Psychiatry in the UK and in many other countries is facing a fundamental crisis in attracting new graduates. This poorly understood problem may be related to negative undergraduate experiences. Many clinicians have learnt through an ‘apprenticeship’ model and few are formally taught how to teach students in a modern clinical setting. Learning theory provides useful models for learning and teaching that can improve undergraduate clinical experiences. A variety of means are available to help teaching clinicians apply these theories, including self-help using published literature and gaining teaching qualifications. As the majority of modern undergraduate psychiatry teaching occurs during clinical placements, the incorporated techniques will need to be sensitive to the teaching environment. Application of these principles to day-to-day teaching practice may help to reverse the current staff shortages.

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.

The author explores key issues related to psychotherapeutic work with people who self-harm. Particular attention is given to the powerful countertransference feelings that practitioners often experience in this work and the importance of managing these. Rather than maintaining a detached distance, therapists should emotionally engage with the patient's experience, creating a unique therapeutic relationship. The common patterns, functions and meanings of self-harm are discussed, with clinical vignettes that highlight the underlying dynamics of the behaviour. Self-harm is a survival stratagem, and methods for helping patients to find other ways to cope are suggested. One such is mentalisation, which can enhance the patient's capacity to think, not impulsively act. If patients learn how to assess more accurately their own and other people's states of mind, less destructive behaviours can emerge.

In their recent articles in APT Mace & Binyon described a four-level approach to the teaching of the psychodynamic formulation. The fourth level requires development of confidence in the use of an operationalised psychodynamic diagnostics (OPD) manual. Here I critically reconsider the aspects necessary to develop the ability to arrive at a psychodynamic formulation. I argue that as one develops more sophistication and clinical confidence, one needs to move from a manualised to a more open-minded reflective mode.

As a gold-standard methodology for the testing of the effectiveness of health treatments, the randomised controlled trial (RCT) continues to evolve to meet the challenges of new contexts and areas of medicine. This article reviews two particular evolving features of RCTs that make them increasingly well adapted to testing psychological interventions in mental health. The first is a new confidence that RCTs can be successfully adapted to test the more complex (often psychosocial) health interventions and technologies. The second is an increasing emphasis on using the RCT method to explore many facets of the process of treatment as well as its outcome. These two developments should help the RCT method to come of age in mental health, increase the face validity of the RCT method for practitioners and aid the effective translation of research work into improvements in practice.

Behavioural phenotypes are patterns of behaviour that present in syndromes caused by chromosomal or genetic abnormalities. They have both physiological and behavioural manifestations with distinctive social, linguistic, cognitive and motor profiles. Their course is not static. Presentation typically varies according to level of learning disability and a host of environmental, developmental and therapeutic influences, and it changes with increasing age.

Patients who repeatedly injure themselves present particular management problems for general psychiatric teams. This article, the first of a series of four, examines the characteristics of those that present to adult mental health services, and the possible underlying background and trigger factors that lead to these anxiety-raising events. Suggestions are made on preventive and assessment procedures, staff reactions and management strategies aimed at helping patients deal with the overwhelming feelings that underlie self-injury.

Mortality from causes other than suicide is higher than expected in schizophrenia. Cardiovascular causes are most common, accounting for the majority of the 5% of sudden and unexpected deaths. Most cases have no clear explanation on post-mortem examination (‘sudden unexplained deaths’) and are thought to result from fatal arrhythmias. Prospective studies show that people with prolongation of the QT interval beyond 500 ms are at increased risk of serious arrhythmias such as ventricular tachycardia and torsade de pointes. In about 1 in 10 cases, the torsade is fatal. Most antipsychotics prolong the QTc interval in overdose but some prolong it even at therapeutic doses. Droperidol, sertindole and ziprasidone extend the QT interval by an average of 15–35 ms; quetiapine, haloperidol and olanzapine by 5 ms, to 15 ms. There is only an approximate relationship between QT prolongation and risk of sudden death, and the risk related to antipsychotics is thought to increase in people with pre-existing cardiac disease, those taking multiple QT-acting drugs and those taking antipsychotics at high dose for long periods. There is little evidence of an association with route of administration. More data are required to clarify to what extent people with mental health difficulties who die suddenly have pre-existing cardiac disease.

Recent work suggests that a broad clinical spectrum of bipolar disorder is more common than previously thought and that the disorder may affect up to 5% of the population. The correct definition and diagnosis of hypomania is central to the identification of bipolar disorder. In this review we focus on recent diagnostic and clinical advances relating to bipolar disorder, with particular reference to hypomanic states. We also highlight some of the controversies in this field and discuss ways in which clinicians might improve their detection of bipolar disorders.

Machines will replace therapists and counsellors. This was the confident prediction made a decade ago. In this article, I discuss the inherent limitations of machines as conversationalists that have prevented the prediction from coming true. Machines can, however, be exploited to assist therapy and I consider the following digital tools: test administration; managing procedural, symptom-relieving cognitive–behavioural therapies; providing virtual environments for immersive behavioural therapies and for e-learning; and assisting training through automated discourse analysis and the use of cognitive maps.

