‘Munchausen's syndrome by proxy’ characteristically describes women alleged to have fabricated or induced illnesses in children under their care, purportedly to attract attention. Where conclusive evidence exists the condition's aetiology remains speculative, where such evidence is lacking diagnosis hinges upon denial of wrong-doing (conduct also compatible with innocence). How might investigators obtain objective evidence of guilt or innocence? Here, we examine the case of a woman convicted of poisoning a child. She served a prison sentence but continues to profess her innocence. Using a modified fMRI protocol (previously published in 2001) we scanned the subject while she affirmed her account of events and that of her accusers. We hypothesized that she would exhibit longer response times in association with greater activation of ventrolateral prefrontal and anterior cingulate cortices when endorsing those statements she believed to be false (i.e., when she ‘lied’). The subject was scanned 4 times at 3 Tesla. Results revealed significantly longer response times and relatively greater activation of ventrolateral prefrontal and anterior cingulate cortices when she endorsed her accusers' version of events. Hence, while we have not ‘proven’ that this subject is innocent, we demonstrate that her behavioural and functional anatomical parameters behave as if she were.

Deception is commonplace and a discipline such as psychiatry, so often reliant upon subjective accounts, may be susceptible to its effects (especially in the fields of military, liaison, medico-legal and forensic practice). However, psychiatric trainees receive little formal teaching on the subject of medical deceit. Here, I review some recent books on deception, emphasising those works that cast tangential light upon everyday psychiatric practice. Useful sources of reference include those concerning the philosophy of deceit, the recent rise of political lying and the clinical problem of feigned illness. A clinically helpful distinction emerges: that between truth (accuracy) and truthfulness (sincerity).

It is difficult, if not impossible, to systematically identify ten books that have been influential over a professional lifetime, not least since many have probably exerted their influence in long-forgotten ways: part of that semantic sediment laid down by protracted reading (and conversation). However, I do know that George Orwell was the first serious writer whom I read ‘of my own free will’ and I know that I would not wish to be without the works of Anthony Burgess, Albert Camus, Bruce Chatwin, Don DeLillo, Graham Greene, Henning Mankell or W.G. Sebald. I can remember that books on Buddhism sustained me through senior house officer jobs in a number of medical specialties (trying to focus, single-mindedly, on the task in hand rather than my tiredness or distraction), and I suspect that the metaphors of my thought and speech had already been much influenced by exposure to the Bible. Here, I focus on those books that have informed the way I think about psychiatry right now and how it might be practised.

A small, city-wide clinical outreach service for the homeless mentally ill in Sheffield, UK, attained its present configuration 6 years ago. This paper discusses the lessons learnt in the course of the service's existence.

The homeless mentally ill identified by the service have disengaged from the ‘mainstream’ services and society. Most are from disturbed homes, nearly all have had prior contact with psychiatric services and as many as half have served prison terms. As service users, they must be actively sought out and engaged, which places specific demands upon a mental health team: flexibility of approach, patience and a willingness not to judge others' values.

Though largely anecdotal, the inferences drawn in Sheffield may have parallels elsewhere, not least since individual lives can turn upon pivotal (‘anecdotal’) encounters and those evinced by the homeless tell us much about society, psychiatry and the values of contemporary healthcare providers. Also, most of the time, the proposed model has been successful.

El “síndrome de Munchausen por poderes” se refiere, en general, a mujeres acusadas de haber inventado o producido enfermedades en niños bajo su cuidado, destinadas a atraer la atención sobre sí misma. Cuando hay pruebas concluyentes, hay dudas sobre la etiología de la enfermedad, pero cuando no hay pruebas, el diagnóstico depende de la negación de la intencionalidad (conducta también compatible con la inocencia). ¿Cómo podrían los investigadores conseguir pruebas objetivas sobre culpabilidad o inocencia? En este artículo analizamos el caso de una mujer condenada por envenenar a su hija. Cumplió la condena en la cárcel, pero sigue reclamando su inocencia. Usando un protocolo modificado de RMf (publicado ya en 2001) realizamos la prueba de neuroimagen mientras ella confirmaba su versión de los acontecimientos y mientras aceptaba la de sus acusadores. Sugerimos la hipótesis de que los tiempos de respuesta serían más largos y se asociaran con mayor activación de la corteza cingular anterior y prefrontal ventrolateral cuando hacía declaraciones falsas (es decir, cuando “mentía”). La mujer fue sometida 4 veces a RM de 3 teslas. Los resultados revelaron tiempos de respuesta considerablemente más largos y un activación relativamente mayor de la corteza cingular anterior y prefrontal ventrolateral cuando aceptaba la versión de los acontecimientos de sus acusadores. Es decir que aunque no hemos “probado” que esta mujer es inocente, demostramos que sus parámetros conductuales y funcionales anatómicos se comportan como si lo fuera.

A responsible person, a moral agent, takes account of their future behaviour and its likely impact upon others. Such an agent may choose to influence their future by exogenous means. If so, might pharmacology help them to do this? Is it doing so already? I argue that it is.

We report a case of recurrent parotid gland swelling in a man receiving clozapine. Our aim is to raise awareness of this iatrogenic condition and to review what is known of its pathogenesis and management.

There has been little systematic study of personality disorders in older people (65 years of age and above). However, with an ageing population worldwide we should expect to find increased numbers of people with Axis II disorders surviving into old age. We undertook a qualitative review of the recent literature concerning personality changes and disorders in older people, their prevalence and possible amelioration.

Avolition affects quality of life in chronic schizophrenia. We investigated the effect of modafinil upon unconstrained motor activity in 18 male patients. In a randomised crossover design study wrist-worn actigraphic monitors were used to objectively record motor activity over a 20 h period. Patients' total activity was significantly greater when given the drug. These data suggest that modafinil increases quantifiable motor behaviour in schizophrenia and may have an impact on avolition.

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.

Avolition affects quality of life in chronic schizophrenia. We investigated the relationship between unconstrained motor activity and the volume of key executive brain regions in 16 male patients with schizophrenia. Wrist-worn actigraphy monitors were used to record motor activity over a 20 h period. Structural magnetic resonance imaging brain scans were parcellated and individual volumes for anterior cingulate cortex and dorsolateral prefrontal cortex extracted. Patients' total activity was positively correlated with volume of left anterior cingulate cortex. These data suggest that the volume of specific executive structures may affect (quantifiable) motor behaviours, having further implications for models of the ‘will’ and avolition.

Yang et al (2005, this issue) report what is probably the first structural neuroimaging study of lying. Adults were recruited from temporary employment agencies in Los Angeles. This will have been a complex and demanding study to perform; it has already yielded significant insights into the neural correlates of antisocial personalities drawn from that environment, indicating reduced prefrontal grey matter and diminished autonomic responsiveness (Raine et al, 2000). The current findings derive from a re-analysis of these data, themselves obtained from reliable blinded measurement of prefrontal white matter by magnetic resonance imaging. The groups were imperfectly matched on some variables (e.g. age), nevertheless, this did not detract significantly from the authors' findings: namely, greater prefrontal white matter volume among those identified as ‘liars' (relative to ‘antisocial’ and ‘normal’ controls).