Psychiatry predominantly uses an evidence-based way of understanding patients. Over the past two decades, however, the idea has become acceptable that something can also be learned from the arts. This article suggests a precise role for ‘narrative understanding’, but argues that something further can be learned by examining a particular mode of attention – that which an experienced viewer might give to a painting or listener to a piece of serious music. The article articulates the contrast between the detached attention of the scientist and the engaged attention of the artist in terms of two traditions of medicine: Hippocratic and Asklepian. It argues that it is possible to combine these and that the ways in which an informed viewer looks at paintings or listener listens to music can be models for this sort of attention.

Although most patients with severe eating disorders are treated in specialist eating disorder services, general psychiatrists are often responsible for the care of many with mild to moderate disorder. Treating and supporting these patients in a non-specialist setting can sometimes be challenging but this need not be the case. Having a clear understanding of the clinical features of these conditions forms the foundation on which a comprehensive assessment and management plan can be made. We summarise the clinical features of eating disorders and explore the unique role of the general psychiatrist in identifying people with these conditions, supporting them and directing them into evidence-based treatments.

Issues relating to capacity are increasingly topical and relevant, particularly following the implementation of the Mental Capacity Act 2005. Powers of attorney are one such issue that requires the assessment of capacity for their execution. This article focuses on lasting powers of attorney (LPAs), which were introduced under the Mental Capacity Act in 2007. We describe how LPAs evolved and how they have been used since the inception of the Act. We review salient case law. In doing so, we elucidate pertinent issues for clinicians, particularly in the case of health and welfare LPAs: for the first time in England and Wales, the law allows donors to nominate an attorney to make decisions about their personal health and welfare once they become incapacitated.

The expansion of the concept of addiction to include non-chemical dependency, and the proposed reclassification of substance-related disorders in DSM-5 under ‘substance use and addictive disorders' are developments that require cautious appraisal.

Over the past decade attention to the provision of healthcare for individuals with personality disorder, particularly those who pose a risk to others, has substantially increased. Keeping pace with such developments with a suitably trained, consistent and motivated workforce, interfacing health and criminal justice systems where necessary, presents an enormous challenge. Staff must be experts in managing conflict at every level, while sustaining an optimistic and therapeutic orientation. Boundaried relationships provide the context for recovery for patients. Key principles and practices likely to promote resilience in personality disorder services, with a focus on the role of supervision, are outlined in order to support staff in keeping themselves afloat, their patients safe, and their services on target.

Substance use disorders are a frequent comorbidity in adult attention-deficit hyperactivity disorder (ADHD). This review discusses the relationship between adult ADHD and substance use disorder, including use of licit and illicit substances such as nicotine, alcohol, cocaine and cannabis. We discuss treatment studies in this area and provide a treatment algorithm to guide clinicians in the management of adult ADHD comorbid with different forms and severities of substance use disorder.

Robin Downie provides useful reminders of the broad basis of medical practice. This should encourage the sort of ‘engaged attention’ that he describes – the sort of attention needed to appreciate works of art. But what else is going on in a clinical encounter (as in a work of art)? This commentary suggests that real communication is to be understood in dramaturgical terms as occurring between actors in real time and space. It involves shared understandings, which require empathy but which depend on something ineffable to do with our standing as human beings in the world.

Assessment and management of the risk of violence in psychiatry inevitably and appropriately draws on emotionally laden ‘intuitive’ modes of thought, as well as deliberative analytic thinking. This article discusses the concept of ‘intuition’ and proposes a brief set of guidelines, derived from work by the cognitive psychologist Robin Hogarth, by which intuitive thinking may be applied by clinicians when undertaking risk assessment work. The guidelines are: consider the learning structure relevant to the risk assessment task; use your own emotions as a source of data; impose ‘circuit breakers' such as cost–benefit analyses and validated structured risk assessment tools; and use a narrative approach to develop formulations. The guidelines are intended to provide a framework for ongoing reflective practice in assessing and managing risk.

