SPMM mocks Flashcards

Question

# Identify the age of the following developmental milestones Copying a square

Answer 1

Non-Competitive NMDA receptor antagonist, 5-HT3 receptor antagonist

Answer 2

Nicotinic receptor modulator, Selective and reversible acetylcholinesterase inhibitor

Answer 3

Pseudo-irreversible acetylcholinesterase inhibitor, Butyrylcholinesterase inhibitor

Answer 4

Selective and reversible acetylcholinesterase inhibitor

Answer 5

Half dose, start new drug, then slow withdrawal

Answer 6

Withdraw and wait for 5-6 weeks

Answer 7

Withdraw and wait for 2 weeks

Answer 8

Stop and start other drug immediately

Answer 9

Cross taper with caution

Answer 10

California Verbal Learning Test ## Footnote Frontal lobe tests include Stroop test, Halstead trial making, cognitive estimates, Tower of London, Wisconsin card sorting test, verbal fluency, Luria's motor tests and multiple errands tests. The California Verbal Learning Test (CVLT) is useful to assess verbal memory. Though it may be affected in patients with frontal lesions, CVLT is not a specific frontal lobe test.

Answer 11

Complex partial seizures

Answer 12

Comprehension is preserved ## Footnote Patients with Broca's aphasia produce slow, halting speech that is rarely grammatical. Typical Broca's aphasics eliminate inflections such as -ed and words not central to the meaning of the sentence, such as 'the' and 'and'.

Answer 13

Creutzfeldt-Jakob disease ## Footnote The neurological complaints occurring early in the course of Creutzfeldt-Jakob disease are often cerebellar or visual. Patients may complain of ataxia, clumsiness, or dysarthria, as well as diplopia, distorted vision, blurred vision, field defects, changes in colour perception, and visual agnosia. Ultimately cortical blindness may occur.

Answer 14

Vermis of cerebellum ## Footnote This boy has features of autistic spectrum disorder that includes poor social interactions, and stereotypical behaviours. Hypoplasia of cerebellar vermis (involving to some extent the cerebellar hemispheres) is well-documented in autism. Purkinje cell count in the cerebellum is significantly lower in patients with autism.

Answer 15

Amygdala ## Footnote The amygdala and hippocampal complex, two medial temporal lobe structures, are linked to two independent memory systems, each with unique characteristic functions. In emotional situations, these two systems interact in subtle but important ways. Specifically, the amygdala can modulate both the encoding and the storage of hippocampal- dependent memories. The hippocampal complex, by forming episodic representations of the emotional significance and interpretation of events, can influence the amygdala response when emotional stimuli are encountered.

Answer 16

Anterior cerebral artery ## Footnote Bilateral infarct involving the anterior cerebral artery produces quadriparesis (legs weaker than arms) and akinetic mutism (ventromedial or cingulate syndrome).

Answer 17

Pre-optic area ## Footnote The pre-optic area is a region of the hypothalamus. It is responsible for thermoregulation. It receives nervous stimulation from receptors in the skin, mucous membranes and hypothalamus

Answer 18

Frontal lobe pathology ## Footnote Anosmia is the inability to perceive odour or loss of the sense of smell. A permanent loss of smell may be caused either by a loss of olfactory receptor neurons in the nose or damage to the olfactory nerve or the brain areas that process smell, usually after head injury or due to tumors of the frontal lobe.

Answer 19

5-hydroxytryptophan | 5-hydroxytryptamine is serotonin

Answer 20

5-HT1A receptors ## Footnote The 5-HT1A receptor is found at both somatodendritic and post-synaptic sites. Somatodendritic 5-HT1A receptors in the dorsal and median raphe nuclei are autoreceptors regulating 5-HT neuronal firing. Post-synaptic 5-HT1A receptors are found in the hippocampus and periaqueductal grey matter where they regulate behaviours such as resilience, impulsivity and restraint of excessive response to stress. The 5-HT1A receptor may be an important target in the action of antidepressants.

Answer 21

Left hemisphere infarction ## Footnote The presentation is suggestive of a cerebral infarct, most likely to be on the left side as the woman is presenting with right-sided weakness.

Answer 22

Acetylcholine ## Footnote The diagnosis is Parkinson's disease dementia. In both Lewy body dementia and Parkinson's disease dementia, brain acetylcholine levels are reduced similar to Alzheimer's disease. Therefore acetylcholinesterases (Anti-dementia drugs) could be used in the treatment of Lewy body dementia.

Answer 23

Neurones ## Footnote Theoretically all the main cell types of the CNS, astrocytes, oligodendrocytes, neurons, perivascular macrophage and microglia, can be infected by HIV-1 since they possess the receptors and/or co-receptors for HIV-1 entry, but only the latter two are the most commonly infected cells by HIV-1. Most studies have indicated an absence of in vivo infection in neurons. It is unclear whether detection of infected neurons is complicated by the loss of the infected neuronal populations.

Answer 24

Prefontal cortex ## Footnote Hypofrontality has been repeatedly demonstrated. In schizophrenia: Hypoperfusion: frontal lobes and frontal cortex, anterior and medial cingulate gyri, and parietal lobes. Hyperperfusion: cerebellum, brainstem and thalamus.

Answer 25

Progranulin ## Footnote This is a case of frontotemporal dementia (FTD). FTD is caused by mutations in progranulin (PGRN) especially in familial FTD. PGRN is located on chromosome 17q21.31.

Answer 26

Pruning ## Footnote Synaptic 'pruning' refers to the natural elimination of unnecessary synapses that normally occurs in adolescence, making the brain more organised and efficient.

Answer 27

Psychosis ## Footnote 'Cerebral torque' refers to opposing right-left asymmetries of frontal and parieto-occipital regions of the brain. Crow's hypothesis and observations suggest that a primary disturbance in psychosis is in brain structure, and this is related to cerebral asymmetry in the form of torque.

Answer 28

Toxoplasma gondii ## Footnote Toxoplasmic encephalitis (TE) is caused by the protozoan Toxoplasma gondii. The disease occurs almost exclusively because of reactivation of latent tissue cysts. Primary infection occasionally is associated with acute cerebral or disseminated disease. Seroprevalence varies substantially among different communities (e.g., approximately 15% the United States and 50%--75% in certain European countries). Prior to the introduction of antiretroviral drugs, the 12-month incidence of TE was approximately 33%. The incidence has decreased substantially with the initiation of ART. Clinical disease is rare among patients with CD4+ T lymphocyte counts more than 200 cells/μL. Primary infection occurs after eating undercooked meat containing tissue cysts or ingestion of oocysts that have been shed in cat feces and have sporulated in the environment (which requires at least 24 hours). No transmission of the organism occurs by person-to-person contact

Answer 29

Mifepristone ## Footnote Mifepristone is a glucocorticoid receptor antagonist. It is a blocker of type 2 glucocorticoid and progestin receptors, and the preliminary research findings suggest that it could effectively ameliorate symptoms of major depression.

Answer 30

Myoclonic epilepsy ## Footnote Common EEG findings include rapid spike wave and poly spike wave.

Answer 31

Neuropeptide Y ## Footnote Food intake is regulated by various factors such as neuropeptide Y. Neuropeptide Y potently induces an increase in food intake, and simultaneously stimulates arginine- vasopressin (AVP) secretion in the brain

Answer 32

Potassium ## Footnote There is a negative resting membrane potential of around -70mV. It is maintained by the sodium pump, which actively transports sodium ions out of the cell and potassium ions into the cell. There is increased concentration of potassium ions in axon terminal prior to depolarization. An action potential is propagated by the depolarization spreading laterally to adjacent parts of the neurone. An action potential is initiated in the axon hillock when the synaptic signals received by the dendrites and soma are sufficient to raise the intracellular potential from -70 mV to the threshold potential of - 55mV. When this potential is reached, the Na+ channels present in the axon initial segment will open. This Na+ influx causes a rapid reversal of the membrane potential from -90 to +40 mV. When the membrane potential reaches +40mV, the Na+ channels close and the voltage-gated K+ channels open. K+ ions move out of the axon, and 'repolarizes' the membrane.

Answer 33

Shortened REM latency is not a specific marker of depression ## Footnote Shortened REM latency is not a specific marker of depression; similar changes have been reported in other psychiatric disorders including mania, schizophrenia, schizoaffective disorder, OCD, panic disorder, and eating disorders. Previously it was thought that REM latency may distinguish between certain subtypes of depression. It is now understood that patients with depression show characteristic sleep-EEG changes, including disinhibition of REM sleep characterised by shortened REM latency, or sleep- onset REM periods, prolonged first REM period, and enhanced REM density. Most antidepressants suppress REM sleep in patients and in healthy volunteers. REM suppression includes prolonged REM latency, reduced time spent in REM sleep, and decreased REM density. Withdrawal of REM suppressing antidepressants is followed by REM rebound (resulting in decreased REM latency, increased REM time, and enhanced REM density).

Answer 34

Troponin ## Footnote The most important consideration is clozapine-induced myocarditis. It occurs within 6-8 weeks of starting clozapine (median 3 weeks). Symptoms include fever, tachycardia, flu-like symptoms, fatigue, dyspnea (with increased respiratory rate) and chest pain. One proposed monitoring protocol recommends obtaining baseline troponin I/T, C- reactive protein and echocardiography, and monitoring troponin and C-reactive protein on days 7, 14, 21 and 28. At least twice the upper limit of normal troponin was found in 90% of cases. In addition, persistent abnormally high heart rate or signs or symptoms consistent with infective illness should be followed by daily troponin and C-reactive protein investigation until features resolve.

Answer 35

Methadone ## Footnote Methadone alone or combined with other arrythmogenic agents may increase the likelihood of QT interval prolongation, which is associated with torsades de pointes and can be fatal. ECG monitoring is therefore recommended whilst taking methadone.

Answer 36

Aripiprazole ## Footnote For most patients with symptomatic hyperprolactinaemia, a switch to non-prolactin elevating drug is the first choice. An alternative with modest but evolving evidence is to add aripiprazole to existing treatment. Hyperprolactinaemia and related symptoms are reported to improve fairly promptly following the addition of aripiprazole.

Answer 37

Clozapine ## Footnote Seizures may occur at any time whilst taking clozapine. It is a dose and plasma level-related effect. Prophylactic valproate or lamotrigine is used in high-risk subjects when titrating to a high dose of clozapine. EEG abnormalities are common in those on clozapine treatment; these abnormalities do not always indicate seizure activity.

Answer 38

Clozapine ## Footnote Clozapine is associated with myocarditis and cardiomyopathy. Myocarditis seems to occur within 6-8 weeks of starting clozapine (median 3 weeks) and cardiomyopathy may occur later in treatment (median 9 months) but both may occur at anytime.

Answer 39

Low body mass ## Footnote Risk factors for SSRI induced hyponatraemia include old age, female sex, low body weight, low baseline sodium concentration, history of hyponatraemia, warm weather, reduced renal function, medical co-morbidity and some drug treatments like carbamazepine, antipsychotics, thiazide diuretics, NSAIDs, cancer chemotherapy and drugs like tramadol, omeprazole and trimethoprim.

Answer 40

Mirtazapine ## Footnote Mirtazapine is associated with weight gain in around 1/5th of subjects, especially in the first 4 weeks of treatment. This effect may be secondary to its effects on the 5-HT2C and H1 receptors.

Answer 41

Tardive dyskinesia ## Footnote The AIMS records the occurrence of tardive dyskinesia (TD) in patients receiving neuroleptic medications. This test is used to detect TD and to follow the severity of a patient's TD over time.

Answer 42

Persistent bradycardia ## Footnote Bradycardia is not a feature seen in patients with NMS. The symptoms and signs of NMS include hyperthermia, rigidity, agitation, altered levels of consciousness, tachycardia, tachypnoea, hypertension, tremor, diaphoresis, raised CPK levels, leukocytosis and metabolic acidosis.

Answer 43

470 msec ## Footnote The upper normal value of QTc in males is 440 msec and females is 470 msec. Mounting evidence links QTc values over 500 msec to a clearly increased risk of arrhythmia.

Answer 44

Valproate ## Footnote Valproate is the most teratogenic mood stabiliser. Valproate confers a higher risk (around 10% for major malformations) than carbamazepine and should not be used in women of child-bearing age except where all other treatment has failed. The most common congenital malformations with valproate are neural tube defects, cardiac anomalies, urogenital malformations (including hypospadias), skeletal malformations, and orofacial clefts. Major malformations, specifically orofacial clefts, have been reported with topiramate, though the risk of oral clefts may be higher in women with epilepsy who use higher doses. There is growing evidence that lamotrigine is safer in pregnancy than carbamazepine or valproate across a range of outcomes. The risk of major malformations with lamotrigine appears to be in the range reported for children not exposed to anticonvulsants.

Answer 45

Mood stabilisers ## Footnote Mood stabilizers (including valproate, carbamazepine, and topiramate), when used during pregnancy have been most associated with orofacial clefts in newborns. First trimester exposure to benzodiazepines were previously associated with an increased risk of oral clefts in newborns, but subsequent studies have failed to confirm this association.

Answer 46

Hypertension ## Footnote Several published reports of SSRI-induced movement disorders are available; they mostly report akathisia, dyskinesia, parkinsonism and occasionally dystonia and bruxism. Most of these were reported when using normal therapeutic doses. SSRIs, especially escitalopram and paroxetine, are occasionally associated with galactorrhea. Though rare, photosensitivity and hallucinations have been anecdotally reported with SSRIs. Nevertheless, therapeutic range of SSRI dose is not associated with systemic hypertension, though SNRIs such as venlafaxine carries this risk especially above the dose of 225mg/day.

Answer 47

Lithium ## Footnote Ebstein's anomaly is a congenital heart defect in which the tricuspid valves are displaced towards the apex of the right ventricle. Lithium use has a well-known association with this cardiac malformation (relative risk is 10-20 times more than control). Some case reports have also implicated benzodiazepines, although this is rare.

Answer 48

0.1 ## Footnote Patients can have generalized tonic-clonic seizures during treatment with clozapine. Life-table analysis predicts a cumulative 10% risk of seizures after 3.8 years of treatment. Clozapine-related seizures appear to be dose-related. High-dose therapy (greater than or equal to 600 mg/day) was associated with a greater risk of seizures (4.4%) than medium (300 to 600 mg/day; 2.7%) or low doses (less than 300 mg/day: 1.0%). Also, rapid upward titration may increase seizure risk.

Answer 49

Rivastigmine

Answer 50

Social phobia ## Footnote The monoamine oxidase inhibitors (MAOIs) have shown superior efficacy to other antidepressants in the the treatment of generalized social phobia. Phenelzine in particular, has extensive placebo-controlled trial evidence in support of its use in social anxiety with nearly 67% patients showing significant improvement during acute treatment.

Answer 51

The efficacy of antipsychotic drugs appear to be determined by the affinity for nigrostriatal dopamine receptors ## Footnote The efficacy of antipsychotic drugs appears to be determined by the affinity for mesolimbic dopamine receptors and not by the affinity for nigrostriatal receptors.

Answer 52

Topiramate ## Footnote There are no large trials indicating the usefulness of topiramate in BPAD. Current evidence is sparse and limited.

Answer 53

Risperidone ## Footnote Paliperidone is 9-OH-risperidone. Citalopram is not a prodrug - escitalopram is the therapeutically active S-enantiomer of citalopram.

Answer 54

Risperidone ## Footnote The apparent half-life of risperidone is 3 hours while the apparent half-life of 9-hydroxyrisperidone (also known as paliperidone) is about 21 hours (in extensive metabolizers). The pharmacokinetics of risperidone and 9-hydroxyrisperidone combined, after single and multiple doses, were similar in extensive and poor metabolizers, with an overall mean elimination half-life of about 20 hoursRisperidone

Answer 55

Smaller, more frequent doses ## Footnote Administer the lithium in smaller, more frequent doses. Propranolol (30 to 160 mg/d) may also be helpful

Answer 56

Sodium valproate ## Footnote Sodium valproate can inhibit the breakdown of lamotrigine and so can result in higher plasma levels of lamotrigine. Valproate also increases the risk of allergic rash seen with lamotrigine.

Answer 57

14 days ## Footnote ICD-10 requires a person to have depressive symptoms most days, most of the time for at least 2 weeks before an episode of depression can be diagnosed.

Answer 58

At least four episodes of bipolar disorder in 1 year ## Footnote Rapid cycling bipolar affective disorder is defined as having 4 or more episodes of mood disturbance (manic, hypomanic, mixed or depressive) within 12 months.

Answer 59

It is a test of theory of mind ## Footnote The Sally Anne test is a test of theory of mind whereby children observe a scenario in which a doll (Anne) removes a marble from another doll's (Sally's) basket and places it in a box. The other doll then enters the scene and the children are asked where it will look for its marble. To pass the children must identify that Sally will look in her basket as she does not know that the marble has been moved. Children generally pass it after the age of 4.

