The lessons I learned as a psychiatrist from my transcultural work in low- and middle-income countries.

Transcultural observations offer an opportunity to study attitude to mental illness in different societies and family structures. The disparity between industrialised and lower-income societies reflects greater tolerance due to the ability of extended families to compensate for the patient's limitations.

AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial.

Background: A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.

The most important things I have learnt in my career as a psychiatrist.

This paper is something of a patchwork, incorporating many issues that have intrigued me during 34 years of research. I have included the importance of maintaining a solid base in clinical work, alongside research activities, and being alert to the possibility of a somatic condition contributing to psychiatric symptoms. I stress the value of careful observation of patients, their response to treatments and reasons for dropping out.

Key Elements of a Family Intervention for Schizophrenia: A Qualitative Analysis of an RCT.

Schizophrenia is a complex biopsychosocial condition in which expressed emotion in family members is a robust predictor of relapse. Not surprisingly, family interventions are remarkably effective and thus recommended in current treatment guidelines. Their key elements seem to be common therapeutic factors, followed by education and coping skills training.

Confronting Auditory Hallucinations Using Virtual Reality: The Avatar Therapy.

The AVATAR therapy is a computer-based intervention which aims to reduce the frequency and severity of voices. The approach is based on computer technology which enables each patient to create an avatar of the entity (human or non-human) that they believe is talking to them. The therapist promotes a dialogue between the patient and the avatar in which the avatar progressively comes under the patient's control.

What do We Know about Family Interventions for Psychosis at the Process Level? A Systematic Review.

The evidence regarding effectiveness of family interventions for psychosis (FIP) is strong and consistent. However, there is a gap in the research on the process of these interventions, and little is known about their active ingredients. This review aims to identify the active ingredients of FIP.

Avatar therapy for persecutory auditory hallucinations: What is it and how does it work?

We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient's control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design.

Interplay between childhood physical abuse and familial risk in the onset of psychotic disorders.

Background: Childhood abuse is considered one of the main environmental risk factors for the development of psychotic symptoms and disorders. However, this association could be due to genetic factors influencing exposure to such risky environments or increasing sensitivity to the detrimental impact of abuse. Therefore, using a large epidemiological case-control sample, we explored the interplay between a specific form of childhood abuse and family psychiatric history (a proxy for genetic risk) in the onset of psychosis.

Expressed emotion among relatives of chronic pain patients, the interaction between relatives' behaviours and patients' pain experience.

Background: Chronic pain is a sensory and emotional experience that causes significant disturbances to a patient's life as well as to their family. Whether the family environment is affected by chronic pain and, in turn, affects the patients' pain experience has yet to be investigated. The interaction between patients and spouses has been assessed using the expressed emotion (EE) construct, a tool previously described in the field of mental health.

Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study.

Background: One in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control.

Aims: To develop a computerised system that enables the patient to create an avatar of their persecutor.

Assessment of posttraumatic symptoms in patients with first-episode psychosis.

Posttraumatic stress disorder is common among patients with psychotic disorders. The present study examined the internal reliability and comparability of the Impact of Event Scale (IES) in a sample of 38 patients with first-episode psychosis and 47 controls exposed to severe physical and/or sexual abuse. The IES total score and both subscales showed high internal consistency in both groups (Cronbach's alpha coefficients of approximately 0.

Satisfaction with inpatient treatment for first-episode psychosis among different ethnic groups: a report from the UK AeSOP study.

Background: There is concern about the level of satisfaction with mental healthcare among minority ethnic patients in the UK, particularly as black patients have more compulsory admissions to hospital.

Aims: To determine and compare levels of satisfaction with mental healthcare between patients from different ethnic groups in a three-centre study of first-onset psychosis.

Method: Data were collected from 216 patients with first-episode psychosis and 101 caregivers from South London, Nottingham and Bristol, using the Acute Services Study Questionnaire (Patient and Relative Version) and measures of sociodemographic variables and insight.

Insight, grey matter and cognitive function in first-onset psychosis.

