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Summary Domestic abuse often begins or escalates during the perinatal period, increasing the risk of adverse pregnancy outcomes and death of the woman and infant. The hidden nature of domestic abuse, compounded by barriers to disclosure, means many clinicians are likely to have unknowingly encountered a patient who is being abused and missed a vital opportunity for intervention. This educational article presents the experience of a woman who was abused during pregnancy. It describes how to facilitate a disclosure and conduct an assessment and illustrates safeguarding duties alongside interventions.

This Personal View highlights how emotional safety is required for a person to keep themselves physically safe. We explain how trying to control behaviour to increase physical safety in the short term can carry the unintended consequence of reducing emotional safety, which might in turn result in higher levels of stress and hopelessness. We use examples from institutions with psychiatric inpatients to describe these processes. We argue that emotional and physical safety cannot be separated, and therefore that the absence of emotional safety compromises basic care either in an acute crisis or in the long term. Staff who fear being criticised, and so feel driven to take autonomy and responsibility away from patients, unwittingly undermine patients' experience of being empathically understood and supported, adding to patients' sense of emotional turmoil and lack of safety. We suggest that a change in culture and regulatory reform is required to bring psychiatric care more in line with the psychological needs of patients to achieve both physical and emotional safety.

SummaryCriminal sanctions including court orders, prosecution and imprisonment persist as responses to suicidality in the UK even where there is no public danger. Their prevalence, the level of clinical involvement and outcomes are unclear. There is an urgent need to examine the national picture of harms, benefits and the responsibilities of mental health professionals.

A 38-year-old professional is brought in by police extremely distressed and in pain. She reports intense feelings of contamination over her arms and torso and fears that this is spreading and killing other people or animals. She has tried neutralising this contamination by applying concentrated sodium hydroxide (figure 1). She was taken to various emergency departments (ED) 39 times in the last 8 months and has a history of serious overdoses requiring intensive care unit admission. She says she did …

New psychiatry residents must rapidly acquire new clinical skills and learn to work effectively with new colleagues. In medical and surgical specialties, high-fidelity simulation with structured debriefing is widely used, but so far this has not been applied to psychiatry. We have developed a one-day simulation-based training course for emergency psychiatry which incorporates clinical and team-working skills training. Five scenarios covering key psychiatric emergencies are delivered in a purpose-built simulation facility. Patients are played by an actor or a high-fidelity manikin. Each scenario is followed by a 45-minute group debrief. Evaluation of a pilot group found that the course was well received and improved participants' workplace confidence. We are now planning to expand the course, provide it to all new residents and conduct further evaluation.

Human voices play a fundamental role in social communication, and areas of the adult "social brain" show specialization for processing voices and their emotional content (superior temporal sulcus, inferior prefrontal cortex, premotor cortical regions, amygdala, and insula) [ [1], [2], [3], [4], [5], [6], [7] and [8]]. However, it is unclear when this specialization develops. Functional magnetic resonance (fMRI) studies suggest that the infant temporal cortex does not differentiate speech from music or backward speech [ [9] and [10]], but a prior study with functional near-infrared spectroscopy revealed preferential activation for human voices in 7-month-olds, in a more posterior location of the temporal cortex than in adults [11]. However, the brain networks involved in processing nonspeech human vocalizations in early development are still unknown. To address this issue, in the present fMRI study, 3- to 7-month-olds were presented with adult nonspeech vocalizations (emotionally neutral, emotionally positive, and emotionally negative) and nonvocal environmental sounds. Infants displayed significant differential activation in the anterior portion of the temporal cortex, similarly to adults [1]. Moreover, sad vocalizations modulated the activity of brain regions involved in processing affective stimuli such as the orbitofrontal cortex [12] and insula [ [7] and [8]]. These results suggest remarkably early functional specialization for processing human voice and negative emotions.

Myelination, the elaboration of myelin surrounding neuronal axons, is essential for normal brain function. The development of the myelin sheath enables rapid synchronized communication across the neural systems responsible for higher order cognitive functioning. Despite this critical role, quantitative visualization of myelinationin vivois not possible with current neuroimaging techniques including diffusion tensor and structural magnetic resonance imaging (MRI). Although these techniques offer insight into structural maturation, they reflect several different facets of development, e.g., changes in axonal size, density, coherence, and membrane structure; lipid, protein, and macromolecule content; and water compartmentalization. Consequently, observed signal changes are ambiguous, hindering meaningful inferences between imaging findings and metrics of learning, behavior or cognition. Here we present the first quantitative study of myelination in healthy human infants, from 3 to 11 months of age. Using a new myelin-specific MRI technique, we report a spatiotemporal pattern beginning in the cerebellum, pons, and internal capsule; proceeding caudocranially from the splenium of the corpus callosum and optic radiations (at 3–4 months); to the occipital and parietal lobes (at 4–6 months); and then to the genu of the corpus callosum and frontal and temporal lobes (at 6–8 months). Our results also offer preliminary evidence of hemispheric myelination rate differences. This work represents a significant step forward in our ability to appreciate the fundamental process of myelination, and provides the first everin vivovisualization of myelin maturation in healthy human infancy.

The aim of this study was to derive a causal model of age-related grey matter atrophy across the cortex on the basis of cortical thickness measures using surface reconstruction of structural magnetic resonance images. Using confirmatory factor analysis, it was shown that the observed interregional correlations matrix between thickness measures could most accurately be accounted for by a single common age-related mechanism. This common factor did not predict cortical thickness directly, but exerted differential effects on individual region through independent lobe-specific systems. This model reconciles two seemingly mutually exclusive hypotheses, namely, the existence of different decay functions being caused by the same underlying mechanism.

