Sexual and relationships difficulties are not uncommon among psychiatric patients. A presenting complaint of anxiety or depression may relate to an underlying sexual or relationship difficulty; commonly used psychotropic medications cause sexual side-effects that can have a significant impact quality of life, relationship maintenance and treatment adherence; patients may exhibit unusual or excessive sexual behaviours when acutely unwell, including risky use of apps to meet sexual partners and accessing online pornography in unsafe ways; patients may have used technology such as the internet to harm others or they may be victims of such harm; the internet and social media might even be influencing sexual expression, for example gender identity. Therefore, psychosexual history-taking remains a key competency for psychiatrists. They must also understand the new language used to describe sexuality, sexual behaviours and the use of social media, apps and so on to form relationships. This article outlines the key areas to consider in carrying out a structured psychosexual assessment. It also gives an overview of current sexual terminology, observed influences of the internet on sexuality and sexual behaviour, and its implications for mental health and potential sexual offending.

It is highly likely that a psychiatrist will be called to an inquest at some point in their career. Our aim in this article is to educate psychiatrists in relation to the law and processes of a coroner's court in England and Wales and provide guidance on engaging with the system. To achieve this we review and discuss the relevant law and medico-legal aspects of inquests. Knowledge and preparation are key to negotiating any inquest and we would hope that the understanding and guidance offered in this article will reduce anxiety, make the situation manageable and aid professionalism, in often tragic circumstances.

Psychological treatments in secure settings have traditionally been based on psychodynamic and cognitive–behavioural approaches. Recent developments, supported by an emerging evidence base, have generated a significant amount of interest in mindfulness-based psychological therapies and their utility in diverse areas of mental healthcare. In this article we analyse the current evidence base and describe possible mechanisms of action of mindfulness-based psychological approaches. On the basis of the evidence, we advocate a cautious but positive approach to using mindfulness-based interventions in secure services.

Fusion legislation is the latest in a long line of reforms in mental health law that have sought to increase patient autonomy. It has not been without controversy, having been proposed and rejected in various jurisdictions throughout the UK and internationally, while causing considerable debate in the academic literature. This article considers some of the history and debate, along with the criminal justice provisions of the first piece of fusion legislation internationally, the Mental Capacity Act (Northern Ireland) 2016, and their potential implications.

There is much Mental Capacity Act 2005 (MCA) case law emanating from the Court of Protection. This article reviews an important and unique case when the court specifically addressed for the first time the question of fluctuating capacity, a not uncommon clinical problem that can often be complex. It describes how the Court of Protection in Royal Borough of Greenwich v CDM [2019] legally approached an issue of fluctuating capacity in a 64-year-old woman with a personality disorder and chronic diabetes. In doing so it elucidates a new conceptual framework to apply when assessing fluctuating capacity in terms of considering micro- and macro-decisions which can be used in routine clinical practice.

Miscarriages of justice occur as a result of unsafe convictions and findings and inappropriate sentences. In cases involving expert psychiatric evidence it is possible that the way evidence is presented by experts or interpreted by the courts has a direct bearing on the case. Using illustrative cases from the Criminal Division of the Court of Appeal, advice is offered to expert psychiatric witnesses on ways to reduce the likelihood of contributing to such miscarriages of justice and on how they may assist in rectifying such miscarriages, should they occur.

In recent years, mass violence associated with men who identify as involuntary celibates (incels) has been of increasing concern. Incels engage in an online community where misogyny and incitements to violence against women are prevalent, often owing to the belief that women are denying them a ‘right’ to sex. Indeed, inceldom can be considered a form of extremism. Information released about the prepetrators of incel-associated violence consistently suggests that mental disorder is a contributory factor and may increase vulnerability to engaging with the incel community. Depression, autism and personality disorder are particularly relevant. To date, there has been little research into the mental health of incels and how, in some, this contributes to violence. This article considers the associations between mental disorder and inceldom, including the risk factors for incel-related violence, and makes recommendations for best practice in risk assessment and clinical intervention.

Psychiatric expert witnesses instructed to undertake assessments of defendants charged with murder should be familiar with the partial defences of diminished responsibility and loss of control. The Coroners and Justice Act 2009 enacted major amendments to the partial defence of diminished responsibility and introduced a new defence of loss of control to replace the provocation partial defence. In this article, the changes to the law are described with particular focus on the implications for the psychiatric assessment.

This review examines whether the diagnosis of dissociative identity disorder (DID) could be used to support a defence of ‘not guilty by reason of insanity’ (NGRI, or the insanity defence). The problem is that DID has doubtful validity and can easily be malingered. However, the diagnosis is listed in standard psychiatric manuals. If accepted as valid, DID would have problematic forensic implications.

People with intellectual disability can have a range of common mental health difficulties that sit at the interface of two psychiatry subspecialties: intellectual disability and general adult psychiatry. Clinical presentations, comorbidities and complexities can affect the setting of boundaries between the two disciplines. This article touches on current concepts, drives for inclusion of people with intellectual disability in mainstream psychiatry services and some of the difficulties at the interface. It focuses on potential solutions for managing this interface between the two subspecialties.

