This article will concentrate on insight into serious mental disorder. Not psychoanalytic insight – nor indeed, the insight all of us have, to a greater or lesser extent, into our own attitudes, motives and behaviour – but the insight which patients with psychosis have into their mental pathology. This is no longer considered an all-or-none phenomenon, but rather a dimensional one, so that subjects can have different levels of awareness into their illness. The suggestion was first mooted by Aubrey Lewis (1934) in his seminal work on insight. Conceptual exploration of insight has been activated in the past decade and is proceeding in parallel with the construction of special scales to measure insight and research into its cognitive, biological, social and cultural basis.

Barring a few exceptions (such as rauwolfia), most of the psychiatric medications have been developed in the West, especially the USA, the UK and Europe. Their safety trials have been conducted in the populations living in these parts of the world. Although these drugs are used all over the world there is a limited research to determine accurate pharmacodynamic and pharmacokinetic profiles across different ethnic groups. Hence, clinicians usually adopt a ‘universalist style’ (seeing every condition and treatment as similar) of managing psychiatric illnesses, but this appears to neglect the information from the emerging literature which advocates a relativist approach to pharmacotherapy (see Lin et al 1995 for review). Anthropologists have encountered ‘phenomenological absolutism’ in a general tendency of people from one culture to perceive and value other cultures in terms unconsciously based upon their own, but phenomenologically experienced as absolute and universally applicable (also known as ethnocentrism). In addition to ethno-biological determinants of drug response, there are significant cultural factors: the concurrent use of pluralistic health systems, alternative therapies and folk remedies which might support, hinder or complicate pharmacotherapy and treatment adherence. In this paper we highlight some key factors of which clinicians need to be aware. These include pharmacodynamic and pharmacokinetic principles, and application of these principles in pharmacological management of psychiatric conditions. Ethnic differences in pharmacodynamics are most clearly demonstrated in the greater sensitivity to a variety of drugs in Caucasians than in Asians or in African–Caribbeans.

Medication non-adherence is a major obstacle to translating treatment efficacy in research settings into effectiveness in clinical practice (Dickson & Kendall, 1986; Scott, 1995). Randomised controlled trials indicate that brief interventions such as cognitive-behavioural educational packages for depression, cognitive therapy for lithium clinic attenders and compliance therapy for people with schizophrenia may be beneficial (Cochran, 1984; Katon et al, 1995; Kemp et al, 1996). However, clinical psychiatry has been surprisingly slow to investigate individual risk factors for medication non-adherence or to use strategies to enhance adherence that have been used extensively in other chronic illness populations.

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).

Recognising the vast extent of psychiatric morbidity internationally and the burden of mental illness on people, communities and nations, the World Psychiatric Association and the World Federation for Medical Education have recently published global guidelines for developing core curricula in psychiatry for medical students (Walton & Gelder 1999). More locally, major changes are taking place in undergraduate medical education throughout the UK. These changes represent a response to the appreciation, both by medical schools and by the General Medical Council (GMC), of two major pressures in undergraduate education. The first is that students have been asked over the years to accumulate more and more factual knowledge while the knowledge base in medicine itself expands and changes more rapidly. The second is that both understanding of illness and delivery of care are developing an increasing focus on the role of the community and community support. These general pressures have led to a number of specific recommendations, initially put forward by the GMC in their document Tomorrow's Doctors (GMC, 1993). This document encourages the reduction of ‘core knowledge’ taught to medical students to 65% of what has previously been taught, together with the identification of special study modules (SSMs), which would fill the remaining time in the curriculum. These SSMs would allow students to explore areas of particular interest in greater depth than was previously possible.

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.

Carlyle Jacobsen and John Fulton, at Yale in the early and mid-1930s, investigated primate frontal lobe function. Following bilateral frontal lobecotomy, monkeys and chimpanzees developed a delayed-response deficit, being unable to perform tasks when there was a significant delay between the stimulus and the required response. There were accompanying behavioural changes, with the animals becoming more placid and lethargic and losing their characteristic inquisitive initiative. They became distractible, with difficulty in maintaining an attention set. They had great difficulty in adapting to changes in the directions of an already learned task, tending to perseverate.

The scientific study of sleep and its disorders is essentially just a few decades old, but during that time impressive advances have been made in the biological knowledge of sleep. There has been recognition and treatment of a wide range of sleep disorders from which many people in all sections of the population suffer. The common adverse consequences of persistent sleep disturbance (at personal, educational, social and occupational levels) for members of the public at large have become clear (Dement & Mitler, 1993), as have the special risks of such problems to which certain groups are exposed – notably people with chronic psychiatric or physical disorders or learning disabilities.