In this clinical reflection, we report on stigma and ageism and their impact on those experiencing signs and symptoms of borderline personality disorder (BPD). We highlight the need for increased collaboration between those with lived experience of the disorder and healthcare providers. This is an important issue in BPD as the impact of structural stigma is significantly affecting the quality of life and short- and long-term trajectories of those with BPD, especially during adolescence.

This article is a concise refreshment for psychiatrists to update their knowledge and understanding of corticosteroid-induced psychiatric symptoms. It summarises the diverse presentation associated with this clinical phenomenon, how frequently it occurs and some pathophysiological considerations. There is a focus on early identification and management, highlighting the importance of an integrated multidisciplinary approach, withdrawal or reduction of the corticosteroid treatment and adjunctive psychotropic medication options for clinicians to consider.

Analysis of court and tribunal judgments in cases where expert psychiatric evidence has been admitted reveals widespread misunderstandings and misuse of the diagnostic and statistical manuals published by the American Psychiatric Association and the similar publications of the World Health Organization. Examples are given here of cases in which their use has caused difficulties in the delivery of justice. For them to be a help and not a hindrance, it is suggested that when used there should be appropriate explanation as to their status, nature, purposes and limitations and that expert witnesses should handle them with the care that they require.

The histories of the DSM and ICD classifications are set out so as to identify weaknesses and limitations that can affect their application in medico-legal reporting. These are illustrated by reference to published judgments and three detailed case studies. The analysis and case studies identify how expert witnesses’ reliance on the DSM and ICD can be challenged in order to seek to undermine their evidence.

Persistent physical symptoms (PPS) are associated with functional impairment, psychological distress and high healthcare costs. They often span multiple diagnostic categories, resulting in substantial challenges for patients and healthcare systems. Understanding the shared processes underlying PPS is crucial to improving outcomes. PPS are shaped by complex and interacting psychological and physiological mechanisms, which interact to perpetuate the condition. A transdiagnostic approach, which targets shared underlying processes, may offer a more efficient and effective framework for treatment compared with traditional disorder-specific interventions. This article describes the theory for a transdiagnostic approach and evidence for its effectiveness. We describe several theoretical models and approaches to understanding the underlying mechanisms of PPS, including central sensitisation, avoidance behaviours, emotion dysregulation and cognitive distortions. We describe interventions, particularly those incorporating key principles of cognitive–behavioural therapy. The proposed approach integrates these insights to inform a comprehensive treatment model.

This editorial introduces the first of two special issues of BJPsych Advances devoted to liaison psychiatry, reflecting collaborative healthcare for patients presenting with both physical and mental health conditions, whether in acute general hospitals, out-patient clinics, in-patient wards or accident and emergency departments.

Psychiatry education at both undergraduate and postgraduate level plays a critical role in shaping the future of psychiatry services. South Asia varies in the training offered and this article captures this aspect.

In this clinical reflection, we briefly overview how physicians’ emotion regulation has been addressed within communication training in the context of Western European medical undergraduate, postgraduate and continuing medical education. For illustrative purposes, two examples of recently developed training programmes targeting both communication skills and physicians’ emotion regulation are described. We also discuss the existing gaps in emotion regulation-based communication training, as well as future directions for medical education regarding these skills.

Diabetes mellitus affects about 830 million people worldwide, with 2.5 million diabetes-related deaths per year. The estimated prevalence of diabetes among psychiatric in-patients in the UK is 10%, and the increased risk of poor diabetes-related physical health outcomes among people with a severe mental illness (SMI) is detrimental to their mental health and social functioning. This article uses two fictitious case vignettes inspired by experience in an in-patient psychiatric facility to explore the challenges of managing diabetes in this setting in the UK. The relationship between psychiatric disorders, their symptoms and management of physical health conditions, including health promotion, monitoring and pharmacological therapy, creates a challenge in the optimal management of diabetes. Recommendations for improving diabetes management in people with SMI are divided into those requiring insulin and those not requiring insulin.

There has been a boom in the availability of wearable neuromodulator devices for the treatment of mental health problems. These can be purchased outside of medical practitioner oversight or prescription. Psychiatrists need to know what these can offer and consider whether, and how, they may be integrated into psychiatric practice. This article briefly considers examples of these devices and their evidence base. It describes the experiences of the author and her husband in using such devices for their own mental healthcare and well-being.

Alcohol use disorders (AUDs) often coexist with psychotic disorders. Both are common and each can cause or perpetuate the other. Comorbid diagnoses are multifactorial in origin, and both diagnostically and therapeutically challenging. This article is a narrative review of the epidemiology, diagnosis and management of comorbid AUDs and psychotic disorders. Although there is a lack of robust evidence on many aspects of this association, AUDs have been repeatedly shown to worsen outcomes in individuals with schizophrenia. The importance of a rigorous approach to diagnosis is emphasised. Three main treatment strategies emerge: considering particular antipsychotic drugs, relapse-prevention medication and engagement with a number of psychosocial interventions.