Malingering is the intentional feigning of illness for external gain. The author has written several papers on the epidemiology, assessment, testing and reporting of this. However, practice in this field can raise considerable challenges, not least the inability to determine motivation for lying, and potential damage from ‘false positives’, where individuals fabricate some aspects of their testimony, yet still have underlying psychiatric problems. This brief article lays out the author's reflections on this complex area.

The phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an underrecognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. Causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.

People with mental disorder and intellectual disability have the same rights to sexual expression as other people, albeit that in some cases a lack of capacity may require curtailment of those rights and regard must be had to protecting the vulnerable. Furthermore, the formation or maintenance of sexual relations, or the attainment of sexual fulfilment, may assist in the maintenance or restoration of mental health or well-being. This article demonstrates how the courts in England and Wales, applying statute law and judicial precedent, are largely supportive of the rights of people with mental disorder or intellectual disability to make decisions about sexual expression, sexual relationships and related matters, notwithstanding some societal and staff attitudes that act to prevent them fulfilling their sexual needs and making decisions about sexual and reproductive matters.

The professional regulatory cases of the psychiatrist Dr Richard Pool and the neuropathologist Dr Waney Squier have given rise to concerns among expert psychiatric witnesses, and indeed medical experts in general. Here we restate the law on expert evidence with particular reference to the judgment of the Supreme Court in the case of Kennedy v Cordia. We emphasise that Pool does not change the law regarding ‘what is expertise’; in particular, the case does not establish restrictive, status-based tests governing the admissibility of expert evidence such as according to whether an expert psychiatric witness has undergone higher training, is on the specialist register as a specialist in a particular field or is a consultant. Rather, expertise continues to be legally defined in terms of a combination of qualification, knowledge and experience. Crucially, the test of medical expertise in legal proceedings is a legal test and not one determined within a medical paradigm.

Mental disorder and criminality are separate entities but some people with a mental disorder commit criminal offences and some criminals have a mental disorder. Before 1800 there was no separate category of mentally disordered offenders (referred to as criminal lunatics until 1948) in UK legislation. The provision of facilities for mentally disordered offenders in Britain and Ireland overlapped with, but was also separate from, provision for the mentally ill generally. The interface between general and forensic psychiatry is an area of tension and of collaboration. To understand how contemporary general and forensic psychiatry interact, it is useful to have an understanding of how factors have evolved overtime.

The Department of Health's best practice guidelines on risk management and violence prevention in UK mental health services highlight the importance of transparency and collaboration with service users. The recovery philosophy echoes the importance of service user inclusion and empowerment in treatment. Our experience in a medium and low secure hospital was that patients were largely excluded from the risk assessment process. In this article, we describe a model for achieving inclusion and transparency in the use of risk assessment tools based on structured professional judgement.

Female drug-using offenders are a large but under-researched and vulnerable population with specific needs. Only a handful of randomised controlled trials of interventions for this population are of sufficient quality to shed light on what might work to reduce their criminal activity and drug use, and interpretation of the results of most of these trials is limited by an ‘unclear’ risk of bias due to a lack of descriptive information. Better-quality research is needed to inform practitioners and policy makers. In the meantime, this month's Cochrane Corner review provides cautious support for the use of some psychosocial treatments, particularly if delivered in a gender-responsive way addressing issues of abuse and victimisation, in the expectation that re-imprisonment can be prevented, even if there is no proven effect on re-arrest rates and only uncertain effects on substance use.

Although a significant proportion of prisoners and patients in secure hospitals are sex offenders and victim surveys reveal a high level of hidden sexual victimisation, the authors of this Cochrane review found only very limited support for pharmacological intervention with sex offenders. Given the nature and extent of the problem of sexual offending and the promise shown by new drugs, there is a need for clinical scientists, lawyers and ethicists to rise to the challenge of ascertaining the effectiveness and safety of drugs which are being used to treat sex offenders, some involuntarily, without the evidence base to justify confidence as to their effectiveness and safety.

Acting as an expert psychiatric witness can be rewarding, but there are potential costs and pitfalls, such that the role should be undertaken only in an informed manner. With reference to the recent disciplinary cases of Dr Richard Pool and Dr Waney Squier, and a judgment of the Supreme Court, advice is offered to potential expert psychiatric witnesses. Suggestions are made as to training, the negotiation of instructions, the citation of published literature, the construction of expert opinion and how to ensure compliance with the ethical duties of the expert witness.

Clear policies regarding sexual expression, sexual behaviour and related decision-making assist in ensuring that the rights of people with mental disorder or intellectual disability are upheld, and that staff know how to react to situations consistently and lawfully without interfering on the basis of their own moral judgements or personal beliefs. Sensitive and holistic planning of care that complies with domestic law, international human rights law and statutory guidance is necessary to complement such policies. Non-intimate physical contact, masturbation, sexual relationships, contraception, sterilisation and vasectomy, pregnancy, termination of pregnancy, sexual dysfunction, parenthood, marriage and civil partnership, divorce, prostitution, pornography, and sex aids and toys are all matters that may properly be part of care planning.