This article will concentrate on insight into serious mental disorder. Not psychoanalytic insight – nor indeed, the insight all of us have, to a greater or lesser extent, into our own attitudes, motives and behaviour – but the insight which patients with psychosis have into their mental pathology. This is no longer considered an all-or-none phenomenon, but rather a dimensional one, so that subjects can have different levels of awareness into their illness. The suggestion was first mooted by Aubrey Lewis (1934) in his seminal work on insight. Conceptual exploration of insight has been activated in the past decade and is proceeding in parallel with the construction of special scales to measure insight and research into its cognitive, biological, social and cultural basis.

The term ‘dymorphophobia’ – derived from the Greek dysmorphia, meaning ugliness (expressly of the face) – was first coined by Morselli in the late-19th century. He described a subjective feeling of a physical defect which the patient feels is noticeable to others, although his appearance is within normal limits. Dysmorphophobia first appeared in the US psychiatric nosology (as an atypical somatoform disorder) in 1980, with the publication of DSM–III (American Psychiatric Association, 1980). However, the term was subsequently criticised both because the condition does not represent a phobia as such, and also because the use of the term had become so broad and imprecise (see Munro & Stewart, 1991).

As Castle & Harrison note in their fine review, imagined ugliness is a not uncommon problem presenting to psychiatrists. The “considerable lag before the disorder comes to the attention of health professionals” was a mean of seven years in the 30 cases of Gomez-Perez et al (1994). Whether the problem is called dysmorphophobia, body dysmorphic disorder (BDD) or something else, its coherence of features resembles that of other psychiatric syndromes.

Much of the drug testing available today is able to determine the presence or absence of a variety of psychoactive substances in a range of body fluids and tissues. For the results of such tests to be confidently interpreted, additional information is required, including general assessment and history-taking. In a wide range of large psychiatric surveys, substance dependence emerges as one of the most common mental health-related disorders, and it is also the one that is least likely to be treated. The range of available tests can be best considered as acting to support and complement a broader assessment and diagnostic procedure.

Adolescence is a transitional stage of development between childhood and adulthood. The physical changes of puberty are generally seen as the starting point of adolescence, while the end is less clearly delineated. Adolescence ends with attainment of ‘full maturity’, and a range of social and cultural influences, including the legal age of majority, may influence this. In developed societies, these tend to delay progression to adulthood. The extension of compulsory schooling and development of further education, with its economic consequences, generally contribute to a delay in reaching full independence. This may, in turn, lead to difficulties in adjusting to the responsibilities of the next stage of life.

We would like to comment on some issues raised by the very helpful paper by Cotgrove & Gowers.

“The psychiatric aspects of ageing are a major problem in any country which, like our own, has a low net reproduction rate and a high standard of social responsibility. The proportion of old people in the community steadily increases so that they provide an increasingly high proportion of our mentally infirm who must be cared for”.

British psychiatry is appreciated all over the world for its empirical approach, its basis as a publicly funded service which is available to all citizens, and for its tradition (shared with the rest of British medicine) of educational connections with many other countries – members of the Royal College of Psychiatrists can be found in 70 countries worldwide. These connections are educational for all of those concerned. For visitors, the experience of seeing what can be done in a different context with different resources – both human and material – compels them, on their return home, to see their usual territory and practice in a new and revealing light.

Those contemplating research in developing countries should bear in mind the following: the collective wisdom of both foreign and local investigators should be pooled to determine the most appropriate research questions and ethical obligations. Several collaborative research programmes launched by the World Health Organization (WHO) have shown that it is eminently possible to engage in high-quality cross-cultural research, and many of these studies have generated a wealth of data from developing countries. Rigorous and highly sophisticated studies are possible in the developing world (Wilson, 1990). At the Schizophrenia Research Foundation (SCARF) we have had several opportunities to collaborate successfully with researchers both within and outside India (Eaton et al, 1995; Thara & Eaton, 1996). This success has largely been due to mutual respect for one another's expertise and role with no room for patronisation and condescension.

There have been many changes in postgraduate education in psychiatry over the past 15 years. The Royal College of Psychiatrists was ahead of most other Medical Royal Colleges in organising supervised training schemes which took into account the educational needs of the trainee as well as providing an appropriate service to patients. The approval exercise, with inspection of both basic specialist and higher specialist training schemes, was introduced more than 20 years ago. Prior to the introduction of ‘Achieving a Balance’ – Plan for Action (Department of Health, 1987), the senior house officer (SHO) and registrar grades in psychiatry were more or less interchangeable, although those in registrar posts tended to rotate outwith their base hospital and gain experience in the sub-specialities.

Clinical governance can be defined as: