Addiction is a global health problem with a chronic relapsing nature for which there are few treatment options. In the past few decades, neuroimaging has allowed us to better understand the neurobiology of addiction. Functional neuroimaging paradigms have been developed to probe the neural circuits underlying addiction, including reward, inhibitory control, stress, emotional processing and learning/memory networks. Functional neuroimaging has also been used to provide biological support for the benefits of psychosocial and pharmacological interventions, although evidence remains limited and often inconclusive in this area, which may contribute to the variability in treatment efficacy. In this article, we discuss the changing definitions and clinical criteria that describe and classify addictive disorders. Using examples from functional neuroimaging studies we summarise the neurobiological mechanisms that underpin drug use, dependence, tolerance, withdrawal and relapse. We discuss the links between functional neuroimaging and treatment, outline clinical management in the UK and give an overview of future directions in research and addiction services.

This article explores the uses of the terms social exclusion and social inclusion in a mental health context. We briefly describe the origins of the term social exclusion and analyse its connotations in relation to four key dimensions: the relative, multifactorial, dynamic and transactional. We discuss Levitas's three discourses concerning social exclusion (the redistributionist, moral underclass and social integrationist) and present a case in favour of a fourth perspective, societal oppression. Focusing on social inclusion as a remedy for the ills of social exclusion, we discuss implications for contemporary mental health policy, practice and research. We highlight the potential contribution of social psychology to social inclusion theory. We conclude that a better theoretical understanding of causal mechanisms is needed to enable the development of more socially inclusive mental health services.

Electroencephalography (EEG) is a non-invasive investigation that can aid the diagnosis of psychiatric and neuropsychiatric disorders. A good predictor of an abnormal EEG recording is the presence of an organic factor identified during the clinical assessment. The non-invasiveness and low cost of the procedure and its ability to measure spontaneous brain activity appear to attract clinicians to utilise this investigative tool. However, studies have reported that EEGs arising from psychiatric referrals have the lowest abnormality detection rate. The focus of this article is to improve this by highlighting the current pitfalls and providing recommendations for appropriate utilisation of EEG. We describe specific EEG changes associated with major psychiatric disorders. We conclude by offering pragmatic considerations when referring a patient for EEG, emphasising the fact that the information provided to the neurophysiologist plays a crucial role in interpreting the EEG recording in a diagnostically meaningful way.

‘Security holds the key’ was the title of a newspaper article concerned with e-commerce (D. Sumner-Smith, The Sunday Times, 6 February, 2000, p. 3.13). However, it applies just as readily to the health sector. The need to safeguard the confidentiality of information that patients share with clinicians is as fundamental as the principle of consent. This issue has come to the fore in the context of the rapid developments and applications of information and communication technologies within society in general and within the health sector in particular. There are also changing societal expectations regarding access to information, confidentiality and disclosure. The emerging scenarios present significant challenges in relation to the traditional methods used to deal with the privacy and confidentiality of personal information (Anderson, 1995). In addition to the impact of new technologies, consideration also needs to be given to the impact of changes in health care organisation and practice, for example multidisciplinary and multi-agency working. Mental health services are in many respects at the vanguard of these changes, where the ideals of community care, shared care and seamless care depend fundamentally on good communication and information sharing. Failures in communicating information, particularly across sectoral boundaries, have led to significant problems in patient care, as revealed in several recent enquiries into homicides (Northamptonshire Health Authority & Northamptonshire Social Services, 1999)

About 6% of older people in the UK are immigrants. Concentrated in deprived inner-city areas, their numbers are rising rapidly, with the ageing of those arriving after the Second World War. Cultural, language and educational differences cause problems in studying this group's mental health. Idioms of distress may affect presentation, help-seeking behaviour and acceptability of treatment. Ethnic elders may be considered vulnerable to depression because of socio-economic deprivation, immigrant status and old age but studies are contradictory and may use inappropriate screening instruments. Relatively few consider immigrant status and dementia. Uncontrolled hypertension could relate to higher dementia rates in Black immigrants which are not reflected in the country of origin. No genetic risk has been found. There is potential for prevention in this population.

Doctor-to-doctor relationships are explored. The impact of the employing organisation on working relationships is considered and methods of analysing problems at the organisational and individual level are described. The application of psychodynamic and systems theory in deepening understanding is discussed, illustrated by vignettes from the work situation. The impact of changes in the work environment are considered and potential sources of support listed.

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.

Children and young people are usually referred to specialist child and adolescent mental health services (CAMHS) by adults because of concerns raised by other adults. Most CAMHS consider them from a developmental perspective and as individuals in the context of their families and other relationships/systems. In this article I discuss ethical and legal challenges posed by making decisions with and about children and young people within CAMHS, with particular reference to duty of care; the rights of minors' and parents'; capacity and consent; and disagreement between decision-makers. It is important to involve children and young people in decision-making, and I suggest ways of acheiving this.

Epilepsy is a common neurological condition with wide-ranging neuropsychiatric manifestations. The relationship between epilepsy and psychiatry has been recognised for centuries. However, the wide range of neuropsychiatric comorbidities and their extent is only now beginning to be appreciated. The impact of these comorbidities on patients' help-seeking behaviour, seizure control and quality of life suggests that early detection and treatment are of paramount importance. Clinical issues in relation to accurate recognition and appropriate management of neuropsychiatric conditions in epilepsy are discussed.