BACKGROUND Attention-deficit hyperactivity disorder (ADHD) is increasingly recognised as occurring in people with intellectual disability (ID), although treatment of ADHD in this population has not been tested widely. Amfetamine has been used to treat ADHD in people with and without ID, although the evidence for its efficacy in people with ID is unclear. OBJECTIVES To examine the effectiveness of amfetamine for the treatment of attention deficit hyperactivity disorder in people with intellectual disabilities. SEARCH STRATEGY MEDLINE, PsycINFO, EMBASE, AMED, ISI Web of Science and WorldCat Dissertations were searched using an extensive list of synonyms for ADHD and ID. CENTRAL, Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register, clinicaltrials.gov were searched in August 2007. Pharmaceutical companies and experts in the field were contacted. Reference lists of review articles were examined and citation searches were performed in ISI Web of Knowledge. SELECTION CRITERIA All randomised controlled studies, both published and unpublished, in any language, in which children or adults with ADHD and ID were treated with amfetamine. DATA COLLECTION AND ANALYSIS Data were extracted independently by two reviewers using a standardised extraction sheet. Risk of bias was assessed by two authors using a standardised framework. Meta-analyses were planned but were not performed due to a lack of suitable studies. MAIN RESULTS Only one study was suitable for inclusion. This was a cross-over study in 15 children with ADHD, ID and Fragile X syndrome. Duration of treatment was only one week. No significant difference was reported between amfetamine and placebo for any of the ADHD measures, but significantly more side effects were reported while taking amfetamine, mainly mood lability and irritability. AUTHORS' CONCLUSIONS There is very little evidence for the effectiveness of amfetamine for ADHD in people with ID . Prescribing in this population is based on extrapolation of research in people without ID. More research into effectiveness and tolerability is urgently needed.

Background Hypochondriasis is associated with significant medical morbidity and high health resource use. Recent studies have examined the treatment of hypochondriasis using various forms of psychotherapy. Objectives To examine the effectiveness and comparative effectiveness of any form of psychotherapy for the treatment of hypochondriasis. Search methods 1. CCDANCTR-Studies and CCDANCTR-References were searched on 7/8/2007, CENTRAL, Medline, PsycINFO, EMBASE, Cinahl, ISI Web of Knowledge, AMED and WorldCat Dissertations; Current Controlled Trials meta-register (mRCT), CenterWatch, NHS National Research Register and clinicaltrials.gov; 2. Communication with authors of relevant studies and other clinicians in the field; 3. Handsearching reference lists of included studies and relevant review articles, and electronic citation search in ISI Web of Knowledge for all included studies. Selection criteria All randomised controlled studies, both published and unpublished, in any language, in which adults with hypochondriasis were treated with a psychological intervention. Data collection and analysis Data were extracted independently by two authors using a standardised extraction sheet. Study quality was assessed independently by the two authors qualitatively and using a standardised scale. Meta-analyses were performed using RevMan software. Standardised or weighted mean differences were used to pool data for continuous outcomes and odds ratios were used to pool data for dichotomous outcomes, together with 95% confidence intervals. Main results Six studies were included, with a total of 440 participants. The interventions examined were cognitive therapy (CT), behavioural therapy (BT), cognitive behavioural therapy (CBT), behavioural stress management (BSM) and psychoeducation. All forms of psychotherapy except psychoeducation showed a significant improvement in hypochondriacal symptoms compared to waiting list control (SMD (random) [95% CI] = -0.86 [-1.25 to -0.46]). For some therapies, significant improvements were found in the secondary outcomes of general functioning (CBT), resource use (psychoeducation), anxiety (CT, BSM), depression (CT, BSM) and physical symptoms (CBT). These secondary outcome findings were based on smaller numbers of participants and there was significant heterogeneity between studies. Authors' conclusions Cognitive therapy, behavioural therapy, cognitive behavioural therapy and behavioural stress management are effective in reducing symptoms of hypochondriasis. However, studies included in the review used small numbers of participants and do not allow estimation of effect size, comparison between different types of psychotherapy or whether people are "cured". Most long-term outcome data were uncontrolled. Further studies should make use of validated rating scales, assess treatment acceptability and effect on resource use, and determine the active ingredients and nonspecific factors that are important in psychotherapy for hypochondriasis.

Kashyap & Sule are right to express outrage at the low pass rates for the Royal College of Psychiatrists Clinical Assessment of Skills and Competencies (CASC), and concern over the difference between UK-trained candidates and those trained elsewhere.[1][1] They offer good suggestions for improvement

At the current level of membership examination fees at the Royal College of Psychiatrists, a resident in psychiatry who passes every part first time pays a total of £2136.[1][1] These costs are intended to cover only expenses rather than to generate profit, a message which many of us have accepted

SummaryMental health staff may have limited exposure to emergencies associated with obsessive–compulsive disorder (OCD) during postgraduate training. The first time they encounter a person in the midst of severe obsessions, or one who has compulsively self-harmed in response to such obsessions, might be when working on call covering the emergency department. This educational article presents the lived experience of one of the authors as a clinical scenario. The scenario is then used to illustrate the severity of disability and the rates of self-harm and suicide-related mortality caused by OCD. The recognition and assessment of OCD is described, along with what helps in emergency situations. Written informed consent was obtained for the publication of clinical details.