It is well established that the immune system can modulate brain functioning and influence behavioural processes. Awareness of communication between the immune and nervous systems has, over the years, progressively heightened interest in the relationship between psychiatric disorders and immune function. By reviewing findings from studies investigating inflammation in the periphery and in the central nervous systems, we summarise here the evidence linking inflammation to the development of depression, schizophrenia and bipolar disorder. We discuss how a pathophysiological role for inflammation has now been recognised across different psychiatric disorders, at least in a significant subpopulation of patients. Finally, we discuss a possible role for these findings in the development of future diagnostic classifications of psychiatric disorders as well as of new treatment strategies.

It is obvious that learning is an essential part of all successful educational processes, including continuing professional development (CPD). Yet learning can be hard work, especially for the mature adult, and being able to recognise the nature of some of its intrinsic difficulties is likely to be helpful. In educational circles today, it is recognised that engaging experienced or senior people in the educational process of CPD is often difficult.

The practice of brief psychotherapy is a distillate of the active ingredients in longer-term work but with the addition of two special elements: limited time and therapist activity in formulating a focus and focusing on it. Typically, patient and therapist work together over 10 to 25 sessions in weekly meetings. In very brief dynamic psychotherapy (VBDT), the time frame is shrunk to fewer than 10 sessions, sometimes just a single session; the constraint means that there is less room for corrective manoeuvre in order to achieve the therapeutic task of maximum benefit and minimum harm in the time available. To do this well requires knowledge, skill and sensitivity. In this paper, special attention is paid to a ‘three-plusone’ intervention (brief intervention and followup (BRF)) that has been tested in a randomised controlled trial (RCT).

This guide to the neurological disorder cerebral autosomal dominant arteriopathy with subcortical infarcts and leuco encephalopathy (CADASIL) is specifically targeted at psychiatrists. The aims are to enhance awareness, provide educational clinical information and offer practical guidance on management of the disorder. An overview of diagnostic algorithms and recent research is also provided.

The phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an underrecognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. Causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.

The neurological deficits in sensory and motor function in schizophrenia have been described using a confusing variety of terms, reflecting their uncertain relevance and significance to psychosis. In this article we explore the nature of neurological abnormalities in psychosis, describe their assessment and suggest their potential relevance for clinician and patient. We propose that the assessment of neurological abnormalities and extrapyramidal side-effects should figure in the assessment of any patient with psychosis, particularly at illness onset. Furthermore, we suggest that neurological abnormalities can inform prognostic predictions and help to identify patients with more complex future care needs.

Taking hostages has a long history as a method, with variable effectiveness, of securing concessions from individuals, organisations and governments. More recently, it has become a popular tactic among terrorist organisations. Although the resilience of individuals should never be underestimated, there is evidence that being taken hostage can have enduring effects, particularly on children. Individuals vary in how they cope with such an experience, both during and subsequent to it. The literature demonstrates that the research base is limited, and many important questions remain to be answered. Hostage-taking is an area of clinical and scientific interest. Apart from the need to establish the most effective post-incident interventions for individual hostages and their families, there are opportunities to develop further insights into the dynamics and effects of unequal power relationships.

Hallucinations (erroneous percepts in the absence of identifiable stimuli) are a key feature of psychotic states, but they have long been known to present in children with non-psychotic psychiatric disorders. Recent epidemiological studies of child populations found surprisingly high rates (about 10%) of hallucinatory experiences. These hallucinatory phenomena are most likely to occur in the absence of psychiatric disorder and are usually simpler, less elaborate and less distressing than those observed in children with psychiatric disorders. This article details the clinical assessment of hallucinations in children and adolescents, taking into account developmental considerations and paediatric organic associations. It describes hallucinations in young people with psychoses (schizophrenia spectrum and mood disorders) and non-psychotic psychiatric disorders (emotional and behavioural disorders), and it addresses therapeutic aspects.

Twenty-four-hour nursed care refers to a model of psychiatric care which in fact varies quite significantly from unit to another. This sort of residential care unit has also been called the “hospital hostel” (Goldberg et al, 1985), “ward in a house” (Wykes & Wing, 1982), “psychiatric nursing home” and in some cases “staffed group home”. Although the unit size, staffing structures and ratios, and the degree of direct management within the National Health Service (NHS) vary, this model of care has some quite specific characteristics, which have been summarised by Shepherd et al (1994) as follows:

The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.

A genuinely critical and reflective approach to psychiatry can potentiate learning, improve practice and promote personal development. To support this assertion, I attempt to link theory and practice. Following a brief overview of the seminal ideas that permeate the literature on critical thinking, I present three perspectives of reflective practice – those of the psychiatric trainee, the teacher and the practitioner – through examples of reflective exploration of personal experience, under the light of relevant evidence. I conclude with a critique on the limitations of reflective psychiatry.

