bluuebunny/crossref_metadata_2025 huggingface dataset:
Adults with learning disability admitted to psychiatric wards
Authors: Chaplin Robert , Flynn Andrew
Published: August 2002

People with learning disability have an increased risk of developing a mental disorder. When they need acute psychiatric hospitalisation, they are frequently admitted to general psychiatric beds under the care of general adult psychiatrists, many of whom have had little training in the assessment and treatment of mental illness in this group. They may have unusual presentations of common mental disorders leading to difficulty in diagnosis and idiosyncratic responses to treatment. Boundary disputes between general adult and learning disability services frequently lead to a reduced quality of care for people with complex needs (see Bernal & Hollins (1995) for an overview of psychiatric illness and learning disability). This paper will focus on the issues specific to the management of people with learning disability on general psychiatric wards, and is aimed at psychiatrists working in both general psychiatry and learning disability.
Working with adults with anorexia nervosa in an out-patient setting
Authors: Connan Frances , Treasure Janet
Published: August 2002

Anorexia nervosa is often a chronic, severe disorder in which morbidity and mortality are high. After 20 years, as many as 20% of clinical series have died (Patton, 1988) and another 20% have experienced poor outcome (Tolstrup et al, 1985).
Management of chronic fatigue syndrome in children
Authors: Wright Barry , Partridge Ian , Williams Christine
Published: August 2002

Certain areas of child and adolescent mental health generate a degree of polarised debate, both within and outside the profession. Media attention, the development of self-help groups and the Internet lead to the publishing of papers and opinion, which exist alongside peer-reviewed research and evidence-based medicine. Parents reading such material may find it hard to know what advice is best. One area that falls into this category is chronic fatigue syndrome (CFS).
The new Civil Procedure Rules. 1. The process of dispute resolution and litigation
Authors: Rix Keith
Published: August 2002

In the second of my previous two articles on the role of the expert witness, I anticipated the implementation of Lord Woolf's proposed reforms to the civil justice system in England and Wales (Rix, 1999). These changes came into effect on 26 April 1999 and they represent the most radical changes to the civil justice system for a hundred years. In the previous article, it was not possible to do more than list a few of the key points relevant to experts. The purpose of this article is to describe the changes in detail and show how they will, or can be expected to, affect the role of the expert.
Adolescent schizophrenia
Authors: Hollis Chris
Published: August 2002

Schizophrenia is a devastating chronic disorder that typically presents in early adult life and impacts on a broad swathe of social and psychological functioning. It is not surprising that psychiatrists have tended to be circumspect about making this ominous diagnosis in children and adolescents. Genuine concerns about the validity of applying ‘adult’ psychotic diagnoses in this young age group, together with the lack of diagnosis-specific interventions, have suggested a cautious approach to diagnosis. Furthermore, the relative rarity of schizophrenia in this age group has meant that most psychiatrists have relatively little experience with ‘atypical’ early presentation of the disorder.
Schizophrenia: early warning signs
Authors: Birchwood Max , Spencer Elizabeth , McGovern Dermot
Published: August 2002

Relapse in schizophrenia remains common and cannot be entirely eliminated even by the best combination of biological and psychosocial interventions (Linszen et al, 1998). Relapse prevention is crucial as each relapse may result in the growth of residual symptoms (Shepherd et al, 1989) and accelerating social disablement (Hogarty et al, 1991). Many patients feel ‘entrapped’ by their illnesses, a factor highly correlated with depression (Birchwood et al, 1993), and have expressed a strong interest in learning to recognise and prevent impending psychotic relapse.
Cognitive impairment in schizophrenia
Authors: O'Carroll Ronan
Published: August 2002

“My whole mental power has disappeared, I have sunk intellectually below the level of a beast”(a patient with schizophrenia, quoted by Kraepelin, 1919, p. 25).
The symptom of depression in schizophrenia and its management
Authors: Mulholland Ciaran , Cooper Stephen
Published: August 2002

Depression is a frequently occurring symptom in schizophrenia. While today it is often underrecognised and under-treated, historically such symptoms were the focus of much attention. Affective symptoms were used by Kraepelin as an important criterion with which to separate dementia praecox from manic–depressive illness. Kraepelin also recognised the importance of depression as a symptom in schizophrenia and identified several depressive subtypes of the illness. Mayer-Gross emphasised the despair that often occurs as a psychological reaction to acute psychotic episodes and Bleuler considered depression to be one of the core symptoms of schizophrenia.
Clinical implications of mechanisms of action of antidepressants
Authors: Leonard Brian
Published: August 2002

The purpose of this review is briefly to consider the biological basis of depression and to attempt to illustrate how antidepressants produce their beneficial effects by correcting these abnormalities.
Chronic exposure to organophosphates: background and clinical picture
Authors: Davies Robert , Ahmed Ghouse , Freer Tegwedd
Published: August 2002