Answer 60

Once the features of Korsakoff have been recognised, they can be reversed using IV Thiamine ## Footnote Korsakoff is irreversible; it may be prevented with treatment in the preceding Wernicke's encephalopathy with high dose parenteral thiamine.

Answer 61

Physical signs often include an abdominal rash ## Footnote Acute Intermittent Porphyria is not typical characterised by a rash; abdominal pain is the most common symptom. It is usually inherited in an autosomal dominant manner but autosomal recessive inheritance has been described. It is caused by mutations in the HMBS gene, which codes for the enzyme porphobilinogen deaminase. It causes acute attacks of abdominal pain and other symptoms, potentially including psychosis. It can be precipitated by the use of medications, including clonazepam, alcohol, low carbohydrate diet, infections and hormone changes during the menstrual cycle. A high-carbohydrate (10% glucose) infusion is recommended, which may aid in recovery. Hematin and heme arginate is the treatment of choice during an acute attack. Heme is not a curative treatment, but can shorten attacks and reduce the intensity of an attack.

Answer 62

It is seeing oneself in one's external space ## Footnote An autoscopic hallucination is a visual misperception in which an individual sees himself or herself as if they are an external stimulus.

Answer 63

MMPI ## Footnote The Minnesota Multiphasic Personality Inventory (MMPI) is a standardised psychometric test which has been used to test personality change and has some validity in cases of post-traumatic brain injury

Answer 64

Delayed recall ## Footnote Delayed recall involves the retrieval of previously encoded words, whereas delayed recognition measures only whether or not a word has been encoded and consolidated. Tests of free recall involve immediate assessment of what is recalled after a list is read e.g. upon hearing the list read, patients are instructed that they will be asked to repeat as many words as they can. Asking the patient to point out whether a given word was in the original list after a delay is testing 'delayed recognition' as well as consolidation. Semantic memory refers to general world knowledge accumulated through the lifespan.

Answer 65

7 days ## Footnote ICD-10 states that manic symptoms must be present for at least 7 consecutive days for a manic episode to be diagnosed. Symptoms must be present for at least 4 days for an episode of hypomania to be diagnosed.

Answer 66

Avoidant ## Footnote Avoidant attachment is characterised by a desire to maintain emotional distance

Answer 67

Moderate learning disability ## Footnote A classification of mild, moderate, severe and profound has been used to describe the degree of learning disability. IQ measurement has traditionally been used to define severity: * Profound - IQ of less than 20 * Severe - IQ of 20-34 * Moderate - IQ of 35-49 * Mild - IQ of 50-70

Answer 68

Schizotypal Personality Disorder ## Footnote The World Health Organization's ICD-10 uses the name schizotypal disorder. It is classified as a clinical disorder associated with schizophrenia, rather than a personality disorder as in DSM-5.

Answer 69

She appears not to mind whether she is praised or criticised ## Footnote F60.4 Histrionic personality disorder Personality disorder characterized by: (a)self-dramatization, theatricality, exaggerated expression of emotions; (b)suggestibility, easily influenced by others or by circumstances; (c)shallow and labile affectivity; (d)continual seeking for excitement and activities in which the patient is the centre of attention; (e)inappropriate seductiveness in appearance or behaviour; (f)over-concern with physical attractiveness. Associated features may include egocentricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt, and persistent manipulative behaviour to achieve own needs.

Answer 70

Simple schizophrenia has been removed ## Footnote Simple schizophrenia was not included amongst the schizophrenia subtypes in DSM-IV. In DSM-V, all schizophrenia subtypes have now been removed.

Answer 71

The delusions must be present for at least one month ## Footnote All the others are not included in the ICD-10. The delusions are usually mood congruent. The diagnosis cannot be made alongside a diagnosis of paranoid schizophrenia or if accompanied by a dementing illness.

Answer 72

Other neurotic disorder ## Footnote Latah is classified under other specified neurotic disorders, along with many other culturally specific syndromes. F48.8 Other specified neurotic disorders: Includes: Briquet's disorder Dhat syndrome koro latah occupational neurosis, including writer's cramp psychasthenia psychasthenic neurosis psychogenic syncope

Answer 73

Attentional bias towards the objects that belonged to the dead person ## Footnote Why should a loss event make us feel sad universally? One explanation is offered through the model of incentive salience for grief (Freed and Mann, 2007). When an attachment figure dies (or leaves us), the rewarding feeling that we generally associate with the cues associated with them persists (e.g. photographs, the daily objects that they used etc.). These cues, given their associated incentive salience, automatically bias our attention towards them and trigger the unpleasant subjective yearning and sense of loss. This excessive attention toward an unavailable attachment figure serves to maintain grief's core symptoms. Successfully reducing this elevated incentive salience during separation will help one to accept the loss. Sadness that emerges during grief reaction is an adaptive coping response, which serves to replace the association of rewarding, incentive salience with an unpleasant feeling that eventually serves to produce detachment.

Answer 74

Logoclonia ## Footnote In logoclonia there is meaningless repetition of the last syllables of a word or phrase.

Answer 75

Ambitendency ## Footnote Ambitendency is a phenomenon in which an individual alternates between resistance to and cooperation with instructions or prompts.

Answer 76

Apathy ## Footnote The negative symptoms of schizophrenia are: apathy, blunted or absent emotional responses, reduced speech, social withdrawal, diminished attention, anhedonia, sexual problems, lethargy.

Answer 77

Asyndesis ## Footnote Asyndesis describes a lack of genuine causal links in which clusters of more or less related sequences of thoughts, instead of well-knit sequences of thoughts are used, creating a feeling of vagueness. Derailment is a form of thought disorder characterised by a sudden change in the train of thought and/or speech, either spontaneously or in response to an internal stimulus, from the topic's track onto another which is obliquely related or entirely unrelated. Metonymy involves approximate uses of words, such as paperskate rather than pen. Fusion involves thoughts being fused together, leading to a loss of goal direction. In drivelling there is a disordered intermixture of the constituent parts of one complex thought.

Answer 78

Awareness of one's physiological state ## Footnote Interoception is defined as the sense of the internal state of the body. It encompasses the brain's process of integrating signals relayed from the allowing for a nuanced representation of the physiological state of the body. This is important for maintaining homeostatic conditions in the body and potentially aiding in self-awareness. It is thought to be impaired in people with ASD.

Answer 79

Delusional memory ## Footnote This is most likely to be a delusional memory. This is the symptom when the patient recalls as remembered an event or idea that is clearly delusional in nature. The delusion is retrojected in time. These are sometimes called retrospective delusions.

Answer 80

Eidetic ## Footnote This is most likely to represent eidetic memory, also called photographic memory. It is unclear if this is a real phenomenon.

Answer 81

Fusion ## Footnote Fusion involves thoughts being fused together, leading to a loss of goal direction.

Answer 82

Waxy flexibility ## Footnote The criteria for catatonic schizophrenia are: a. Stupor (marked decrease in reactivity to the environment and in spontaneous movements and activity) or mutism; b. Excitement (apparently purposeless motor activity, not influenced by external stimuli); c. Posturing (voluntary assumption and maintenance of inappropriate or bizarre postures); d. Negativism (an apparently motiveless resistance to all instructions or attempts to be moved, or movement in the opposite direction); e. Rigidity (maintenance of a rigid posture against efforts to be moved); f. Waxy flexibility (maintenance of limbs and body in externally imposed positions); g. Other symptoms such as command automatism (automatic compliance with instructions), and perseveration of words and phrases.

Answer 83

Chaining ## Footnote Chaining involves breaking a complex behaviour into steps and then teaching one step at a time, adding a new one to those that have come before. The previous steps act as a prompt for the new one, thus building a chain. Shaping involves giving positive reinforcement for approximations of a behaviour until it is mastering, e.g. congratulating a child for holding a fork when they hold it by the tines rather than the handle when teaching them to use cutlery. Prompting involves reminding a child of what they need to be doing, however this is done. In the context of memory retrieval, cueing is achieved via prompts or cues, which include anything that is connected in some way to target information in long-term memory, prompting retrieval of it.

Answer 84

Proximity ## Footnote The 5 principles of Gestalt psychology are: proximity, similarity, good continuation, closure, and the law of common fate. They were described to explain human perception of groups of objects and how we perceive parts of objects and form whole objects on the basis of these. The concept of proximity is sometimes referred to as the principle of distance.

Answer 85

Systematic desensitisation ## Footnote Counter-conditioning is a technique that is often employed as a part of systematic desensitisation when managing phobias and similar disorders. It involves the conditioning of an unwanted behaviour or response to a stimulus into a wanted behaviour or response by the association of positive actions with the stimulus. For example, when managing a phobia of dogs, a therapist may aim to associate an anxiety-provoking stimulus, such as a dog being in the next room, with a positive reward. Therefore, this will associate the positive reward with the stimulus and diminish the anxiety associated with the latter. Wolpe, the proponent of systematic desensitization used Guthrie's (1952) concept of counterconditioning to explain the long-term benefits of systematic desensitisation and claimed that desensitization replaced anxiety with relaxation.

Answer 86

Stimulus preparedness ## Footnote Stimulus preparedness implies that fear-relevant stimuli are biologically prepared, as opposed to only occurring in those who already fear snakes.

Answer 87

Temporary increase in work performance due to the presence of others ## Footnote The Hawthorne effect describes the phenomenon of individuals or a group changing their behaviour in response to being observed. The bystander effect is a social psychological phenomenon in which individuals are less likely to offer help when other people are present. The horn effect, closely related to the halo effect, is a form of cognitive bias that causes one's perception of another to be unduly influenced by a single negative trait. The Pygmalion effect, or Rosenthal effect, is a psychological phenomenon wherein high expectations lead to improved performance in a given area. The targets of the expectations internalise their positive labels, and those with positive labels succeed accordingly; a similar process works in the opposite direction in the case of low expectations. The group attribution error refers to people's tendency to believe either (1) that the characteristics of an individual group member are reflective of the group as a whole, or (2) that a group's decision outcome must reflect the preferences of individual group members, even when external information is available suggesting otherwise.

Answer 88

Recognition ## Footnote The scenario describes one of the simplest forms of testing for recognition, which makes the retrieval process easy to record and analyse.

Answer 89

Retrograde Amnesia ## Footnote Retrograde amnesia, particularly for autobiographical memory is the most persistent complication after ECT. Confusion and disorientation usually resolves within 24-48 hours. Anterograde amnesia usually resolves within few weeks.

Answer 90

Instrumental aggression ## Footnote Instrumental aggression is used with a specific goal in mind, such as obtaining money in the course of an armed robbery. Hostile aggression is in response to a stimulus or provocation. Aggression can be overt and easily identifiable, or covert and "passive-aggressive", e.g. bullying.

Answer 91

It is a type of attribution error ## Footnote Some people attribute their successes to internal factors and their failures to external factors. It is called the self-serving bias, which helps to boost self-esteem.

Answer 92

Risky shift ## Footnote Risky shift describes the phenomenon whereby a group will make more risky decisions than an individual. This is similar to group polarisation in which a group makes more extreme decisions than the individuals would, but in terms of their initial inclination, either cautious or risky.

Answer 93

Self-serving bias ## Footnote Self-serving bias is a type of cognitive bias in which positive events are attributed to one's own character, and negative events to external factors. This can be reversed in depression.

Answer 94

Being consistent ## Footnote Minority influence is increased by consistency in messaging, flexibility, appealing to the majority view and persuading majority figureheads to help propagate their views. If the minority is seen as being more similar to the majority, it also increases their influence.

Answer 95

Change one of their beliefs or attitudes ## Footnote Individuals experiencing cognitive dissonance can resolve this by: * Changing behaviours * Changing beliefs or attitudes to reduce the dissonance * Reduce the importance of the dissonance * Ignore information that emphasises the dissonance Of these, changing behaviours is the least likely to occur. Individuals do not tend to acknowledge the dissonance explicitly as this would involve recognising that their thoughts are contradictory, which is psychologically threatening. They are most likely to change their beliefs or attitudes to reduce the dissonance.

Answer 96

Diffusion of responsibility ## Footnote Diffusion of responsibility describes the phenomenon of a person being less likely to take responsibility for action or inaction when others are present. It is considered a form of attribution as the individual assumes that others either are responsible for taking action or have already done so.

Answer 97

Equality between members ## Footnote Asch theorised that group conformity was more likely with larger numbers, more challenging tasks, conversations being more public and individuals perceiving other members as being more senior than them.

Answer 98

Feels less identified with a group ## Footnote A lesser degree of identification with a given group increases the likelihood an individual will express ambivalence or a dissenting opinion.

Answer 99

Interpersonal accord and conformity ## Footnote She is likely in the conventional stage of interpersonal accord and conformity, or the good boy/girl orientation whereby individuals conform to social standards and are receptive to approval or disapproval from others as it reflects society's views. They try to be a "good boy" or "good girl" to live up to these expectations having learned that being regarded as good benefits the self.

Answer 100

Black and South Asian individuals are less likely to obtain mental healthcare ## Footnote Among BME communities, mental illnesses are more prevalent but less treated. There is relatively higher prevalence of anxiety and depression in South Asian women (63.5% compared with 28.5% of white women), and psychotic disorders in Afro- Caribbean men (3.1% compared with 0.2% of white men). In general, people from ethnic minorities are less likely than their White British counterparts to have contacted their GP about mental health issues in the last year, to be prescribed antidepressants, or to be referred to specialist mental health services. There is some evidence that hard-to-reach groups, including BME, are less likely to obtain appropriate mental healthcare and may be disadvantaged either because they are unable to access services or because they receive inadequate help from services. Factors considered important barriers to accessing services include cultural competence (i.e. the ability of providers and organisations to effectively deliver healthcare services that meet the social, cultural and linguistic needs of patients); cultural models of illness; stigma; fear and perceived discrimination and barriers to communication.

Answer 101

Bouffée délirante ## Footnote Bouffée délirante describes sudden attacks of brief duration with paranoid delusions and often concomitant hallucinations, typically precipitated by an intense fear of magical persecution through sorcery or witchcraft. It is a syndrome occurring in Francophone West Africa and Haiti.

Answer 102

In patients with schizophrenia whose families have high expressed emotion, males have a higher risk of relapse than females ## Footnote There is no evidence for a difference in the rate of relapse for men and women with schizophrenia exposed to high expressed emotion.

Answer 103

Integrated ## Footnote Cultural integration is a form of cultural exchange in which one group assumes the beliefs, practices and rituals of another group without sacrificing the characteristics of its own culture.

Answer 104

All adults reach the post-conventional stage ## Footnote All adults do not reach the post-conventional stages of moral development. At the same time, people in different cultures seem to move through the sequence at different rates and to reach different end-points. Edwards et al., in 1980, reported that in the West, most urban middle-class adults reach stage 4 (conventional), with a small percentage using some stage 5 (post-conventional) reasoning. In the isolated villages and tribal communities of many countries, however, it is rare to find any adult beyond Stage 3.

Answer 105

Denial, rationalization ## Footnote Denial, rationalisation and intellectualisation are commonly seen in patients with anorexia nervosa.

Answer 106

Intellectualisation ## Footnote Intellectualisation is a form of defence mechanism where an individual concentrates on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions. Rationalisation is a defence mechanism where the individual devises reassuring or self-serving but **incorrect** explanations for his or her own or others' thoughts, actions, or feelings.

Answer 107

Isolation ## Footnote Isolation is not a Kleinian defence. It is characterised as a mental process involving the creation of a gap between an unpleasant or threatening cognition, and other thoughts and feelings. By minimising associative connections with other thoughts, the threatening cognition is remembered less often and is less likely to affect self-esteem or the self- concept. The other defences listed are more primitive and were addressed more by Klein in her work with children.

Answer 108

Repression ## Footnote Repression has been referred to the Primary Defence for the unconscious as it involves preventing thoughts or impulses becoming conscious.

Answer 109

Suppression ## Footnote Suppression is the conscious decision to delay paying attention to a thought, emotion, or need in order to cope with the present reality; making it possible later to access uncomfortable or distressing emotions whilst accepting them.

Answer 110

Thanatos ## Footnote Dual instinct theory looks at Eros and Thanatos as life and death instincts. Freud believed that Thanatos underlay and accompanied Eros and so could be seen as more primal.

Answer 111

Undoing ## Footnote In undoing an individual tries to "undo" an unhealthy, destructive or otherwise threatening thought by acting out the reverse of the unacceptable. It involves symbolically nullifying an unacceptable or guilt provoking thought, idea, or feeling by confession or atonement.

Answer 112

Imprinting ## Footnote This describes filial imprinting that is often seen in birds. Newly hatched chicks will identify an object seen after birth as their mother and follow it persistently. This tends to occur within a certain critical time period shortly after hatching. More generally, imprinting is any kind of phase-sensitive learning (learning occurring at a particular age or a particular life stage) that is rapid and apparently independent of the consequences of behaviour.

Answer 113

Polythematic questions ## Footnote Compound or polythematic questioning is adding two or more questions in a single statement. This interview technique confuses the patient and will lead to either a vag response or non-response.

