There are many different course designs for the teaching of old age psychiatry. It may be taught in blocks or spread over the undergraduate curriculum and/or integrated with either psychiatry or medicine for the elderly. Whichever approach is used, at the end of their undergraduate training, students should have the same core knowledge, skills and attitudes.

The Thorn Initiative was put together by a group of people, most of whom were researchers who had conducted randomised controlled trials on various kinds of social treatments. Isaac Marks had worked on assertive community treatment (ACT), whereas my experience was in family work for schizophrenia, as was that of Nick Tarrier. In addition, Tarrier had carried out a recent trial of cognitive approaches to reducing delusions and hallucinations. It was rather like trying to turn an assemblage of prima donnas into a chorus, and it is a tribute to the personal qualities of Jim Birley that he succeeded in this seemingly impossible task.

We describe the case of a child presenting with what initially appeared as a pervasive developmental disorder (ICD F84.1) associated with, and in our view, induced by, schizophrenic illness in the mother. Important issues are raised for both adult and child psychiatry, in particular that the failure of the Mental Health Act (1983) to address the mother's needs adequately, left the child vulnerable to her untreated illness.

The article by Byrne gives a general overview of dementia with Lewy bodies (LBD) and discusses treatment in terms of modulation of neurotransmitter systems, treatment of psychotic symptoms and extrapyramidal features. However, as is the case with Alzheimer's disease, the dementia is related to underlying pathological processes which result in death and/or malfunction of neurons. Prevention or amelioration of this neuronal loss is therefore the ultimate aim of treatment. Such treatment is not yet available and the possibility of its development is likely to depend on further elucidation of the underlying pathological process. The relationship of LBD to Alzheimer's disease and Parkinson's disease should be considered, as this is important for the determination of the underlying pathological processes in LBD.

Anthony Winston reviews and describes current perspectives on the aetiology of borderline personality disorder, covering areas such as the role of traumatic factors, attachment theory and self-psychology. The author links these to the psychopathology of the borderline patient who experiences difficulties such as regulation of affect, impulse control and cognitive capacity to both think and reflect. The psychological function of splitting is considered along with other defence mechanisms as having adaptive potential for the borderline patient. Winston describes in a helpful way the links between human development, psychodynamics and psychopathology as he reveals some of the more recent contributions to the field of BPD. At the beginning of his article, he emphasises the problems encountered when attempting to treat or manage patients with BPD. He centres these difficulties on the counter-transference of the clinician, pointing out how such feelings can “all too easily be transformed into therapeutic nihilism”. His article can easily be read as an attempt to counter such a state of mind and he appears to try to generate a more hopeful if not optimistic outlook. In doing so, I fear that he goes beyond his own account of the research evidence for the effectiveness of treatment. Such enthusiasm or optimism can readily be understood as a reactive polar opposite to nihilism or pessimism. I would like to consider further Winston's statements germane to this aspect of his article and raise for further discussion some other ideas which extend beyond the narrower confines of aetiology and psychological therapy.

I comment on two papers by Koenig and colleagues that advocate the integration of religion into routine psychiatric practice. In my opinion, their selective overview of research, although useful, lacks balance. It omits any mention of the literature on worldwide scandals over child sex abuse (and other abuses of power) perpetrated and facilitated by religious authority within several faith groups. There is no mention of damaging ‘religiously informed’ treatments such as sexual orientation conversion therapy, which is still practised in the UK despite widespread condemnation. Their recommendations for clinical practice conflate association with causation. They do not offer practice guidance on managing the impact of power imbalances associated with religion in multicultural societies. In summary, despite more than a decade of research and debate, there are still no generally accepted ways of avoiding boundary violations where psychiatrists introduce religion into their clinical practice.

At a time when patients are challenged to cope adaptively with both the diagnosis and treatment of cancer, clinicians need to respond appropriately to the many inevitable questions about the causes of cancer and contributing factors, including ‘Is this my fault?’. The evidence guiding answers to such questions has been confounded by many methodological challenges, but personality, stress and life events are no longer considered causes of cancer. However, social isolation, untreated depression and social deprivation continue to influence quality of life and reduce cancer survival times. Psychiatry might play a role in promoting lifestyle changes that reduce the risk of cancer, but more importantly it can influence disease progression by optimising patients' adaptation to the many challenges that cancer brings.

Robin Downie provides useful reminders of the broad basis of medical practice. This should encourage the sort of ‘engaged attention’ that he describes – the sort of attention needed to appreciate works of art. But what else is going on in a clinical encounter (as in a work of art)? This commentary suggests that real communication is to be understood in dramaturgical terms as occurring between actors in real time and space. It involves shared understandings, which require empathy but which depend on something ineffable to do with our standing as human beings in the world.

The category ‘somatoform disorders' was introduced comparatively recently in DSM–III and thereafter in ICD–10: it is the umbrella term currently favoured to cover a heterogeneous group of interrelated and overlapping syndromes, which have been given many names over the years. All these syndromes have in common the process of somatisation: that is, the presence of physical symptoms unexplained by physical disease, with variable degrees of distress and loss of function, about which the patient consults doctors.

Psychosis is a complex presentation with a wide range of factors contributing to its development, biological and environmental. Psychosis is a feature present in a variety of psychiatric disorders. It is important for clinicians to keep up to date with evidence regarding current understanding of the reasons psychosis may occur. Furthermore, it is necessary to find clinical utility from this knowledge so that effective primary, secondary and tertiary preventative strategies can be considered. This article is the first of a three-part series that examines contemporary knowledge of risk factors for psychosis and presents an overview of current explanations. The articles focus on the psychosis risk timeline, which gives a structure within which to consider key aspects of risk likely to affect people at different stages of life. In this first article, early life is discussed. It covers elements that contribute in the prenatal and early childhood period and includes genetic, nutritional and infective risk factors.

Since 2018, the International Task Force on Benzodiazepines (ITFB), a group of academic psychiatrists and academic psychologists, has advocated that clinical guidelines should change to promote benzodiazepines from second- to first-line treatment for anxiety disorders, accept their use as maintenance treatment for anxiety conditions (in particular, panic disorder) and increase their use in gastrointestinal disorders. There is merit in much of what the ITFB argues, but in this article I analyse four major claims it has made in opinion editorials that I believe are not fully supported by the available evidence.

The media offers opportunities for psychiatrists to communicate with a wide and varied audience, thereby influencing the views of the public and policy makers on mental health issues. There are many different types of media outlet, including daily news media, documentary makers, specialist media, features and comment, and new media. The Science Media Centre is an independent press office that aims to help ensure that the views of scientists, clinicians and researchers are heard in the UK national news media when their area of expertise hits the headlines. In the news media, journalists work to tight time frames and often focus on sensational and controversial topics, presenting challenges for those wanting to engage. For experts to work effectively with the news media it helps to understand more about the way the media works and how to develop necessary skills. Psychiatrists who do work successfully with the media can help ensure that the public receive accurate information about mental health problems, and gain an appreciation of the importance of research in the field and a better understanding of the role of the psychiatrist.

Gamblers Anonymous (GA) is perhaps the least used of the twelve-step approaches to dealing with addictions. This relative lack of visibility and use, at least in the UK, is reflected in healthcare professionals' lack of awareness and knowledge of gambling addiction and its treatment, including GA. In this article, we introduce the basic tenets of GA and discuss how these translate into treatment.

This article examines how madness is depicted in the work of Dostoyevsky. It gives a brief account of Dostoyevsky's life before looking at the many ways in which he portrayed insanity. It suggests that he provided a sophisticated and complex picture of mental illness which has relevance for how contemporary clinicians conceive of psychiatric illness.

The artist Arshile Gorky played a central role in the development of Abstract Expressionism during the 1940s. Born in Armenia, his early figurative works recall a childhood of persecution by Ottoman Turks, a period during which he suffered a number of significant losses. The painting The Artist and His Mother (c. 1926–1936) is based on a photograph showing the 7-year-old Gorky with his mother, 7 years before she starved to death during the Armenian Genocide. This article explores the early experiences that haunt this painting and the difficulties Gorky struggled with during his adult life as an immigrant to the USA – factors that contribute to an understanding of his suicide in 1948.

In recent years, there has been growing recognition of the significant incidence of child abuse and neglect in the population, and of its adverse effect on the development of children and their mental and physical health. This awareness has led, especially following the implementation of the Children Act 1989, to an increased demand for psychiatric assessments of children for the courts by social services, solicitors, guardians adlitem and the courts themselves. There has been some reluctance to take up this work, for two main reasons. First, there has been concern that these time-consuming assessments will result in a shift of resources away from treatment, thus having an adverse impact on the balance of child mental health services. In some areas, the need has been recognised within the commissioning and contracting processes. Provision has been increased accordingly, acknowledging that it is part of the responsibility of the health authorities to assist the local authorities in this way.

In this article we start with the effectiveness paradox between different psychotherapeutic modalities, considering common factors, before moving on to give a brief overview of the three main psychotherapeutic approaches – psychoanalytic, cognitive–behavioural and humanistic – and their developments. We conclude that it is the therapeutic relationship – considered in the context of the above – that is core to all therapeutic engagement, medical or otherwise.

Making effective use of psychotherapy can be difficult for patients and their doctors, for a number of reasons. First, the term ‘psychotherapy’ itself is unsatisfactory, used by some people to indicate a particular type of psychotherapy (usually psychodynamic), and by others to embrace all forms of psychological treatment. When we use the term ‘medication’ we usually add a qualifying adjective (e.g. antidepressant or antipsychotic medication) and it is helpful to do so in psychotherapy (e.g. dynamic therapy, cognitive therapy, etc.).