A male farmer in his forties from the Irish Republic was referred for an opinion on his mood swings and their possible relationship with organophosphate exposure. He had been regularly exposed to organophosphorus sheep dips for around 15 years prior to the assessment.
Molecular biology of Alzheimer's disease
Authors: Holmes Clive , Wilkinson David
Published: August 2002

At present, the treatment options for Alzheimer's disease are largely symptomatic giving rise to temporary remissions in cognitive decline or the amelioration of troublesome behavioural and psychological symptoms. However, as more is becoming known about the molecular biology of Alzheimer's disease, there is a clear movement to treatments directed towards disease modification. Disease modification is now a realistic option and its importance is highlighted by the fact that a delay in the progression of the disease by just five years would halve the disease prevalence. Ultimately, however, drug therapy based on the molecular biology of Alzheimer's disease will be preventive. These treatment strategies are still in their infancy, but our understanding of the processes requiring therapeutic manipulation is improving at a dramatic rate.
Substance misuse in adolescents
Authors: Swadi Harith
Published: August 2002

There is increasing evidence that substance misuse among British adolescents is escalating (Miller & Plant, 1996; Sutherland & Willner, 1998). Swadi (1992) found that, among adolescents aged 12–17 years referred to mental health services, the prevalence of drug use was 13.1% (16.3% among boys and 9.3% among girls). Despite this relatively high prevalence, there are very few organised treatment services for adolescents in the UK. Instead, there is extensive emphasis on prevention even though there is no universal agreement on what prevention can achieve. This approach also overlooks the fact that a significant number of adolescents fail to respond to preventive measures in any form.
Recent developments in borderline personality disorder
Authors: Winston Anthony P.
Published: August 2002

Patients with borderline personality disorder (BPD; known in ICD–10 (World Health Organization, 1992) as emotionally unstable personality disorder) pose some of the most difficult management problems facing the clinical psychiatrist. They frequently present in crisis, but are often difficult to engage in any form of treatment. Their behaviour causes considerable anxiety but their ambivalence about treatment often leaves professionals feeling frustrated and resentful. These feelings can all too easily be transformed into therapeutic nihilism. As well as being a significant problem in its own right, comorbid personality disturbance complicates the management of other psychiatric disorders and has a negative effect on their prognosis (Reich & Vasile, 1993).
Commentary
Authors: Cawthra Richard
Published: August 2002

Anthony Winston reviews and describes current perspectives on the aetiology of borderline personality disorder, covering areas such as the role of traumatic factors, attachment theory and self-psychology. The author links these to the psychopathology of the borderline patient who experiences difficulties such as regulation of affect, impulse control and cognitive capacity to both think and reflect. The psychological function of splitting is considered along with other defence mechanisms as having adaptive potential for the borderline patient. Winston describes in a helpful way the links between human development, psychodynamics and psychopathology as he reveals some of the more recent contributions to the field of BPD. At the beginning of his article, he emphasises the problems encountered when attempting to treat or manage patients with BPD. He centres these difficulties on the counter-transference of the clinician, pointing out how such feelings can “all too easily be transformed into therapeutic nihilism”. His article can easily be read as an attempt to counter such a state of mind and he appears to try to generate a more hopeful if not optimistic outlook. In doing so, I fear that he goes beyond his own account of the research evidence for the effectiveness of treatment. Such enthusiasm or optimism can readily be understood as a reactive polar opposite to nihilism or pessimism. I would like to consider further Winston's statements germane to this aspect of his article and raise for further discussion some other ideas which extend beyond the narrower confines of aetiology and psychological therapy.
The new Civil Procedure Rules. 2. Part 35 provisions and their implications
Authors: Rix Keith
Published: August 2002

The previous article (Rix, 2000) in this series described the process of dispute resolution and litigation under the new Civil Procedure Rules, which have now been implemented in England and Wales following the recommendations of Lord Woolf. The purpose of this article is to provide detail of the provisions of ‘Part 35: Experts and Assessors' and examine the accompanying practice direction, the pre-action protocols, the ‘Draft Protocol of Best Practice in the Instruction and Use of Experts' and the ‘Draft Code of Guidance for Experts and Assessors' as they relate to the role of the medical expert.
Support systems. 1. Introduction
Authors: Holloway Frank , Szmukler George , Carson Jerome
Published: August 2002

“Employers have a key role to play in safeguarding the mental health of their workforce, both by providing a supportive work environment and by encouraging the use of the workplace to provide health education and health promotion activities” (Department of Health (DoH), 1998a, 4.64)
Commentary
Authors: Hale Robert , Kraemer Sebastian
Published: August 2002