Answer 114

Suggestive questions ## Footnote In suggestive questions, the answers are contained in the question. It misleads both the patient and the doctor. The patient is left with little choice.

Answer 115

Disapproval ## Footnote Disapproval is expressing unhappiness with a topic that the patient wants to discuss; may lead to withdrawal and not revealing the important problem faced by the patient

Answer 116

Setting traps ## Footnote Setting traps is tricking the patient using his words. Often seen as doctor's attempt to negate patient's problems.

Answer 117

Hypercalcaemia ## Footnote Polydipsia is a common symptom of hypercalcaemia. Hypercalcaemia is relatively common in cancer (20-30% of cancer patients develop hypercalcaemia). The most common cancers associated with hypercalcaemia are breast and lung cancer, and multiple myeloma.

Answer 118

Hyponatraemia ## Footnote He has likely taken MDMA which results in chatty and overfamiliar behaviour, and excessive thirst. He has developed hyponatreamia secondary to over- drinking water due to this excessive thirst. MDMA also causes syndrome of inappropriate antidiuretic hormone (SIADH) which contributes to hyponatremia.

Answer 119

Metabolic alkalosis ## Footnote Metabolic alkalosis is associated with excessive vomiting. In this case, it is likely that Lena has started to binge and purge following the breakdown of her relationship putting her at risk of developing metabolic alkalosis.

Answer 120

Sleep myoclonus/hypnic jerk ## Footnote Sleep myoclonus/hypnic jerk is an involuntary twitch that occurs just as a person is beginning to fall asleep

Answer 121

Parkinsonism ## Footnote Parkinsonism is associated with antipsychotic medication resulting in stiffness, bradykinesia and tremor

Answer 122

Athetosis ## Footnote Athetosis is slow involuntary writing movements of the limbs caused by degeneration of the basal ganglia, as seen in Huntington's disease. It can also be secondary to stroke or trauma.

Answer 123

Anankastic personality disorder ## Footnote Anankastic personality disorder: Traits include a preoccupation with orderliness and control (including over money), at the expense of flexibility. Rules are very rigidly maintained.

Answer 124

Histrionic personality disorder ## Footnote Histrionic personality disorder: Traits include excessive attention-seeking emotions including inappropriately seductive behaviour.

Answer 125

Antisocial personality disorder ## Footnote Antisocial personality disorder: Traits include ease on forming relationships, but not keeping them, superficial charm, lack of remorse for criminal or law-breaking activity, disregard for the rights of others.

Answer 126

Narcissistic personality disorder ## Footnote Narcissistic personality disorder can be recognised by elevated sense of importance and significance compared to others.

Answer 127

Emotionally unstable personality disorder ## Footnote Emotionally unstable personality disorder usually involves marked impulsivity and a desultory approach to life; this usually leads to difficulties with finances and at work.

Answer 128

Pulmonary embolism ## Footnote Chest pain and dyspnoea would make a pulmonary embolus likely. Significant hypoxia could lead to confusion.

Answer 129

Absence seizures ## Footnote Describes absence seizures (also known as petit mal seizures) with classic brief periods of unresponsiveness but without any movement abnormalities.

Answer 130

Lithium toxicity ## Footnote Llikely lithium toxicity due to dehydration. The patient has exerted themselves in a warm environment and has experienced fluid loss as a result.

Answer 131

Social phobia ## Footnote diagnosis of social phobia or social anxiety characterised by difficulties in a school or social environment.

Answer 132

Adjustment disorder ## Footnote suffering from adjustment disorder, which occurs up to 3 months (usually within 1 month) after a stressor and does not persist for more than 6 months after the stressor.

Answer 133

Obsessive-compulsive disorder ## Footnote a diagnosis of obsessive-compulsive disorder describing obsessional intrusive thoughts and counting compulsions.

Answer 134

Normal pressure hydrocephalus ## Footnote Difficulty in gait initiation is typical in normal pressure hydrocephalus. It can also occur in Parkinsonism but difficulty in initiating movements tends to occur similarly in upper and lower limbs.

Answer 135

Cerebral palsy ## Footnote A gait in which the legs cross over or scissor is typical of an upper motor neurone lesion, particularly in cerebral palsy.

Answer 136

Huntington's disease ## Footnote A chaotic gait impaired by choreic movements is characteristic of Huntington's disease.

Answer 137

Parkinson's disease ## Footnote A festinate gait is characterised by rapid small steps done in an attempt to keep the centre of gravity in between the feet while the trunk is leaning forward involuntarily and is classical in Parkinson's disease and similar disorders.

Answer 138

Cerebellar dysfunction ## Footnote This scenario describes a broad-based gait and symptoms suggestive of truncal ataxia, both of which are associated with cerebellar disease.

Answer 139

Potency ## Footnote Potency of a drug with receptor binding action refers to the amount of the drug needed to produce a particular effect compared to another standard drug with similar receptor profile ('vigor').

Answer 140

Affinity ## Footnote Affinity refers to the ability of the drug to bind to its appropriate receptor ('affection').

Answer 141

Efficacy ## Footnote Efficacy refers to how well the drug produces the expected response i.e. the maximum clinical response produced by a drug ('productivity').

Answer 142

Chlorpromazine, prochlorperazine, promazine, thioridazine or fluphenazine

Answer 143

Haloperidol, droperidol or benperidol

Answer 144

Quetiapine

Answer 145

Aripiprazole ## Footnote From a pharmacological perspective, aripiprazole is different from other antipsychotic agents, as it is the only approved antipsychotic that reduces dopaminergic neurotransmission through D2 partial agonism, not D2 antagonism.

Answer 146

Buspirone ## Footnote Buspirone is a full agonist at presynaptic 5-HT1A receptors and a partial agonist post-synaptically.

Answer 147

Vortioxetine ## Footnote Vortioxetine is a relatively new antidepressant that acts on the serotonin transporter (SERT) to reduce reuptake, in line with SSRIs. In addition, it also acts as an agonist of 5- HT1A on the presynaptic neuron, in line with pindolol and buspirone. This prevents the desensitization of this autoreceptor, and thus accelerates the antidepressant effects.

Answer 148

Olanzapine ## Footnote Olanzapine binds with high affinity to the following receptors: serotonin 5HT2A/2C, 5HT6, dopamine D1-4, histamine H1, and adrenergic a1 receptors.

Answer 149

Granular and Pyramidal cells ## Footnote Numerous neurons utilise glutamate as a neurotransmitter, including granular and pyramidal cells. Glutamate is also shuttled via astrocytes, though these cells do not use glutamate as a neurotransmitter primarily.

Answer 150

Pyramidal cells ## Footnote Pyramidal cells, particularly Betz cells, are part of the corticospinal tracts that conveys motor signals from the motor cortex to the spinal cord.

Answer 151

Ependymal cells ## Footnote Ependymal cells line the cerebral ventricles.

Answer 152

D2 receptor ## Footnote Most antipsychotics block D2 receptors and have the potential to cause hyperprolactinaemia due to blockade in the pituitary. This is more frequent in patients taking amisulpride, risperidone, paliperidone or a first generation antipsychotic. Common consequences of this are infertility and osteoporosis in the long-term. Galactorrhoea is also possible in both men and women.

Answer 153

Alpha-1-adrenergic receptors ## Footnote The scenario appears to describe episodes of postural hypotension which can be linked to antagonism of alpha-1-adrenergic receptors. TCAs, mirtazapine and some antipsychotics are associated with this effect.

Answer 154

Muscarinic receptors ## Footnote Antimuscarinic effects, which are common side-effects of TCAs, can cause urinary retention, as well as dry mouth, blurred vision and a variety of other effects.

Answer 155

Histamine receptors ## Footnote Histamine antagonism, such as that caused by mirtazapine, can cause marked sedation, which some patients find undesirable. Promethiazine and quetiapine also have this effect.

Answer 156

Oligodendrocytes

Answer 157

Schwann cells

Answer 158

Astrocyte ## Footnote Rapid removal of glutamate from the synaptic space is required for the survival of releasing neurons. Although glutamate transporters are expressed by all CNS cell types, astrocytes are the cell type primarily responsible for glutamate uptake.

Answer 159

Ependymal cells ## Footnote Ependymal cells line the CSF filled ventricles in the brain and the central canal of spinal cord.

Answer 160

Procedural memory ## Footnote Procedural memory, or 'knowing how', is the unconscious memory of skills and how to do things. It is acquired through repetition and practice.

Answer 161

Declarative memory ## Footnote Declarative memory is memory of facts and events that can be consciously recalled (also known as explicit memory).

Answer 162

Semantic memory ## Footnote Semantic memory is a structured record of meanings, concepts, facts, knowledge about the world; it's to do with general factual knowledge that is shared with others, independent of personal experience.

Answer 163

Prospective memory ## Footnote Prospective memory refers to that which needs to be remembered in the future, and may be defined as 'remembering to remember'; it can be either event-based or time- based, and is often triggered by a cue (e.g. finishing breakfast).

Answer 164

Episodic memory ## Footnote Episodic memory refers to experiences and specific events in time in serial form, from which we can reconstruct the actual events that took place in our lives; it is the memory of autobiographical events, and has an emotional charge.

Answer 165

Projection ## Footnote Projection is commonly seen in narcissism. It involves taking one's own unacceptable qualities or feelings and ascribing them to other people. For example, a narcissist with a strong dislike for someone, might instead believe that the other person does not like him. Narcissistic defences include the following: 1. repression 2. denial 3. rationalisation 4. projection

Answer 166

Agoraphobia ## Footnote Avoidance is a powerful cognitive and behavioural strategy that serves as a negative reinforcer to reduce anxiety associated with agoraphobia. (Most questions on defence mechanism/cognitive styles are based on psychotherapeutic theoretical grounding; not on quantitative evidence regarding frequency and prevalence) F40.0 Agoraphobia include fears not only of open spaces but also of related aspects such as the presence of crowds and the difficulty of immediate easy escape to a safe place (usually home). The term therefore refers to an interrelated and often overlapping cluster of phobias embracing fears of leaving home: fear of entering shops, crowds, and public places, or of travelling alone in trains, buses, or planes.

Answer 167

Males become more introverted with age ## Footnote Males and females both show a decrease in extraversion, neuroticism and psychoticism with ageing.

Answer 168

Concrete operational stage ## Footnote Lack of conservation, presence of centration, irreversibility, class inclusion, and transitive inference are all characteristics of preoperative thought. The preoperational stage lasts from around 2-7 years of age. Most children learn the rules for conservation at concrete operational stage (age 7 onwards).

Answer 169

Transitional object ## Footnote Infants initially have a period of so-called subjective omnipotence as their desires are fulfilled seemingly automatically, despite the objective reality being different. Realising that they are separate to their mothers or other caregivers can be distressing for the infant as they are reliant on another for their needs. Through fantasizing about the object of its wishes the child will find comfort. A transitional object can be used in this process. Donald Winnicott described this phenomenon. Winnicot observed that the transitional object may be any material object (often a blanket, piece of cloth or a soft toy) to which young children frequently develop intense, persistent attachments. This object would be manipulated, sucked, or stroked, and often became an indispensable aid for falling asleep.

Answer 170

14-24 months ## Footnote Rapprochement refers to a development stage in Mahler's separation-individuation theory, which occurs between 14-24 months. The child uses the caregiver as a base for exploration and frequently returns to them for reassurance whilst exploring their environment.

Answer 171

2 years - 5 years ## Footnote In Margaret Mahler's Separation-Individuation Theory successful completion of this phase marks the development of an internalized mental model of the mother, which unconsciously accompanies and supports the child even when they are physically separated. In addition, a sense of individuality begins to develop. The degree of ambivalence in the internalized model implicates the formation of a healthy self-concept and self-confidence.

Answer 172

Decrease in grey matter and increase in white matter ## Footnote Between adolescence and adulthood the brain undergoes synaptic pruning, resulting in a steady decline of grey matter. Myelogenesis is active during childhood and adolescence, peaking in the third decade of life, then decreases.

Answer 173

Attachment ## Footnote Harlow studied the mechanism by which newborn rhesus monkeys bond with their mothers, suggesting that attachment develops as a result of tactile comfort, and not just the provision of food.

Answer 174

2 separation and 2 reunion episodes ## Footnote Ainsworth constructed a strange situation experiment with 2 separation and 2 reunion episodes. It is a controlled observation carried out in a comfortable room equipped with toys. An infant is observed in the presence and absence of its mother and a stranger in the vicinity in seven different combinations. According to the infant's behaviour it is classified as type A, B or C. A- Anxious avoidant B-Secure C- Anxious resistant

Answer 175

3-4 years of age ## Footnote Gender identity refers to the unshakable self-conviction of being male or female that begins around 18 months and gets fixed by 24 to 30 months. By age 3, most children are able to label themselves as either a boy or a girl. Most children develop stable sense of gender identity by age 4.

Answer 176

2-3 years ## Footnote In terms of fine motor skills, a child can copy a straight line with a crayon. By 30 months (2.5 years), he or she tries to copy a circle and a plus sign.

Answer 177

2-3 years ## Footnote Boys enter puberty at an average age of 11-12 (one year later than girls) but this may occur anytime. One of the largest cohorts of the pubertal adolescents reported so far has estimated the duration of puberty in boys to be around 2.4 years; in girls about 1.9 years. In this study, duration was defined by the difference in ages at onset of a pubertal growth spurt (OGS) and peak height velocity (PHV). Depending on the method used, the duration of puberty varies between 2 to 3 years in both sexes, with boys having longer duration than girls consistently (refer to Tanner's method and Gasser's method for further discussion).

Answer 178

A 5-year-old child can tell time by quarter of an hour accuracy ## Footnote Reception class children (ages 4-5) should be beginning to read the time to the hour. Year 1 children (ages 5-6) should be able to read the time to the hour or the half hour on analogue clocks. Year 2 children (ages 6-7) should be able to read the time to the hour, half hour or quarter hour on analogue clocks.

Answer 179

Anaclitic depression ## Footnote Spitz described this. When children are hospitalised for physical health problems, a short period of separation from primary caregiver ensues; this loss produces anaclitic (object loss) depression. It is thought to be counterproductive to a child's development. But recovery can be very good if maternal deprivation is kept to a minimum i.e. less than three months. To some extent, surrogate mothering can help an infant experiencing anaclitic depression.

Answer 180

Animism ## Footnote Animism refers to the attribution of life and consciousness to certain inanimate objects.

Answer 181

Autistic phase ## Footnote Margaret Mahler proposed a separation-individuation theory in which a normal autistic phase was described.

Answer 182

1 week ## Footnote Both ICD-10 and DSM-4 specify the manic episode should last at least 1 week and the disturbance is sufficiently severe to impair social and occupational functioning.

Answer 183

6 months ## Footnote Adjustment disorder requires a stressor and that the symptoms should resolve within 6 months of termination of the stressor or its consequences.

Answer 184

Adjustment disorder ## Footnote The most common psychiatric diagnosis among those presenting to emergency departments following self-harm is adjustment disorder.

Answer 185

Evidence of childhood conduct disorder ## Footnote A callous lack of concern for others, irresponsibility, irritability, aggression, tendency to act outside social norms, a disregard for the feelings of others, inability to maintain enduring relationships, low threshold for violence, a tendency to blame others, evidence of childhood conduct disorder are the reported features of dissocial personality.

Answer 186

Low frustration tolerance ## Footnote ICD-10 diagnostic criteria include: * a callous lack of concern for the feelings of others * an incapacity to maintain (not establish) enduring relationships * an incapacity to experience guilt * a persistent proneness to blame others * disregard for social norms * a very low frustration tolerance Conduct disorder during childhood and adolescence, though not invariably present, may further support the diagnosis. Persistent irritability may be an associated feature.

Answer 187

Toxoplasmosis ## Footnote Cerebral toxoplasmosis commonly affects patients with advanced HIV immunodeficiency. Toxoplasmosis with CNS involvement in patients who are immunocompromised can be severe and debilitating, and the condition may be fatal. Magnetic Resonance Imaging (MRI) scan shows multiple ring-enhancing lesions with extensive surrounding oedema in supratentorial as well as the infratentorial region.

Answer 188

Trail making tests ## Footnote The Trail Making Test (TMT) has two parts and the times taken to complete each part are used to measure central executive functioning. In Part A, the participant must draw a line to connect consecutive numbers, 1 to 25. This tests visual screening, processing speed, attention. In Part B the participant connects numbers and letters in an alternating progressive sequence (i.e. connect A-1-B-2-C-3 and so on). This tests central executive processes of task-set inhibition, cognitive flexibility, and the ability to maintain a response set. In order to measure central executive functioning, the difference in time taken to complete TMT-B and TMT-A (which has little executive input) is calculated.

Answer 189

Transition ## Footnote Transition is an interview technique used when moving from one to another topic. It is a very useful interview skill and preferably must be done as smoothly as possible to keep the patient interested.

Answer 190

Unilateral resting tremor ## Footnote Unilateral resting tremor is the most common presenting feature in Parkinson's disease.