Victims of stalking are a diverse group, but most individuals who are subjected to the persistent pursuit of a stalker, regardless of age, gender or socioeconomic background, experience fear. Some suffer profound distress and lifestyle disruptions, and many experience a decline in their psychological and physical well-being. Stalking is not uncommon in today's society and there is evidence to suggest its incidence is increasing (Budd & Mattinson, 2000). It is therefore anticipated that the victims of these behaviours will be presenting to law enforcement and health professionals in ever-expanding numbers. The efficacy of the interventions they receive will determine whether they can reclaim their lives and premorbid functioning or whether, through ignorance, they are condemned to continuing torment and chronic disability, to the detriment of society as a whole.

Feedback is an essential part of the learning process. Feedback can be positive or negative, constructive or destructive, minimal or in depth. It must always occur and should never be ignored. The role of effective feedback is critical in the modern postgraduate medical educational process in the UK, with its emphasis on competency-based curricula and workplace-based assessment. Feedback is not new in medical education and has been shown in research to be effective in bringing about change, particularly improvement in clinical performance. There are clear principles and features of good and bad feedback and these are highlighted, along with descriptions of models for use in daily practice.

I review some of the evidence that parental personality disorder represents a risk to child development, in terms of both transmission of genetic vulnerability and the environmental stress of living with a parent who has a personality disorder that negatively affects their parenting capacities. I argue that there are two compelling reasons to impose a duty on mental healthcare providers to offer services for adults with personality disorders that specifically focus on their parenting identity: first, because effective therapies for personality disorder are now available; and second, because there is a strong utilitarian and economic argument for improving parental mental health so as to reduce the economic and psychological burden of their offsprings' future psychiatric morbidity.

As Northern Ireland celebrates the first year in 30 years when a soldier or police officer has not been killed and as it currently struggles to implement yet another political initiative to gain peace, now seems an appropriate time to reflect upon the effect of political violence on the psychiatric services in the province. For almost two generations the campaign of political violence has touched every doctor professionally. Indeed, one of us was a houseman in the front line Royal Victoria Hospital and the other was just born when the sectarian street pogroms and internecine violence first erupted. Neither of us knew that what was to follow would determine our professional futures. In the fresh air of the new millennium, and particularly following the horror of the Omagh massacre of August 1998 and the hope of the Good Friday agreement of April 1998, we can reflect upon and review the psychiatric aspects of politically inspired violence.

Autism spectrum disorder (ASD) is a complex, multifactorial disorder, the prevalence of which is rising. Specific biomarkers are yet to be identified for the classic ASD phenotypes, so despite treatment advances, most interventions focus on the comorbid disorders of ASD and have little impact on the underlying pathogenesis of the disorder. This article describes drug treatments that target the core symptoms of ASD and its comorbid conditions in children and adolescents. Difficulties and challenges encountered when treating the most frequent comorbidities are discussed, with emphasis on the safety, tolerability and efficacy of medications. In view of its widespread use, complementary and alternative medicine is also described.

This article outlines the current provision and describes the role of forensic psychotherapy in the management of forensic patients. The authors maintain that the contribution of forensic psychotherapy is not limited solely to treatment provision. The forensic psychotherapist has a supervisory role, which can help staff and institutions to understand the dynamic processes that arise from the effects of managing forensic patients. The article outlines how forensic psychotherapy can contribute towards risk assessment and highlights some particular areas of concern for the forensic psychotherapist.

This brief article describes the main health indicators of Brazil and gives an overview of psychiatric care. It points out the primary pitfalls of the mental healthcare system and presents some suggestions for the future of mental health in the country.

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.

There is considerable debate about the diagnosis of personality disorder in adolescence. It is argued that, because personality is still developing in the teenage years, it is impossible to state with certainty that a young person's personality is disordered. Alternatively, some researchers and clinicians argue that it is possible to diagnose emerging personality disorder on the basis of trait theories of personality. We review the evidence for both sides of the debate.

Comorbidity and dual diagnosis have a fashionable, and thus ephemeral, ring that belies their relevance to day-to-day practice. The topic has been increasingly addressed in North American literature where there is a recognition of the extent of substance misuse in the severely mentally ill, and the need to find ways of effectively managing its consequences. Substance misuse may colour the diagnosis, management and prognosis of major mental illness and can adversely affect the relationship between staff and patients. Despite its common occurrence, it frequently remains undetected (Ananth et al, 1989). With burgeoning research interest, there is some consensus as to how to manage the problem, but, as yet, little agreement on the precise nature of causal relationships.

A number of studies have noted an association between being the victim of bullying and psychotic symptoms. We offer an overview of the topic, focusing especially on a developmental perspective. We highlight the results of the latest studies on psychosis across the continuum and its relationship with bullying. Then we summarise the three main explanatory models investigated: developmental, biological and cognitive. We recommend that bullying in psychosis requires careful study of the developmental trajectories involved, and that research should now focus on how personal, social and biological factors interact.