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Records of violent incidents were retrospectively analysed to identify trends associated with violent incidents within an NHS medium secure psychiatric unit. Over a 12‐month period, 116 incident forms related to 112 incidents. These incidents were compared with a study from the previous 12 months within the same unit. Both studies were based upon work from within a high‐security setting (Caldwell and Naismith, 1989). There was a significant reduction in the overall number of violent incidents.The majority of incidents continued to occur within the intensive care admission unit. There continued to be a higher incidence of assaultive behaviour throughout the afternoon and evening. Seasonal variations demonstrates a reduction of incidents throughout the autumn and winter months compared with the previous year, and a significant change in the number of incidents that occurred during the summer.There remain opportunities for comparison with other secure units and further refinement of the methodology.

A major difficulty identified many years ago in psychiatric care is the shortage of appropriate instruments with which to carry out valid and reliable therapeutic assessments which are behaviourally based and therefore appropriate for use in a variety of contexts. The aim of this project was to ascertain the utility of a forensic nursing risk assessment tool - Behavioural Status Index (BEST-Index). The paper aims to discuss these issues.

A multi-site cross-sectional survey was undertaken using mixed method design. Quantitative data was generated using BEST-Index to allow comparisons across three different levels of security (high, medium and low) in Scotland and Ireland. Qualitative data were gathered from patients and multi-disciplinary team (MDT) members using semi-structured interviews and questionnaire.

Measured over an 18-month period, there was a statistically significant improvement in behaviour, when comparing patients in high and medium secure hospitals. Two key themes emerged from patient and staff perspectives: “acceptance of the process” and “production and delivery of information”, respectively. The wider MDT acknowledge the value of nursing risk assessment, but require adequate information to enable them to interpret findings. Collaborating with patients to undertake risk assessments can enhance future care planning.

Studies using cross-section can only provide information at fixed points in time.

The BEST-Index assessment tool is well established in clinical practice and has demonstrated good utility.

This project has served to highlight the unique contribution of BEST-Index to both staff and patients alike and confirm its robustness and versatility across differing levels of security in Scottish and Irish forensic mental health services.

Psychological and epidemiological literature suggests that the built environment plays both causal and therapeutic roles in schizophrenia, but what are the implications for designers? The purpose of this paper is to focus on the role the built environment plays in psycho‐environmental dynamics, in order that negative effects can be avoided and beneficial effects emphasised in architectural design.

The approach taken is a translational exploration of the dynamics between the built environment and psychotic illness, using primary research from disciplines as diverse as epidemiology, neurology and psychology.

The built environment is conceived as being both an agonist and as an antagonist for the underlying processes that present as psychosis. The built environment is implicated through several means, through the opportunities it provides. These may be physical, narrative, emotional, hedonic or personal. Some opportunities may be negative, and others positive. The built environment is also an important source of unexpected aesthetic stimulation, yet in psychotic illnesses, aesthetic sensibilities characteristically suffer from deterioration.

The findings presented are based on research that is largely translated from very different fields of enquiry. Whilst findings are cogent and logical, much of the support is correlational rather than empirical.

The WHO claims that schizophrenia destroys 24 million lives worldwide, with an exponential effect on human and financial capital. Because evidence implicates the built environment, architectural and urban designers may have a role to play in reducing the human costs wrought by the illness.

Never before has architecture been so explicitly implicated as a cause of mental illness. This paper was presented to the Symposium of Mental Health Facility Design, and is essential reading for anyone involved in designing for improved mental health.

Over 100 years ago, Emil Kraepelin revolutionised the classification of psychosis by identifying what he argued were two natural disease entities: manic depressive psychosis (bipolar disorder) and dementia praecox (schizophrenia). Kraepelin's discoveries have since become the “twin pillars” of mainstream psychiatric thinking, practice, and research. Today, however, a growing number of researchers, clinicians, and mental health service users have rejected this model and call for a symptom‐led approach to prioritise subjective experience over diagnostic category. The purpose of this paper is to ask: how can the published first‐person accounts of experts by experience contribute to these debates?

This paper analyses the representation of psychiatric diagnosis in two prominent autobiographies: Kurt Snyder's Me, Myself, and Them: A Firsthand Account of One Young Person's Experience with Schizophrenia (2007) and Elyn Saks' The Center Cannot Hold: My Journey Through Madness (2007).

As well as providing a prognosis and a plan for treatment, the psychiatric diagnosis of schizophrenia gives shape and meaning to the illness experience and ultimately becomes the pivot or platform from which identity and memoir unfold.

The paper introduces two popular autobiographical accounts of schizophrenia which may be useful resources for mental health service users and clinicians.

The paper highlights the complex ways in which people interpret and make meaning from their psychiatric diagnosis.

The paper demonstrates that first‐person accounts make an important, if frequently overlooked, contribution to debates about psychiatric diagnosis.

Rabbit syndrome (RS) is an antipsychoticinduced rhythmic motion of the mouth/lips resembling the chewing movements of a rabbit. The movement consists of a vertical-only motion, at about 5 Hz, with no involvement of the tongue. Long-term exposure to typical antipsychotics has clearly been associated with RS, but little is known of the risk of RS due to exposure to newer atypical antipsychotics. There have been isolated reports of RS in patients treated with the atypical agents risperidone, aripiprazole, olanzapine, and clozapine. We present the case history of a 44-year old female patient treated for paranoid schizophrenia for 22 years and RS during her last 10-month clozapine treatment. Background information from the literature is also discussed.

