Psychiatry is part of the medical discipline and a key medical specialty which deals with mental illness and mental, emotional and behavioural disorders in the presence or absence of physical disorders. Psychiatric disorders include a number of problems starting from childhood to older age as well as chronic severe mental illness and common mental disorders and psychiatry of learning disability. Biopsychosocial models of aetiology and management are generally followed. Thus the psychiatrist needs to be aware of medical interventions, social care and psychological therapies along with spiritual and anthropological aspects of care. They may not provide these directly but must be aware of where help should be sought from. There are various models of training and frameworks for what are the roles and responsibilities of psychiatrists. First and foremost psychiatrists need to be clinicians along with abilities to be a professional, have academic abilities, be able to communicate and manage resources. Being a team player is an essential criterion. A good psychiatrist should be able to synthesise all the information including biological, psychological, social and spiritual and cultural factors in making sense of the patient’s distress emotional and behavioural experiences. A good psychiatrist can manage uncertainty and deal with ambiguity. They must be able to help patients and their families navigate the complex health care systems. Working with families and working as an advocate for patients and their families is a critical but often unappreciated aspect of the role of the psychiatrist. In these changing times, good psychiatrists will also engage in public mental health agenda.

Major psychosis and mood disorders are neuroprogressive illnesses that develop from prodrome to episodic onset to relapse and recurrence and finally chronic, debilitating illness. There is considerable evidence supporting a staged model for mental illness. Moreover, acknowledging the staged progression of major psychiatric illness creates new opportunities for intervention. Conventional treatments focus on symptom reduction and prevention of relapse, with many services requiring triage levels that exclude all but the most severe patients. This generally results in most of the mental health resources being directed towards patients in the later stages of illness. Re-conceptualising major psychosis and mood disorders as staged illnesses suggests that there is a potential for improvement with regards to illness burden for patients and reduced health care costs if a greater portion of mental health resources were directed towards patients in early stages of illness and toward treatments that may prevent neuroprogression. Successful service models for early intervention already exist, such as Orygen Youth Mental Health in Australia, and many treatments that may impede the progression of mental illness have been identified. Ongoing research is investigating mechanisms by which illness neuroprogression occurs and is evaluating the neuroprotective capabilities of treatments. There is already sufficient experience and knowledge, as well as stage appropriate treatment and possible neuroprotective agents with mechanisms of action that may counteract the mechanisms of neuroprogression. There are sufficient tools to apply the staging model to our treatment and services now, and doing so will lead to better outcomes for patients.

Four different models of Borderline Personality Disorder (BPD), each based on a different psychopathological theory, have produced manualized treatments and on this basis controlled outcome studies that evidenced their efficacy. It can be argued, on the ground of the comparable results of the outcome studies, that these different treatments share a common mechanism of action related to the same psychopathological kernel of BPD . The hypothesis that such a psychopathological kernel can be described as dissociative and caused by chronic psychological traumatization in the developmental years allows for a synthetic description of the basic psychotherapy processes allegedly shared by the four different models of BPD treatment.

Complaints about insufficient sleep are among the hallmarks of many psychiatric disorders and, in fact, insomnia in some patients may be a psychiatric disorder of its on. Moreover, psychiatric patients are at increased risk to suffer from genuine sleep disorders, such as obstructive sleep apnea or restless legs syndrome. Vice versa, sleep disorders are risk factors to develop psychiatric disorders and depression in particular. Hence, a thorough work up of psychiatric patients always must include sleep and, shedding light at the other side of the coin, daytime sleepiness. In diagnostic terms, ICD and DSM-IV look at disturbed sleep and daytime sleepiness in psychiatric patients mainly as secondary symptoms. Novel DSM-V, in contrast, defines insomnia and hypersomnia disorders as largely independent of other psychiatric cnditions, an interesting but also quite debatable view. The DSM-V position underlines the fact that sleep related complaints deserve specific attention and treatment (e.g. by CMT-I). The insomnia and hypersomnia disorder concept, however, neglects that still, in the majority of patients disturbed sleep has a distinguishable cause. Just as an example, severe insomnia complaints in psychiatric patients might be caused by the restless legs syndrome and daytime sleepiness might due to obstructive sleep apnea. Therefore, a detailed look at sleep in psychiatric patients leads to more precise diagnostic results and finally in many cases to more appropriate and successful therapy.

