Bullying among girls is often subtle and relational, which can go unnoticed by parents, teachers and healthcare professionals. This article explores how covert aggression – such as social exclusion, gossip and emotional manipulation – can cause profound psychological harm to targeted girls, many of whom may not even realise they are being bullied. Through an analysis of defining attributes of girl-to-girl bullying and general implications for mental health, this article aims to highlight the importance of early identification and treatment. The article also points out how social patterns of bullying found predominantly in girls’ social circles carry over well into adulthood, emerging in the work environment, social circles and cyberspace. Focused on practical application, this educational paper aims to enhance clinicians’, caregivers’ and teachers’ recognition of relational aggression, develop collaborative approaches to prevention and facilitate useful interventions for those affected. Ultimately, increased sensitivity to subtle bullying has the power to reduce subsequent harm and result in healthier social contexts.

Reduced access to dementia healthcare services by elders from ethnic minority backgrounds is often a manifestation of underlying systemic disadvantages within dementia assessment and treatment services. In this narrative review of current literature on UK dementia healthcare services we identify risk factors contributing to the inequalities faced by people with dementia from ethnic minorities, point to major knowledge gaps in dementia diagnosis, management and long-term care for these groups and highlight clinical challenges arising in delivering services to them. We describe the inequity in diagnostic rates, their poorer treatment outcomes and the lack of culture-specific support for people from ethnic minority communities. We present proposals for South Asian and the Black ethnic minority groups by which local healthcare systems may minimise some of these disadvantages. This will enhance our understanding of the aetiology and management of long-term conditions such as dementia by improving access to and dialogue with ethnic minority communities and healthcare providers.

This article provides a brief introduction (or recapitulation) of what variable types are and how the choice of the variable type may affect which research questions can be answered and the data analysis. The nine-item Patient Health Questionnaire and a simulated data-set are used as an illustration throughout.

Barricaded incidents, hostage-taking and sieges occur in the community, where police negotiators are usually called on to bring about a peaceful resolution. They occur also in prisons and psychiatric hospitals, where they will be managed by the institution’s staff, with police support if needed. Psychiatrists and other mental health professionals have been involved in providing training and on-call support for negotiators and decision makers in these crisis situations. This article describes definitions and goals in relation to such incidents, and outlines a five-phase framework for their management (training; first responders, preliminary interventions and inquiries; negotiations; resolution; aftercare), indicating the psychiatrist’s role during each phase. Ethical issues are also discussed.

The Autistic Spectrum, published almost 30 years ago, remains an important text for all those who work with autistic individuals. This brief article highlights the significant contribution of Lorna Wing to how we view autism, including the observation that many of the issues being highlighted today regarding the appropriate management of autistic individuals are not new and can be found in the thoughts of Dr Wing.

Dementia is a progressive and irreversible deterioration in cognition that has a significant impact on the person’s activities of daily living and quality of life. Currently, there is no curative treatment for dementia, and the treatments used in clinical practice have limited therapeutic reach. We begin this descriptive review with a discussion of apolipoprotein E4 (apoE4) and its role in the pathogenesis of dementia. We consider the molecular involvement of statins and why they are no longer clinically indicated in mild cognitive impairment or mild to moderate dementia. We then explore the evidence regarding the effects of statins and cyclodextrins on apoE4, presenting evidence in support of and against their neuroprotective effects in cognitive impairment. Although the studies on cyclodextrins have all been on animals, they provide a strong background for a potential research hypothesis for future clinical trials in the treatment of dementia.

In the past 20 years, there has been growing interest in post-traumatic stress disorder (PTSD) in people with intellectual disabilities. It is now widely recognised that individuals with intellectual disabilities are more likely to be affected by traumatic experiences than those without. The authors discuss advancements in understanding trauma and PTSD in individuals with intellectual disabilities, as well as improvements in clinical assessment and treatment. They also emphasise the need for further research into the effects of trauma and PTSD on this vulnerable and often marginalised population.

Although fundamental advances in the life sciences raise the exciting possibility of novel translational therapies, optimal evidence-based usage of established treatments should be the bedrock of current clinical care. The authors argue that there are instances where well-established treatments are ‘underused’ in psychiatry; electroconvulsive therapy, clozapine and lithium are exemplars of this. This article explores possible reasons for, and strategies to address, this underuse.

The Mental Health Act assessment or interview is a commonplace process in psychiatric services during which significant decisions are made about a person’s care and liberty. Individuals have reported negative experiences of being subjected to these assessments, at times even influencing their ongoing relationship with healthcare and recovery. A 2018 independent review of the Mental Health Act 1983 (MHA) for England and Wales identified numerous areas for practice improvement, including the identification of epistemic injustice as part of current MHA processes. Nevertheless, the assessment process has received little attention on how it is conducted, with scant clinical guidance, training or research available on the subject. In this article the authors propose seven principles that assessors can incorporate into interviews to improve the way in which the MHA assessment is conducted. These principles have been drawn from a dialogical and relational approach to psychiatric care called Open Dialogue. A dialogical approach to MHA assessment could improve experiences of being assessed, information gathered, and, by preserving therapeutic relationships, give better longer-term outcomes.