Background: the increased incidence of psychosis in African‐Caribbeans in the UK compared to the white British population has been frequently reported. The cause for this is unclear; social factors are said to account for this increase and one factor that is often cited is discrimination.Aims and method: we have looked at two groups of psychotic patients, blacks of Caribbean origin and white British, and present a qualitative comparison of the individual's experience of unfair treatment and its perceived cause.Results: the African‐Caribbean patients did not describe more perceived discrimination than their white counterparts but were more likely to claim that their distress was due to racial discrimination perpetrated by the psychiatric services and society in general. The white patients were more likely to attribute perceived discrimination to their mental illness.Conclusion: this mismatch of explanatory models between black patients and their doctors may account for some inequalities in their treatment, their relative non‐engagement and adverse outcome.Declaration of interest: none.

Several studies reported high rates of psychiatric commorbidity among methadone patients. We examined the relationships of measures of psychopathology to outcomes of screening urine tests for cocaine, opiates, and benzodiazepines in a sample of 56 methadone patients. They also completed the Symptom Check List-90-Revised (SCL-90-R). The highest scales in the SCL-90-R profile of our patients were those indicating somatic discomfort, anger, phobic anxiety, paranoid ideation, and also obsessive-compulsive disorder symptoms (scores above the 39th per centile). The only significant correlations between urine tests and SCL-90-R psychopathology were those involving benzodiazepines: patients with urine tests positive for benzodiazepines had lower social self-confidence (r=0.48), were more obsessive-compulsive (r=0.44), reported a higher level of anger (r=0.41), of phobic tendencies (r=40), of anxiety (r=0.39), and of paranoid tendencies (r=0.38), and also reported more frequent psychotic symptoms (r=0.43).

Paedophilic individuals are a highly misunderstood and stigmatised group, with the general public tending to equate paedophilia with child sexual abuse. Given that paedophilia is often conflated as a psychiatric/mental health disorder and an extreme violent offence, the current study examined whether the stigma towards paedophilic individuals is related to negative associations with severe mental illness and extreme violence. The authors also used the terror management theory (TMT) to provide further insights into why paedophilia is so highly stigmatised.

A sample of 126 participants was split into one of six conditions and provided punitive and moral character judgements, as well as salience of death thoughts. Conditions were divided into three main stigma conditions (paedophilia vs schizophrenia vs homicidal ideation), which were further divided into two conditions (offending vs non-offending).

Results showed that judgements were harsher in the offending conditions than the non-offending conditions. Results also showed that the stigmatisation of paedophilic and schizophrenic individuals may be mediated by terror management processes. These findings suggest that paedophilia is believed to be associated with severe forms of mental illness where an individual is not able to control their own state of mind.

Thus, addressing perceptions of dangerousness towards individuals with severe mental illness is a crucial step towards developing effective strategies to help reduce such stigma.

As one of the first studies to use TMT in this way, the current study provided much-needed insight into an important and under-researched area using available methods for such a sensitive topic.

The efficacy of cognitive-behavioural therapy (CBT) for schizophrenia in community and general psychiatric settings has been widely investigated and its practice recommended in primary and secondary care. In secure forensic mental health services the evidence is less established. The purpose of this paper is to evaluate the effectiveness of group CBT for schizophrenia in a high secure hospital.

In all, 27 male forensic patients completed a manualised CBT group and were compared on primary and secondary outcomes to patients receiving treatment as usual (TAU). Primary outcomes were positive and negative symptoms as measured by the Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS) and the Psychotic Symptom Rating Scales (PSYRATS). A secondary outcome was interpersonal functioning as measured by the Inventory of Interpersonal Problems (IIP-64).

CBT participants showed improvement on negative symptoms; affective flattening, alogia, anhedonia and avolition; in comparison to participants in TAU. CBT participants also showed reductions in delusions and hallucinations on the SAPS but not the PSYRATS. TAU participants improved on positive symptoms as measured by the PSYRATS. CBT participants showed reductions in overall interpersonal problems, and most notably in being socially inhibited and self-sacrificing. No iatrogenic effects of treatment were found; improvements in depression anxiety and stress were reported by group completers, which contrasted to experiences of the TAU group.

Absence of random allocation to CBP or TAU groups retains the risk of recruitment bias. Findings are preliminary given the sample size. Multiple outcome assessments increase risk of a type I error.

CBT for schizophrenia can be effective with clients in secure forensic mental health settings. Improvements in negative symptoms and interpersonal functioning appear to be particular gains. Self-report measures might be subject to specific demand characteristics in such settings.

The evaluation includes a comparator group in a high secure setting, which is typically absent in reported evidence for this population (Blackburn, 2004). The study also investigated changes in interpersonal functioning, which has previously been noted as an important but absent outcome in CBT for psychosis (Haddock et al., 2009). Iatrogenic outcomes were also considered in the evaluation to ensure no adverse effects were experienced from treatment.