This is a timely and useful start to a major debate that should now be taking place in mental health services. The authors have successfully woven the need for staff support into the themes of clinical governance and the national service framework for mental health and other Government initiatives. While concentrating on the particular stresses of consultants, they recognise that other grades and other disciplines in the field also suffer.
Role of the community psychiatric nurse in the management of schizophrenia
Authors: Gournay Kevin
Published: August 2002

This paper will describe the increasingly important role of the community psychiatric nurse (CPN) in the treatment and management of people with schizophrenia, and draw attention to new training programmes which have a focus on skills acquisition in evidence-based methods. However, before describing the way in which these programmes of training improve CPN skills, it is worth examining the history of community psychiatric nursing.
Commentary
Authors: Leff Julian
Published: August 2002

The Thorn Initiative was put together by a group of people, most of whom were researchers who had conducted randomised controlled trials on various kinds of social treatments. Isaac Marks had worked on assertive community treatment (ACT), whereas my experience was in family work for schizophrenia, as was that of Nick Tarrier. In addition, Tarrier had carried out a recent trial of cognitive approaches to reducing delusions and hallucinations. It was rather like trying to turn an assemblage of prima donnas into a chorus, and it is a tribute to the personal qualities of Jim Birley that he succeeded in this seemingly impossible task.
Management of schizophrenia in conditions of high security
Authors: Thomson Lindsay D. G.
Published: August 2002

There are four high-security hospitals in the UK: Broadmoor Hospital in Berkshire (founded in 1863), Rampton Hospital in Nottinghamshire (1914), Ashworth Hospital in Merseyside (1990), which opened following the amalgamation of Park Lane (1974) and Mosside Hospitals (1913), and the State Hospital at Carstairs in Lanarkshire (1948). The first three are known as the special hospitals and serve England and Wales. The latter offers a special security service, combining high and medium secure care, for the whole of Scotland and Northern Ireland – there is no form of medium secure psychiatric provision in these countries. All four hospitals provide care for patients with mental disorders and dangerous, violent or criminal propensities. There are approximately 1550 beds in these facilities and all patients are formally detained under mental health or criminal legislation. The special hospitals are currently administered by the high-security psychiatric services commissioning team, managed locally as individual authorities, although in the future it is intended to integrate them more fully into the National Health Service (NHS) and to organise both high and medium secure services at a regional level. Carstairs is administered by the State Hospital Board for Scotland which has the status of a special health board.
Psychiatric conditions with relevance to fitness to drive
Authors: Harris Margaret
Published: August 2002

In the interest of road safety, driving license holders who suffer from a medical condition likely to affect fitness to drive must notify the Driver and Vehicle Licensing Agency (DVLA) and not drive. The Secretary of State for the Environment, Transport and the Regions (of the Department for the Environment, Transport and the Regions, DETR) has the responsibility, via his Medical Advisers at the Drivers Medical Unit of the DVLA, to ensure that all licence holders are fit to drive.
Sexual dysfunction in old age
Authors: Phanjoo André Ludovic
Published: August 2002

The sexual behaviour of older people is more often the target of jocularity or ridicule than the subject of serious scientific research. As a consequence, relatively little is known about the sexual behaviour of the over-65s and such information as is available shows a polarisation according to gender, male sexual behaviour and dysfunction being viewed very much in the light of physical problems, whereas women's sexual behaviour revolves around attitudes towards sexuality and the psychological effects of ageing. This review will address the biological changes associated with ageing, the psychological and social concomitants, the prevalence of sexual dysfunction, its aetiological factors, and the management of common sexual problems including those found in an institutional setting.
Young offenders with a learning disability
Authors: Hall Ian
Published: August 2002

Young offenders with a learning disability may encounter a variety of different psychiatrists, most of whom do not claim any particular expertise in helping them. Child and adolescent psychiatrists, learning disability psychiatrists and forensic and prison psychiatrists may all see young offenders referred to them who have a learning disability –that is, ‘mental retardation’ as defined in ICD–10 (World Health Organization, 1992) (Box 1). Many of these psychiatrists do not see such referrals as a core part of their role, and perhaps because of this, surprisingly little is known about this group of young offenders. They frequently fall into the borderlands between different types of service provision, and as a result can become marginalised. This is of particular concern since recent work has suggested that young offenders with a learning disability may have substantial mental health needs. This article aims to summarise what is known about this group and describe how some of their mental health needs might be met.
Commentary
Authors: McCarthy Jane
Published: August 2002

I am certain this review by Hall is welcomed by psychiatrists working across a number of specialities, who in the course of their work are asked to assess a young offender with a learning disability. The main difficulty the paper highlights is how little research has been undertaken in this area, leaving clinicians to rely on their experience and that of a handful of colleagues specialising in this area. The literature on the more able population is a useful source of information, as there is considerable overlap between the two groups.
Child and adolescent mental health problems in primary care
Authors: Kramer Tami , Garralda M. Elena
Published: August 2002

