Natoli et al present a comprehensive higher level framework aligning dimensional personality pathology assessment with treatment delivery through a hierarchical model. Their approach integrates common therapeutic factors with trait-specific interventions, offering a promising pathway for clinical implementation. Despite strong evidence supporting the superiority of dimensional models and the field's shift towards dimensional classification, they remain largely unused in clinical practice after a decade, despite evidence of clinical utility and learnability. Although the authors’ framework demonstrates how dimensional approaches could work in practice, particularly through matching severity to treatment intensity and traits to specific interventions, healthcare systems require evidence of improved clinical outcomes before undertaking systemic change. Without controlled trials demonstrating enhanced treatment effectiveness, dimensional models risk remaining theoretically superior but practically unused. While healthcare systems remain tethered to categorical diagnostic approaches, the authors’ framework offers a practical pathway for implementing dimensional models – one that now requires testing in real-world settings.

The post-traumatic stress disorder (PTSD) diagnosis encompasses heterogeneous presentations, many of the diagnostic criteria are not trauma-related and almost all PTSD symptoms are common to several psychiatric diagnoses. Flashbacks are the only symptom unique to PSTD. However, the absence of a consensus definition of flashbacks means that this term means different things to different people, causing misunderstanding and miscommunication, and presumably affecting treatment. This Refreshment discusses how flashbacks are defined in DSM-5-TR and ICD-11 (essentially, as reliving/re-experiencing when awake) and briefly describes the dual representation theory's account of flashbacks. In discussing what flashbacks are and are not, it aims to promote improved understanding, assessment and diagnosis of PTSDs.

Primary hyperparathyroidism (PHPT) is the presence of hypercalcaemia with an elevated or inappropriately normal parathyroid hormone level. In clinical psychiatry this is often detected on routine blood investigations. This article aims to help mental health professionals understand the relevance of PHPT to psychiatry and offers some guidance about further management of patients presenting with this endocrine abnormality in mental health settings. PHPT can be associated with both mental and physical health problems in some individuals, making it a crucial diagnosis that should not be overlooked.

Paediatric functional gastrointestinal disorders (P-FGIDs) are common, affecting up to 25% of children worldwide. They are characterised by chronic abdominal pain and/or altered bowel habits without an underlying disease pathology. P-FGIDs are often associated with co-occurring anxiety and depression across all ages and treating P-FGIDs may provide an opportunity to develop a young person's wider emotion regulation capacities. Using a fictitious case vignette, we outline the range of psychosocial and biomedical treatments for the disorder and the need for an integrated and holistic approach. We propose that by intervening early and enabling children to be curious about, rather than fearful of, their bodily sensations, clinicians may be able to alter harmful illness trajectories in both pain and psychiatric domains.

Kushner's monograph (published in 2000) explores clinicians’ developing understanding of a syndrome first described 200 years ago. This article highlights changing concepts of the disorder, its aetiology and treatment over its long history, as described by Kushner, and considers the current differential diagnosis of DSM-5 ‘Tourette's disorder’. It points out Kushner's astute observation that the clinical syndrome originally described by Itard and Gilles de la Tourette as ‘maladie des tics’ is not what is defined in the 21st century as Tourette syndrome.

Quality improvement (QI) is an evidence-based approach to analysing and improving healthcare systems. QI's success has led it to become a required competency expected of medical professionals in several countries. However, much of the QI literature to date has not focused on mental health. Moreover, many psychiatrists have no formal training in QI. To address this gap, this article introduces key QI concepts, including six dimensions of quality care, the Model for Improvement and plan–do–study–act cycles. Each QI concept is illustrated using a fictitious case study of an out-patient psychiatrist reducing chronic benzodiazepine use in their clinic.

This commentary responds to Carona & Atanázio's discussion of Sylvia Plath's novel The Bell Jar in this issue of BJPsych Advances. Although I agree with their emphasis on empathy and sensitivity in medical practice, I argue that they overlook the broader insights of the medical humanities. By examining themes of suicide and patriarchy in The Bell Jar, I highlight how the novel itself, and the humanities scholars who have studied it, provide a counternarrative to the biomedical model, urging a more holistic understanding of psychological distress. I advocate engaging with Plath's work beyond diagnostic criteria, appreciating its cultural and structural dimensions.

Metabolic dysfunction has been long associated with severe mental illness (SMI), often viewed as a comorbidity to be managed. However, emerging evidence suggests that metabolic dysfunction, particularly at the mitochondrial level, may be a foundational element in the pathophysiology of neuropsychiatric disorders. This commentary expands on the current understanding by exploring the brain energy theory of mental illness, which posits that mitochondrial dysfunction is central to both metabolic and psychiatric conditions. The roles of insulin resistance, chronic stress and environmental factors are highlighted as shared biopsychosocial determinants that contribute to deterioration in both metabolic and mental health. The therapeutic potential of the ketogenic diet is discussed, particularly its ability to improve mitochondrial function and alleviate psychiatric symptoms. This shift in perspective, from viewing metabolic dysfunction as a secondary concern to recognising it as a root cause of SMI, has significant implications for clinical practice and research. By focusing on bioenergetic deficits and mitochondrial health, psychiatry may advance towards more effective, integrated treatment approaches that target the underlying cellular dysfunctions driving both metabolic and mental illnesses.

