Stalking (Box 1) has only recently been distinguished from a wide range of other socially inappropriate, intrusive and potentially distressing activities. It is now a specific form of criminal offending and has established itself as a recognised social problem (Meloy, 1998; Mullen et al, 2000). Stalking may well reflect, as Emerson et al (1998) argue, “intricate social processes”, but if the psychopathology of the stalker is a necessary, even if far from sufficient, cause then treating that psychopathology may end the stalking (Mullen & Pathé, 2001).

Paranoid and suspicious thoughts are a significant clinical topic. They regularly occur in 10–15% of the general population, and persecutory delusions are a frequent symptom of psychosis. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them, and cognitive–behavioural techniques are being used to reduce distress. In this article we present the theoretical understanding of paranoia that underpins this transformation in the treatment of paranoid thoughts and summarise the therapeutic techniques derived. Emphasis is placed on the clinician approaching the problem from a perspective of understanding and making sense of paranoid experiences rather than simply challenging paranoid thoughts. Ways of overcoming difficulties in engaging people with paranoid thoughts are highlighted.

Clinicians working with women patients in secure units will already know that they are the centre of a debate not of their own making, which is about the appropriate specification of services for women patients with security needs. This paper attempts to outline the relevant issues and proposed solutions.

Adult patients with medically unexplained symptoms (somatisation) in primary care are numerous and make disproportionately high demands on health services. Most of these individuals are open to the suggestion that their illness reflects psychological needs. Empowering explanations from doctors can enable patient and doctor to work collaboratively in managing the problem and can reduce healthcare contacts. Parental medically unexplained symptoms, sexual and physical abuse in childhood and childhood neglect are associated with a greater risk of medically unexplained symptoms in adulthood. The overall prognosis for the majority of primary care patients with medically unexplained symptoms is very good. The two most common approaches to dealing with medically unexplained symptoms in primary care are stepped-care approaches and teaching general practitioners new skills to manage consultations more effectively.

The emphasis on the evidence base of treatments may diminish awareness that critical appraisal of research into other aspects of psychiatric practice is equally important. There is a risk that diagnostic tests may be inappropriate in some clinical settings or the results of a particular test may be over-interpreted, leading to incorrect diagnosis. This article outlines the method of critically evaluating the validity of articles about diagnostic and screening tests in psychiatry and discusses concepts of sensitivity, specificity and predictive values. The use of likelihood ratios in improving clinical certainty that a disease is present or absent is examined.

Delusions are a key symptom of psychosis and they are frequently distressing and disabling. Existing treatments, both pharmacological and psychological, are only partially effective. It is important to develop new treatment approaches based on theoretically derived and empirically tested processes. Delusions are associated with a reasoning bias: the jumping to conclusions (JTC) bias involves gathering limited information to reach decisions. It is proposed that this bias influences appraisals of psychotic experiences leading to the formation and persistence of delusions. Existing treatments do not influence JTC. A new intensive treatment approach – ‘reasoning training’ – is described. It aims to encourage participants to gather information, consider alternative explanations for events and review the evidence before reaching a decision. Preliminary data suggest that it is possible to change the JTC bias and that this improves belief flexibility and may reduce delusional conviction. The concepts and methods of this new approach have implications for clinical practice.

Challenging behaviour is common in intellectual disability but it is difficult to diagnose and manage. It can adversely affect the quality of life of the individual and cause the breakdown of community placements, resulting in hospital admission. This article discusses the aetiology of challenging behaviour (including the complex relationship with mental illness), diagnostic problems, the current evidence base in relation to psychosocial and pharmacological treatments, and service delivery.

The negative effects of parental mental illness on children are not dependent on the parent's diagnosis, but are related to that parent's behaviour, the responses of other key adults (both familial and professional), and the degree to which development of the child's resilience has been encouraged. Parental mental illness can be responsible for serious interruptions in a child's cognitive and emotional development, which in turn can have implications for their future mental health. Resilience can be promoted by relatively simple interventions, but these require the active participation of both adult- and child-focused professionals involved with the family, particularly those concerned with the parent's treatment.

Catatonia is an important phenomenon in both psychiatry and general medicine. This article provides an overview of the key aspects of catatonia, including clinical features, differential diagnoses, management and prognosis. The different types of catatonia, the position of catatonia in the psychiatric classificatory systems, use of catatonia rating scales and the association between catatonia and neuroleptic malignant syndrome are also covered. Abnormalities that have been hypothesised as being possible underlying mechanisms in catatonia are highlighted. The article aims to provide clinicians with a comprehensive update on the subject, with information derived from an extensive range of relevant references.

