The forensic psychiatry of learning disability is a subspeciality which exists on the ‘borderlines’ between other areas. It takes in information from forensic psychiatry, learning disability, child and adolescent psychiatry, psychology, genetics and pharmacology to name but a few.

Intoxication with alcohol and drugs is commonly associated with criminal offending. The relationship between intoxication and criminal culpability is complex and may be of psychiatric relevance, especially if a mental condition legal defence is being considered. This article outlines the legal issues (such as they apply in England and Wales) of which psychiatrists should be aware when preparing medico-legal opinions about mentally disordered offenders.

Obsessive–compulsive disorder (OCD) is one of the most debilitating psychiatric conditions in young people. In DSM-5 it is no longer characterised as an anxiety disorder, but instead is part of a group of ‘obsessive–compulsive and related disorders'. In the past 10 years, cognitive—behavioural therapy (CBT) has become well established as the first-choice treatment. This article explains some of the elements of CBT and describes new directions in research which might improve interventions.

The UK National Institute for Health and Care Excellence guidance suggests that psychodynamic principles may be used to understand the experiences of people with psychosis. In this article we consider the application of psychodynamic principles in psychotherapy for psychosis, focusing on one particular model: supportive psychodynamic psychotherapy (SPP). We describe this approach with a detailed fictitious case example and discuss how SPP has developed through significant modifications of classical psychoanalytic therapy and the evidence base for it. We consider its overlap with cognitive–behavioural therapy, its advantages and disadvantages, and the arguments for making SPP available as a treatment option in services for psychosis.

Patients with Huntington's disease can be a challenge to psychiatrists and to psychiatric services. We present a patient whose case history illustrates this and underlines the need for prompt and adequate treatment of psychiatric problems in this population. We discuss the psychiatric and behavioural manifestations of the illness, the treatments available and the role of psychiatric services in providing care for people with Huntington's disease.

Workshops are used in many psychiatric teaching and learning contexts, from undergraduate to continuing professional development. Most psychiatrists have at some time attended a workshop. However, the terms workshop, tutorial and small-group teaching are used indiscriminately. It is therefore important to reflect on what characterises a workshop, the learning theories behind their development and what learning needs workshops best meet. We give an outline of the evidence for workshops in medical education and review the principles governing how to conduct workshops and the use of technology to enhance their delivery. Data collected from an undergraduate psychiatry course delivered in an Irish university are used to illustrate how applying these principles contributes to optimising the use of workshops from both the learners’ and facilitators’ perspective.

Shopping addiction (compulsive buying disorder) has been an area of increased interest in recent years. Shopping addiction can adversely affect the individual and their family, social and occupational life. The addiction is associated with high rates of psychiatric comorbidity. Early identification and appropriate management can limit the long-term adverse consequences and improve outcome. This article reviews the aetiology, epidemiology, clinical features, psychiatric comorbidity and management of the disorder.

Testing for illicit drug use is used in pre-employment checks, the criminal justice system, sports medicine and for screening and confirmatory purposes in patients with physical and mental illnesses. The types of drugs tested for and the methods used vary depending on the indication. This article focuses primarily on blood, urine and oral fluids, which are specimens more commonly used in mental health settings, although hair and sweat are increasingly used in medico-legal cases and in child protection issues. The main drugs and their metabolism are discussed to gain a better understanding of the methods used and for accurate interpretation. Methods to ensure validity during sample collection are explored. False-positive and false-negative tests are common and possible confounders are discussed.

The assessment and management of violent behaviour in mentally disordered patients are no longer the sole domain of forensic psychiatrists, but are increasingly part of the day-to-day work of all psychiatrists and mental health professionals. Violence risk assessment has become a huge industry, and although the importance of dynamic, as well as actuarial, risk factors is now recognised, a more systematic approach exploring the psychodynamics in the aetiology, assessment and treatment of violent behaviour is often lacking. In this article I revisit some of the key psychodynamic principles and concepts relevant to an understanding of violence, summarising the historical contributions of key psychoanalytic writers on violence and aggression, and exploring the ideas of more contemporary writers working in the field of forensic psychotherapy. A psychodynamic framework for working with violent patients is introduced, focusing on the setting and containment, specific therapeutic interventions and monitoring countertransference reactions.

Operational criteria for detecting prodromal, or at-risk, mental states have been developed largely on the basis of individuals seeking help for attenuated or brief, self-limiting symptoms that do not meet threshold criteria for psychotic disorder. These individuals present largely to primary care and other non-specialist mental health settings. Follow-up studies have confirmed that 15–40% will make the transition to full psychosis within 12 months. Cognitive therapy alone or in combination with low-dose atypical antipsychotics has been shown to be efficacious in reducing or delaying the transition to psychosis, as well as in ameliorating the severity of non-psychotic symptoms and distress. Antipsychotic medication alone has not shown significant efficacy, but results are suggestive of some advantage from drug treatment. Further work is needed to clarify the relative merits of these interventions.

As we doctors are beginning to understand more and more about dementia, the public has become increasingly aware of the condition and in turn this has been reflected in the arts. This article discusses four books whose main focus is the experience of dementia, each written from an entirely different perspective: a novel giving a first-person account of dementia by the Dutch writer J. Bernlef; a biography of the famous novelist Iris Murdoch by her husband John Bayley; Linda Grant's account of her mother's multi-infarct dementia (which also describes Jewish migration to the UK two generations ago); and Michael Igniateff's autobiographical novel Scar Tissue. Such accounts, offering insights into how patients and carers feel, cannot but help make us better doctors.