Epidemiological research has revealed that psychiatric disorders in children and adolescents are common, persistent and handicapping. Only 1 in 10 of those with a disorder is seen in specialist mental health services. However, the majority of children and adolescents see their general practitioner (GP) every year. Although the majority present with physical complaints, there are indications that rates of psychiatric disorder in those attending are increased and that psychiatric disorder is associated with increased consulting. These findings raise questions about the role of primary care in the promotion and management of mental health in young people.
Psychiatric help for survivors of torture
Authors: Turner Stuart
Published: August 2002

When asked for advice about a survivor of torture (or of some other form of organised state violence), there are at least two people to consider. In addition to the needs of the patient, those of the person asking for advice – the health professional – must be taken into account. There are some forms of violence which can damage others, even in the controlled circumstance of a consulting room. There is a context, often a community or a family, in which the person exists. This paper will first address some of these broader issues before going on to consider some of the narrower, more technical, matters of best available treatment.
Video for teaching purposes
Authors: Vassilas Chris , Ho Luk
Published: August 2002

Over the past 20 years or so, video has become a ubiquitous medium for teaching in psychiatry. It is increasingly being used in both undergraduate and postgraduate teaching. One of the reasons that we wrote this article was that when we wanted to obtain guidance on how to develop the use of video in our own teaching programme, there seemed to be little in the way of concise practical advice available. The focus of the paper will therefore be on the practicalities involved in how feedback from video recordings of interviews can be used to help with the acquisition of clinical skills. We will attempt to give an overview of the variety of different applications for video and give a brief account of the historical development of video feedback in medical training. Appendix 1 is a guide to the practical and technical side of setting up a video recording session. We think that the experiences that we gained while teaching psychiatry in a district general hospital will be useful to all those involved in teaching wherever they are based.
Support systems. 2. Staff sensitivity groups
Authors: Haigh Rex
Published: August 2002

It is deeply satisfying to all mankind that many ailments, once dangerous, mysterious and worrying, now offer the therapist of today wonderful opportunities for the exercise of his skill; but with recalcitrant distress, one might almost say recalcitrant patients, treatments tend, as ever, to become desperate and to be used increasingly in the service of hatred as well as love; to deaden, placate and silence, as well as to vivify. (Main, 1957, in The Ailment)
Cigarette smoking and schizophrenia
Authors: Kelly Ciara , McCreadie Robin
Published: August 2002

It has been recognised for many years that patients with psychiatric illnesses, especially schizophrenia, smoke to excess. However, recently there has been a resurgence of interest in the high prevalence of nicotine addiction in patients with schizophrenia. It has become increasingly clear that heavy cigarette smoking is intimately associated with the schizophrenic illness and that this may have implications for the underlying neurobiology of schizophrenia.
Assessment of drug-related movement disorders in schizophrenia
Authors: Gervin Maurice , Barnes Thomas R.E.
Published: August 2002

Conventional antipsychotic drugs remain one of the mainstays of treatment of schizophrenia and related psychotic disorders. The therapeutic efficacy of these drugs is well established, both for treatment of acute symptoms and in relapse prevention. Unfortunately, they are associated with a broad range of side-effects, the most prominent of which is the development of a variety of movement disorders (see Box 1). Compared with the conventional antipsychotic agents, the newer, atypical antipsychotics have a lower liability for the acute extrapyramidal side-effects (EPS) and, for a few of the new drugs, there is some evidence of a lower risk of tardive dyskinesia (Barnes & McPhillips, 1999). Nevertheless, even with these newer agents, movement disorders are seen in a significant proportion of patients.
What the clinician needs to know about magic mushrooms
Authors: Seivewright Nicholas , Lagundoye Olawale
Published: August 2002

This term refers to mushrooms that grow naturally and have hallucinogenic (sometimes called psychedelic) properties. Consumption of different species has occurred in various cultures over the centuries, with use in ritual ceremonies in Mexico being particularly well known. In the UK at present the species most commonly used is Psilocybe semilanceata, also known as the ‘liberty cap’ mushroom. This grows in many areas, particularly in dark places and after heavy rainfall, with fruition occurring from September to November. It is creamy-yellow or brown in colour, very small (5–15 mm across) with a thin fragile stalk. In the USA a closely related type is used.
Management of alcohol detoxification
Authors: Raistrick Duncan
Published: August 2002