Nidumolu et al’s article in BJPsych Advances illustrates how psychiatrists might use the key concepts of quality improvement (QI) to analyse and improve mental healthcare systems. This commentary on the article points out the importance of recognising the type of problem for which QI is best suited and the role of softer, relational approaches alongside the technical tools of improvement. It also highlights that QI can bring broader benefits to a team and organisation, including improvements in staff engagement and well-being. In mental health services, psychiatrists can play a key role in enabling and role-modelling this approach to problem-solving, as their extensive experience of leading multidisciplinary teams and shared decision-making with patients can be a great asset in QI.

Suicidal and self-harming behaviours present a significant challenge for mental health services. Recent national guidelines advocate abandoning tools based on box-ticking and a move towards a personalised psychosocial assessment. This article examines evidence from theoretical and empirical research in this area and attempts to integrate it by introducing the source–problem–solution–motive (SPSM) model. The model, which builds on the contributions of other suicidologists, specially Jean Baechler, could be used as a framework for the assessment and management of these behaviours. The four stages of the model provide a comprehensive approach that enables an exploration of the internal logic of the behaviour. The model covers ‘because’ and ‘in-order-to’ motives. This allows a personalised approach, but also a structured one that can be taught and generalised.

Experiences in Groups is a revolutionary text in the understanding and analysis of group dynamics which remains highly relevant to mental health practice today. This article considers its key themes as well as its development in the context of Wilfred Bion’s work as a doctor and a psychoanalyst.

Despite being the most prevalent personality disorder, borderline personality disorder remains a diagnosis with many unanswered questions, particularly concerning pharmacological management. Although many clinical practice guidelines suggest not prescribing medication unless there are significant clinical comorbidities, it is one of the psychiatric diagnoses with the highest rates of polypharmacy. This commentary on a BJPsych Advances article aims to raise clinical questions regarding the voids of knowledge and the appropriateness of medicating and, perhaps, overmedicating in this particular group.

Regardless of any socially held perceptions of privilege or power differentials, boys and men present unique developmental vulnerabilities and disproportionate rates of specific mental health problems, such as disruptive behaviour disorders, substance misuse and completed suicide. Moreover, men are less likely than women to seek help for psychological distress and adhere less well to treatments. In this brief article, some of the unique mental health problems experienced by boys and men are reviewed within a developmental perspective and general clinical guidance is outlined to improve adherence and treatment outcomes.

Although published over 30 years ago, Motor Disorder in Psychiatry remains a thought-provoking consideration of motor disorder in the context of the psychiatric patients. Rogers hypothesises a common aetiology of motor disorder regardless of a predominating psychiatric or neurological presentation, arguing that the former demands further scrutiny within a neurological/neuropsychiatric framework.

The post-traumatic stress disorder (PTSD) diagnosis encompasses heterogeneous presentations, many of the diagnostic criteria are not trauma-related and almost all PTSD symptoms are common to several psychiatric diagnoses. Flashbacks are the only symptom unique to PSTD. However, the absence of a consensus definition of flashbacks means that this term means different things to different people, causing misunderstanding and miscommunication, and presumably affecting treatment. This Refreshment discusses how flashbacks are defined in DSM-5-TR and ICD-11 (essentially, as reliving/re-experiencing when awake) and briefly describes the dual representation theory's account of flashbacks. In discussing what flashbacks are and are not, it aims to promote improved understanding, assessment and diagnosis of PTSDs.

Primary hyperparathyroidism (PHPT) is the presence of hypercalcaemia with an elevated or inappropriately normal parathyroid hormone level. In clinical psychiatry this is often detected on routine blood investigations. This article aims to help mental health professionals understand the relevance of PHPT to psychiatry and offers some guidance about further management of patients presenting with this endocrine abnormality in mental health settings. PHPT can be associated with both mental and physical health problems in some individuals, making it a crucial diagnosis that should not be overlooked.

Paediatric functional gastrointestinal disorders (P-FGIDs) are common, affecting up to 25% of children worldwide. They are characterised by chronic abdominal pain and/or altered bowel habits without an underlying disease pathology. P-FGIDs are often associated with co-occurring anxiety and depression across all ages and treating P-FGIDs may provide an opportunity to develop a young person's wider emotion regulation capacities. Using a fictitious case vignette, we outline the range of psychosocial and biomedical treatments for the disorder and the need for an integrated and holistic approach. We propose that by intervening early and enabling children to be curious about, rather than fearful of, their bodily sensations, clinicians may be able to alter harmful illness trajectories in both pain and psychiatric domains.

Kushner's monograph (published in 2000) explores clinicians’ developing understanding of a syndrome first described 200 years ago. This article highlights changing concepts of the disorder, its aetiology and treatment over its long history, as described by Kushner, and considers the current differential diagnosis of DSM-5 ‘Tourette's disorder’. It points out Kushner's astute observation that the clinical syndrome originally described by Itard and Gilles de la Tourette as ‘maladie des tics’ is not what is defined in the 21st century as Tourette syndrome.

Quality improvement (QI) is an evidence-based approach to analysing and improving healthcare systems. QI's success has led it to become a required competency expected of medical professionals in several countries. However, much of the QI literature to date has not focused on mental health. Moreover, many psychiatrists have no formal training in QI. To address this gap, this article introduces key QI concepts, including six dimensions of quality care, the Model for Improvement and plan–do–study–act cycles. Each QI concept is illustrated using a fictitious case study of an out-patient psychiatrist reducing chronic benzodiazepine use in their clinic.