The categorisation of personality pathology into discrete disorders has been an enduring standard. However, dimensional models of personality are becoming increasingly prominent, in part owing to their superior validity and clinical utility. We contend that dimensional models also offer a unique advantage in treating mental illness. Namely, psychotherapy approaches and the components of dimensional models of personality can both be arranged hierarchically, from general to specific factors, and aligning these hierarchies provides a sensible framework for planning and implementing treatment. This article begins with a brief review of dimensional models of personality and their supporting literature. We then outline a multidimensional framework for treatment and present an illustrative fictitious clinical case before ending with recommendations for future directions in the field.

In legal parlance, a ‘witness’ must have personal knowledge of the facts that form the basis of their inference or opinion. However, unlike an ordinary or a professional witness, an expert witness can provide opinion evidence, an exception to this doctrine. The evolution of the role of an expert witness or a skilled witness (in Scotland) is outlined in this clinical reflection.

In 1978, William Alwyn Lishman's Organic Psychiatry: The Psychological Consequences of Cerebral Disorder was published, fostering the development of neuropsychiatry and leading to the recognition of Lishman as the father of neuropsychiatry. This article is a narrative account of his personal struggles, as well as conceptual dilemmas he dealt with while writing this book, and how through its four editions it has evolved to become an anchor for psychiatrists as they seek to develop understanding of the workings of the brain, and a beacon for them when they discuss clinical implications of diagnosis with patients and families.

Lunatic Asylums, published 130 years ago, is a fascinating insight into how these institutions were managed in the late Victorian era. This brief article considers what it reveals about the zeitgeist of the time and the book's author, the remarkable Charles Mercier.

Domestic abuse – abusive behaviour perpetrated by an adult towards another adult to whom they are personally connected (e.g. partners, ex-partners or family members) – damages mental health, increases mental health service use and challenges clinical management. Training and guidance for mental health professionals on identifying and responding to patients exposed to domestic abuse are available, but there has been less development of resources for mental health professionals in identifying, assessing and responding to perpetrators of domestic abuse. In this article, we describe a framework for responding to domestic abuse perpetration in clinical settings in general adult mental health services, aimed at improving practice. This could support mental health professionals in sensitive enquiry and assessment for domestic abuse perpetration, and guide appropriate responses, as part of routine training and continuing professional development.

Medical dramas such as Grey's Anatomy influence young people's career aspirations, creating unrealistic expectations. This article examines the gap between these portrayals and the reality of medical practice, highlighting challenges such as rigorous training and high stress. Using Italy's ‘numero chiuso’ (‘closed number’) system as a case study, it addresses the global issue of intense competition in medical school admissions. The article advocates for realistic education and better support to prepare future healthcare professionals.

Following the COVID-19 pandemic, assessments by video link became a standard and acceptable form of medico-legal evaluation. The various challenges to achieving an accurate and robust medico-legal assessment via a remote platform are explored in this clinical reflection. It is concluded that any limitations to a remotely undertaken assessment must be highlighted to the court and an in-person assessment considered as a reasonable alternative in some cases.

Navigating the complex relationship between violence and psychosis can frequently be challenging. Psychiatrists may find assessing and managing the risk of violence in this context daunting. In their article on the topic, Anderson et al helpfully summarise the role that psychopathology can play in this process. However, although careful elucidation of an individual's experiences may assist in the nuanced formulation of their risk and could offer a specific focus for interventions, the approach has potential shortcomings in certain settings. For some phenomena the link with violence is unclear and it may be constellations of symptoms that are important. Causal pathways are not always linear and there may be important mediators linking psychopathological features to behavioural outcomes. In the resource-limited settings in which many contemporary health services operate, a detailed assessment of psychopathology may be hampered by time or other constraints. Alternative, more scalable solutions may therefore be needed in particular scenarios.

Personality disorders can worsen with age or emerge after a relatively dormant phase in earlier life when roles and relationships ensured that maladaptive personality traits were contained. They can also be first diagnosed in late life, if personality traits become maladaptive as the person reacts to losses, transitions and stresses of old age. Despite studies focusing on late-life personality disorders in recent years, the amount of research on their identification and treatment remains deficient. This article endeavours to provide an understanding of how personality disorders present in old age and how they can be best managed. It is also hoped that this article will stimulate further research into this relatively new field in old age psychiatry. An awareness of late-life personality disorders is desperately needed in view of the risky and challenging behaviours they can give rise to. With rapidly growing numbers of older adults in the population, the absolute number of people with a personality disorder in older adulthood is expected to rise.

In an article in this issue of BJPsych Advances a courageous psychiatrist describes judicial criticism of his expert testimony in a case before the UK's Upper Tribunal (Immigration and Asylum Chamber). This commentary reflects on the value of criticism and feedback on expert witness work, contrasting the psychiatrist's positive response to the judge's words with the reaction of an expert witness in clinical negligence case, who rejected criticism of his evidence.