The physical co-presence of psychotherapist or counsellor and client has been considered essential to the development of the therapeutic relationship. Psychotherapists have often, therefore, been resolutely opposed to anything other than face-to-face therapy. The richness and ubiquity of internet communication is likely to change that. I consider here the circumstances in which internet psychotherapy is indicated, some of the new problems it poses, including boundary-keeping and ethics, along with some solutions to these problems. The potential of the internet has already been exploited by many clients themselves and I conclude with a consideration of the growth of internet-based peer support groups.

Physical symptoms with no medical explanation are commonly experienced by healthy people and those attending clinics. Psychiatrists see such patients in liaison settings and clinics for those with psychotic and affective disorders. The pathophysiology remains obscure; physical investigations are usually performed to exclude pathology rather than elucidate dysfunction. However, modern neuroimaging has allowed the study of nervous system structure and function. Although there are few diagnostically specific findings, patterns of association have emerged: where action is impeded (certain forms of conversion disorder and chronic fatigue syndrome) frontal systems of the brain are often implicated; when subjective awareness of the body is disturbed (passivity phenomena and anorexia nervosa) temporo-parietal cortices appear to be dysfunctional. The caudate nuclei (components of the frontal executive circuit) are implicated in a variety of syndromes (including body dysmorphic disorder, somatisation and chronic fatigue). The brain may be viewed as a cognitive neurobiological entity, crucially oriented towards action (for survival). Psychiatric syndromes that have an impact on bodily awareness signal dysfunction within systems representing that body and its performance in time and space.

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.

Clinicians have been divided in their views on whether systematic needs assessment leads to an improvement in the outcome of care for people with chronic mental illness. Policy makers assume that assessment and evaluation will improve the clinical and cost-effectiveness of mental health services. Many of these assumptions are already embedded within mental health policy and practice. A decade of research has not resolved this tension. However, clinicians need to know about the options available to guide systematic assessment and evaluation of care. They can then make informed decisions about their use to promote effective care planning or as a tool to direct socially inclusive service development.

The non-motor symptoms of Parkinson's disease, which include cognitive, behavioural and psychological problems, are significant not just in epidemiological terms but also in their impact on patients and carers. Each symptom requires careful evaluation, owing to the potential overlap with comorbid conditions and also to the multiple aetiological pathways in Parkinson's disease. Such monitoring allows enhanced management. However, the diagnostic difficulties arising from these non-motor symptoms require further research. Here we describe the efficacy and some of the problems of medication used for non-motor symptoms, including antiparkinsonian medication, antipsychotics and acetylcholinesterase inhibitors.

Scarcity of resources compared with need results in resource-allocation decisions that will have a beneficent effect on some clinical populations and will be detrimental to others. Political philosophy, through theories of social justice, aims to establish generally applicable principles to guide such decision-making. We introduce here the work of the foremost liberal political philosopher of the second half of the 20th century, John Rawls. As well as having implications for resource allocation, John Rawls's work is of relevance to law and ethics in clinical practice, especially for psychiatrists, who often work with vulnerable, disadvantaged and stigmatised people.

John Rawls's theory of justice has been embraced by both the political left and the right, albeit for different reasons. This commentary points out some caveats regarding Rawls's theory as applied to healthcare in general and psychiatry in particular. An alternative political philosophy, the theory of ‘entitlement justice’ as advanced by Nozick, is presented and it is argued that this has more real-life relevance for healthcare ethics than the Rawlsian theory of distributive justice. The reader is invited to determine which theory, if either, is the best fit for psychiatry. The article concludes with some thoughts on the limits to autonomy that mental illness imposes and likens it to the concept of ‘interstitial autonomy’.

The purpose of this first article of four addressing the electronic approaches to psychotherapy (e-therapy) is to introduce the equipment (computers) and systems (the World Wide Web and the internet) involved. I describe some of their many elements (e.g. bits and bytes), uses (such as search engines, email, web mail) and a few abuses (e.g. spam, spyware).

Cannabis is the most commonly used illicit drug in the UK and a significant proportion of users have symptoms of dependence. In addition, there are a number of adverse consequences of use, including an association with psychotic disorders. Thus there is a need for effective treatment of cannabis misuse. Psychological therapies have been developed based on principles of motivational interviewing, cognitive–behavioural therapy and relapse prevention. The evidence base for these therapies is explored in this review, and studies targeting both adult users and young people are considered. Possible new pharmacological treatments are also discussed.

Medically unexplained somatic complaints are among the most common clinical presentations in primary care in developing countries and they are a considerable burden for patients and the healthcare system. They are assumed to be the result of psychosocial factors, and the process by which symptoms are experienced is termed somatisation. Common mental disorders, somatoform disorders and socio-economic adversities are the major risk factors for these complaints. There is evidence suggesting that cognitive–behavioural therapy, which has proven efficacy for somatoform disorders in the developed world, can be used in developing countries with some adaptations (e.g. by simplifying the content so that it can be applied in primary care by non-specialist health practitioners; using culturally appropriate analogies; and delivering the intervention over fewer and shorter sessions). The main components of such an intervention are presented in this article.