The huge majority of people with an alcohol dependence problem that is uncomplicated by serious mental illness or social chaos receive treatment in the community.Tackling Alcohol Together: The Evidence Base of a UK Alcohol Policy(Raistricket al, 1999, chapter 9) provides strong evidence supporting the move towards briefer and community-based treatments, while at the same time recognising the need for intensive and in-patient treatments for people with more complicated problems. It follows that the traditional sequencing of care, which might be characterised as having four phases – assessing and engaging patients, detoxification, specific therapy and aftercare – is less tidy than it used to be. Detoxification is seen much more as a standalone procedure that should be undertaken when the patient is ready, rather than as a prerequisite of starting treatment. Of course, there are also instances where detoxification may be required as an expedience, for example during an unplanned admission into hospital, or where regular high levels of intoxication are a barrier to treatment. Equally, where the focus of treatment is on mental illness rather than alcohol dependence, then detoxification may well be viewed as a necessary first step.
Psychiatric aspects of chronic exposure to organophosphates: diagnosis and management
Authors: Davies Robert , Ahmed Ghouse , Freer Tegwedd
Published: August 2002

In a recent article (Davies et al, 2000) we covered the background to and clinical presentation of the neuropsychiatric consequences of chronic exposure to organophosphates. In particular, we dicussed a syndrome that appears to develop in about 10% of chronic exposees: chronic organophosphate-induced neuropsychiatric disorder (COPIND). In this article we consider the diagnosis and management of patients with this condition, and related issues.
Neuropsychological assessment in older people: old principles and new directions
Authors: Morris Robin G. , Worsley Claire , Matthews David
Published: August 2002

Neuropsychological assessment, in the broader sense, is common clinical practice with older adults because of the widespread use of mental status examinations and dementia rating scales. In the more narrow sense, a neuropsychological assessment conducted by a clinical psychologist or clinical neuropsychologist is used less frequently and for more specific purposes. This paper outlines these uses and provides a brief overview of the different types of test that might be used, with a clinical example to illustrate the type of information gained. This review is designed not to be comprehensive, but to provide a pointer towards the latest trends in test development.
Local initiatives in clinical effectiveness
Authors: Kehoe Robert
Published: August 2002

With the arrival of clinical governance, psychiatrists working for the National Health Service (NHS) can no longer work in isolation, and commitment to both clinical effectiveness and continuing professional development (CPD) is expected and likely to become mandatory. Clinical governance gives clinical effectiveness a high priority within NHS organisations, both at primary and secondary care levels, together with clearer lines of accountability.
The Care Programme Approach in learning disability psychiatry
Authors: Roy Ashok
Published: August 2002

For nearly three decades, closure of large psychiatric and learning disability hospitals has continued and more people with mental health needs remain in the community. With this continuing decrease in hospital provision, there has been an increased focus on the development of systems of safe care and effective treatment for people with significant mental health problems living in the community. Attempts to make this a central plank of mental health care have been reflected in legislation and guidance produced by the Department of Health. The Care Programme Approach (CPA) was introduced in 1991 after the publication of HC (90) 23/LASSL (90) 11 and subsequent guidance from the White Paper Caring for People (Department of Health, 1990).
Tier 2 CAMHS and its interface with primary care
Authors: Appleton Peter
Published: August 2002

During the past decade, increasing attention has been paid to the primary care level of service for children and adolescents with mental health problems. In particular, a number of national reports have advised service commissioners and providers to increase the amount of specialist child and adolescent mental health services (CAMHS) support to primary care colleagues (Department of Health/Department for Education/Social Services Inspectorate, 1995; National Health Service (NHS)/Health Advisory Service (HAS), 1995; Audit Commission, 1999).
Evaluating risks
Authors: Kapur Navneet
Published: August 2002

Mistakes are inevitable in any branch of medicine, but psychiatry is a particularly risky business (Holloway, 1997). When psychiatrists get it wrong there may serious consequences for their patients, the clinical team and the wider public. The Government introduced a series of initiatives in the 1990s: the Care Programme Approach (1990), the supervision register (Department of Health & Home Office, 1994) and supervised discharge (Secretary of State for Health, 1997). One of the main purposes of this legislation was to minimise the risk psychiatric patients pose to the community. Future service provision will be shaped by clinical governance and the National Service Framework for Mental Health (Secretary of State for Health, 1997), and evaluation and management of risk will become increasingly important.
How to keep up with the Mental Health Act
Authors: Humphreys M. S. , Kenney-Herbert J. P. , Cope R. V.
Published: August 2002