Background: Several studies have suggested that neuropsychological and structural brain deficits are implicated in poor insight. Few insight studies however have combined neurocognitive and structural neuroanatomical measures.

Aims: Focusing on the ability to relabel psychotic symptoms as pathological, we examined insight, brain structure and neurocognition in first-onset psychosis.

The culture and identity schedule a measure of cultural affiliation: acculturation, marginalization and schizophrenia.

Background: Previous epidemiological studies have shown a high incidence of schizophrenia in African-Caribbeans in the UK, but not in Asians.

Aims: We investigated the hypothesis that cultural adherence might protect the Asians against the stress of living in a majority white culture.

Methods: The Culture and Identity Schedule (CANDID) was given to patients with a diagnosis of schizophrenia making their first contact with psychiatric services, and to a matched group of controls randomly selected from the general population.

Reliability and comparability of psychosis patients' retrospective reports of childhood abuse.

An increasing number of studies are demonstrating an association between childhood abuse and psychosis. However, the majority of these rely on retrospective self-reports in adulthood that may be unduly influenced by current psychopathology. We therefore set out to explore the reliability and comparability of first-presentation psychosis patients' reports of childhood abuse.

Gender differences in the association between childhood abuse and psychosis.

Background: Studies demonstrating an association between childhood trauma and psychosis in adulthood have not systematically explored gender differences.

Aims: To investigate gender differences in the prevalence of childhood sexual and physical abuse among people with psychosis in comparison with healthy controls.

Method: The Childhood Experiences of Care and Abuse Questionnaire was completed to elicit experiences of sexual and physical abuse during childhood in first-episode psychosis cases and population-based controls.

Neurological abnormalities and cognitive ability in first-episode psychosis.

Background: It remains unclear if the excess of neurological soft signs, or of certain types of neurological soft signs, is common to all psychoses, and whether this excess is simply an epiphenomenon of the lower general cognitive ability present in psychosis.

Aims: To investigate whether an excess of neurological soft signs is independent of diagnosis (schizophrenia v. affective psychosis) and cognitive ability (IQ).

Unemployment, social isolation, achievement-expectation mismatch and psychosis: findings from the AESOP Study.

Introduction: In this study, we aimed to establish: (1) whether social isolation modifies the effect of unemployment on first episode psychosis and duration of untreated psychosis (DUP); and (2) whether the gap between high employment expectations and perceived poor employment achievement is associated with first-episode psychosis; and (3) whether the relationship of this achievement-expectation gap and first-episode psychosis is strongest in the African-Caribbean population.

Method: All patients with a first episode of psychosis presenting to specialist mental health services within tightly defined catchment areas in south-east London and Nottingham over a 2-year period were included in the study. A random sample of healthy participants living within the same catchment areas was also recruited.

Perceptions of disadvantage, ethnicity and psychosis.

Background: People from Black ethnic groups (African-Caribbean and Black African) are more prone to develop psychosis in Western countries. This excess might be explained by perceptions of disadvantage.

Aims: To investigate whether the higher incidence of psychosis in Black people is mediated by perceptions of disadvantage.

Duration of prodromal phase and severity of volumetric abnormalities in first-episode psychosis.

Background: First-episode psychosis is typically preceded by a prodrome in which there is deterioration in global and social functioning.

Aims: To examine whether the duration of the prodromal phase influences grey and white matter volumes at the onset of psychosis.

Methods: Eighty-two people were scanned using magnetic resonance imaging when they developed a first episode of psychosis.

Grey matter abnormalities in first-episode schizophrenia and affective psychosis.

Background: Grey matter and other structural brain abnormalities are consistently reported in first-onset schizophrenia, but less is known about the extent of neuroanatomical changes in first-onset affective psychosis.

Aims: To determine which brain abnormalities are specific to (a) schizophrenia and (b) affective psychosis.

Method: We obtained dual-echo (proton density/T2-weighted) magnetic resonance images and carried out voxel-based analysis on the images of 73 patients with first-episode psychosis (schizophrenia n=44, affective psychosis n=29) and 58 healthy controls.