The recent film Boys Don't Cry illustrates in a highly dramatised form the problems that the phenomenon of gender identity disorder can create in an extreme situation. The film is based on the true story of a young person, Brandon, with a female body who perceived himself as a male. In the film we do not know when the issue of his male gender identity first appeared, but we see him living in a male role as a teenager trying to conceal, to his peers, the reality of his female body. (I refer to Brandon as ‘he’ because this is how Brandon presents himself in the film. The dilemma about using ‘he’ or ‘she’ typically confronts professionals in the management of teenagers like Brandon.) The struggles of these concealments are well portrayed, as in the scene when he steals tampons from a shop. He joins in male activities and displays of physical strength as a confirmation of his male role. He is well accepted as a boy within a troubled and troublesome group of young people. He falls passionately in love with a girl, Lana, who accepts him as he is without much questioning, and a close intimate relationship develops, which the peer group seems to accept. The reality of his body is eventually revealed. His girlfriend can accept the new situation, but had she really not known or had she turned a blind eye? Unfortunately, two young men become more and more disturbed by this realisation. It stirs a primitive violence in them, which leads first to Brandon's rape and then to his murder.

Disasters are complex events that challenge the coping abilities of individuals and communities. This article reviews the likely impact of such events and factors that compromise the ability of survivors to cope with that impact. The principles of early intervention are also considered, particularly with regard to the role of a mental health adviser. This role is an important and demanding one, and its aims and principles of professional conduct should be carefully scrutinised.

Mental health professionals in Western societies are generally less religious than their patients and receive little training in religious issues. Using case studies, the author discusses issues involved in working with patients who hold religious beliefs: problems of engagement; countertransference; religious and spiritual issues not attributable to mental disorder; problems of differential diagnosis; religious delusions; religion and psychotherapy; psychosexual problems; and religiously oriented treatments. The article ends with a discussion of the various ways in which religious themes can be incorporated into mental health work, especially the need to involve religious professionals and develop collaborative patterns of working together with mental health professionals.

Recovery approaches are now being developed in forensic as well as general mental health services. These are welcome developments that offer new ways of working with a socially excluded group of patients. However, the theoretical basis of recovery, with its individual humanistic ethos, may struggle to articulate the unique problems of forensic service users. In this article, we describe those problems and propose a ‘third way’ of thinking that bridges the recovery agenda (which looks for the best in people) and the forensic agenda (which must consider the worst in people). We propose using a ‘narrative approach’, which sees the forensic service user's offence and cruelty as part of their human story. We link this explicitly with the work of Dan McAdams and his concept of the redemption narrative.

The role of the general adult psychiatrist has changed significantly over the past decade. There is a focus (almost exclusively in some cases) on the management of patients with severe mental illness. Within the multi-disciplinary team, the key role of the psychiatrist is often perceived as the management of medication, making decisions about clinical risk and acting as gatekeeper to often restricted in-patient beds. Psychological and social interventions are commonly seen as the remit of other members of the team. Although psychiatric training should equip psychiatrists to have at least a reasonable understanding and practical knowledge of psychological treatments, many consultants in their day-to-day practice do not have sufficient time to utilise such treatments. These factors brought together result in a situation where the practice of many general adult psychiatrists is almost exclusively the treatment of patients with severe illness and within the treatment of such patients, psychiatric practice is much more about medication and risk management than the personal implementation of psychological interventions.

There is increasing concern about the level of violence within mental healthcare settings. In this article I review what is known on this subject, discuss the relationship between mental disorder and violence and summarise the different ways to prevent and manage violence. When planning strategies to prevent violence in such settings it is important to consider not only patient risk factors but also risk factors in the environment. Staff need to have all the possible techniques for managing violent behaviour available to them in order to weigh up the risks and benefits for any specific patient in any particular situation.