Making decisions in the context of risk is an integral part of psychiatric work. Despite this, decision-making skills are rarely systematically taught and the processes behind decisions are rarely made explicit. This article attempts to apply contemporary evidence from cognitive and social psychology to common dilemmas faced by psychiatrists when assessing and managing risk. It argues that clinical decision-making should acknowledge both the value and limitations of intuitive approaches in dealing with complex dilemmas. After discussing the various ways in which clinical decision-making is commonly derailed, the article outlines a framework that accommodates both rational and intuitive modes of thinking, with the aim of optimising decision-making in high-risk situations.

Analysing interpersonal dynamics is an approach through which the multidisciplinary team can develop a shared understanding of their patients. This empirically based method provides an insight into repeated patterns of dysfunctional behaviour, which not only have been evident in the past, but are currently having an impact on the patient's relationships with caring staff. The technique is accessible to any team member with only minimal training required. It provides the team with a coherent map of the patient's relationship patterns that underpins the formulation of an effective strategy for care. The multidisciplinary team is then able to work towards shared goals, supporting all members in their provision of effective interventions within the full range of therapeutic modalities. The approach promotes positive staff–patient interactions and provides an additional dimension to the assessment and management of risk.

Clinical formulation was introduced in its present form a little over 30 years ago and is, in essence, a concise summary of the origins and nature of a person's problems, together with opinion on what may go wrong in the future and what steps should be taken to improve matters. In our article we discuss how, in recent times, the task of preparing a clinical formulation has rightly become a multidisciplinary exercise involving the whole clinical team and, even more important, that nowadays the patient – the subject of the clinical formulation – together with their carers should also be actively involved in the process and feel some ownership of the conclusions and decisions. In addition, we compare these developments in clinical formulation with similar developments, arising for the same reasons, in clinical teaching and education.

Psychiatry predominantly uses an evidence-based way of understanding patients. Over the past two decades, however, the idea has become acceptable that something can also be learned from the arts. This article suggests a precise role for ‘narrative understanding’, but argues that something further can be learned by examining a particular mode of attention – that which an experienced viewer might give to a painting or listener to a piece of serious music. The article articulates the contrast between the detached attention of the scientist and the engaged attention of the artist in terms of two traditions of medicine: Hippocratic and Asklepian. It argues that it is possible to combine these and that the ways in which an informed viewer looks at paintings or listener listens to music can be models for this sort of attention.

Post-traumatic stress disorder (PTSD) causes significant distress and is often associated with markedly reduced functioning. Recent reviews have consistently recommended trauma-focused psychological therapies as a first-line treatment for PTSD. Pharmacological treatments have also been recommended but not as consistently. This article reviews the available trials of the pharmacological treatment of PTSD and discusses their implications.

With the subspecialisation of psychiatry in the UK, clinicians encounter problems at the interfaces between specialties. These can lead to tension between clinicians, which can be unhelpful to the clinical care of the patient. This article focuses on the interface between general and forensic psychiatry in England and Wales. The pattern of mental health services in England and Wales differs to an extent from those in Scotland, Northern Ireland and in the Republic of Ireland. Consequently, the interface between general and forensic psychiatry is subject to varying influences. Important interface issues include: the definition of a ‘forensic patient’; the remit and organisation of services; resources; clinical responsibility; and care pathways. This article also discusses a general overview of how to improve collaboration between forensic and general adult psychiatric services.

Aripiprazole, brexpiprazole and cariprazine are partial dopamine (and serotonin) agonists developed as novel antipsychotics. This article discusses their pharmacology, evidence on their licensed and off-licence uses (including psychosis, mania, bipolar depression, Tourette syndrome and autism spectrum disorder) and side-effects. In schizophrenia, they have a low risk of Parkinsonism or hyperprolactinaemia, cause modest increases in body weight and are of moderate efficacy.

This paper reviews the evidence base supporting the use of pharmacological treatments for child and adolescent psychiatric disorders. Recent advances in knowledge are highlighted, with some of the controversies. New evidence supports a role for selective serotonin reuptake inhibitors in the treatment of anxiety disorders and obsessive–compulsive disorder. Educational and behavioural approaches remain the mainstay of treatment for children and adolescents with autism, but there is evidence that adjunctive medication may be effective. Atypical antipsychotics have been investigated in the treatment of Tourette syndrome and early-onset schizophrenia. Many questions remain unanswered and further research is needed in all areas of paediatric psychopharmacology.

The teaching of medical skills to medical students and to other doctors is a skill in itself. The traditional ‘apprenticeship’ system of learning within medicine is now known to be inefficient and flawed, in both the UK and in other countries where it has been scrutinised. This article sets out guiding principles to help doctors set up ‘teaching the teachers' courses, which teach the skills of teaching. Psychiatrists at all grades, from senior house officer up to consultant, need some teaching skills, and the authors outline how to plan a course, determine the needs of potential learners and set its objectives and content. Guidance is given on some of the opportunities that are available to obtain formal qualifications in medical education.