Answer 191

Upper quadrantanopia ## Footnote Temporal lesions produce upper quadrantanopia due to damage to optic radiation.

Answer 192

Validation ## Footnote Validation statements facilitate the continuation of a clinical interview by 'normalising' experiences e.g. 'it is normal to cry at difficult times.'

Answer 193

Water intoxication ## Footnote Water intoxication occurs particularly in patients with chronic schizophrenia. The clinical presentation includes polyuria, polydipsia, hyponatraemia, confusion, seizures, cerebral and peripheral edema. Death can occur in extreme cases. The cause is generally unknown.

Answer 194

White matter hyperintensities on MRI brain ## Footnote Late-onset schizophrenia is characterised by: * a predominance of females * fewer negative symptoms * infrequent formal thought disorder * prominent hallucinations (notably visual) Associations include: * social isolation * sensory impairment * premorbid paranoid personality traits. Family loading for schizophrenia is lower than for early-onset cases (Howard et al., 2000). White matter hyperintensities are not associated with late-onset schizophrenia (Howard 1995; Rivkin 2000) though one contradictory study exists favouring higher frequency of WMH in late-onset schizophrenia

Answer 195

Why do you think your neighbours want you to do that? ## Footnote The main purpose of the interview is to collect clinically useful information that will enable diagnostic process and facilitate management. It is important to maintain a good therapeutic relationship with the patient while pursuing the above goals. Enquiring 'Why do you think your neighbours want you to do that?' serves both these purposes.

Answer 196

It is a self-administered scale ## Footnote Flanagan's QOLS originally had 15 items, but was expanded to include a 16th item (independence). It measures five conceptual domains of quality of life: 1. material and physical well-being 2. relationships with other people 3. social, community and civic activities 4. personal development and fulfilment 5. recreation It is most often used in samples with chronic illnesses. The QOLS is usually self-administered. It can also be completed by interview format. The QOLS can be completed in about 5 minutes. Scores can range from 16 to 112.

Answer 197

Stereotypy ## Footnote This patient is demonstrating stereotypy; a symptom characterised by repetitive, functionless motor behaviour. Stereotypies, mannerisms, and verbigeration are often elicited in patients with catatonic schizophrenia. Hemiballism - hyperkinetic movement disorder characterised by violent involuntary proximal limb movements on one side of the body, caused by damage to the subthalamic nucleus of the basal ganglia. Unrelated to schizophrenia. Ambitendency - a motor symptom where a patient who has been given an instruction alternates between automatic obedience and negativism e.g. when asked to shake hands, the patient appears indecisive, repeatedly extending and withdrawing their hand. Ambivalence - described by Bleuler as one of the four primary symptoms of schizophrenia and was defined as having positive and negative emotions at the same time. Patients exhibiting ambivalence often have an inability to decide on an action. Mannerisms - repetitive, goal-directed movements (e.g. saluting).

Answer 198

Stereotypy ## Footnote Repetitive, non-goal-directed motor activity (e.g. finger-play, repeatedly touching, patting or rubbing self) is called stereotypy. It is an abnormality not inherent in act but in its frequency.

Answer 199

Synaesthesia ## Footnote This is a classical example of synaesthesia described by Sims. The phenomenon of perceiving a stimulus of one modality in a different modality (may be single or multiple modalities) is called synaesthesia. E.g. tasting the music, hearing colours and smelling voices. It is not a hallucination as the perceived object has an appropriate stimulus. Reflex hallucinations are a hallucinatory form of synaesthesia. A stimulus in one modality produces a hallucination in another modality.

Answer 200

Tangentiality ## Footnote Tangentiality - speech is organised, but not goal directed. The subject answers a question in an indirect manner with vague relevance. The answer appears distant and drifted away from the original goal.

Answer 201

Tendency to be inappropriately euphoric ## Footnote Puerile, childish, frivolous, or silly behaviour occurs with right frontotemporal lesions and in frontotemporal dementia. In such cases, moria (foolish or silly euphoria) and Witzelsucht (a tendency to tell inappropriate jokes are seen).

Answer 202

7+/-2 ## Footnote Short term memory: It holds a small amount of information. The capacity of STM according to Miller is 7+/- 2, as evident while testing digit span. By chunking, larger information could be sorted into 7+/- 2 items and effectively stored. Chunks are bits of information coordinated together with the help of long-term memory. Unaided, STM lasts 15 to 30 seconds. By maintenance rehearsal (repetition of items in one's mind) this duration can be increased further up to indefinite periods. STM largely uses acoustic coding (mostly) or visual coding. Recall of information is effortless and usually error-free. Information is held in STM by the process of rehearsal. Loss of information from STM occurs mainly through displacement (newly acquired items entering STM displaces existing material) and decay (recently acquired material has a higher trace strength than older items)

Answer 203

All of the above ## Footnote Modes of retrieval (LTM store being passed onto STM) are through: * recognition (solving MCQs) * recall (actively searching and reproducing) * relearning * confabulation * reintegration (recollection of past experiences based on certain cues) An eyewitness testimony is a reconstructive memory, which is a mode of retrieval from long-term memory. However, a reconstructive memory of events as in eyewitness testimony is affected by the type of questioning asked to elicit the information.

Answer 204

Alternating attention is the highest level of attention. ## Footnote Divided attention is the highest level of attention, and it refers to the ability to respond simultaneously to multiple tasks or multiple task demands. Alternating attention refers to the ability to switch between tasks; to stop one task to participate in another and then be able to return to the initial task.

Answer 205

Blood-injection-injury type phobia ## Footnote Blood-injection-injury type phobia is unique in that a paradoxical drop in blood pressure occurs during exposure to a particular stimulus, leading to fainting. Applied tension involves contraction of large muscle groups to maintain a normal blood pressure during exposure. This practice is contrary to the progressive muscle relaxation that is employed when treating other forms of anxiety.

Answer 206

Classical conditioning ## Footnote Classical conditioning occurs when a patient associates some aspect of the oncology clinic (e.g. the room, smell, the sight of the intravenous infusion bottle) with the nausea previously experienced during the intravenous process itself. Thus, the mere sight or smell of one or more components of the experience can produce the conditioned response of nausea and vomiting.

Answer 207

Digit span ## Footnote The terms used in psychology and psychiatry are somewhat different which could lead to some confusion. The terms used in psychology are short term memory (immediate memory in psychiatry) and long-term memory (recent memory and remote memory in psychiatry). In psychology, short term memory refers to immediate memory, which is tested by the recall of digits immediately after their presentation (digit span). However, in psychiatry it is often referred to as a test of immediate memory. Recollection of a name and an address after 5 minutes is seen as a test of recent memory (which, in fact, is a part of LTM and should not be considered as a test of STM)

Answer 208

Distorted negative thoughts ## Footnote Aaron Beck first proposed the theory behind cognitive distortions that are associated with depression.

Answer 209

Exposure should be sufficiently long for response to occur ## Footnote Exposure therapy has been shown to be an evidence-based treatment component for phobias, GAD, OCD, panic disorder. There are several variations of exposure therapy (in vivo, graded, flooding, imaginal, interoceptive, systematic desensitisation). Over time, people find that their reactions to feared objects or situations decrease. Exposure can help weaken previously learned associations between feared objects, activities, or situations and bad outcomes. The correct answer is: Exposure should be sufficiently long for response to occur

Answer 210

Framing ## Footnote Framing is a cognitive heuristic in which people tend to reach conclusions based on the 'framework' within which a situation was presented. A judgment is made based on whether the options are presented with positive or negative connotations.

Answer 211

Frontal cortex ## Footnote Dorsolateral prefrontal cortex is considered to be a significant seat of working memory capacity. Impairment of fronto-parietal networks in schizophrenia is thought to be related to working memory deficits seen in this disorder.

Answer 212

Gestalt ## Footnote When the perceptual system forms a percept or gestalt, the whole thing has a reality of its own, independent of the parts. The Gestalt psychologist Kurt Koffka made a famous statement about this: "The whole is other than the sum of its parts." This statement is often translated into English as, "The whole is greater than the sum of the parts." Koffka did not like that translation. He firmly corrected students who substituted "greater" for "other" (Heider, 1977). "This is not a principle of addition," he said. The statement as originally worded was supposed to mean that the whole had an independent existence in the perceptual system

Answer 213

Increasing cognitive dissonance ## Footnote Motivational interviewing attempts to encourage people to take on responsibility for their own life and to deal with their problems themselves. The nature, principles and techniques of MI are, without exception, found to relate to one or more of the principles of cognitive dissonance. In creating a cognitive dissonance, however subtly or gently you may do that, you are inevitably directing the client to where, in many ways, you as the therapist want them to be, to get them to be open to change.

Answer 214

Intelligence ## Footnote According to Sternberg's triarchic theory, intelligence has three components: analytical, creative, and practical.

Answer 215

Intelligence ## Footnote It is a test of intelligence. Around 50% of the population are said to have an IQ between 90 and 110. In the Stanford-Binet test, IQ is calculated as follows: IQ = Measured Age/Chronological Age multiplied by 100.

Answer 216

Introverts have a more reactive reticular activating system ## Footnote In introverts, the ascending reticular activating system (ARAS) is over-aroused and excited. In extraverts, the ARAS is under-aroused and inhibited.

Answer 217

Principlism ## Footnote Principlism refers to Childress and Beauchamp's four prima facie principles in ethics: autonomy, beneficence, non-maleficence, and justice.

Answer 218

25 weeks ## Footnote In the United Kingdom women have access to termination of pregnancy for maternal reasons until 24 weeks' completed gestation, but it is accepted practice for children born at or beyond 25 weeks' gestation to be treated according to the child's perceived best interests even if this is not in accordance with parental wishes. There is no legislation imposing an age limit in UK for resuscitating premature babies as of now. If this is a choice, this must be chosen.

Answer 219

Alzheimer's disease ## Footnote There is no significant causal association between increased risk of Alzheimer's disease (AD) and socioeconomic status (SES). There is an association between low education and increased AD risk, but this is not mediated by adult SES or socioeconomic mobility.

Answer 220

Autonomy ## Footnote Individual freedom is based on the principle of autonomy in modern medical ethics. It is the principle that a person should be free to make his or her own decisions.

Answer 221

Biculturalism ## Footnote The acculturative process involves acquisition and retention as well as relinquishing attitudes/values and practices in both majority and minority populations that continues over several generations. The rate of change and the circumstances that influence it vary greatly, both between and within groups. For these reasons, studies of groups experiencing acculturative change often divide the groups by temporal experience into first, second, and third-generation immigrants. Families within such groups have been categorised as traditional, transitional, or bicultural. * Traditional families are characterised as using their native tongues rather than English, living in ethnic enclaves, avoiding interaction with majority cultural institutions, and maintaining preimmigration values and behaviours. * Transitional families are characterised by greater fluency in the language of the host culture and by children who are becoming familiar with the values and social behaviours of the dominant majority population through attendance at school and school-related activities. * Bicultural families are defined as those with a high degree of language fluency in their native languages as well as English, economic stability, and residence in multiethnic settings. Biculturalism appears to be more adaptive and associated with minimal acculturation stress.

Answer 222

Brown and Harris ## Footnote In 1978, as the result of two community surveys carried out in Camberwell between 1969 and 1975 of women aged 18 and 65 and a series of comparable psychiatric patients, Brown and Harris published their influential book, 'Social Origins of Depression'.

Answer 223

0.05 ## Footnote Risk of seizures at clozapine dose: <300 mg/d = 1% to 2% 300 to 600 mg/d = 3% to 4% >600 mg/d = 5%

Answer 224

15-20% ## Footnote 5-20% of patients on oral medication and up to 30% of patients on depot formulations who develop the syndrome will die from the condition if untreated.

Answer 225

Agranulocytosis ## Footnote Common side effects of sodium valproate include weight gain, nausea, vomiting, diarrhoea, sedation, tremor, thrombocytopenia and hair loss with curly regrowth. Agranulocytosis is listed as a rare/very rare side effect.

Answer 226

Akathisia ## Footnote Akathisia is a subjective state of motor restlessness, which is seen in 20-25% of patients prescribed with anti-psychotic medication. It is an unpleasant state of inner restlessness where there is a strong desire or compulsion to move. It may become prominent as the dose of antipsychotic medication is increased. Akathisia can be mistaken for psychotic agitation and has been linked with suicide and aggression towards others.

Answer 227

Amisulpiride ## Footnote Amisulpride, sulpiride, risperidone and paliperidone are particularly associated with hyperprolactinaemia.

Answer 228

Amitriptyline ## Footnote The antidepressant class most associated with QTc prolongation is tricyclic antidepressants such as amitriptyline. Moclobemide, citalopram, and venlafaxine have a low effect on QTc prolongation. Mirtazapine and SSRIs (except citalopram) have no effect on QTc prolongation.

Answer 229

Amitriptyline ## Footnote Amitriptyline, due to its atropine-like anticholinergic action, can slow GI transit with a resultant slow absorption. However, nearly 95% of the orally administered drug gets absorbed.

Answer 230

Amitriptyline, nortriptyline, imipramine or fluoxetine.

Answer 231

Aspirin, clopidogrel and NSAIDs ## Footnote There is an increased risk of bleeding when SSRIs are taken with antiplatelet drugs such as low-dose aspirin or clopidogrel and non-steroidal anti-inflammatory drugs (NSAIDs). However, the risk is higher with aspirin than other NSAIDs. A large Canadian study found patients taking both aspirin and an SSRI had a 42% increased risk of a bleeding episode - gastrointestinal bleeding, hemorrhagic stroke or other forms of bleeding that required hospital admission - compared with those taking aspirin alone.

Answer 232

Asthma ## Footnote Propranolol and other beta-blockers are recommended to treat akathisia, but beta-receptor blockade causes bronchospasm, and so are contraindicated in asthma.

Answer 233

Bradycardia ## Footnote Bradycardia is not a feature of neuroleptic malignant syndrome (NMS). NMS can occur at anytime during treatment with neuroleptics. It consists of the tetrad of: 1. extreme hyperthermia 2. severe muscular rigidity 3. confusion 4. autonomic fluctuations (tachycardia and elevated/labile blood pressure) Other clinical features of neuroleptic malignant syndrome include diaphoresis, dysphagia, tremor, shuffling gait, tachycardia, dyspnoea, incontinence, delirium progressing to lethargy, stupor, coma.

Answer 234

Flattening or inversion of the T wave. ## Footnote The most frequently observed change during treatment was flattening or inversion of the T wave. * Heart rate decreased * P-Q interval increased slightly during therapy * There was no change in the ST segment * There was no change in QTc Well-monitored lithium treatment of patients with serum lithium concentrations of about 0.6 mmol/L does not cause serious ECG abnormalities. In the absence of symptoms or signs of heart disease, routine monitoring of ECG is not necessary during lithium treatment.

Answer 235

Thioridazide ## Footnote The effect on QTC prolongation is high for some psychotropic drugs like thioridazine, pimozide, sertindole, and any intravenous antipsychotic. Thioridazine prolongs the QTc interval in a dose-dependent manner. The branded product was withdrawn worldwide in 2005 because it caused severe cardiac arrhythmias. There is a moderate effect on QT-c prolongation for psychotropic drugs such as chlorpromazine, quetiapine, ziprasidone and tricyclic antidepressants.

Answer 236

Acamprosate interacts with disulfiram ## Footnote Acamprosate does not interact with disulfiram. It is believed to act through enhancing GABA transmission in the brain. It is licensed to prevent relapse to alcohol use and has been found to have a modest treatment effect. Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase. Alcohol consumption results in increased serum acetaldehyde, causing diaphoresis, palpitations, facial flushing, nausea, vertigo, hypotension, and tachycardia. This aggregation of symptoms is known as the disulfiram-alcohol reaction and discourages alcohol intake.

Answer 237

Agomelatine ## Footnote Agomelatine is a new antidepressant with a novel mechanism of action. It acts as an agonist to both the melatonin receptors MT1 and MT2. It is also an antagonist to the 5- HT2C serotonin receptor.

Answer 238

Allosteric modification of GABA receptor ## Footnote * Benzodiazepines (BDZS) bind to the gamma sub-unit of the GABA-A receptor. * Their binding causes an allosteric (structural) modification of the receptor that results in an increase in GABA-A receptor activity. BDZS therefore increase the frequency of channel opening events which leads to an increase in chloride ion conductance and inhibition of the action potential. BDZs do not substitute for GABA, which binds at the alpha sub-unit.

Answer 239

Alpha-1 antagonism ## Footnote Alpha-1 blockade causes priapism when using trazodone or risperidone.

Answer 240

Alpha-1 adrenergic blockade ## Footnote Side effects due to alpha-1 adrenergic blockade include sedation, postural hypotension, impotence and ejaculatory failure. Alpha-1 adrenergic blockade leads to a moderately high reported incidence of ejaculatory problems such as retrograde ejaculation and rarely priapism. Sexual dysfunction has been reported as a side effect of all antipsychotics and up to 45% of people taking conventional antipsychotics experience sexual dysfunction.