Exposure to acute versus chronic stressors and threats activates the immune system in adaptive and maladaptive manners respectively. Chronic activation arising from persistent stress exposure can contribute to an inflammatory response in the periphery and in the brain that has been implicated in stress-related psychopathology, including depression and anxiety. We review the immunology of acute and chronic stress exposure, integrate this discussion with the emerging literature linking heightened immune activation and inflammation to mood and anxiety disorders, and consider the translational implications of the immune system's role in these psychiatric conditions, with a brief overview of potential interventions.

Training in general and forensic psychiatry in the assessment and treatment of sex offenders is in need of considerable improvement. Although most sex offenders are not mentally ill, many are subject to substance misuse, abnormal personality traits, personality disorder, learning disability or dysphoric mood, and in some organic factors will be involved. Comprehensive assessment of sex offenders includes a full history and mental state evaluation, obtaining a collateral history from other sources, observation, psychometric testing, and psychophysiological methods of assessment, including penile plethysmography. Trials of the use of the polygraph are also under way. The treatment of sex offenders, especially those with paraphilias, may include medication with selective serotonin reuptake inhibitors or anti-libidinal agents. Ethical considerations can be problematic, but a balance can often be found between the welfare of the offender and the safety of the public.

Over the past few years electroconvulsive therapy (ECT) has come under increased scrutiny in the UK, with the first systematic review of patients' experiences and new national guidelines. Our aim in this article is to translate recent and sometimes confusing research and policy statements into practical guidance that benefits patients. We examined the evidence on the permanent memory and cognitive effects of ECT, with a focus on delineating their nature, understanding how ECT may cause them, informing prospective patients about them, and assessing their impact on former patients. We describe a simple and effective method for assessing retrograde amnesia. Data do not exist at this time to confirm the mechanisms by which ECT exerts its adverse effects, but clinicians should fully inform patients of the possible permanent adverse effects of the treatment, which include amnesia, memory disability and cognitive disability, and should provide follow-up testing using relevant instruments.

“Contrary to popular belief, partial recovery from Korsakoff's Psychosis is the rule and 21% recover more or less completely. However the extent to which the patient will recover cannot be predicted with confidence during the acute stages of the illness. Failure to appreciate these facts about the natural history of the mental illness may result in the premature confinement of the patient to a mental hospital” (Victor et al, 1971).

Generally, people with learning disabilities now live in community settings and use generic health services. Those who develop behavioural or psychiatric disturbances may be taken to a hospital accident and emergency (A&E) department. An A&E visit can be the starting point of a comprehensive assessment of these disturbances. This article provides a framework for the initial assessment, management and disposition of patients with learning disabilities and behavioural disturbance presenting to an A&E department.

Sexually disinhibited behaviours are quite common (prevalence 2–17%) in people with dementia, occurring with about equal frequency in men and women. Assessment of the behaviours, the contexts in which they arise and their risks is essential. It is important to manage the environment and to educate and discuss the issues with carers and families. Behavioural measures are helpful, although no specific behavioural intervention has been shown to be effective in this area. Several classes of drug may help to control the behaviours, but all are potentially harmful and none is licensed for hypersexuality in this population.

Since its original conception by Bowlby to explain an important evolutionary function of the child–caregiver relationship, attachment theory has been supported by much empirical research in a variety of settings. However, although attachment theory began as a clinical enterprise, its wider application to the everyday clinical understanding of adult mental health problems has lagged behind the available research. The theory can afford valuable insight not only into the developmental nature of common psychiatric disorders, but also into the development of the therapeutic relationship. This article gives an overview of (a) the current conceptualisations of attachment and the measurement of attachment for clinical research purposes and (b) the application of attachment theory to different psychopathologies. The importance of attachment to the therapeutic relationship will be discussed in a future article.

Sensory impairment is often regarded from a medical/disability point of view and its effects on mental health can be poorly recognised. Communication is a key issue for deaf and deaf–blind people and difficulties here underlie developmental, psychological and emotional problems and delay or prevent appropriate assessment and treatment. Children may have additional problems associated with the cause of their sensory impairment and need early multi-disciplinary intervention. Emotional and practical support is needed for families to make fully informed choices. Those with and without sensory impairment need the same access to mental health services and this is particularly difficult to achieve for deaf and deaf–blind people. Local and specialist teams need to work together to implement the National Service Framework for this vulnerable patient group.