Social aesthetics canalso be seen as a mandate to develop a humanistic medicine that is not onlyconcerned with the ‘whats”, but which instead focuses on the ‘hows”. The callfor the implementation of social aesthetics in practice necessitates a paradigmshift in the treatment of mental disorders. The focus should then no longeronly be just upon the effectiveness of treatment, but also, and quitefundamentally, on the attractiveness of treatment, in particular as makingtreatment objectives and programmes more attractive will lead to reduceddrop-out rates, in turn improving treatment effectiveness. The challenge in thetherapeutic process is not only to recognize the significance of the pathologybut to find ways out of the imagined impossibilities by opening up newpossibilities and uncovering potential that has often quite literally beenburied. In this context atmospheres play a major rule. ‘Atmosphere’ is the elusiveand almost indefinable ‘air’ that imbues and envelops a given situation, theglobal awareness of that situation. In the clinics of mental disorders, theconcept of ‘atmosphere’ applies both to what is felt by the patient (e.g.,‘existential feelings’) and by the clinician (e.g., ‘atmospheric diagnosis’). The relationship between the two is controversial. This is the central elementof the Orpheus Programme that has been developed at the Anton Proksch Institutein Vienna. In contrast to the principles of former deficiency orientedtreatment programs the Orpheus Programme focuses on opening up spaces andcreating atmospheres in which it becomes possible for the ill individuum.

Psychotherapies are treatments performed through psychological means, based in specific techniques, which arouse from different theoretical models. Either individual or in-group, they are all accomplished through an inter-human relationship that implies a ‘changing process”.

Whether it is considered relevant to become a psychotherapist, psychiatrists will often find themselves placed in a psychotherapeutic position. However, being a psychotherapist doesn’t just happen out of the blue, and no one should be practicing psychotherapy without a proper training.

During this presentation, we will put psychotherapy into practice with the help of one clinical example. We will picture how therapists from different schools would treat one particular patient.

Decades of research supports the use of many different psychotherapies for patients with psychiatric disorders; therefore trainees and post-professionals need effective methods for learning psychotherapy and keeping up with the literature. New technologies can assist with this process. The purpose of this presentation is to present two, blended psychotherapy programs currently operating at McMaster University in Canada and Upstate Medical University in Syracuse, New York. At McMaster, a web-based program has been integrated into the standard curriculum. PTeR, or ‘psychotherapy training e-resources” contains several psychotherapy e-modules which contain video clips of specific therapies, power point presentations, reference materials, MCQs to assess knowledge base, an innovative interactive ‘virtual therapist” which assesses clinical competence, and guidelines for teaching psychotherapy. Preliminary results reveals residents and faculty can improve their knowledge base in psychotherapy, and participants report satisfaction with this e-resource. At Upstate university webcam supervision is being creatively utilized to record therapy sessions, and the OQ45, a patient rated instrument has been utilized to provide feedback to therapists. Webcam supervision permits more accurate feedback to be delivered to the trainee about process, content and specific therapeutic interventions and outcomes. This method of training is integrated with a very comprehensive program which teaches psychodynamic, CBT, DBT, family and many other therapies. This highly interactive workshop will present both these programs, discuss the use of e-learning in Europe, and provide participants with an opportunity to discuss incorporating some of these methods of training in their own training programs.

Young people with mental challenges have very limited access to mental health services. Although the burden of disease for addiction and mental illness in that age group is dramatic and most severe persistent mental conditions have their onset in adolescence and early adulthood access to targeted prevention or care is nearly impossible across the globe. Web and social media are changing not only communication patterns especially for young people, but also the way they are looking for help, sharing experiences, learning new behaviors. Web based screening and assessment, information and online treatment are an opportunity to provide quality care with more capacity. Walkalong is a Canadian web-hub for youth with mood challenges providing several features addressing specifically their needs. It is an integrated platform aiming to empower young individuals to overcome their problems and better deal with mood disorders.

IPad assisted treatment of patients with schizophrenia

OPUS is an integrated, early intervention treatment, whichis provided by multidisciplinary teams and can be defined as a rich assertivecommunity treatment model, including protocols for medication, familyinvolvement, and social skills training. The team includes the following professions:psychiatrist, psychologist, psychiatric nurses, occupational therapist, andsocial worker. Each patient is offered integrated treatment for a period of twoyears. A primary team member is designated for each patient and is thenresponsible for maintaining contact and co-coordinating the treatment withinthe team and across different treatment and support facilities. The patientsare visited in their homes or other places in their community, or they are seenat the office according to the patient’s preference.