Answer 241

Alpha-4 beta-2 (a4ẞ2) nicotinic acetylcholine receptor partial agonist ## Footnote Varenicline is a partial agonist at the alpha-4 beta-2 (a4ẞ2) unit of nicotinic acetylcholine receptor. It assists smoking cessation by relieving nicotine withdrawal symptoms and reducing the rewarding properties of nicotine.

Answer 242

Amantadine ## Footnote Amantadine is an antiviral agent and prevents viral uncoating. It also induces dopamine release from nerve terminals and so is used in Parkinsonism.

Answer 243

Most orally administered antipsychotics undergo first pass metabolism ## Footnote * The correct answer is: Most orally administered antipsychotics undergo first pass metabolism. * First pass metabolism will serve to reduce bioavailability. * It does not influence passage via BBB. * Chlorpromazine inhibits TCA metabolism thereby increasing TCA levels.

Answer 244

24 hours ## Footnote The half-life of risperidone and of its active metabolite is about 24 hours. The apparent half-life of risperidone is 3 hours in extensive metabolisers and 20 hours in poor metabolisers.

Answer 245

3-6 months ## Footnote The depot medication may require 3-6 months to reach a steady plasma level, therefore oral antipsychotic medication should be continued until steady state plasma level is achieved. Attainment of peak plasma levels, therapeutic effect and steady state plasma levels are all delayed with depot injection. The use of adjunctive oral medication to assess depot requirements may be helpful and oral anti psychotic cover is sometimes required for longer periods of time. Moreover, in most clinical trials relapse seems only to occur six months after withdrawing depot therapy; roughly the time required to clear steady state depot drug levels from the blood.

Answer 246

60-120mg ## Footnote Duloxetine inhibits the re-uptake of both serotonin and noradrenaline. It is used for the treatment of major depressive disorder (60mg once daily), generalised anxiety disorder (30-120mg) and the treatment of diabetic neuropathy (60-120mg in divided doses).

Answer 247

Chromosome 14 ## Footnote Some cases of early onset Alzheimer's dementia (EOAD) are clearly inherited in an autosomal-dominant manner. The beta APP gene on chromosome 21, the PS-1 (presenilin-1) gene on chromosome 14, and the PS-2 (presenilin 2) gene on chromosome 1 have all been characterised as genes in which mutations lead to familial EOAD.

Answer 248

Diploid cells ## Footnote Mitosis is cell division to produce two identical daughter cells with a full complement of chromosomes (46 in humans). Meiosis results in gametes or haploid cells.

Answer 249

Frontotemporal dementia ## Footnote Approximately 10% of cases of FTD are inherited in an autosomal-dominant manner. Mutations in the gene of microtubule-associated protein tau (MAPT) was the first identified monogenic cause of FTD. Since then, seven mutations in over ten other genes have been identified, with the progranulin gene (GRN), C9orf72 (Chromosome 9 open reading frame 72), TARDBP (TAR DNA-binding protein), FUS (fused in sarcoma), and UBQLN2 (ubiquilin 2). The progranulin gene is located in the 17q21.32 region and is composed of 13 exons. Progranulin is a neurotrophic growth factor. Progranulin mutation is the most common identified genetic variation associated with FTD.

Answer 250

17p11.2 microdeletion ## Footnote This is likely to be Smith-Magenis syndrome which is a genetic disorder with features including intellectual disability, facial abnormalities, difficulty sleeping, and numerous behavioural problems such as self-hugging and skin-picking. Smith-Magenis syndrome affects an estimated between 1 in 15,000 to 1 in 25,000 individuals. It is a microdeletion syndrome characterised by an abnormality in the short (p) arm of chromosome 17 and is sometimes called the 17p syndrome.

Answer 251

Alpha-synuclein ## Footnote This is most likely to represent Parkinson's disease. This is characterised by cell death in the brain's basal ganglia and the presence of Lewy bodies (alpha-synuclein protein) in many of the remaining neurones. People with parkinson's disease can develop progressive memory loss and eventually develop dementia. The stooped posture can cause balance problems leading to repeated falls in parkinson's disease.

Answer 252

DRD4 ## Footnote The genome-wide linkage studies conducted to date show divergent findings. Nevertheless, candidate gene studies have produced consistent evidence implicating the genes coding for DRD4, DRD5, SLC6A3, SNAP-25, and HTR1B in the aetiology of ADHD. Ref: Faraone SV, Mick E. Molecular genetics of attention deficit hyperactivity disorder.

Answer 253

Early maternal support enhances hippocampal development ## Footnote DNA methylation (an epigenetic mechanism) in children raised in institutions is different compared with those raised by their biological parents. In addition, maternal support observed in early childhood is noted to be strongly predictive of hippocampal volume measured at school age.

Answer 254

Dominant parietal and/or frontal lobe ## Footnote Apraxia or dyspraxia is most likely to be due to a lesion affecting the dominant parietal and/or frontal lobe. It is possible for it to result from damage to the non-dominant side, but this is less common.

Answer 255

Nucleus accumbens ## Footnote There are numerous areas associated with the reward system but specific reward centres are thought to be located in the nucleus accumbens shell, ventral pallidum, parabrachial nucleus, orbitofrontal cortex and insular cortex.

Answer 256

Optic tract ## Footnote Homonymous hemianopia is a term that describes the visual field loss on the same side of both eyes. It can result from lesions of the contralateral occipital lobe or optic tract. * Chiasmal lesions lead to bipolar hemianopia. * Optic nerve lesions result in monocular blindness. * Temporal and parietal lobe lesions lead to superior and inferior quadrantanopia respectively.

Answer 257

Stimulus generalisation ## Footnote Pavlovs' dog experiments were conducted using human subjects by Watson & Rayner and paved the way for founding the school of behaviourism. Watson produced 'phobia' in an infant called Little Albert. By exposing him to loud, frightening noise whenever he was shown a white rat, eventually Albert became fearful of the white rat, even when he heard no loud noise. A similar fear response was seen when any furry white object was shown to Albert. This 'spread' of associative learning from one stimulus to other is called stimulus generalisation.

Answer 258

Stimulus preparedness ## Footnote Stimulus preparedness (Seligman) explains why snake and spider phobia are commoner than shoe phobia or watch phobia. In evolutionary terms, the stimuli that were threatening to hunter-gatherer man has been hard-wired in our system to respond immediately - and phobia develops more readily for such 'prepared stimuli'.

Answer 259

Negative reinforcement ## Footnote Reinforcement can be positive or negative according to the way reinforcers are handled i.e. if something is given or taken away. If a particular behaviour increases by providing a reinforcer, then this is positive reinforcement. If a particular behaviour increases by removal of an aversive stimulus then this is negative reinforcement. Similarly punishment can also be positive (smack) or negative (take the chocolate away) though it is often used in positive sense.

Answer 260

Hypothyroidism ## Footnote Can cause a variety of thyroid problems - the most common being a benign hypothyroid state. 5% patients may develop goiter, and overt hyperthyroidism is also reported in some cases. Thyroid deficiency is common in those with high risk for preexisting antithyroid antibodies such as middle-aged women. The risk is 3-4:1 in women and is high in first two years of treatment. Rapid-cycling patients are at higher risk. High TSH is seen in nearly 1/3rd of chronic lithium-treated patients - without clinical hypothyroidism. In resistant depression or non-responsive cyclers with bipolar it may be useful treating this subclinical state with thyroxine.

Answer 261

Nausea/vomiting ## Footnote a D2 receptor partial agonist and therefore, more likely to induce side effects like nausea and vomiting.

Answer 262

Word finding difficulties ## Footnote Several studies have documented language impairment due to the use of topiramate. Word-finding difficulties are noted in 7.2% of epileptic patients taking topiramate, especially those with a positive family history of epilepsy, or simple partial seizures and left temporal seizures.

Answer 263

Intraneuronal synuclein deposits in cortex and substantia nigra + Sensitivity to antipsychotics ## Footnote This is a case of Lewy body dementia characterised by neuroleptic sensitivity and the presence of Lewy bodies on pathological examination. Lewy bodies are intraneuronal deposits.

Answer 264

Presence of e-4 allele + Neurofibrillary tangles and amyloid plaques in neocortex, ## Footnote This is an example of Alzheimer's disease characterised by amyloid plaques, neurofibrillary tangles and apo-E4 gene.

Answer 265

Atrophy of frontal poles + Mutation in Tau gene ## Footnote This case describes frontotemporal dementia characterised by frontal and temporal lobe atrophy and mutations in the tau gene.

Answer 266

Clomipramine

Answer 267

Desipramine

Answer 268

P-R interval of 280 ms and P waves present before every QRS, Diffuse ST elevation with saddle formation ## Footnote This is a case of clozapine-induced myocarditis. It generally occurs within 6-8 weeks of starting clozapine treatment. Saddle elevation of ST waves is due to pericardial involvement. Diffuse T wave inversion can also be seen. The normal PR interval of 120 to 200ms (3 - 5 small squares) is altered resulting in an abnormal prolongation of PR along with tachycardia. In some cases, complete heart block may ensue.

Answer 269

P-R interval of 280 ms, P waves present before every QRS ## Footnote This is a patient who is started on acetylcholinesterase inhibitors for dementia. This group of drugs often causes prolongation of PR interval on ECG along with sinus bradycardia. The correct answer is:

Answer 270

Gait Ataxia + Anosognosia ## Footnote This patient is most likely to have Wernicke's encephalopathy. The classic triad includes ophthalmoplegia, ataxia and confusion. The most common ophthalmoplegia here is a bilateral 6th nerve (not 4th nerve) lesion. The 4th nerve may be affected in few cases.

Answer 271

Anosognosia + Constructional Apraxia ## Footnote The non-dominant parietal lobe has a significant role in constructional praxis and also in awareness of illness states.

Answer 272

Ipsilateral optic atrophy + Anosmia ## Footnote Frontal meningiomas are associated with anosmia (often present due to the common olfactory groove distribution of tumours causing pressure) and ipsilateral optic atrophy, on the side of the tumour. Anosmia with ipsilateral optic atrophy and contralateral papilloedema is also known as Kennedy-Foster syndrome

Answer 273

Low effect

Answer 274

Moderate effect

Answer 275

High effect

Answer 276

Repression ## Footnote In repression, recalling at will is absent. Repression can form the basis of dissociative / conversion disorders.

Answer 277

Suppression ## Footnote By contrast, suppression is a mature defense that involves conscious postponement of an issue - recalling at will is possible in suppression.

Answer 278

Humour ## Footnote Focusing on funny aspects of a painful situation is called humour. It is a mature defence strategy.

Answer 279

Clinical Disorders (e.g. anorexia, alcohol intoxication, psychosis due to medical condition)

Answer 280

Personality Disorders/Mental Retardation (e.g. moderate mental retardation, anxious personality traits)

Answer 281

General Medical Conditions (e.g. epilepsy, hypertension)

Answer 282

Psychosocial and Environmental Problems (e.g. unemployment)

Answer 283

Global Assessment of Functioning (e.g. GAF score of 60)

Answer 284

Flapping tremor ## Footnote A flapping tremor is seen in cases of respiratory, hepatic or cardiac failure with encephalopathy.

Answer 285

Ataxia ## Footnote Ataxia and ophthalmoplegia with nystagmus on a background of impaired consciousness are characteristic of Wernicke's encephalopathy.

Answer 286

Lhermitte's sign ## Footnote Lhermitte's sign is characterised by a sudden unpleasant (but not painful) electric shock-like sensation starting in the neck and radiating along the spine towards distal limbs. It is seen in patients with multiple sclerosis.

Answer 287

Neck stiffness

Answer 288

Ophthalmoplegia

Answer 289

Dementia with prominent but short lucid intervals ## Footnote Dementia with Lewy Bodies is characterised by spontaneous motor features of Parkinsonism, along with a fluctuating cognition, recurrent visual hallucinations of well- formed and detailed imageries. The cognitive decline is severe enough to affect normal social and occupational functioning.

Answer 290

Rapidly progressing dementia ## Footnote Creutzfeldt-Jakob disease: The clinical picture is one of rapidly deteriorating dementia, myoclonus, cerebellar and extrapyramidal signs leading to death within a year. Patients may present with non-specific symptoms such as lethargy, depression and fatigue. Within weeks, more fulminant symptoms develop, including progressive cortical- pattern dementia, myoclonus and pyramidal and extrapyramidal signs. Myoclonus becomes prominent as the disease progresses. Patients may develop cortical blindness.

Answer 291

Emotional blunting ## Footnote In Parkinson's disease dementia, affective blunting is prominent often due to well-established Parkinson's disease.

Answer 292

Piaget theory of cognitive development ## Footnote This describes a child in Piaget's concrete operational stage of cognitive development.

Answer 293

Kohlberg's moral development ## Footnote An example of moral development, with the child described being in the punishment avoidance stage, as described by Kohlberg.

Answer 294

Grief ## Footnote Describes stages of grief. There are various theories around the stages of grief. Bowlby's 4 stages of grief include protest and despair.

Answer 295

The onset is usually within one month of a stressful life event ## Footnote Adjustment disorders are conceived of as developing in response to a variety of causal stressful events within a month, the symptoms representing an adaptation to these stressors or their continuing effects. The ICD-10 states that the diagnosis depends on a careful evaluation of the relationship between form, content and severity of symptoms; previous history and personality; and stressful event, situation or life crisis. The latter should be established clearly before the diagnosis can be made, and there should be strong presumptive evidence that the disorder would not have arisen without it.

Answer 296

Transexualism

Answer 297

Schizophrenia and other primary psychotic disorders ## Footnote 'Personality disorders', 'schizophrenia and other primary psychotic disorders', and depressive episodes in 'mood disorders' each include significant dimensional elements to enable clearer descriptions of the symptomatology experienced by patients. In schizophrenia and other primary psychotic disorders, this includes: positive symptoms; negative symptoms; depressive mood symptoms; manic mood symptoms; psychomotor symptoms; and cognitive symptoms. Neurodevelopmental disorders also include qualifiers for a diagnosis of autism spectrum disorder to enable a description of the extent of impairment of intellectual functioning and language abilities.

Answer 298

Treatment with carbamazepine has been shown to be effective ## Footnote Normally REM sleep is associated with a loss of muscle tone and dreaming. In RBD, there is no loss of muscle tone, and the dreams are acted as complex behaviours. Patients act out their dreams, with limited awareness of surroundings. The episodes arise during the middle to the latter third of the night during REM sleep. It may occur idiopathically. It is associated with disorders such as Parkinson's disease, diffuse Lewy body disease, multiple system atrophy and Gullian-Barre syndrome. RBD may be the prodrome of neurodegenerative diseases, such as DLB or Parkinson disease. It can precede the diagnosis of a movement disorder by several years. It is likely that the associated lesions are situated in the brainstem. Treatment with clonazepam has been shown to be effective.

Answer 299

Visual but not auditory hallucinations ## Footnote This is a tricky question. Almost all the listed symptoms have been recognized in schizophrenia. But presenting with visual hallucinations in the absence of auditory hallucinations is rare and must lead to further diagnostic evaluation to rule out organic causes.

Answer 300

Vocal tics ## Footnote Inattention may accompany Tourette's but it is not a diagnostic feature.

Answer 301

Hecker ## Footnote Hecker coined the term hebephrenia, which predates the DSM concept of disorganized type.

Answer 302

Referred transition

Answer 303

Repeat TSH in a month's time ## Footnote This lady has a subclinical thyroid disease. This is estimated to be present in 4 to 8.5% of the general population, and up to 20% of women older than 60 years, and about 2% general population are thought to be subclinically hyperthyroid. As she is on lithium, the TSH levels must be monitored in addition to symptoms.

Answer 304

Respectful statement ## Footnote Such statements convey the mutual respect maintained by the therapist in the wake of an emotionally important disclosure. This can facilitate further conversations.

Answer 305

Rey-Osterrieth Complex Figure Test ## Footnote Rey-Osterrieth Complex Figure Test (CFT) is a standard measure of perceptual organisation and visual memory in brain-injured individuals.

Answer 306

Single-photon emission computed tomography ## Footnote Single-photon emission computed tomography (SPECT) is a nuclear tomographic imaging technique that uses gamma rays.

Answer 307

Spinal flexion ## Footnote Hallucinations are seen in nearly 40% of patients with Parkinson's Disease (PD), and fall into three categories: 1. Minor forms, consisting of a sensation of a presence (person), a sideways passage (commonly of an animal) or illusions in 25.5%. 2. Formed visual hallucinations in 22.2%. 3. Auditory hallucinations in 9.7%. The estimated prevalence of orthostatic hypotension in PD is 30%. Camptocormia is the extreme forward flexion of the spine associated with dystonia, Tourette syndrome, amyotrophic lateral sclerosis, and PD. While initially thought to be a rare manifestation of PD, recent estimates of the prevalence of camptocormia in patients with PD vary from 3-12%, making it a relatively uncommon feature of PD.