Depressive symptoms commonly occur in schizophrenia and have a significant impact on the distress and burden of the illness. Yet they are often overlooked, inadequately characterised by current classification systems and not consistently integrated into treatment. We discuss nosology, practical and clinical implications of symptom differentiation, and the role of causal and confounding factors, including iatrogenic, as targets for therapeutic intervention. The evidence base of psychosocial and psychotropic management is reviewed, with recommendations for the treatment of established syndromal depression in people with schizophrenia.

This article examines John Clare's prose account of his escape from High Beach Asylum in 1841. Clare has attracted attention for his nature poems as much as for his humble, peasant background and his well-described mental illness, including his asylum committals. Recollections of journey from Essex is unique as a piece of writing describing escape from an asylum and illustrating to some degree the mental state and experiences of a psychiatrically ill person in England in the mid-1800s.

Scottish legislation on incapacity differs significantly from English and Welsh legislation. Clinicians must be aware of the authority of attorneys, especially in relation to welfare and medical treatment. The number of welfare attorneys is growing and they may not be aware of how best to use their powers.

This article describes the psychological experiences of guilt and shame. Although these affects have an important role in holding our communities together, they can also become extremely distressing and debilitating for individuals. As such, they are transdiagnostic problems which are frequently encountered in mental healthcare. The origin of these affects is considered from religious, cultural and psychological perspectives. The article then explores the clinical manifestations of guilt and shame. Finally, consideration is given to therapeutic options, including general approaches as well as specific psychological therapies.

A growing body of evidence suggests that the most common type of dementia in schizophrenia differs from Alzheimer's disease in its clinical features, natural course, neuropathology, neuroanatomical substrates and prognosis. Furthermore, there is some evidence that the risk of developing cognitive impairment and its progression in early-onset schizophrenia differ compared with late- or very-late-onset schizophrenia. The diagnosis and management of dementia in schizophrenia is challenging for both general adult and old age psychiatrists. This article reviews the evidence base regarding dementia in schizophrenia. It discusses the diagnosis of dementia in schizophrenia, its management and prognosis, and identifies some future research opportunities.

Sir Arthur Conan Doyle trained as a doctor and practised in a number of areas, but found real success only as an author. He is best known as the creator of the Sherlock Holmes stories. This article considers the individuals in Doyles' life that seem to have inspired the character of Holmes, a flawed genius with dark aspects (including intravenous drug use and instability of mood).

There is currently a huge variation in clinical practice as to whether patients being assessed for dementia undergo neuroimaging investigations. With an ageing population it is likely that there will be greater pressures on psychogeriatric services, so accurate assessment, diagnosis and prompt treatment will be required. This article will examine the evidence for the use of different neuroimaging techniques in the diagnosis of mild cognitive impairment and dementia.

Vascular dementia is associated with a group of diverse pathologies affecting the cerebrovascular circulation and with other dementia pathologies, particularly Alzheimer's disease. It is rather rare on its own. There is a spectrum of severity of cerebrovascular disease ranging from pathology but no cognitive impairment, to mild cognitive impairment to a dementia syndrome (vascular dementia). Where present, cerebrovascular disease can magnify the impact of other pathologies such as Alzheimer's disease. Current criteria for diagnosing vascular dementia are inadequate. Neuroimaging can be very helpful in defining the extent of pathology. Assessment needs to take into account a wide range of issues. Specific evidence-based treatments are limited, but attention should be given to managing risk factors and associated psychiatric problems such as depression.

Structured professional judgement risk management schemes such as the Historical, Clinical, Risk Management - 20 (HCR-20) can be described as clinical guidelines produced by a collaborative process between mental health clinicians and researchers. The purpose is to provide clinicians with a framework to guide interventions designed to manage specific risks such as violence against others. The use of evidence-based clinical methods, especially in a multidisciplinary setting, is now commonly considered a best-practice approach when managing violence and related risks. This article describes some of the practical implementation challenges that may arise when using schemes such as the HCR-20 in multi-disciplinary team meetings.