The therapeutic basis is cognitive therapy. A crisisplan is developed for each patient.

The OPUS team in the western part of Jutland ischallenged by a thinly populated area, and the patients often live far apart. The team has not received extra resources despite this challenge. As aconsequence, the employees waste many hours on the road.

Accordingly, the team decided to carry out some of thepatient contact via iPad. With help from a software development firm, wecreated an app for iPad, which enabled us to have video contact with thepatient and simultaneously fill out cognitive worksheets.

At first, the team workers were hesitant but thepatients were very excited. All in all, we find that the usage of iPads hasevolved our treatment as well as made contact with the patients easier. On topof this, we are saving hours on the road.

Telepsychiatry is a relatively new method of therapy, which has been lately introduced in Poland. In one of the studies performed recently among psychiatric patients before the application of Telepsychiatry tools, the majority of the participants responded that this new method of treatment may be complementary to a visit to a doctor in person, but it cannot replace it. Following this attitude of patients a program has been developed, in which patients treated in an outpatient department in a traditional way have been given an additional possibility of contacting their doctors with the use of a special application on a portable electronic device. Other functions of this application are possibilities of PANSS, Calgary and CGI measurements and cognitive trainings for the patients. This type of a remote contact with patients can be an effective tool in the work in a community therapy attitude in an outpatient setting.

The Shadow of The Electronic World on Patients & Healthcare Systems – A Global Perspective

With justification doctors and patients across the world have looked at technology to provide answers and make improve health. Whether it has been the promise of devices, of magnetic mesmerism, or of new processes and behavioural change, such as the hygienic advances of Semelweiss or Nightingale, physicians and consumers have welcomed and disparaged paradigm shifting developments.

Over the 25 years of the world wide web, the internet and remote technologies have transformed the delivery of health care. In the consumption of knowledge or the provision of information that empowers consumers and carers, opportunities thrive. Many have seen this New Age of Enlightenment as ripe with potential. Many speakers and symposia have described the excellent work that the internet has enabled. Its potential for good is undeniable.

However with the easy transfer of data, the gathering of huge amounts of intelligence, there lies a potential for abuse. Organizations have harnessed the power of computing to influence individuals, to get them to make choices they would not normally make. With the bright light cast by search engines, there is a shadow. We shall look at this dichotomy, the darkness that accompanies this good; at what are the threats to the new frontier and releasing the untold benefits it could bring.

Healthy active lives (HeAL); an international consensus on the importance of protecting the cardiometabolic health of young people experiencing their first episode of psychosis.

A gold standard for success in treating any illness is impact on mortality. Despite many advances in our understanding of psychosis over the last few decades, those affected still face a 15-20 year life expectancy gap mainly accounted for by poor physical health. Compared with the general population, higher rates of obesity, cardiovascular disease (CVD) and diabetes contribute to a widening health gap; cardiovascular disease is now the most frequent cause of premature death for people with psychosis, being more common than suicide.

Efforts to date have tended to concentrate on treating the end-points of these physical disorders. This may be missing an opportunity for disease prevention and in an effort to address these issues, the Healthy Active Lives (HeAL) declaration (http://www.iphys.org.au/, www.iphys.org.au/)argues that it is time to extend the early intervention paradigm toembrace a far more holistic body mind approach, commenced from theonset of psychosis. This presentation will highlight the rationale for eAL derived from evidence for cardiometabolic disturbances arising in the early stages of psychosis and some of the ways preventive approaches can be targeted on increased rates of tobacco use, inactivity, poor nutrition, and the weight gain and cardiometabolic disturbance evident soon after antipsychotic treatment initiation.

This presentation will present an overview of recent research on the relationship between schizophrenia and violent outcomes. It will first present a synthesis of studies that have examined whether schizophrenia increases the risk of violence compared to the general population, and compare this risk with other psychiatric disorders. Then risk factors for violence will be outlined in patients with schizophrenia, and whether they are shared with different adverse outcomes including suicide. Finally, using data from Swedish national registers, I will present the findings of a new study that has investigated whether the rates of violent crime in patients with schizophrenia has changed over the last four decades, and compare these findings with research from other countries.