In recent years there has been a marked increase in the proportion of individuals with mental disorders detained in hospital involuntarily, compared to those admitted on an informal basis (Wall et al, 1999). There is also growing concern about legally incompetent patients being treated under the doctrine of necessity (Eastman & Peay, 1998). The rise in the numbers of detained patients may have come about for a variety of reasons. Suggested possible contributory factors include a reduction in psychiatric hospital beds; the move towards community care and the consequent tendency to maintain patients at home for longer; increasing comorbidity and more severely disturbed behaviour on hospital wards; and a greater number of individuals transferred to hospital care from the criminal justice system (Mental Health Act Commission, 1999). Statutory mental health legislation in the UK has remained essentially unchanged, in some cases, for nearly 15 years. There have been additions and amendments during that period, as well as new law. For instance, the Mental Health (Patients in the Community) Act 1995, dealing with the care and treatment of people with mental disorders, and the Criminal Evidence (Amendment) Act 1994, covering specific issues to do with certain groups of those suffering from psychiatric disorders. Despite this there is clear evidence from recent research from various parts of the UK that medical practitioners, most particularly psychiatrists, and even those using the Mental Health Act on a day-to-day basis, do not necessarily possess a detailed knowledge of the law. Among a random sample of Section 12(2) approved medical practitioners in the West Midlands, none of those interviewed was able to define the term mental disorder as used in the Act, and only just over one-third correctly identified the four legal categories of mental illness, mental impairment, severe mental impairment and psychopathic disorder (Bhatti et al, 1999). In similar studies undertaken in Scotland, only one in 10 of a national sample of consultant psychiatrists was able to give the statutory definition of the term mental disorder (Humphreys, 1998) and among a similar non-consultant sample only 28% were able to give the correct title and year of the Mental Health (Scotland) Act 1984 (Humphreys, 1997). It would seem important, therefore, that psychiatrists do not become complacent about their knowledge and use of the Act, even though there has been considerable debate around the issue of how much expertise and precise factual knowledge of specific legislation is actually required.
Running an effective community mental health team
Authors: Singh Swaran P.
Published: August 2002

Community psychiatric teams are an integral part of modern mental health services. The development of such teams has allowed the care of patients to be transferred from institutions to the community. A Cochrane review of community-based programmes showed that community team-based psychiatric services led to a reduction in suicide rates, improved patient engagement and were more acceptable to patients (Tyreret al, 1999). Community care also reduces the number of days patients stay in hospital, but not the number of admissions (Marshallet al, 1995). However, community mental health teams (CMHTs) have been criticised for their ambiguous and overambitious aims, and their tendency to neglect people with the most challenging health- and social-care needs (Patmore & Weaver, 1991; Sayceet al, 1991). All mental health workers are not necessarily eager, or skilled, to work effectively in teams. Building and maintaining an effective team requires commitment, clarity of purpose, a shared vision and frequent review of team operations. In a previous issue ofAPT, Burns & Guest (1999) described the adaptation and running of an assertive community treatment team in an inner-city area. Here I examine the attributes of effective CMHTs (Box 1), enumerate barriers and challenges to team-working (Box 2) and suggest strategies for improving team effectiveness (Box 3).
Contextual evaluation of social adversity in the management of depressive disorder
Authors: Morriss Richard K. , Morriss Elaine Egan
Published: August 2002

Contextual rating of social adversity has its origins in the work of George Brown and colleagues (Brown & Harris, 1978). This review evaluates its strengths and weaknesses in rating the effects of social adversity on depressive disorder. We write from the perspective of its usefulness for clinical and training purposes both to the consultant psychiatrist and to the community mental health team working in general adult psychiatry.
Narrative and severe mental illness: what place do stories have in an evidence-based world?
Authors: Roberts Glenn A.
Published: August 2002

“Once the patient's biography becomes part of the care, the possibility that therapy will dehumanise the patient, stripping him of what is unique to his illness experience becomes much less likely” (Kleinman, 1988).

“The loss of story making and telling has its impact on failure to care for the long term chronic or incurable patient” (Hunter, 1991).
Methods of working with primary care
Authors: Gask Linda , Croft Justine
Published: August 2002

By the 1980s, one-fifth of all general psychiatrists in England and Wales (Strathdee & Williams, 1984) and one-half in Scotland (Pullen & Yellowlees, 1988) were spending some proportion of their time working in primary care. Rather than limit this process, the growth of general practice fundholding fostered it and developments in general practice total purchasing and extended fundholding have encouraged it further (Lee et al, 1999). At the same time, nationally there has been a gradual increase in referrals directly from general practitioners (GPs) to community psychiatric nurses (CPNs). Referrals from GPs constituted 37% of all referrals to CPNs in 1990 and 46% in 1996 (Brooker & White, 1997: further details available from L.G. upon request), even though there has been a trend away from the primary care service base (21% in 1990 compared with 14% in 1996).
Systemic family therapy and the influence of post-modernism
Authors: Boston Paula
Published: August 2002