Metabolic syndrome comprises a number of cardiovascular risk factors that increase morbidity and mortality. The increase in incidence of the syndrome among psychiatric patients has been unanimously demonstrated in recent studies and it has become one of the greatest challenges in psychiatric practice. Besides the use of psychotropic drugs, factors such as genetic polymorphisms, inflammation, endocrinopathies and unhealthy lifestyle contribute to the association between metabolic syndrome and a number of psychiatric disorders. In this article, we review the current diagnostic criteria for metabolic syndrome and propose clinically useful guidelines for psychiatrists to identify and monitor patients who may have the syndrome. We also outline the relationship between metabolic syndrome and individual psychiatric disorders, and discuss advances in pharmacological treatment for the syndrome, such as metformin.

The first few years of a consultant's professional life can be difficult for all concerned. In this article we argue that the tasks facing the newly appointed consultant are in part instrumental, but that there are also important emotional and development challenges to be faced before the individual psychiatrist can truly fill out the consultant role. For the past 2 years we have been running a group, which we have called the transition group, for specialist registrars and newly appointed consultants working in the West of Scotland. The aim of this group is to provide peer support during this transitional process. Here we draw on our experience in this group to explore the development of professional identity, the exercise of personal authority and how this process can be supported by a group such as ours.

Patient suicide is a relatively common event: 50–70% of consultant psychiatrists and 40–50% of psychiatric trainees have experienced at least one patient suicide. Patient suicide can have significant personal and professional effects on psychiatrists, including increased stress, social withdrawal, disruption to relationships, symptoms of post-traumatic stress disorder and consideration of early retirement. Following patient suicide, psychiatrists derive most support from informal contacts with team members, family and friends; additional support may be available through formal support structures or local team initiatives. It is important to place appropriate emphasis on the effects of patient suicide in psychiatry training programmes; to maintain awareness of the importance of informal supports following patient suicide; to strengthen formal systems of support; to identify other potential forms of assistance (e.g. spiritual support); and to develop local team initiatives in this area.

Clinical records are the most basic of clinical tools. Aggregated, they form a permanent account of individual considerations and the reasons for decisions. Essential for effective communication and good clinical care, they are often accorded low priority, are poorly maintained and not readily available. Independent inquiries, health ombudsmen's reports and the courts have repeatedly criticised the quality of records and the resulting failings of care. Most advice from professional bodies, indemnity organisations and the General Medical Council is extremely brief and confined to individual entries in the record. Patient safety and the demands of clinical governance make change essential. This article draws together standards and concludes with some good practice points for a fit-for-purpose, structured, multidisciplinary record to support good care and protect the interests of patients and clinicians. These principles should be equally applicable to electronic records.

The prevalence of moderate to profound learning disability is roughly 3 per 1000 and of mild learning disability about 3 per hundred (Abramowicz & Richardson, 1975). There are estimated to be more than 120 million people with learning disability worldwide.

Humans have attempted and successfully committed suicide since time immemorial. The reasons for killing or harming oneself vary with cultures and societies and in urban or rural settings.

The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

Women patients suffer from a range of mental disorders similar to those that men may experience. However, there are some striking differences in the prevalence of specific disorders, and in their presentation and management. Some mental illnesses only occur in women. It seems that women patients may have a different experience of treatment, a consequence of differences in their needs and also of the way that health professionals perceive those needs. These differences are embedded in the wider cultural milieu in which we live. There are particular issues for women patients in relation to, for example, childhood sexual abuse, rape and domestic violence. At present, tools to measure needs of individual patients are generally not gender specific.

The management of delirium requires careful consideration of the potential value both of pharmacological interventions and of a range of non-drug strategies. Although placebo-controlled studies of delirium treatment are lacking, less robust evidence can still inform practice. This review makes the case for more active management of delirium on the basis of recent studies of prevention, early identification and treatment both during an episode and managing the aftermath in survivors. A drug-treatment algorithm for delirium advising how drug treatments can be tailored to the specific needs of individual patients is described.

Globalisation means crossing borders. It is a complex, large-scale social phenomenon that presents to mental health services both challenges and opportunities. These relate to the increased cultural diversity of service users and service providers; the effects of migration on mental health; and the implementation of international protocols in relation to training, policy and education. In the aftermath of 11 September 2001 in the USA, the relationship between large-scale social change and mental health has also focused attention on the concepts of anomie and social capital. An explicit return to the principles of biopsychosocial psychiatry and a positive engagement with globalisation will advance the development of effective, evidence-based models of care appropriate to the changing needs of patients.

Dementia is is stereotypically associated with older people. However, in a significant minority it can affect people in their 40s and 50s, or even younger. Currently there is a lack of awareness, even among healthcare professionals, and there is a dearth of appropriate services for such patients. Despite the attention given to this condition by National Institute for Health and Clinical Excellence guidelines, provision of specialist early-onset dementia services in the UK remains patchy. Carers and patients often find themselves being passed ‘from pillar to post’ between psychiatry and neurology, and also between adult, old age and liaison psychiatry. The responsibility for identifying available and appropriate help is often left with carers. This leads to unnecessary delays, causes undue distress to patients and places an added burden on carers.