Although most people experiencing psychosis are not violent, a diagnosis of a psychotic disorder is associated with an increased likelihood of violence. Some progress has been made in delineating the nature of this association, but it remains unclear whether specific types of psychotic experience make a specific contribution to the propensity for violence. Just as the phenomenological approach has produced a fuller understanding of psychotic experiences (that can inform improved aetiological and interventional frameworks), the authors assert that such an approach (with its closer attention to the full extent of the patient's subjectivity) has the potential to advance our understanding of the relationship between psychosis and violent behaviour in a way that has clinical applicability. This article examines this potential by overlaying approaches to the phenomenology of psychosis with a framework for the subjectivity of violence to demonstrate how a fuller explanatory formulation for violent behaviour can be derived.

Although forensic psychiatrists are often asked to comment on a defendant's capacity to form the necessary mens rea for their alleged offence, little has been written on how mental disorders map onto legal concepts of mens rea, particularly those of intention. In this article we explore legal concepts of mens rea and the relevance of mental disorders and alcohol intoxication. We briefly consider philosophical approaches to intentional action and a variety of common mental disorders. We conclude that despite the presence of significant psychopathology it is rare for mental disorders to cause a defendant to lack the ability to form mens rea. Experts should therefore be cautious about coming to the conclusion that they do lead to a lack of capacity to form mens rea and should make clear the limits of their expertise, given the difficulty of translating clinical mental states into legal concepts of liability.

In this issue of BJPsych Advances Siddaway explores the challenges of assessing and treating post-traumatic stress disorder (PTSD) and complex PTSD. In this commentary I reflect on those challenges, not least of which is the need for a thorough understanding of different approaches to diagnoses. The very concept of diagnostic classification systems can be problematic, but when used sensitively they can aid communication, assessment and treatment. The relatively new diagnosis of complex PTSD may serve as a more accurate and more useful description of some psychological difficulties, leading to better treatment decisions. Good assessment, leading to accurate diagnosis, useful formulation and effective treatment takes time, and adequate resources should be allocated. Professionals can help patients to make well-informed choices about treatment options and they should offer evidence-based treatments without unnecessary delay.

When admitting patients to hospital and treating them, psychiatrists and other health professionals may need to deprive them of their liberty. Where this occurs, professionals will need to work within a statutory framework to practice legally and protect their patients’ right to liberty under Article 5 of the European Convention on Human Rights. Within England and Wales, some clinical scenarios will require a choice to be made between the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA) and its Deprivation of Liberty Safeguards (DoLS). This choice can be complex, is often overlooked and frequently misunderstood in clinical practice. Deciding between the two frameworks must be done on a case-specific basis. With the use of code of practice guidelines, case law and an unfolding clinical scenario we aim in this article to support clinicians in taking a clear-sighted approach to the dilemma and the factors to consider when deciding between the two regimes.

E-mental health tools are a promising solution to reducing the high prevalence of perinatal mood and anxiety disorders and addressing barriers faced by women seeking professional help. This article summarises the main e-health tools used in perinatal mental healthcare, including examples of evidence-based tools for assessment, prevention and treatment of such disorders. We also highlight the main characteristics of the development process of e-mental health tools, which are based on cognitive–behavioural therapy, as well as the ethical concerns to be considered with their use and integration in healthcare systems.

Post-traumatic stress disorder (PTSD) is a complex, heterogeneous mental health problem that can be challenging to identify, assess, understand, diagnose and treat. This article provides an overview and critique of key topics, literature and principles to inform comprehensive and meticulous assessment of PTSDs. Although expert witnesses are the target audience, this article will have relevance for identifying, assessing, understanding and diagnosing PTSDs in all clinical contexts. A range of topics relevant to assessment are discussed, including: the complex relationship between trauma and PTSDs; DSM-5-TR PTSD and ICD-11 PTSD and complex PTSD diagnoses and the similarities and differences between them; the clinical presentation of PTSDs; psychological models of PTSDs; how to approach assessment and differential diagnosis; the impact of PTSD on neuropsychological abilities and functioning (disability); causation, reliability and assessing PTSDs when this is being considered as a legal defence; evidence-based interventions (medication, psychological therapy, when is the ‘right time’ for therapy, contraindications); and prognosis (if untreated, how long therapy/change takes). Given ongoing debate, the article proposes that trauma exposure is best defined in future iterations of the DSM and ICD as exposure to one or more psychologically threatening or horrific experiences that are overwhelming.

The Parole Board for England and Wales advises on the release, recall and licence conditions of a small subgroup of prisoners serving determinate sentences and the majority of those serving indeterminate sentences. Since the establishment of the Parole Board in 1968, the parole process has been shaped and clarified by further legislation and case law. In certain scenarios, psychiatric expert evidence may be sought to inform the Board's determination of whether a prisoner can be safely released into the community. Psychiatrists preparing expert reports for the Parole Board should be familiar with the current operationalisation of parole. This involves an understanding not only of the functioning of the Parole Board, but also of the criminal justice context in which prisoners subject to parole are managed. Having set the scene, by describing the role of the Parole Board and the wider context, this article examines how to undertake assessments and complete psychiatric reports for the Board.