Post-modernism is a term that is omnipresent in the media, academic circles and contemporary culture. It is also a term that has caused substantial consternation among systemic family therapists. Systemic family therapy traces its origins from the 1950s, and there are currently several different models contained within the systemic paradigm. A unifying feature of systemic therapy is the importance placed on understanding psychological difficulties in the context of social relationships. Another point of agreement among systemic therapists is the significance of drawing distinctions and marking ‘difference’ as an aspect of creating change. A third common feature is the practice of working in teams, where one therapist conducts the interview, while a small number of others comment on their observations. The degree to which these models and practices have been influenced by postmodernism varies.
Gender identity disorder in young people
Authors: Di Ceglie Domenico
Published: August 2002

The recent filmBoys Don't Cryillustrates in a highly dramatised form the problems that the phenomenon of gender identity disorder can create in an extreme situation. The film is based on the true story of a young person, Brandon, with a female body who perceived himself as a male. In the film we do not know when the issue of his male gender identity first appeared, but we see him living in a male role as a teenager trying to conceal, to his peers, the reality of his female body. (I refer to Brandon as ‘he’ because this is how Brandon presents himself in the film. The dilemma about using ‘he’ or ‘she’ typically confronts professionals in the management of teenagers like Brandon.) The struggles of these concealments are well portrayed, as in the scene when he steals tampons from a shop. He joins in male activities and displays of physical strength as a confirmation of his male role. He is well accepted as a boy within a troubled and troublesome group of young people. He falls passionately in love with a girl, Lana, who accepts him as he is without much questioning, and a close intimate relationship develops, which the peer group seems to accept. The reality of his body is eventually revealed. His girlfriend can accept the new situation, but had she really not known or had she turned a blind eye? Unfortunately, two young men become more and more disturbed by this realisation. It stirs a primitive violence in them, which leads first to Brandon's rape and then to his murder.
CPD portfolios and personal development plans: why and how?
Authors: Holloway Josanne
Published: August 2002

It is Government policy that increased attention should be given to the quality (as well as the quantity/efficiency) of clinical care. To achieve this, it has set national standards through the National Service Framework for Mental Health (NSF–MH; Department of Health, 1999a) and the National Institute for Clinical Excellence (NICE).
Advances in psychiatric treatment in primary care
Authors: Dowrick Christopher
Published: August 2002

Following ground-breaking work by Shepherd et al (1966) and, more recently, Goldberg & Huxley (1992), primary care is now recognised as the arena in which most contact occurs between the National Health Service (NHS) and people with mental health problems. General practitioners (GPs) remain the first, and in many cases the only, health professionals involved in the management of a whole range of conditions, from common anxiety and depressive disorders to severe and enduring mental illnesses.
Proposed treatment for adolescent psychosis. 1: Schizophrenia and schizophrenia-like psychoses
Authors: Clark Andrew F.
Published: August 2002

Psychotic disorders in adolescence are uncommon, but often mark the beginning of a lifetime of contact with mental health services. They pose a challenge and anxiety to sufferers, to their families and to professionals involved in assessment and treatment. Accurate and early diagnosis, coupled with appropriate treatment, is essential to minimise secondary handicaps. However, their rarity means that professionals are frequently unfamiliar with some aspects of presentation or management and that appropriate service provision is not readily available (e.g. admission directly into an in-patient bed in an age-appropriate environment). A lack of age-appropriate provision may also mean that adult psychiatrists are occasionally called on to manage and treat a younger teenager presenting with a psychotic disorder.
Risk factors for dementia
Authors: McCullagh Catriona D. , Craig David , McIlroy Stephen P. , Passmore A. Peter
Published: August 2002

There is little doubt that dementia is a very common cause of disability and dependency in our society. Since dementia of whatever type is usually more common with increasing age, then as population demographics change, so will the prevalence of dementia. Dementia is a generic term and the objective for clinicians, once dementia is suspected, is to attempt to define the cause. Alzheimer's disease is the most common cause of dementia, and in most centres vascular dementia would feature as the next most common aetiology. In some centres, Lewy body dementia is the second most common cause. Mixed Alzheimer's disease and vascular dementia would also feature high on the list at most centres.
Developmental assessment
Authors: Bolton Patrick
Published: August 2002

Assessment of development constitutes one of the core components of any psychiatric evaluation. This is because evaluation of psychopathology generally entails determining the extent to which behaviours and experiences are appropriate for an individual's age and stage of development and because developmental disorders are common and frequently associated with psychiatric and behavioural disorders. I will describe methods of evaluating and diagnosing developmental disorders, but the principles and techniques also apply to evaluating development during any comprehensive psychiatric assessment.
Commentary
Authors: Bellman M. H.
Published: August 2002

Growth and development are at the core of paediatric practice and are the fundamental factors that make medical work with children different from adult medicine. All paediatricians must have an understanding of the basic science of growth and development and how to measure them. This is fairly straightforward with regard to physical characteristics, but more difficult for mental development. However, it is a skill that must be familiar to children's doctors working in the fields of neurological disease and mental health and, arguably, to all paediatricians.
Systematic management approach to pharmacotherapy for people with learning disabilities
Authors: Einfeld Stewart L.
Published: August 2002

