This article outlines the changes to psychotherapy training for psychiatrists proposed in the Royal College of Psychiatrists' new specialist training curriculum. There is some debate about whether this curriculum should be taken up in its present form because of the limitation of resources to implement it. I describe the effect of taking the College at its word that psychotherapy training should be mandatory and the improvement this has already brought about in psychotherapy training on the Exeter and South Devon training rotations. I also discuss what will be required to implement the new requirements.

Not all traumatic events cause post-traumatic stress disorder (PTSD), and people develop PTSD symptoms after events that do not seem to be overwhelmingly traumatic. In order to direct services appropriately, there is a need to distinguish time-limited post-traumatic symptoms and acute stress reactions (that may improve spontaneously without treatment or respond to discrete interventions) from PTSD, with its potentially more chronic pathway and possible long-term effects on the personality. In this article, we describe acute and chronic stress disorders and evidence about the most effective treatments.

Risk assessment has become a large and anxiety-provoking part of the work of many psychiatrists. This article unpicks the different meanings of the word ‘risk’ to seek out the source of that anxiety, looking at both statistical and sociological ideas about risk. A risk assessment is often a subjective, plastic and context-dependent statement about a patient that carries strong moral overtones. Risk management is also highly anxiogenic for those charged with carrying it out, because uncertainty about the future is impossible to eliminate and the consequences of an adverse outcome in the patient may also carry hazards to the doctor making the risk assessment. This leads to behaviour change in people carrying out risk assessments as they attempt to minimise their anxiety in a rationally selfish way, often with unintended negative consequences for patients, doctors and health service providers generally. Some possible strategies for minimising this effect are considered.

Post-traumatic stress disorder (PTSD), recognised as a diagnostic entity in 1980, was originally associated with combat or war experiences. It has since been recognised that it is prevalent in any population exposed to traumatic events. Although much has been written about the management of PTSD, the concepts of resilience and vulnerability have not received the same attention. This article reviews the conceptualisation, epidemiology and comorbidities of PTSD and highlights the factors underlying vulnerability and conveying resilience.

Anabolic androgenic steroids (commonly known as anabolic steroids) are synthetic derivatives of the hormone testosterone. They are being increasingly used by professional and recreational athletes to enhance performance, and by men and women to improve physical appearance. This article discusses the characteristics of such steroid ‘misusers’ and the techniques of use. It highlights the psychiatric complications associated with these steroids, including increased risk of aggression, personality disorders, psychosis and mood disorders, particularly manic symptoms. Medical complications of steroid use are common and frequently reversible. Use is associated with an increased risk of injury, cardiovascular events, gastrointestinal complications, virilisation in women, and gynaecomastia and testicular atrophy in men. Whether addiction to these steroids can occur is debatable, but there is evidence for dependence and a withdrawal syndrome. Steroid use may be a ‘gateway’ to other addictions. Users are often reluctant to seek treatment and the psychiatrist's role in the recognition and management of use is presented.

This article reviews our understanding of the epidemiology and aetiology of premenstrual syndrome and premenstrual dysphoric disorder, and its assessment and management. It also addresses the concerns of the feminist community and the views of women themselves about this condition and its management. Service provision in the UK for women with these problems is unfocused and greatly varying, and they might be better assessed and treated by psychiatrists.

This article considers the contribution that psychodynamics can make to the work of teams providing early intervention in psychosis. Psychodynamic understanding enriches the stress and vulnerability psychosis model; can contribute to resolving the issues involved in relapse prevention; informs individualised formulations; and can make sense of patients' reactions to prescribing in psychosis. A rationale is given for longer-term individual, group and family dynamic psychotherapies within early intervention teams.

Antidepressant discontinuation symptoms occur with all classes of antidepressant. A well-described discontinuation syndrome occurs with the selective serotonin reuptake inhibitors, common symptoms including dizziness, headache, nausea and lethargy. Rare antidepressant discontinuation syndromes include extrapyramidal syndromes and mania/hypomania. All these syndromes, even isolated discontinuation symptoms, share three common features that facilitate diagnosis; abrupt onset within days of stopping the antidepressant, a short duration when untreated and rapid resolution when the antidepressant is reinstated. Clinicians need to be familiar with strategies for the prevention and management of such symptoms. Preventive strategies include warning patients about the possibility of discontinuation symptoms, encouraging good antidepressant adherence and tapering antidepressants at the end of treatment. Most symptoms are mild and short-lived. Consequently symptoms that follow planned termination of an antidepressant can often be managed by providing an explanation and reassurance. More severe symptoms should be treated symptomatically or the antidepressant restarted, in which case symptoms usually resolve within 24 h. More cautious tapering can then follow.

‘Mindfulness' has become a popular topic among psychological therapists. This introductory article explains what mindfulness is and how it can be developed, before exploring how it has been incorporated within psychoanalytic and cognitive–behavioural psychotherapies. These reflect general as well as specific presumed therapeutic actions. At present, variations in the way mindfulness is understood, taught and applied mean that it is too early to fully assess its potential. They demonstrate how the use of attention and awareness in therapy cuts across traditional divisions and where mindfulness in therapy is most in need of further investigation.

