We discuss the complicated nature of communication between people from different cultural groups, perhaps using a second language. We focus on the fact that mental health practitioners and service users often have in common neither their cultural backgrounds nor their explanatory models of illness. Communication even in a shared language can be less than optimal as words carry multiple meanings. Consequently, consultations that involve culturally grounded explanatory models of illness challenge the professional. We give examples showing that reconciling different explanatory models during the consultation is a core task for psychiatrists and mental health practitioners working in multicultural settings.

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.

Agitation in psychiatric settings, particularly in psychosis, presents a staggering challenge for clinicians, who must both manage the patient's acute symptoms and simultaneously make an accurate diagnosis. Too often, the management of the former confounds the latter. Patients are very often sedated medically, which masks their underlying condition, rendering accurate diagnosis delayed and inherently difficult. Significant data are available regarding both pharmacological and non-pharmacological interventions for agitation that maximise symptom control while minimising confounding side-effects. In this article, a review of the historical evolution of agitation management in psychotic illness is presented, followed by an evidence-based clinical guideline for managing agitation in psychosis in the USA.

Of the many interactions with psychotropic drugs, a minority are potentially hazardous. Most interactions are pharmacodynamic, resulting from augmented or antagonistic actions at a receptor or from different mechanisms in the same tissue. Most important pharmacokinetic interactions are due to effects on metabolism or renal excretion. The major enzymes involved in metabolism belong to the cytochrome P450 (CYP) system. Genetic variation in the CYP system produces people who are ‘poor’, ‘extensive’ or ‘ultra-rapid’ drug metabolisers. Hazardous interactions more often result from enzyme inhibition, but the probability of interaction depends on the initial level of enzyme activity and the availability of alternative metabolic routes for elimination of the drug. There is currently interest in interactions involving uridine diphosphate glucuronosyltransferases and the P-glycoprotein cell transport system, but their importance for psychotropics has yet to be defined. The most serious interactions with psychotropics result in profound sedation, central nervous system toxicity, large changes in blood pressure, ventricular arrhythmias, an increased risk of dangerous side-effects or a decreased therapeutic effect of one of the interacting drugs.

Cinema is at once a powerful medium, art, entertainment, an industry and an instrument of social change; psychiatrists should neither ignore nor censor it. Representations of psychiatrists are mixed but psychiatric treatments are rarely portrayed positively. In this article, five rules of movie psychiatry are proposed, supported by over 370 films. Commercial and artistic pressures reduce verisimilitude in fictional and factual films, although many are useful to advance understanding of phenomenology, shared history and social contexts in psychiatry. Acknowledging some negative representations, three areas are explored where cinema gets it mostly right: addictions, bereavement and personality disorder. Although there are excellent representations of psychosis on film, film-makers have more often portrayed it violently – ultimately demonising people as psychokillers in more than 100 films cited. When people with mental illness are stigmatised through stereotypes, examining unwelcome depictions can uncover important truths. Psychiatrists' engagement with film will ensure professional and artistic gains.

In recent years, mass violence associated with men who identify as involuntary celibates (incels) has been of increasing concern. Incels engage in an online community where misogyny and incitements to violence against women are prevalent, often owing to the belief that women are denying them a ‘right’ to sex. Indeed, inceldom can be considered a form of extremism. Information released about the prepetrators of incel-associated violence consistently suggests that mental disorder is a contributory factor and may increase vulnerability to engaging with the incel community. Depression, autism and personality disorder are particularly relevant. To date, there has been little research into the mental health of incels and how, in some, this contributes to violence. This article considers the associations between mental disorder and inceldom, including the risk factors for incel-related violence, and makes recommendations for best practice in risk assessment and clinical intervention.

Chronic physical illness is a significant risk factor for psychological symptoms, psychiatric disorder and suicide. Properly targeted cognitive–behavioural therapy (CBT) can improve outcomes for people with chronic physical illnesses. This article looks at practical aspects of the use of CBT as part of the overall medical and psychiatric management of chronic physical illness.

‘Mindfulness' has become a popular topic among psychological therapists. This introductory article explains what mindfulness is and how it can be developed, before exploring how it has been incorporated within psychoanalytic and cognitive–behavioural psychotherapies. These reflect general as well as specific presumed therapeutic actions. At present, variations in the way mindfulness is understood, taught and applied mean that it is too early to fully assess its potential. They demonstrate how the use of attention and awareness in therapy cuts across traditional divisions and where mindfulness in therapy is most in need of further investigation.

The DSM–IV classification of body dysmorphic disorder (BDD) refers to an individual's preoccupation with an ‘imagined’ defect in his or her appearance or markedly excessive concern with a slight physical anomaly (American Psychiatric Association, 1994). An Italian psychiatrist, Morselli, first used the term ‘dysmorphophobia’ in 1886, although it is now falling into disuse, probably because ICD–10 (World Health Organization, 1992) has discarded it, subsuming the condition under hypochondriacal disorder.

We argue that current debates about attention-deficit hyperactivity disorder (ADHD) can be considered afresh using an evolutionary lens. We show how the symptoms of ADHD can often be considered adaptive to their specific environment. We suggest that, from an evolutionary point of view, ADHD symptoms might be understood to result from an ‘evolutionary mismatch’, in which current environmental demands do not fit with what evolution has prepared us to cope with. For example, in our ancestral environment of evolutionary adaptedness (EEA), children were not expected to sit still and concentrate on academic tasks for many hours a day. Understanding ADHD in terms of such a ‘mismatch’ raises significant issues regarding the management of childhood ADHD, including ethical ones. An approach based on the concept of mismatch could provide an alternative to current debates on whether ADHD results from nature or nurture and whether it is under- or over-diagnosed. It would allow clinicians and policy makers to take both the child and the environment into account and consider what might be desirable and feasible, both in society and for specific children, to lessen the mismatch.