Many memorable characters in Western culture could be viewed as having features of autism or Asperger syndrome. In spite of the familiarity of autistic stereotypes such as Star Trek‘s Mr Spock, more completely described characters with autism are still unusual. In recent years there has been a growing interest in autism, mirrored by an increase in depictions of autism in popular works of fiction and autobiography. In this article I will outline the issues that have preoccupied writers and the techniques they have used to demonstrate autistic difference. Some writers have illuminated aspects of the autistic triad of social impairment, abnormalities of language and need for sameness. Other writers have opened our eyes to the autistic world view in its strangeness and richness. Still more have started to examine prejudice, disability rights and the implications of an international autism community. As in other areas of mental health, literature can help inform, entertain and question our attitudes and values.

Neuroimaging is traditionally divided into structural and functional imaging. Structural imaging looks at brain structure or anatomy and includes computed tomography (CT) and magnetic resonance imaging (MRI). Functional techniques seek to examine the physiological functioning of the brain, either at rest or during activation, and include single photon emission computed tomography (SPECT), positron emission tomography (PET), MRI spectroscopy, functional MRI (fMRI) and encephalographic brain mapping. Although fMRI, MRI spectroscopy and brain mapping are likely to have clinical applications in the near future, the main imaging modalities of current clinical relevance to psychiatrists are CT, MRI and SPECT, which will be the focus of this article.

The Disability Discrimination Act, passed by Parliament in 1995, is an important piece of legislation with the potential to protect the employment rights of people with disabilities. It covers people with physical or mental impairments that have a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities. The Act has sections regarding protection from discrimination in employment, in the provision of goods, services and facilities, and in education. These parts of the Act have implications for people working in mental health services when they are considering employment and educational opportunities for service users.

Delusional disorder, rare in clinical practice, remains one of the most enigmatic conditions in psychiatry. Linked to schizophrenia spectrum disorders since the mid-20th century, recent work has confirmed 19th-century notions of an aetiology based on attentional biases and personality dimensions. Unfortunately, the literature exists largely as case reports and series, often published as ‘curiosities’, and therefore lacks the rigour of formal diagnosis. This article reviews current thinking on aetiology and epidemiology, considers diagnosis, and reviews recent work on physical and psychological therapies. It concludes that delusional disorder is likely to respond well to treatment with standard antipsychotics, often at low doses, but that adherence and concordance remain particular problems. Cognitive therapy has been shown to be beneficial but is time-consuming and resource-intensive. Selective serotonin reuptake inhibitors may profit further investigation. There remains considerable scope for investigation of this fascinating condition.

Caring for people in distress or illness is emotionally draining and physically demanding. This article focuses on the experiences and needs of health service staff as professional carers. It overviews the current circumstances in the UK and links readers to the findings of: the Stevenson/Farmer Review of 2017; the report of the General Medical Council on the state of medical education and practice of 2018; and the British Medical Association survey of doctors and medical students published in 2019. We review the sources of stress that affects healthcare practitioners and introduce the concepts of emotional labour, psychological safety and psychosocial resilience. We draw attention to the vital importance of social support and leadership to protecting healthcare staff. We conclude this review of the topic by outlining a stepped model for actions that aim to: develop staff of healthcare services and help them to thrive at work; support staff who are struggling at work; and intervene to care for staff who are distressed or unwell whether they are continuing to work or not.

Liaison and diversion services are concerned with ensuring that individuals with mental health problems and related vulnerabilities who come into contact with the criminal justice system receive appropriate support and treatment. In the past 15 years there have been significant changes in policy, legislation and the broader landscape in community, custodial and hospital settings which have shaped these services. The Bradley Report, published in 2009, represents an important landmark in this field. Bradley made 82 recommendations, from interventions to improve identification of mental illness and vulnerable individuals at risk of offending to effecting speedier transfers of mentally disordered prisoners to hospital. Some progress has been made in achieving these recommendations, and further investment is promised, but at present only half of England is covered by liaison and diversion services.

Body integrity identity disorder (BIID) is a rare and complex identity disorder described by the desire to acquire a physical disability and an associated sense of incompleteness at being able-bodied. Individuals with the disorder often delay presentation until later in life because of perceived stigma about wishing to acquire a physical disability, and may have sought amputation already through ‘underground’ means or self-harm (attempts at self-amputation). In this article we present an account of the recent history and origins of the disorder, from its early descriptions and case reports through to the current neuropsychiatric theory of right superior parietal lobe dysfunction as basis for the disorder. We consider the epidemiology, pathogenesis and clinical features of this identity disorder of bodily integrity, highlighting the associations with conditions such as gender identity disorder. With this we then discuss the ethical considerations for available treatment options, mainly elective surgical amputation.

This second of two articles on the ‘typical’ (‘first-generation’) antipsychotics covers non-phenothiazines: thioxanthenes (flupentixol and zuclopenthixol), butyrophenones/diphenylbutylpiperidines (including one-time world market-leader haloperidol, and pimozide) and sulpiride, for many years the only substituted benzamide available in the UK. Several tolerability issues ascribed specifically or more frequently to older antipsychotics are also discussed.