We are held responsible for our deeds – even if we did not act according to our will. From a third-person perspective, to be deemed ‘mad’ is to be held not responsible for one’s actions. From a first-person perspective, to be mad is to feel that one’s deeds are not one’s own, thus not responsible for them – or vice versa to feel responsible for deeds that are not one’s own. The vulnerability to madness, the cypher of condicio humana, imbues responsibility: loss of responsibility (alienation) and excess of responsibility (guilt) are the extreme polarities of the dialectics of answerability in human existence. To be human is to be at odds with responsibility, that is, with the involuntary dimension of our being. Responsibility is at the same time a presupposition and a task since society expects a person to feel responsible for her deeds; yet responsibility is not an a priori, rather an achievement to be obtained through education. As Ricouer puts it: ‘Education is education to responsibility’. It is very difficult to disentangle responsibility from non-responsibility and standard assessment procedures are not always helpful for this. Taking the literary case of Musil’s serial murderer Moosbrugger, I sketch an alternative view based on the reconstruction of the life-world in which a given action takes place – rather than on the assessment of isolated symptoms. ‘To the judge –Musil writes – Moosbrugger was a universe, and it was very hard to say something convincing about a universe”. The judicial assessment of accountability is an ‘anaemic concept‘ if it does not takes into account the person‘s ‘universe’, that is, the ontological framework in which she is posited.

Politicians, Murder and Schizophrenia: A Case Example

This presentation uses publicly available information to describe the tragic case of Christopher Clunis and the tragic murder of Jonathan Zito. Christopher Clunis is a man diagnosed with schizophrenia who left a psychiatric hospital. Jonathan Zito was a young married man waiting to get on an underground train when without warning he was attacked and killed by Christopher Clunis. This event made headlines and was major news in the United Kingdom for some time afterwards.

There were a number of very significant consequences that followed affecting people beyond his family and friends. The outline facts of the case will be followed by a description and commentary on the political reaction to this, and the impact that this had on patient care.

Finally some suggestion will be made for a way forward in dealing with these tragic cases.

Psychiatry, forensic psychiatry and mental health are not photogenic. In the past few years, Israeli Psychiatry was majorly exposed in mass media reaching a highlight when the involvement of a psychiatrist as a consultant in a reality show has raised serious accusations as well as ethical and clinical questions regarding this involvement. As a public, we are constantly exposed to huge amounts of “raw” information by written and electronic media, influencing our perspective of our environment and as professional we are facing the consequences of this influence on our practice and our patients. In accordance to these, the insights from two years of managing active public relations and lobbying by the Israeli psychiatric association will be discussed. Subsequently a case of an 80 years old woman who was compulsorily hospitalized in a mental health center and that has attracted the mass media attention. This case clearly demonstrates the complex relations between the media and mental health and its impact over mental health services, the legal system, politicians influencing the formulation of public policy and the ambivalent attitude many clinicians share towards the media.

The role of forebrain serotonin (or 5-hydroxytryptamine, 5-HT) in the chemical neuromodulation of mammalian behaviour remains unclear. Two prominent hypotheses are that it is implicated primarily in (i) behavioural inhibition; or ii) aversive punishment, although distinguishing between these hypotheses is difficult because of intrinsic asymmetries in how these systems control behavior. Previous, apparently paradoxical, findings appear to show that 5-HT depletion both reduces and enhances the effects of aversive reinforcers in humans and rodents, suggesting independent modulations of dissociable neural systems. Evidence will be surveyed from experimental animals, using intra-cerebral treatments with a selective 5-HT neurotoxin, 5,7 dihydroxytryptamine, or microinfusions of selective 5-HT receptor agents, and from human volunteers using acute dietary depletion of tryptophan (ATD) or systemic treatments with serotonin re-uptake inhibitors, in order to address these distinctions. Central manipulations of 5-HT generally disrupt behavioural inhibition, including both impulsive and compulsive behaviour, although often with no effect on sensitive measures of response inhibition in the stop-signal reaction time task. Some evidence in humans using ATD suggests that the behavioral inhibition is greater for aversively motivated than appetitively motivated behavior. However, in direct comparisons of effects of local depletions of 5-HT in the orbitofrontal cortex and amygdala in the marmoset monkey, both forms of motivated behavior are impaired, especially in the anticipatory phase of behavioural response to impending appetitive or aversive reinforcers. These findings are related to a variety of neuropsychiatric disorders in which 5-HT dysregulation has been postulated, including depression, drug addiction and obsessive-compulsive disorder.