Answer 308

Stimulant ## Footnote Stimulants are substances that induce a number of characteristic symptoms. CNS effects include alertness with increased vigilance, a sense of well-being and euphoria. Many users experience insomnia and anorexia, and some may develop psychotic symptoms. Stimulants have peripheral cardiovascular activity, including increased blood pressure and heart rate.

Answer 309

Sub-dural haematoma ## Footnote Subarachnoid haemorrhage generally present more acutely with signs of increased intracranial tension and focal neurological deficits. Chronic SDH (male:female 2:1) is commonly seen in elderly, alcoholics, usually after a mild head injury. The average time between the occurrence of head trauma and the diagnosis of chronic SDH is 4-5 weeks. The presentation is often insidious, with decreased level of consciousness, headache, difficulty with gait or balance, memory loss, mild motor deficits (e.g. hemiparesis) and headache (especially in younger patients).

Answer 310

Knowing today's date ## Footnote Orientation is usually assessed to time, place and person; it is not particularly sensitive, and intact orientation does not exclude a significant memory disorder, particularly if there is concern about memory from an informant. Time orientation is the most helpful and should include the time of day. Many normal people do not know the exact date, and being out by two days or less is considered normal when scoring this formally.

Answer 311

Thiamine deficiency ## Footnote Thiamine should always be administered prior to glucose infusion because glucose metabolism may rapidly deplete patients' thiamine reserves in cases of long-standing poor nutrition.

Answer 312

Throughout the interview ## Footnote Mental state examination takes place throughout the clinical interview.

Answer 313

Thyroid stimulating hormone assay ## Footnote The best screening test for detecting subclinical hypothyroidism is an assay of TSH hormone levels.

Answer 314

Hearing voices originating inside the body ## Footnote Coenaesthetic hallucinations (that emanate from body parts) are suggestive of schizophrenia The correct answer is: Hearing voices originating inside the body

Answer 315

It is associated with an unpleasant emotional state ## Footnote Depersonalization is an unpleasant subjective experience where the patient feels as if they have become 'unreal'. It is a non-specific symptom occurring in many psychiatric disorders as well as in healthy people during periods of fatigue, stress, etc.

Answer 316

Nihilistic delusions ## Footnote Patients with psychotic depression may exhibit nihilistic delusions where they deny the normal functioning and existence of their body, self, others and the world around them. The example in this question is a translated excerpt from Cotard's original case of a 43-year-old woman described in 1880.

Answer 317

Normal perception, delusional meaning ## Footnote Delusional perception is a primary delusion, which arises as a result of a normal perception. The percept is a real external object and not a hallucinatory experience.

Answer 318

Obsession of symmetry ## Footnote An obsessive need for symmetry and exactness and a compulsion to sort and arrange results in slowness.

Answer 319

Nuremberg code ## Footnote The interest in research ethics was stimulated by the atrocities committed during Second World War. Numerous unethical experiments including forceful sterilization, treacherous poisoning, inducing malaria and typhus, high-altitude experiments and severe dehydration were conducted by Nazi doctors on prisoners at concentration camps. A series of trials took place at Nuremberg following the world war and a code for human experimentation was set up. This is popularly called as Nuremburg code.

Answer 320

Shenjing shuairuo ## Footnote Shenjing shuairuo is a culture-bound syndrome seen in China. Literally means "nerve weakness." Symptoms include - chronic fatigue, dizziness, headaches, sleep difficulties, nonspecific, and multiple somatic complaints. These conditions are likely related to depression, anxiety, fibromyalgia, chronic fatigue, and irritable bowel syndromes.

Answer 321

Social acceptance of people with disabilities without devaluation ## Footnote Social role valorisation is best described as a concept formulated in 1983 by Wolf Wolfensberger as the successor to the principle of normalization that deals with the enablement, establishment, enhancement, maintenance, and/or defense of valued social roles for people. SRV is primarily a response to the historically universal phenomenon of social devaluation and especially societal devaluation.

Answer 322

The children ## Footnote Children adapt more easily and develop biculturalism more frequently than adults and the elderly when immigrating.

Answer 323

The therapist's view of the patient's cultural identity ## Footnote The patient's own view of his cultural identity is more important than the therapist's view.

Answer 324

Thomas Szasz ## Footnote Thomas Szasz, a prominent anti-psychiatrist, argued against the existence of mental illness. The book 'Myth of mental illness' was written by him.

Answer 325

Upbringing and choice ## Footnote Race is perceived as a permanent entity determined by genetic ancestry and characterised by physical appearance. Culture is perceived as a changeable entity determined by upbringing and choice and characterised by behaviours and attitudes. Ethnicity is perceived as partially changeable entity determined by social pressure and psychological need characterised by a sense of group identity and belonging.

Answer 326

Utilitarian moral theory ## Footnote Consequentialist moral theories are teleological: they aim at some goal state and evaluate the morality of actions in terms of progress toward that state. The best-known version of consequentialism is utilitarianism. As most clearly stated by Mill (who was a proponent of the utilitarianism), the basic principle of utilitarianism is: Actions are right to the degree that they tend to promote the greatest good for the greatest number. In contrast, deontological principles are duty-based. Kant's theory is an example of a deontological or duty-based ethics: it judges morality by examining the nature of actions and the will of agents rather than goals achieved. A deontological theory looks at inputs rather than outcomes.

Answer 327

Willowbrook School Study ## Footnote Willowbrook School Study (1963 - 1966): Willowbrook State School, situated in New York State, was an institution for mentally handicapped children. Parents of children in the institution gave consent for their children to participate in a study. The intent of the research study was to follow the course of viral hepatitis and study the effectiveness of an agent for inoculating against hepatitis. Parents were provided with study information describing the drug administration as vaccinations. However, the children were deliberately infected with the hepatitis virus. There is evidence that the school only admitted children to the school whose parents gave permission for them to be in the study.

Answer 328

Prolonged grief disorder ## Footnote Prolonged grief disorder is a new mental health disorder under ICD-11 categorised under disorders specifically associated with stress. It describes a persistent and disabling grief reaction, which lasts longer than 6 months and is out of keeping with what is expected for the cultural context. 'Trichotillomania' was in ICD-10, as was hyperkinetic disorder, which has now been re-categorised as ADHD. Sadomasochism and other consensual sexual practices are no longer generally considered to be pathological. 'Acute stress reaction' is no longer seen as a mental health condition, but as a normal reaction to extreme stress. It is categorised under factors influencing health status or contact with health services.

Answer 329

Wendigo psychosis

Answer 330

Aversive conditioning ## Footnote Aversive conditioning: This is an operant conditioning where punishment is used to reduce the frequency of target behaviour e.g. the use of Disulfiram (noxious stimuli) to reduce the frequency of drinking alcohol.

Answer 331

The mouse ## Footnote The mouse was previously a neutral stimulus; it has been associated with an unconditioned stimulus (the noise) that naturally triggers an automatic response in Timmy (fear). The mouse therefore becomes a conditioned stimulus, eliciting fear in Timmy.

Answer 332

Implosion ## Footnote Flooding is an operant conditioning technique where actual exposure to feared stimulus takes place for a substantial amount of time so the accompanying anxiety response fades away while the stimulus is continuously present. This will lead to extinction of fear. When a similar technique is attempted with imagined exposure then it is called implosion.

Answer 333

Sensory memory ## Footnote Sensory memory: This is modality specific, has a large capacity but gets disrupted by an inflow of new information in the same modality. Each sense has its own sensory memory e.g. iconic (visual), echoic (auditory). Iconic lasts for 0.5 seconds while echoic lasts for 2 seconds. No processing is involved in sensory memory. Information that is attended to is transferred to short-term memory store, and information that is not selected for processing is rapidly lost. The correct answer is: Sensory memory

Answer 334

Sex ## Footnote Drives refer to purposeful activity initially produced to satisfy an internal need. Drives are commonly divided into primary and secondary drives. Examples of primary drives are eating, drinking, sex. Examples of secondary drives are affection, comfort, achievement, dominance and socialisation. The secondary drives acquire their values through their association with primary drives and often through a social learning process.

Answer 335

Shaping ## Footnote Shaping is an operant conditioning method for producing an entirely new behaviour by using rewards to guide an organism toward a desired behaviour (called 'successive approximations'). The organism is rewarded with each small advancement in the right direction.

Answer 336

Dissociality ## Footnote The maladaptive traits that can be used to describe a diagnosis of personality disorder in ICD-11 are: negative affectivity, detachment, dissociality, disinhibition and anankastia. A further qualifier of 'borderline pattern' can also be used.

Answer 337

Shaping ## Footnote Shaping is a teaching technique by which a child is rewarded for a successful approximation of a target skill. If a child is learning to write his or her name, say "Alex," a teacher would shape the responses by starting with the letter A and providing the other letters: The next step would be perhaps for the child to write the first and last letters independently. The process would continue until the child can write his name independently.

Answer 338

All disorders can be diagnosed at any age ## Footnote ICD-11 takes a lifespan approach to diagnosis, permitting diagnoses which were usually associated with childhood or adolescence, such as attachment or conduct disorder, to be diagnosed at any age. It specifically considers the cultural background of a patient in diagnosis. A dimensional approach has been taken in personality and primary psychotic disorders, as well as for depressive episodes in mood disorders. Minimum symptom counts have been removed from diagnostic criteria for most disorders, but not major depression. Gender incongruence, replacing gender identity disorder, has been moved to the sexual health chapter of ICD-11 as it is not a mental health disorder.

Answer 339

Spearman ## Footnote The two-factor theory of intelligence was postulated by Spearman. Spearman carried out a factor analysis of the result of children's performance on a number of tests and concluded that all tests measured both a common factor of general intelligence (g) and a specific factor (s). He believed that individual differences were due to differences in (g). According to Sternberg, component intelligence is used for executive tasks and experiential intelligence is used for routine tasks that have already been learnt or mastered.

Answer 340

Intimacy vs. isolation ## Footnote During young adulthood (between the ages of 20 and 40), a life crisis of intimacy vs. isolation occurs. The outcomes are love and commitment/superficial relationships.

Answer 341

Sensorimotor stage ## Footnote Jean Piaget, a Swiss psychologist, believed that intelligence is the product of a natural and inevitable sequence of developmental stages. He did not suggest that it was simply born, but rather that it developed as a result of the constantly changing interaction of the child and the environment. He also believed that the child went through different stages of development, and each stage is characterised by qualitatively different ways of thinking about the world. The earliest of these stages is the sensorimotor stage (birth to 2) when the baby differentiates self from objects, recognises self as agent of action and begins to act intentionally. The baby also develops object permanence i.e. an object that is not seen can continue to exist.

Answer 342

Shows discomfort when mother leaves but not for being alone ## Footnote In secure attachment pattern, the child uses the mother as a secure base, explores freely, may be distressed at separation but greets positively on the reunion, seeks comfort, settles down and returns to exploration. Secure infants anticipate that their caregiver is accessible and available to them for comfort when necessary, and their primary carer is sensitive to the infants' signals and cues.

Answer 343

Single parent family ## Footnote The rate of child abuse in single parent households is 27.3 children per 1,000, which is nearly twice the rate of child abuse in two-parent households (15.5 children per 1,000).

Answer 344

Small family size ## Footnote A large sized, overcrowded family is associated with more delays in language development.

Answer 345

Social learning ## Footnote Social learning theorists identified specific sex-typed behaviours (Mischel, 1970). A behaviour is sex-typed when it is more expected and therefore seen as appropriate when performed by one sex, but less expected and therefore seen as inappropriate when performed by the other sex. Gender socialisation works, according to social learning theorists, by rewarding children for engaging in sex-typed behaviour that is consistent with their assigned sex category. The classic example is crying; while a little girl may be soothed when she cries, a little boy may be told that boys don't cry. Crying is a sex-typed behaviour, seen as OK for girls and therefore not a punishable behaviour. But because it is not seen as an appropriate behaviour for boys, the little boy may be punished or corrected for his crying behaviour. Through these kinds of interactions, gender socialisation occurs.

Answer 346

Social learning ## Footnote According to the social learning theory, a child learns several gender-related behaviours through reinforcement and modeling (Golombok & Fivush, 1994). This is acquired first through parents who give the child his or her initial social position. Parents begin this process by typically encouraging sons to be more independent, competitive and achieving than they do for daughters (Lamb, 1986; Block, 1979). Parents also encourage daughters to be more passive and to seek protection (Chafetz, 1978). There have been differences shown in the reinforcement fathers and mothers give to sons and daughters. Even parents who strive to be egalitarian in their dealings with their children have been found to discourage certain non-traditional play behaviours more in one gender than the other. For example, parents are more likely to discourage their sons from playing with dolls than they are to discourage their daughters from playing with trucks (Weisner & Wilson-Mitchell, 1990). This behaviour on the part of parents (and others in the society) serves to model and reinforce gender stereotyped behaviours in children.

Answer 347

Symbiosis ## Footnote The stage of normal autism lasts from 0 to 2 months. Here the child spends most time in sleep, as if the intrauterine aloofness continues. The stage of symbiosis lasts from 2 to 5 months. Here, inner and outer world is studied by the child via senses but perceives mother and self as one unit.

Answer 348

1 in 100,000 ## Footnote In those taking valproate alone: 1 in 100,000 patients. Risk factors for hepatotoxicity include young age (less than ten years old), sensitivity during the first few months of treatment, severe epilepsy, and use of multiple drugs.

Answer 349

Amitriptyline ## Footnote Drugs with significant anticholinergic properties such as amitriptyline notoriously cause signs of prostatism in elderly males. They may produce urinary retention and sometimes bladder distension.

Answer 350

Anticholinergic syndrome ## Footnote Anticholinergic syndrome results from the inhibition of cholinergic neurotransmission at muscarinic receptor sites. Psychotropics such as phenothiazines, tricyclic antidepressants and antiparkinsonian agents have anticholinergic properties. When they are administered in combination, the action of these drugs becomes additive resulting in anticholinergic syndrome. Features of a mild organic brain syndrome, which includes disorientation, difficulty in concentrating and impaired short-term memory are seen, especially noticeable at nighttime. Other physical symptoms include flushing, dry skin and mucosa, mydriasis with loss of accommodation and fever.

Answer 351

Cheese ## Footnote Cheese can induce tyramine related reaction in those on MAOIS.

Answer 352

Chlorpromazine ## Footnote Allergic dermatitis and photosensitivity can occur with low-potency agents. Long-term chlorpromazine use can cause blue-gray discoloration of skin areas exposed to sunlight. This is reversible. Irreversible retinal pigmentation is associated with the use of high dose thioridazine (above 1000 mg a day).

Answer 353

SSRI e.g. citalopram ## Footnote The risk of inducing a switch to mania is less with SSRIs and more with other classes of antidepressants such as TCAS, MAOIS and SNRIs.

Answer 354

Clonazepam ## Footnote Treatments for akathisia include reducing the antipsychotic drug or change to an atypical drug. A reduction in symptoms of akathisia may be seen with propranolol, clonazepam, mirtazapine, trazodone, mianserin and cyproheptadine.

Answer 355

Clonidine ## Footnote Clonidine is an alpha-2 adrenergic receptor agonist. Agonist effects at these receptors, which are located presynaptically in adrenergic neurons, reduce the release of epinephrine from these neurons.

Answer 356

Clonidine ## Footnote Weight gain may be more pronounced in children than adults with antipsychotics and this may limit their use. Clonidine has been shown in open studies to reduce the severity and frequency of tics and could bring a substantial reduction in tics.

Answer 357

Coarse tremor is a common side effect ## Footnote Lithium chloride causes a concentration dependent block of the peak sodium current in cardiac pacemakers, but even at therapeutic doses, abnormal ECG can be documented, often with no clinical implications. Fine hand tremor is a common side effect often seen at lower doses; coarse tremor indicates toxicity.

Answer 358

AMPA ## Footnote D-serine is an endogenous ligand for the glycine site of the N-methyl-D-aspartate receptor. Some recent studies suggest that there is a low affinity and stereo-selective site at the agonist-binding pocket of AMPA receptors as well for D-amino acids such as d-serine.

Answer 359

Amphetamine ## Footnote The fresh leaves of Catha edulis from East Africa were used as a stimulant for amphetamine-like effects from the main ingredient cathinone. Cathinone has most of the CNS and peripheral actions of amphetamine. It is typically absorbed buccally after chewing the leaf and being an alkaloid, gets metabolized rapidly with low chances of toxicity.

Answer 360

Aripiprazole ## Footnote The addition of aripiprazole to clozapine may be particularly effective in reversing metabolic effects (such as weight gain) and could be used as an augmenting agent to clozapine.

Answer 361

Blocks testosterone receptors ## Footnote The mechanism of action of cyproterone acetate is to block testosterone receptors. The direct antiandrogenic effect of cyproterone is to block the binding of dihydrotestosterone to the specific receptors in the prostatic carcinoma cell. In addition, cyproterone exerts a negative feed-back on the hypothalamo-pituitary axis, by inhibiting the secretion of LH resulting in diminished production of testicular testosterone.