The focus of this article is the assessment and management of medically unexplained (‘psychogenic’) amnesia, which we classify here as global or situation specific. Other psychiatric causes for memory disorder and neurological conditions that could cause diagnostic confusion are briefly reviewed, as are forensic aspects of memory complaints. Finally, brain and physiological mechanisms potentially associated with psychogenic amnesia are discussed.

The Royal College of Psychiatrists' Annual General Meeting in Edinburgh in June 2007 witnessed the launch of the joint position statement from the College, the Care Services Improvement Partnership and the Social Care Institute for Excellence ‘A Common Purpose: Recovery in Future Mental Health Services’ as part of its opening session. This is now available as a stimulus and a guide for clinicians and teams to consider how to engage in the recovery agenda and whether to make it their common purpose also.

If personality disorder is no longer to be a diagnosis of exclusion it needs a conceptual framework that fits both the symptoms of the illness and the behavioural problems that constitute its current diagnostic criteria. In this article, we suggest that personality disorder is best understood as disorganisation of the capacity for affect regulation, mediated by early attachments. We present evidence for this argument based on both developmental and neurobiological research.

Although the physical health of doctors is largely better than that of the general population, they continue to have high levels of stress, depression and substance misuse. These aspects of mental ill health are particularly elevated in psychiatrists, and in a number of studies psychiatrists have also been found to be those doctors most likely to face disciplinary proceedings. This article explores the individual and organisational causes of these problems and the ways they may interact within the psychiatrist's work role, and suggests a variety of possible interventions to improve the mental health of doctors in psychiatry.

Most people with schizophrenia have frequent contact with their families. Therefore, the family should be involved in their relative's treatment and care wherever possible, so that they can contribute to that person's recovery and the family's own needs for information, support and treatment can be addressed. Family psychoeducation refers to a group of structured psychotherapeutic interventions that involve the person with schizophrenia and their family as partners in care. Trained practitioners adopt a collaborative approach to information sharing and provide training in coping, communication and problem-solving skills. This article describes the common principles and techniques of family psychoeducation (FPE), along with the substantial evidence for its benefits for families, especially reduced relapse rates for the person with schizophrenia. Despite recommendations in clinical practice guidelines, FPE is not widely available throughout the world. The current challenge is to address this through systemic approaches to practice change and tiered approaches to family service delivery.

Over the past century war and organised violence have led to the displacement of large populations and threatened or resulted in genocide of many ethnic or cultural groups. Although many people are internally displaced within their own country, some flee and seek asylum in other countries. The United Nations High Commission on Refugees (UNHCR) defines a refugee as someone who:

The presence of cognitive deficits in schizophrenic illness has been extensively documented, and deficits in memory and executive functioning may be related to poor prognosis. Targeting these deficits during the early phase has potential benefits. The neural basis for cognitive deficits in schizophrenia is not well understood, and hence pharmacological interventions alone are insufficient. Future strategies should focus on pharmacological interventions combined with psychological techniques such as cognitive remediation. This review summarises recent findings relating to first-episode schizophrenia.

We now recognise that withdrawal symptoms from antidepressants are common, and can be severe and long-lasting in some people. Many withdrawal symptoms overlap with symptoms of anxiety or depression, making it difficult to distinguish withdrawal from relapse. We describe how their onset soon after dose reduction, the association of psychological with physical symptoms, their prompt response to reinstatement, and their typical ‘wave’ pattern of onset, peak and resolution can help distinguish withdrawal symptoms from relapse. We also examine evidence that suggests that antidepressant withdrawal symptoms are misdiagnosed as relapse in discontinuation studies aimed at demonstrating the ability of antidepressants to prevent future relapse (relapse prevention properties). In these discontinuation studies people have their antidepressants stopped abruptly, or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.

The use of simulated patients in medicine offers students a standardised learning experience and a reproducible way of exploring attitudes and teaching communication skills. This would seem to be particularly relevant to psychiatry with its focus on attitudes and interpersonal skills, but doubts have been raised about the utility of simulated patients in teaching skills such as empathy and the generalisability of this learning to the real world. This, tempered with cost implications, may have limited the use of simulated patients to assessment through objective structured clinical examinations rather than to teaching and to learning. This article examines the educational advantages and disadvantages of the use of simulated patients in psychiatric teaching and argues that their judicious use complements undergraduate and postgraduate training in psychiatry. The article offers practical tips on writing simulated patient scenarios to deliver specific learning objectives and discusses the potential use of novel simulation techniques in psychiatric education.

Cardiac safety of antipsychotic drugs continues to be a concern for both typical and atypical antipsychotics. Risk appears greatest in those with pre-existing cardiac disease but many patients may have occult cardiovascular disease. In addition, several drugs appear to increase the likelihood of diabetes and weight gain, which may have an additive adverse effect. On the basis of risk of sudden cardiac death and risk of QTc prolongation we suggest considering antipsychotics in two categories – higher and lower risk. Of most concern is the use of large cumulative doses of antipsychotics that are sometimes given inadvertently by different prescribers. Clinicians need to be aware how to read an ECG, and how to monitor physical parameters and interpret the significance of QTc prolongation in relation to antipsychotic prescribing. We suggest provisional guidance on antipsychotic monitoring in relation to cardiac safety but acknowledge that future studies will help clarify which antipsychotic drugs and which concomitant risk factors are most important for those with and without established cardiac disease.