Comprehensive health care services respond effectively to the needs of their patients not just in terms of treatment of health problems but also by addressing overall well-being by understanding, informing, involving, counselling and respecting the individual. By contrast, the history of health care for people with learning disabilities has been characterised by a lack of communication and poor understanding of their ordinary and special needs. There have been many barriers to access to health services that most members of the population take for granted. In addition, people with learning disabilities have many special health care needs that also have to be addressed. Therefore, person-centred services must be aware of the wide range of needs to which they must be able to respond while treating each person as an individual (see Box 1).

Over the past decade, the study of error in medicine has expanded to incorporate new insights from cognitive psychology, generating increased research and clinical interest in cognitive errors and clinical decision-making. The study of cognitive error focuses on predictable errors in thinking that result from the use of cognitive shortcuts or ‘heuristics’. Heuristics reduce the time, resources and cognitive effort required for clinical decision-making and are a feature of mature clinical thinking. Heuristics can also lead to bias and must be used with an awareness of their weaknesses. In this article, we describe heuristics commonly used in clinical decision-making and discuss how failure of heuristics results in cognitive error. We apply research findings on decision-making in medicine to decision-making in psychiatry and suggest directions for training and future research into cognitive error in psychiatry.

Dangerous and severe personality disorder (DSPD) services have a relatively short history but are increasingly involved in the implementation of therapeutic programmes. We describe the background to the DSPD initiative in England and consider issues that arise in planning and delivering treatment services. Two bodies of evidence are particularly relevant: previous research into personality disorder and its treatment, which we suggest is as yet of limited value, and research into the outcomes of offender treatment programmes. The latter is clearly relevant but greater consideration of adapting programmes for the patient population and of breadth of treatment is required in the DSPD setting. The important task is to integrate components for the treatment of personality disorder and offending behaviour in a holistic manner. We describe three further challenges in delivering treatment and suggest that ongoing evaluation of treatments is critical in this area of practice, given the impoverished knowledge base.

Pervasive refusal syndrome is a severe, pervasive and life-threatening disorder. Most commonly seen in girls between the ages of 8 and 15, although also affecting boys and younger age groups, it is characterised by a profound and pervasive refusal to eat, drink, talk, walk and engage in any form of self-care. A determined resistance to treatment is a striking component of the condition. The causes are unclear, but likely to be complex, multiple and associated with a sense of hopelessness. Treatment needs to be comprehensive and is based on supporting the child in recovering at her own pace, while ensuring physical safety and well-being. The prognosis is good, provided treatment is appropriate, but recovery tends to take a year or more.

Childhood conduct disorder casts a long shadow over adulthood, often leading to antisocial personality, drug misuse, increased rates of psychosis and earlier death. This article reviews a range of effective treatments, and shows what is ineffective. The common theme underlying interventions that work is that they change the environment around the young person, with parent training emerging as the most effective. Medication is largely ineffective. The task now is to enable more of these interventions to be available at a reasonably early age.

Conventional antipsychotic drugs remain one of the mainstays of treatment of schizophrenia and related psychotic disorders. The therapeutic efficacy of these drugs is well established, both for treatment of acute symptoms and in relapse prevention. Unfortunately, they are associated with a broad range of side-effects, the most prominent of which is the development of a variety of movement disorders (see Box 1). Compared with the conventional antipsychotic agents, the newer, atypical antipsychotics have a lower liability for the acute extrapyramidal side-effects (EPS) and, for a few of the new drugs, there is some evidence of a lower risk of tardive dyskinesia (Barnes & McPhillips, 1999). Nevertheless, even with these newer agents, movement disorders are seen in a significant proportion of patients.