Answer 362

Buprenorphine ## Footnote Buprenorphine is a partial agonist at the mu-opioid receptor and has a reduced risk of fatal respiratory depression.

Answer 363

Bupropion ## Footnote Bupropion is an atypical antidepressants with dopaminergic and noradrenergic actions, and it has been advocated by NICE for smoking cessation.

Answer 364

Clonazepam ## Footnote Treatment with clonazepam has shown to be effective in REM sleep behavioural disorders.

Answer 365

Clonidine ## Footnote Clonidine is a sympatholytic medication, which is classified as a centrally acting a2-adrenergic agonist. It has specificity towards the presynaptic a2 receptors in the vasomotor center in the brainstem.

Answer 366

Carbamazepine ## Footnote The combination of carbamazepine and clozapine is generally contraindicated. First, carbamazepine and clozapine each produce hematologic side effects at higher frequencies than do most other available drugs. Another consideration is that carbamazepine lowers the level of clozapine, possibly more than it lowers levels of traditional neuroleptics.

Answer 367

Carbamazepine ## Footnote Carbamazepine has a tendency to induce its own metabolism leading to reduced plasma steady state levels.

Answer 368

Cigarette smoking ## Footnote Antipsychotics, methylphenidate, acetazolamide, aspirin, cimetidine, thiazides, fluoxetine and sodium bicarbonate increase tricyclic antidepressant (TCA) concentrations. Cigarette smoking decreases their concentration through its action on the CYP1A2 enzyme.

Answer 369

Citalopram ## Footnote Fluoxetine has the longest half-life of all the SSRIs, one to three days, because of a metabolite. Paroxetine, the SSRI with a long t1/2 compared to the others, has a half-life of only 21 hours.

Answer 370

Cough syrup ## Footnote Cough and cold medications bought over the counter often contain alcohol and can precipitate a disulfiram reaction. Severe Antabuse reaction (also known as disulfiram reaction) is characterised by respiratory depression, seizures, cardiovascular collapse, and even death.

Answer 371

Cross-tolerance ## Footnote Cross-tolerance refers to decreased response to one medication due to exposure to a different medication. Here exposure to barbiturates has produced cross-tolerance to benzodiazepines.

Answer 372

Diazepam ## Footnote Diazepam is a benzodiazepine which has a very long elimination half-life (20 - 100 hours with an active metabolite 36 - 200 hours); as a result withdrawal symptoms are not very common with diazepam.

Answer 373

Diazepam ## Footnote Diazepam has the most rapid onset of action among orally administered benzodiazepines.

Answer 374

Ethnicity ## Footnote There is a 77% increase in risk for Afro-Caribbean people to develop clozapine-induced neutropenia. Other risk factors include young age and having a low baseline white cell count.

Answer 375

Temporal lobe ## Footnote Seizures originating in the medial temporal lobe are most likely to lead to a sense of déjà vu.

Answer 376

Parietal lobe ## Footnote "Two gyri in the parietal lobe are important to locate and become familiar with in regard to language. The first is the supramarginal gyrus (area 40), which curves around the posterior end of the lateral sylvian fissure. The second, the angular gyrus (area 39), lies directly posterior to the supramarginal gyrus. It curves around the end of a prominent sulcus in the temporal lobe, the superior temporal sulcus (see Fig. 2-5). Damage in the area of the angular gyrus in the dominant left hemisphere may cause word-finding problems (anomia), reading and writing deficits (alexia with agraphia), as well as left-right disorientation, finger agnosia (inability to identify the fingers), and difficulty with arithmetic (acalculia)."

Answer 377

Pineal gland ## Footnote CJD is characterised by bilateral basal ganglia hyper-intensities (Pulvinar sign) on T2W and DWI MRI.

Answer 378

The suprachiasmatic nucleus ## Footnote The suprachiasmatic nucleus is a region of the brain in the hypothalamus, situated directly above the optic chiasm, responsible for controlling circadian rhythms, by communication with many other regions of the brain and the use of various peptides and neurotransmitters.

Answer 379

Noradrenaline, 5-HT and tyramine ## Footnote MAO-A metabolizes noradrenaline, 5-HT and tyramine. MAO-B metabolizes dopamine, tyramine and phenethylamine.

Answer 380

Dopamine, tyramine and phenethylamine ## Footnote MAO-A metabolizes noradrenaline, 5-HT and tyramine. MAO-B metabolizes dopamine, tyramine and phenethylamine.

Answer 381

Phenylethanolamine-N-methyltransferase ## Footnote The occurrence of phenylethanol-amine-N-methyltransferase is largely restricted to the adrenal medulla, but with detectable levels in association with epinephrine neurons in the brain. Inhibition of enzyme activity decreases epinephrine biosynthesis. There is, however, a less specific N-methyl-transferase present in many tissues.

Answer 382

Physiological withdrawal is not seen ## Footnote LSD is primarily used via oral administration but can be inhaled, injected, and transdermally applied. The onset of effects is rapid following intravenous administration (10 minutes). Following oral ingestion, the onset of the first effects are experienced in 20-30 minutes. Frequent, repeated doses of LSD are unusual, and therefore tolerance is not commonly seen. Tolerance does develop to the behavioral effects after 3-4 daily doses, but no withdrawal syndrome has been described.

Answer 383

Reduced 5-HIAA ## Footnote Reduced homovanillic acid/5-hydroxyindolacetic acid (HVA/5-HIAA) ratios in cerebrospinal fluid (CSF) in depressed suicide attempters have been reported. The levels of norepinephrine (NE), dopamine (DA) serotonin (5-HT) and its metabolite 5-hydroxyindole acetic acid (5-HIAA) are reduced in those attempting suicide compared to healthy controls. A large effect size drop in 5-HIAA suggested that CSF 5-HIAA level may be used as an early biochemical indicator of a suicidal attempt.

Answer 384

Release of histamine ## Footnote It is believed that p-receptor agonist morphine causes the release of histamine in neurons leading to H2 receptor activation and subsequent relief of pain.

Answer 385

Reserpine ## Footnote Reserpine prevents the synthesis and storage of norepinephrine in sympathetic nerve terminals.

Answer 386

Serotonin ## Footnote One of the most consistent findings in all of psychobiology is the link between low serotonin in the brain and impulsive, explosive acts of violence.

Answer 387

Substance P ## Footnote Substance P is a neuroactive peptide synthesized in the cell body on the rough endoplasmic reticulum.

Answer 388

Vanillylmandelic acid ## Footnote Vanillylmandelic acid - also called VMA, is the major metabolite used to detect phaeochromocytoma. It indicates noradrenaline excess. mCPP is a metabolite of trazodone. 5-HIAA is a serotonin metabolite.

Answer 389

Cerebellum ## Footnote CJD is a type of multifocal dementia involving the cerebellar structures, where amyloid plaques are prominent.

Answer 390

3 months ## Footnote Newborns sleep for 16 - 18 hours daily though the longest sleep episode lasts only 2.5 to 4 hours. Newborns have three types of sleep: quiet sleep (similar to NREM), active sleep (analogous to REM), and indeterminate sleep. Sleep onset occurs through REM, unlike adults where it occurs through NREM. In infants, each sleep episode is made of only one or two cycles (instead of 4 or more in adults). This infantile sleep architecture disappears when circadian rhythms are fully entrained. Circadian rhythm development in the first 3 months includes: * emergence of the 24-hour core body temperature cycle (1 month of age) * progression of nocturnal sleeping (2 months of age) * cycling of melatonin and cortisol hormones in a circadian rhythm and sleep onset begins with NREM (3 months of age)

Answer 391

ACTH stimulation test ## Footnote This patient has Addison's disease which, due to insidious onset, often goes unnoticed until something else brings the symptoms to notice. The ACTH stimulation test is the most commonly used test for diagnosing adrenal insufficiency. In this test, blood cortisol, urine cortisol, or both are measured before and after a synthetic form of ACTH is given by injection. The normal response after an ACTH injection is a rise in blood and urine cortisol levels. People with Addison's disease or long-standing secondary adrenal insufficiency have little or no increase in cortisol levels.

Answer 392

Alpha rhythm ## Footnote During states of quiet wakefulness or drowsiness, the EEG pattern becomes slower (8 to 13 Hz with an average amplitude of 50 V) than what is seen during an alert state. This constitutes the alpha rhythm.

Answer 393

D2 receptors ## Footnote Raclopride is a D2 antagonist that can be radiolabelled with the carbon-11 radioisotope for use in positron emission tomography (PET) scanning to assess the distribution of D2 receptors and the degree of endogenous dopamine binding to this receptor.

Answer 394

Low body weight ## Footnote Risk factors for antidepressant-induced SIADH include: Old age, low BMI, concomitant use of diuretics and female gender.

Answer 395

Serotonin syndrome ## Footnote Serotonin syndrome is the excess of serotonin resulting in a constellation of symptoms including confusion, agitation, lability in blood pressure and temperature, tremor and clonus. To differentiate between neuroleptic malignant syndrome and serotonin syndrome - onset for serotonin syndrome is much shorter (usually < 12hours), it is associated with hyperreflexia and clonus (NMS is associated with hynoreflexia) dilated pupils and also hyperactive bowel sounds

Answer 396

Amnesia ## Footnote Amnesia is defined as partial or total inability to recall past experiences and events. Its origin may be organic or psychogenic.

Answer 397

Pseudologia fantastica ## Footnote Pseudologia fantastica or fluent plausible lying (pathological lying) describes confabulation that can be seen in those without organic brain pathology, such as personality disorders/difficulties of the antisocial or dissocial type.

Answer 398

Retroactive interference ## Footnote Ordinary memory failure can be caused by interference from related material. In proactive interference, old memories interfere with new learning and hence with recall, while in retroactive interference new memories interfere with the retrieval of old material.

Answer 399

4 weeks ## Footnote Cannabis, if used occasionally stays in the system for three days. But on high daily use, it could stay in the body system even up to 4 weeks.

Answer 400

1-3 days ## Footnote Heroin could be detected in urine from 1 to 3 days, but methadone could be detected even after three days.

Answer 401

6-8 hours ## Footnote Crack is a street name for cocaine, and it stays in the system for only 6-8 hours. However note that some of its non-specific metabolites can be detected up to 2-4 days.

Answer 402

8 days ## Footnote 'Angel dust' is a street name for phencyclidine, which is an atypical hallucinogen, and it could detected in the urine for up to 8 days.

Answer 403

Cocaine withdrawal ## Footnote Cocaine withdrawal is characterised by a 'crash' with symptoms of anxiety, tremulousness, dysphoric mood, lethargy, fatigue, nightmares (accompanied by rebound REM sleep), headache, profuse sweating, muscle cramps, stomach cramps, and insatiable hunger. The most serious withdrawal symptom is depression, which can be particularly severe and associated with suicidal ideation or behaviour.

Answer 404

Cannabis intoxication ## Footnote Effects of cannabis intoxication include mild euphoria ('the giggles'), a sense of enhanced well-being, a subjective sense of enhanced sensation, relaxation, altered time sense, and increased appetite ('the munchies'). Physically, there is mild tachycardia and variable dysarthria and ataxia.

Answer 405

Heroin intoxication ## Footnote Acute medical problems associated with heroin intoxication include nausea and vomiting, constipation, respiratory depression, and loss of consciousness with aspiration (the cause of many fatalities). Physical effects also include pupillary constriction and changes in blood pressure, heart rate, and body temperature.

Answer 406

Ketamine intoxication ## Footnote Ketamine can cause hallucinations and a dissociated state in which the patient has an altered sense of the body and reality and little concern for the environment. On physical examination, the patient may be hypertensive and tachycardic, and have increased salivation and bidirectional or rotatory nystagmus.

Answer 407

Pre-comtemplation ## Footnote In the pre-contemplation stage a person is not even considering changing his or her behaviour and does not see the behaviour as a problem. He or she minimizes the issue, denies associated risks and avoids information to the contrary.

Answer 408

Contemplation ## Footnote In the contemplation stage, the user may accept that there is a problem and begins to look at both the pros and cons of continued drug use. The person has become aware of why the behaviour is a problem but is ambivalent about changing.

Answer 409

Relapse ## Footnote Relapse is the final change in each phase. It is a return to previous behaviour but with the possibility of gaining useful strategies to extend the maintenance period on the user's next attempt.

Answer 410

Action ## Footnote This is action stage, practising new behaviour for 3-6 months.

Answer 411

Ready for action ## Footnote This is ready for action/preparation stage. There is some experience with change and is trying to change by 'testing the waters'.

Answer 412

Topiramate ## Footnote Topiramate can cause nausea, appetite loss, and weight loss. Topiramate is an antiepileptic medication that is also used as an adjunct treatment for mood disorders and binge-eating disorder. One of its notable side effects is appetite suppression, which often leads to weight loss in individuals taking the medication. Patients may also experience nausea, which can contribute to decreased food intake and, consequently, weight loss.

Answer 413

Lithium ## Footnote Some skin conditions such as psoriasis and acne can be aggravated by lithium.

Answer 414

Lamotrigine ## Footnote 10-14% of patients receiving lamotrigine will develop rash. Most are benign. A minority may be serious/life-threatening skin reactions requiring hospitalisation (e.g., Steven- Johnson syndrome, toxic epidermal necrolysis, angio-oedema, and a rash associated with several systemic manifestations).

Answer 415

Unsocialised type ## Footnote According to ICD-10, there are three subtypes: 'conduct disorder confined to the family context' (F91.0), 'unsocialised conduct disorder' (F91.1, where the young person has no friends and is rejected by peers) and 'socialised conduct disorder' (F91.2, where peer relationships are normal). Also note that ICD recommends that age of onset be specified, with childhood-onset type manifesting before 10 years and adolescent-onset type after 10 years. Note that DSM-5 endorses only the age-of-onset based subtypes. Nevertheless, DSM recognises that when compared to individuals with Childhood Onset Type, the adolescents are less likely to show aggression, but display more socialised pattern of peer relationships and less often show conduct problems that develops into an adult Antisocial Personality Disorder.

Answer 416

Confined to the family context ## Footnote According to ICD-10, there are three subtypes: 'conduct disorder confined to the family context' (F91.0), 'unsocialised conduct disorder' (F91.1, where the young person has no friends and is rejected by peers) and 'socialised conduct disorder' (F91.2, where peer relationships are normal). Also note that ICD recommends that age of onset be specified, with childhood-onset type manifesting before 10 years and adolescent-onset type after 10 years. Note that DSM-5 endorses only the age-of-onset based subtypes. Nevertheless, DSM recognises that when compared to individuals with Childhood Onset Type, the adolescents are less likely to show aggression, but display more socialised pattern of peer relationships and less often show conduct problems that develops into an adult Antisocial Personality Disorder.

Answer 417

Socialised type ## Footnote According to ICD-10, there are three subtypes: 'conduct disorder confined to the family context' (F91.0), 'unsocialised conduct disorder' (F91.1, where the young person has no friends and is rejected by peers) and 'socialised conduct disorder' (F91.2, where peer relationships are normal). Also note that ICD recommends that age of onset be specified, with childhood-onset type manifesting before 10 years and adolescent-onset type after 10 years. Note that DSM-5 endorses only the age-of-onset based subtypes. Nevertheless, DSM recognises that when compared to individuals with Childhood Onset Type, the adolescents are less likely to show aggression, but display more socialised pattern of peer relationships and less often show conduct problems that develops into an adult Antisocial Personality Disorder.

Answer 418

Finger Tapping ## Footnote Finger tapping is a standard measure of simple motor speed. It is particularly useful for documenting lateralised motor impairment.

Answer 419

Interpreting Proverbs ## Footnote Abstract reasoning is the ability to shift back and forth between general concepts and specific examples. Having the patient identify similarities between like objects or concepts (apple and pear, bus and airplane, or a poem and a painting) as well as interpreting proverbs are useful ways to assess one's ability to abstract.

Answer 420

Digit Span ## Footnote Working memory is synonymous with short-term memory, which is responsible for the immediate recall of small amounts of verbal (as in digit span) or visuospatial information.

Answer 421

Clock Drawing ## Footnote Clock drawing is a useful technique for assessing constructional ability and is also sensitive to organisation and planning.

Answer 422

Wisconsin Card Sorting ## Footnote The best formal test of set shifting is the Wisconsin Card Sorting Test, which also involves problem-solving and hypothesis testing.

Answer 423

Paraprosopia ## Footnote Metamorphopsia or dysmegalopsia refers to change in the perceived shape of an object. When metamorphopsia affects faces, it is referred to as paraprosopia. Faces generally transform into a grotesque mask (monster, vampire, werewolf). Autoparaprosopia is a term used to describe a phenomenon where an individual perceives a transformation or alteration in their own facial appearance while gazing into a mirror. Note that paraprosopia is a distortion of reality seen in conditions such as schizophrenia and is seen as a delusional misidentification similar to Capgras and Fregoli delusions), while the term prosopagnosia is an inability to identify faces seen in organic conditions affecting brain's face recognition area.