Music therapy attempts to facilitate communication and expression – core problems for autistic people – through the development of experiences and relationships mediated by music. This commentary assesses a Cochrane Review of the effects of music therapy, compared with placebo or standard care, for autistic people, and its conclusion that music therapy is probably associated with an increased chance of global improvement and perhaps a slight increase in quality of life and reduction in total autism symptom severity in the short to medium term. The review was not able to examine longer-term effects as the longest follow-up period was 12 months. The certainty of the evidence was graded from moderate to very low, and therefore the results need to be viewed with caution.

Clozapine is the only evidence-based intervention for treatment-resistant schizophrenia. One of the drug's most well-known and potentially fatal adverse effects is agranulocytosis (severe neutropenia). Hence, regular blood tests are an essential component of clozapine treatment. This article presents a narrative review of the history, incidence, potential aetiology and management of clozapine-associated neutropenia. It gives an overview of clozapine monitoring requirements, including those for benign ethnic neutropenia. We point to the growing body of evidence that the risk of clozapine-induced agranulocytosis is mostly confined to the first year of treatment and that the risk of fatality is considerably lower than previously assumed. Given the absence of alternative evidence-based interventions for treatment-resistant schizophrenia, we suggest that rechallenging with clozapine should be considered in most patients with clozapine-associated mild to moderate neutropenia who do not respond to other treatments. A more careful risk–benefit analysis is needed in cases of severe neutropenia (agranulocytosis).

Entrustable professional activities (EPAs) have gained traction in the medical education field as a means of assessing competencies. Essentially, an EPA is a profession-specific task that a trainee is entrusted to conduct unsupervised, once deemed competent by their supervisor through prior evaluations and discussions. The integration of EPAs into postgraduate assessment strategies enhances the delivery of capability-based curricula. It strategically bridges the theoretical–practical divide and addresses existing issues associated with workplace-based assessments (WBPAs). This article aims to (a) provide an overview of EPAs, (b) review the application of EPAs in postgraduate psychiatry so far, exploring their conceptual framework, implementation, qualities and potential benefits and concerns, and (c) propose a theoretical framework for their integration into the UK psychiatry curriculum.

Cognitive–behavioural therapy (CBT) has been widely used for a broad range of mental health problems for several decades and has been researched extensively. Its techniques are relatively easy to learn and follow in treatment protocols. Many new CBT-based psychotherapies have been developed that go further than traditional CBT, some specifically addressing personality disorders. These so-called third-wave approaches target emotional responses to situations by using strategies such as mindfulness exercises and acceptance of unpleasant thoughts and feelings (observing thoughts as ‘from afar’). In this article, we discuss the historical context of these therapies, dissect common and specific factors in some treatment modalities often used to treat personality disorders, and suggest potential future directions for research and treatment.

Until recently, statistical consultants did not have to worry about being replaced by artificial intelligence. There was no statistical analogue to ‘Dr Google’ before ChatGPT arrived on the scene. Although ChatGPT (most of the time) adequately responds to basic queries such as the assumptions of different statistical tests or summarises relevant manuals on statistical software providing clear instructions with point-and-click software such as SPSS, there are many important aspects of statistical consulting that ChatGPT does not cover. This tutorial article is about these aspects: a summary of what statistical consulting is, its purpose and possible settings during the empirical research cycle, the role and responsibilities of the consultant and the client, how to ensure a good consulting experience, how to prepare for a consulting session, typical questions and more. The article was written for researchers who are considering contacting a statistician for the first time and aims to facilitate a good and fruitful consulting experience for all parties involved.

This article examines the complex phenomenon of self-harm, exploring its motivations, theoretical underpinnings and the intricate transference and countertransference reactions that arise in clinical settings. It aims to integrate psychiatric understanding with contemporary theories of the impact of trauma on both the body and the mind, to deepen the knowledge of self-harm and increase the effectiveness of treatment approaches. The article argues for a nuanced view of self-harm and emphasises the need for compassionate, well-informed care. By addressing the psychodynamics of self-harm, the article seeks to improve therapeutic outcomes and foster an empathetic and effective clinical response. Fictitious case studies are used to illustrate these concepts, demonstrating the critical role of early attachment experiences and the challenges faced by healthcare providers in management.

This article discusses the importance of personal recovery in psychiatry and proposes a new socially constitutive process. The author, an expert by experience, emphasises that recovery is not only an individual endeavour but also an intersubjective one. Moreover, social relationships and external factors such as community, family, health service culture and social norms influence the recovery process. The socially constitutive process posits that support from professionals and family members is crucial, significantly reducing the burden of responsibility carried by individuals with mental illness.