Functional neurological disorder (FND) is a well-recognised condition often involving a complex interplay of biopsychosocial factors. Although awareness of FND among the general population and clinical staff has increased and improved over recent years, challenges remain for the sufferers across multiple areas. This reflective piece explores these challenges using a relational understanding. The model of cognitive analytic therapy (CAT) is used to examine some of the dynamics and concepts at play in FND.

Machine learning, an artificial intelligence (AI) approach, provides scope for developing predictive modelling in mental health. The ability of machine learning algorithms to analyse vast amounts of data and make predictions about the onset or course of mental health problems makes this approach a valuable tool in mental health research of the future. The right use of this approach could improve personalisation and precision of medical and non-medical treatment approaches. However, ensuring the availability of large, good-quality data-sets that represent the diversity of the population, along with the need for openness and transparency of the AI approaches, are some of the challenges that need to be overcome. This article provides an overview of current machine learning applications in mental health research, synthesising literature identified through targeted searches of key databases and expert knowledge to examine research developments and emerging applications of AI-enabled predictive modelling in psychiatry. The article appraises both the potential applications and current challenges of AI-based predictive modelling in psychiatric practice and research.

Clozapine remains the only evidence-based treatment for treatment-resistant schizophrenia, supported by guidelines from the National Institute for Health and Care Excellence (NICE) and other authorities. However, clozapine is still underutilised for treatment-resistant schizophrenia, despite its proven benefits, including reduced all-cause mortality. This is attributed mainly to its association with adverse effects, including cardiac adverse effects. This review focuses on the latter, with a detailed exploration of clozapine-induced myocarditis – a potentially fatal acute hypersensitivity reaction – and cardiomyopathy, tachycardia and conduction deficits. Among other things, we discuss their pathophysiology, diagnosis and management, with signposting to international diagnostic criteria and monitoring protocols.

Only a minority with mental disorders worldwide receive treatment with negligible coverage of interventions to prevent associated impacts, prevent mental disorders or promote mental well-being. Reasons include insufficient public mental health (PMH) skills and training. An electronic search found limited availability of PMH courses globally. Improved access to PMH training informed by a core curriculum will support sustainable reduction of mental disorders, promotion of population mental health well-being and broad associated impacts across sectors. Regular assessment of PMH training coverage and impact will support sustainable progress.

This article provides the general psychiatrist with a pragmatic guide to working confidently and productively in the emergency department (ED). The focus is on effectively navigating the distinctive physical environment, personnel, systems, time pressures, legal boundaries, special challenges and broad scope of practice applicable to this setting to maximally support both patients and staff. It brings to the reader’s attention special considerations at all stages of workflow, including pre-assessment preparations, the assessment process and ongoing planning. It considers common requests and the application of mental health law (in England and Wales) associated with both capacity assessment and involuntary care. Finally, it explores unique challenges associated with risk assessment, physical health advocacy and management of conflict in the ED setting. The specific systems described are those of the UK’s National Health Service, but the principles involved are universal.

This article reflects on a collaborative drawing group in a mother and baby unit, exploring the clinical value of arts-based interventions in perinatal psychiatry. Grounded in an evolutionary and biopsychosocial theory, it highlights how creative practice can reduce hierarchy, support emotion regulation and foster relational safety. A practical group model is described, encouraging clinicians to draw on their own creative skills to enrich care, build connection and hold space for meaning beyond symptom management.

Panic disorder, characterised by sudden episodes of intense fear or anxiety, affects 1–4% of the population. Symptoms include rapid heartbeat, chest pain and fear of dying. Panic disorder often co-occurs with substance dependence and major depression. This review article examines pharmacological treatments, focusing on antidepressants and benzodiazepines, but also considering antipsychotics and anticonvulsants. It overviews the history of antidepressants and benzodiazepines in the treatment of panic disorder and their mechanisms of action. The results of a recent Cochrane Review network meta-analysis are then presented and contrasted with six current national and international treatment guidelines. Rankings of the various drugs in terms of efficacy, tolerability and safety are summarised, along with levels of evidence and lines of recommendation as a treatment option (first-, second or third-line, or reserved for treatment-resistant cases).

Section 63 is one of the most widely used provisions of the Mental Health Act 1983 (MHA). Case law has evolved and established that a range of physical health treatments, ancillary to the core mental disorder, can be subsumed and authorised under s.63. This article reviews two court judgments whereby unique treatments were authorised under s.63 – the provision of clinically assisted nutrition and hydration, and renal dialysis. In doing so, it elucidates key issues around implementing s.63 and assessing potential ancillary treatments for clinical practice.