With progressive deinstitutionalisation in many countries, the general psychiatrist is now more frequently requested to provide assistance with behavioural problems in people with learning disabilities. There are a range of challenges in providing quality care for these people. There are challenges in assessment and diagnosis, in coordinating behavioural and social interventions with pharmacotherapy, and in the lack of psychopharmacological research in this population, which results in a diminished evidence base. In addition, there are numerous factors beyond the patient. These include legal consent requirements and the complex system of carers surrounding those with disabilities with whom the practitioner may need to interact.
Creutzfeldt–Jakob disease and its implications for psychiatric management
Authors: Butler Rob , Fleminger Simon
Published: August 2002

Creutzfeldt–Jakob disease (CJD) is a devastating illness that is rare and notorious in equal measures. In 1996 a ‘new variant’ (vCJD) was identified (Will et al, 1996), which is likely to be caused by humans eating beef infected with bovine spongiform encephalopathy (BSE). Although the number of new cases of vCJD has not started rising, the long incubation period means that it will be many years before a major epidemic in humans can be ruled out. In the meantime, representatives of patients with vCJD have expressed concerns about the care that sufferers receive. In particular, patients often present with psychiatric symptoms, but there is some delay before the correct diagnosis is made.
Running an ECT department
Authors: Russell Eve
Published: August 2002

An editorial in The Lancet two decades ago (Lancet, 1981) described the contemporary practice of electroconvulsive therapy (ECT) in Britain as “a shameful state of affairs”. It concluded that, “if ECT is ever legislated against or falls into disuse it will not be because it is an ineffective or dangerous treatment; it will be because psychiatrists have failed to supervise and monitor its use adequately”.
Domestic violence: working with perpetrators, the community and its institutions
Authors: Blacklock Neil
Published: August 2002

Every year one in ten women in the UK is subjected to physical abuse from a partner or ex-partner, while one in four experiences such abuse at some point in their lives (Mooney, 1993; Morley & Mullender, 1994a). Domestic violence is one of the most pervasive of all social problems, affecting most of the population directly or indirectly (Box 1). I cannot think of a single close friend or colleague whose life has not been touched by this largely hidden problem.
Psychiatric implications of chronic civilian strife or war: Northern Ireland
Authors: Curran Peter S. , Miller Paul W.
Published: August 2002

“Sectarianism lives in all of us – it is in the choices we make, it is in the words we say, it is even in the friends we make. It lives in our churches and it taints our community life. It makes possible the violent actions which we abhor” (McKittrick et al, 1999).

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.
Emotional factors and continuing professional development
Authors: Taylor David
Published: August 2002

It is obvious that learning is an essential part of all successful educational processes, including continuing professional development (CPD). Yet learning can be hard work, especially for the mature adult, and being able to recognise the nature of some of its intrinsic difficulties is likely to be helpful. In educational circles today, it is recognised that engaging experienced or senior people in the educational process of CPD is often difficult.
Intrusive re-experiencing of chronic strife or war
Authors: Schreuder B. J. N. , Igreja V. , van Dijk J. , Kleijn W.
Published: August 2002

The most important psychiatric implication of experiencing trauma during war is post-traumatic stress disorder (PTSD). The core symptoms of PTSD are intrusive re-experiencing of traumatic events, hyperarousal in reaction to minor stimuli and avoidance of trauma-related triggers. In this paper we describe the phenomenon of intrusive reexperiencing, of which the post-traumatic nightmare (PTNM) is an impressive manifestation that causes considerable distress (Mellman et al, 1995; Schreuder, 1996; Ørner & de Loos, 1998; Schreuder et al, 1998).
Management of people with challenging behaviour
Authors: Xeniditis Kiriakos , Russell Ailsa , Murphy Declan
Published: August 2002

The term ‘challenging behaviour’ was introduced in North America in the 1980s, and was originally used to describe problematic behaviours in people with ‘mental retardation’ (learning disabilities). Challenging behaviour can, however, occur across the intellectual spectrum, being particularly prevalent in populations with psychiatric disorder.
Treatment of severe depression – non-pharmacological aspects
Authors: Porter Richard , Linsley Keith , Ferrier Nicol
Published: August 2002

Depression, in its severest forms, causes severe morbidity, has a high incidence of mortality and requires emergency treatment. In a previous article in this journal (Porter & Ferrier, 1999), we discussed the emergency treatment of severe depression by pharmacological means and electroconvulsive therapy (ECT). Here, we will discuss the contribution of non-pharmacological aspects of management to fast, effective and safe treatment of severe depression. We will also complete our review of this subject by examining the efficacy of some emerging therapeutic interventions for severe depression.