The cognitive behavioural analysis system of psychotherapy (CBASP) is a new therapy specifically designed to treat chronic depression. Conceptually the bio-psychosocial signs and symptoms of chronic depression are viewed as the result of either arrested maturational development at a Piagetian preoperational stage (in early-onset patients) or heightened emotionality and general functional regression (in late-onset patients). In this therapy, patients learn how their cognitive and behavioural patterns produce and perpetuate interpersonal problems and how to alter maladaptive patterns of interpersonal behaviour. The focus is primarily on interpersonal interactions, including with the therapist, through the latter's disciplined personal involvement. In this article we outline the therapy process and key mechanisms of change using examples to illustrate specific techniques. We also outline the theoretical model underpinning CBASP and summarise the evidence from a large clinical trial.

The purpose of this article is to update practitioners on the latest published research into the prevalence of prolonged cerebral seizure activity following electroconvulsive therapy (ECT). This research is drawing attention to the real practical challenges of recording and reading an electroencephalogram (EEG) tracing in the ECT clinic. In particular, determination of the seizure end-point is not always practicable and this poses a major problem in the detection and management of prolonged cerebral seizure activity. Some practical tips are suggested, and an update is given on the status of EEG monitoring in the assessment of seizure adequacy.

A good therapeutic alliance between mental health professionals and patients with psychosis can enhance adherence to medication regimens and improve clinical outcome. This article explores how the therapeutic alliance might be developed with respect to decisions to prescribe antipsychotic medication. It does this by presenting the implications for practice that arise from a recent qualitative interview study with consultant psychiatrists. We consider strategies for strengthening the therapeutic alliance, occasions when it might be appropriate to suspend shared decision-making temporarily, techniques used to enable discussion of symptoms and side-effects, and how issues of adherence are uncovered and addressed. Psychiatrists already possess considerable skills in these areas. The dissemination of these to colleagues forms an important opportunity for CPD.

Intimate partner violence is associated with significant psychiatric comorbidity. Treatment has focused on male perpetrators but recent studies indicate that this is of limited success in reducing male violence. This article reviews the current available treatments from three perspectives: that of the victim, the perpetrator, and the couple who wish to remain together. It also provides guidelines to assist the general psychiatrist in determining what treatment to offer patients who present with intimate partner violence. Guidelines emphasise the need for assessment of risk factors that indicate a potentially lethal relationship and the importance of the diagnosis and treatment of comorbidity, especially alcohol misuse and dependence.

The rationale for assessing the spiritual needs of psychiatric patients is examined as a prelude to addressing the question of how to do this. A number of approaches are considered. The emphasis is on varieties of practical history-taking suitable for the repertoire of every psychiatrist in training and those engaged in CPD. Finally, some of the consequences of identifying spiritual needs in psychiatric patients are discussed.

This article describes research ethics and the UK research ethics system for psychiatrists who are engaged in research or in supporting trainees with research projects. The emphasis on practical aspects should ensure that submissions to research ethics committees are improved, and consequently the likelihood of a successful outcome is increased.

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.

Much has changed in the National Health Service in the UK in the past 10 years and consultant roles need to adapt accordingly. This article describes the drivers for change in consultant roles, including enhanced roles for other mental health professionals, increased expectations of users and carers, changes in junior doctors' work patterns and the new consultant contract. The recommendations of the report on New Ways of Working for Psychiatrists are reviewed, with suggestions for changes in the consultant role in out-patient clinics, community teams and acute care. Enhanced roles for other mental health professionals and the increasing trend to specialisation are also discussed.

Schizophrenia and other schizophrenia-spectrum disorders are neurodevelopmental disorders which may share genetic susceptibility factors and represent differential expressions of an underlying vulnerability. Schizophrenia may have its onset in childhood and can be reliably diagnosed. However, developmental factors modulate disease expression in children. Although the prevalence of schizophrenia in childhood is low, children who develop schizophrenia in adult life may show subtle and non-specific developmental abnormalities, consistent with the neurodevelopmental hypothesis. Studies of the schizophrenia prodrome also demonstrate that abnormalities may be apparent years before the onset of positive symptoms. Such evidence raises the possibility of using preventive approaches in the treatment of schizophrenia. Further advances in our knowledge of the aetiopathology of schizophrenia (and the identification of endophenotypes within the group of schizophrenia and related disorders) may further improve our ability to predict disease development, making implementation of preventive interventions more achievable.

The article covers the state of play of adoption from local authority care in the UK and research into the factors influencing placement outcomes. The major contentious issues about placement are discussed in relation to competing opinions and available evidence. Ways of intervening in adoptive families in difficulty are considered, together with current efforts to establish what makes for effective support services. This article recommends comprehensive assessments of the children to be placed and carefully targeted adoption-aware psychosocial interventions.