Answer 424

Hallucination ## Footnote Charles Bonnet syndrome is a condition in which complex visual hallucinations occur in the absence of any psychopathology and in clear consciousness. It is associated with either central or peripheral reduction in vision and not surprisingly is most common in the elderly, although it can occur in younger people also. These visual hallucinations can be accompanied by pleasure and amusement.

Answer 425

Illusion ## Footnote In illusions, stimuli from a perceived object are combined with a mental image to produce a false perception. Affect illusions arise in the context of a particular mood state. For example, a bereaved person may momentarily believe they 'see' the deceased person.

Answer 426

Circular causality ## Footnote Circular causality focuses on the reciprocal relationship between two events. While linear causality implies a process in which one event causes the occurrence of another, circular causality implies that one has influence over the other. Circular questioning is used in family therapy to yield information about the dynamics and relationships in a family.

Answer 427

Enmeshment ## Footnote Salvador Minuchin used the term enmeshment to describe the overinvolved relationships that develop from diffuse boundaries within family systems and between family members and other systems.

Answer 428

Triangulation ## Footnote In the family context, triangulation refers to the involvement of a child in a parental conflict to defuse tension within the interparental subsystem, and generally includes parents' pressure on children to become involved as well as children's self-directed attempts to intervene.

Answer 429

Pyramidal cells ## Footnote Pyramidal cells serve as the principal excitatory neurons responsible for rapid signal transmission between brain regions and cortical processing in the cerebral cortex.

Answer 430

Pyramidal cells ## Footnote Pyramidal cells serve as the principal excitatory neurons responsible for rapid signal transmission between brain regions and cortical processing in the cerebral cortex.

Answer 431

Von Economo neurons ## Footnote Von Economo in 1925 did pioneering work on the cytoarchitectonics of the cerebral cortex and discovered a specialized and unique cell type in the fronto-insular and anterior cingulate cortex. These von Economo neurons (VENS) appear as large sticks, rods or corkscrew cells because of their extremely elongated and relatively thin cell body which is distinct from the more common oval or spindle-shaped infragranular neurons.

Answer 432

Basket cells ## Footnote Basket cells, specialised cells first described by Ramon y Cajal, are inhibitory interneurons in the neocortex, cerebellum and hippocampus; they form 'baskets' of axonal arborizations onto and around the somata of target neurons.

Answer 433

Astrocytes ## Footnote Astrocytes, characterized by their star-shaped morphology, play a multifunctional role in the brain, including synaptic integration, regulation of neurotransmitters, nutrient support for neurons and overall brain homeostasis.

Answer 434

Microglia ## Footnote The microglia, which are derived from macrophages, are involved in removing cellular debris following neuronal death. The functions of microglia in the non-diseased brain probably include a role in synaptic maintenance.

Answer 435

Astrocytes ## Footnote There are three types of glial cells. The most common are the astrocytes, which have several functions, including nutrition of neurons, deactivation of some neurotransmitters, and integration with the blood-brain barrier. The astrocyte carries most of the extracellular glutamate.

Answer 436

Medium spiny neurons ## Footnote GABA-ergic medium spiny neurons (MSNs), the principal neuron type in the striatum, are projection neurons with predominantly dopaminergic and glutamatergic inputs. The loss of MSNS in the striatum is the hallmark of Huntington disease.

Answer 437

Anxious-avoidant ## Footnote Mary Ainsworth devised the Strange Situation procedure with 12- to 18-month infants, which categorised infant-parent relationships. The procedure involves separations and reunions with caregivers and observes response. In insecure (anxious)-avoidant attachment, the child seems unconcerned at separation or reunion. It is associated with unresponsive parenting.

Answer 438

Emphasis on individual variability ## Footnote There are two main approaches to conceptualise and describe variations in personality: nomothetic and ideographic. In nomothetic approaches, personality is seen in terms of attributes shared by individuals. There are two subdivisions: type (or categorical) approaches - in which there are discrete categories of personality - and trait (or dimensional) approaches - in which a limited number of qualities, or traits, account for personality variation. Unlike nomothetic approaches, ideographic approaches on the other hand, emphasise individuality and seek to understand an individual's personality by understanding that specific individual and their development, rather than by reference to common factors. Examples include psychoanalytic, humanistic, and cognitive-behavioural approaches.

Answer 439

It facilitates collection of epidemiological data ## Footnote In classical categorical systems, each entity or disorder is distinct and appears only once in a clearly defined place. With a few exceptions, ICD and DSM are such classical categorical systems. WHO member states are responsible for reporting health statistics based on ICD to WHO (e.g. causes of morbidity and mortality, prevalence). ICD remains structured as a categorical taxonomic system because this format is necessary for its application as the classification system for global health statistics. Wide use of non-standard categories would not generate valid data for global health statistics.

Answer 440

There was a significant relationship between the number of childhood abuse categories and depression as an adult ## Footnote The CDC-Kaiser Permanente adverse childhood experiences (ACE) study is one of the largest studies of the long-term relationship of childhood experiences to important medical and public health problems. The ACE study questionnaire was mailed to over 13 000 adults in California, USA, with a 70% response rate. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; and living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4 to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. The study found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Answer 441

Altruism can reduce the physical perception of pain ## Footnote Altruistic behaviours occur among many animals, including humans. It is well-documented that performing altruistic behaviours has a positive effect on psychological well-being and health. There is also evidence that performing altruistic behaviours relieves physical pain.

Answer 442

Hippocampus and amygdala ## Footnote Maternal sensitivity consists of the accurate interpretation followed by prompt and appropriate response to the infant's signals. It is a well-documented predictor of attachment. The hippocampus and amygdala are key components of the limbic system that are centrally implicated in socio-emotional functioning. The amygdala plays a salient role in orienting to and processing emotionally significant information. The hippocampus is central to learning and memory. The hippocampus and amygdala are activated during interactions between infants and their caregivers.

Answer 443

Object permanence ## Footnote According to Piaget, the critical achievement of the sensorimotor stage is the development of object permanence or the schema of the permanent object. This relates to the child's ability to understand that objects have an existence independent of their involvement. Infants learn to differentiate themselves from the world and maintain a mental image of an object, even when it is not visible.

Answer 444

Conventional ## Footnote Lawrence Kohlberg integrated Jean Piaget's concepts and described multiple stages of moral development within three significant levels of morality. The first level is pre-conventional morality, in which punishment and obedience are the determining factors. The second level is conventional morality, in which right and wrong are defined in terms of convention and 'what people would say. Children try to conform to gain approval and maintain good relationships with others and are also guided by rigid codes of 'law and order (authority orientation). The third and highest level is the morality of self-accepted moral principles (post-conventional), in which children voluntarily comply with rules based on a concept of universal ethical principles and make exceptions to rules in certain circumstances.

Answer 445

Lexical semantics ## Footnote Lexical semantics is the study of word meaning. Phonology, orthography, syntax, and phenomenology are all relevant aspects of linguistics, but they deal with different aspects of language, such as sound patterns (phonology), written symbols (orthography), sentence structure (syntax), and subjective experiences (phenomenology), respectively. Lexical semantics specifically deals with the meaning of words themselves.

Answer 446

Authoritarian ## Footnote The authoritarian parenting style is characterised as low in responsiveness but high in demandingness. Parents of this style tend to use hostile control or harsh punishment in an arbitrary way to gain compliance, but they seldom provide explanation or allow verbal give-and-take.

Answer 447

Protest, despair, detachment ## Footnote Underlying attachment theory were numerous observations of separations and reunions between young parents and children. The process has been described as occurring in phases; called protest, despair, and denial by Robertson; and protest, despair, and detachment by Bowlby. Bowlby, among others, preferred the term detachment because it was a natural counterpart to attachment. When separation anxiety is activated, the most prominent sign of the first phase - protest - is the child's acute distress. If the parent fails to return for long, the behaviour will be replaced by expressions of the next phase - despair. If the separation continues, the despair is gradually replaced by detachment.

Answer 448

Repression ## Footnote The classic Freudian view of the genesis of neuroses regards conflict as essential. The conflict can arise between instinctual drives and external reality or internal agencies, such as the id and the superego or the id and the ego. Moreover, because the conflict has not been worked through to a realistic solution, the drives or wishes that seek discharge are expelled from consciousness through repression. Repression consists of the expelling and withholding from consciousness awareness of an idea or feeling.

Answer 449

Stroop test ## Footnote Stroop tests are based on the fact that it takes longer to call out the colour names of coloured patches than to read words, and even longer to name the colour of an ink in which a colour name is printed when the print ink is a colour different from the colour name. The latter phenomenon, a markedly slowed response when a colour name is printed in ink of a different colour, is interpreted as a failure of selective attention.

Answer 450

2 ## Footnote In ICD-11, recurrent depressive disorder is characterised by a history of at least two depressive episodes separated by at least several months without significant mood disturbance.

Answer 451

Minimal seeking of comfort ## Footnote In ICD-11, reactive attachment disorder is characterised by grossly abnormal behaviours in early childhood, occurring in the context of a history of grossly inadequate child care. Even when an adequate primary caregiver is newly available, the child does not turn to the primary caregiver for comfort, support, and nurture, rarely displays security-seeking behaviours towards any adult, and does not respond when comfort is offered.

Answer 452

Hoarding motivated by obsessional thoughts ## Footnote Individuals with OCD may accumulate excessive amounts of objects (i.e. compulsive hoarding). However, unlike hoarding disorder, the behaviour is undertaken with the goal of neutralising or reducing concomitant distress and anxiety arising from obsessional content such as aggressive, sexual/religious, contamination, or symmetry/ordering themes. Furthermore, even in individuals affected by OCD who have poor or absent insight, the behaviour is generally unwanted and distressing, whereas in hoarding disorder it may be associated with pleasure or enjoyment. Generally in hoarding disorder, items are hoarded because of their emotional significance, instrumental characteristics, or intrinsic value (e.g. perceived aesthetic qualities).

Answer 453

>6 months ## Footnote Prolonged grief disorder is a disturbance in which, following the death of a person close to the bereaved, there is a persistent and pervasive grief response characterised by longing for the deceased or persistent preoccupation with the deceased accompanied by intense emotional pain. In ICD-11, the grief response must have persisted for an atypically long period of time following the loss (more than 6 months at a minimum).

Answer 454

With melancholia ## Footnote In ICD-11, available specifiers for a depressive episode include: with prominent anxiety symptoms; with panic attacks; persistent; with melancholia; with seasonal pattern.

Answer 455

Persistent difficulties sustaining relationships ## Footnote Whereas the ICD-11 diagnostic requirements for complex PTSD include all essential features of PTSD, the diagnosis of complex PTSD also requires the additional essential features of severe problems in affect regulation, persistent negative beliefs about oneself, and persistent difficulties in sustaining relationships.

Answer 456

HAM-D ## Footnote The Hamilton Rating Scale for Depression (HAM-D) is an interviewer-rated, 17-item rating scale for depressive illness. It is not a diagnostic instrument, but is used to measure changes (e.g. as a result of drug treatment). 17 items are scored according to severity, producing the final score.

Answer 457

Quick data collection ## Footnote One advantage of using a cross-sectional method in studying developmental phenomena in children is that it allows for quick data collection from participants of different age groups at a single point in time. This method is efficient for obtaining a snapshot of developmental trends across different age cohorts, but it does not provide longitudinal insights into individual development or establish temporal causality. Attrition rates can vary, and the use of this design alone does not inherently improve response rates.

Answer 458

National Adult Reading Test ## Footnote Since the ability to pronounce irregular words correctly is highly educationally dependent, a test of irregular word reading, the National Adult Reading Test (NART), is widely used to predict premorbid intellectual disability.

Answer 459

Proverb testing ## Footnote Abstract reasoning is the ability to shift back and forth between general concepts and specific examples. Having the patient identify similarities between like objects or concepts (apple and pear, bus and airplane, or a poem and a painting) as well as interpreting proverbs are useful ways to assess one's ability to abstract.

Answer 460

Weight loss to achieve thinness ## Footnote Individuals with anorexia nervosa (AN), like individuals with avoidant-restrictive food intake disorder (ARFID), present with a pattern of restricted eating and significantly low body weight, with similar health-related consequences. The difference is that in AN, behaviours to establish or maintain an abnormally low body weight are usually explicitly motivated by a desire for thinness or an intense fear of gaining weight. In ARFID, the pattern of eating behaviour is not motivated by preoccupation with body weight or shape.

Answer 461

2 ## Footnote In ICD-11, disorders of Intellectual development are characterised by intellectual functioning and adaptive behaviour that are approximately two or more standard deviations below the mean (approximately less than the 2.3rd percentile), based on appropriately normed, individually administered standardised tests.

Answer 462

Apophany ## Footnote Conrad proposed five stages in the development of delusional psychosis: 1) Trema: delusional mood representing a total change in perception of the world 2) Apophany: a search for, and the finding of, new meaning for psychological events 3) Anastrophy: heightening of the psychosis 4) Consolidation: forming of a new world or psychological set based on new meanings 5) Residuum: eventual autistic state

Answer 463

Flight of ideas ## Footnote In flight of ideas, thoughts follow each other rapidly; there is no general direction of the thinking; and the connections between successive thoughts appear to be due to chance factors which, however, can usually be understood. The absence of a determining tendency to thinking allows the associations of the train of thought to be determined by chance relationships, verbal associations of all kinds, clang associations, proverbs, maxims, and cliches. The chance linkage of thoughts in flight of ideas is demonstrated by the fact that one could completely reverse the sequence of the record of a flight of ideas, and the progression of thought would be understood just as well (or just as poorly).

Answer 464

Magical thinking ## Footnote Magical thinking refers to a belief in personal power to control or cause external events in the real world beyond culturally and rationally accepted laws of causality. It is found when one attributes magical properties to thoughts or behaviours (e.g. 'if I throw this piece of paper in the bin five times in a row, then I'll pass my exams'). This defence is associated with OCD.

Answer 465

Moderate impairment ## Footnote The threshold for a personality disorder diagnosis is at least Mild personality disorder (i.e., some impairment as per ICD-11) or Moderate impairment of personality functioning (DSM-5).

Answer 466

Psychotic symptoms ## Footnote In ICD-11, a hypomanic episode is accompanied by characteristic symptoms such as rapid speech, rapid/racing thoughts, increased self-esteem, an increase in sexual drive or sociability, decreased need for sleep, distractibility, and/or impulsive or reckless behaviour. In a hypomanic episode, there are no accompanying delusions or hallucinations.

Answer 467

Schizotypal disorder ## Footnote For ICD-11 diagnosis of schizotypal disorder, symptoms should have been present, continuously or episodically, for at least 2 years. Symptoms of schizoaffective disorder must have persisted for at least one month. ICD-11 notes that the duration of adjustment disorder varies widely; symptoms that resolve within a few days do not typically warrant a diagnosis of adjustment disorder, but ICD-11 does not designate a specific duration of symptoms. Symptoms must have persisted for at least one month in order for a diagnosis of schizophrenia to be assigned. In ICD-11, delusional disorder is characterised by the development of a delusion or set of related delusions, typically persisting for at least 3 months and often much longer.

Answer 468

Significant physical aggression ## Footnote According to ICD-11, individuals with intermittent explosive disorder (IED) are more likely to exhibit significant physical aggression than those with oppositional defiant disorder (ODD). Severe temper outbursts that are grossly out of proportion to the provocation are core to IED, but also occur in the context of ODD with chronic irritability- anger. Individuals with ODD with chronic irritability-anger typically display other features of ODD - including defiant, headstrong, or vindictive behaviours - which are not characteristic of IED.

Answer 469

Synaesthesia ## Footnote Synaesthesia is the experience of a stimulus in one sense modality producing a sensory experience in another (e.g. 'tasting' sounds or 'hearing' colours).

Answer 470

The patient appears awake and alert ## Footnote Note that in neurology the term stupor is used to refer to any state of reduced consciousness. In psychiatry, stupor is the absence of movement and communicative behaviour (akinesia + mutism) where there is no impairment of consciousness. It can be regarded as an extreme form of hypokinesia. Functional stupor occurs in a variety of psychiatric illnesses wherein patients are mute and paralyzed but generally appear alert with preserved intellectual function.

Answer 471

Those who drink alcohol regularly from an early age are more likely to develop later alcohol misuse/abuse ## Footnote Young people between the ages of 15 and 17 years are more likely to binge drink, which is associated with other health risk behaviours such as unprotected or regretted sexual activity; antisocial and criminal behaviour; and self-harm and thoughts of suicide. Those who drink regularly from an early age are more likely to develop later alcohol misuse or abuse. Alcohol use can negatively impact upon young people's educational performance, their friendships, their relationships with their parents, and the dynamics of their peer group. The Health Behaviour in School-Aged Children Survey (HBSC), as used in the UK, provides information on alcohol and substance use, including cannabis.

Answer 472

Upon hearing a clock strike 12, a man believes that he is the Messiah ## Footnote A delusional perception is a primary delusion of any content that is reported by the patient as having arisen following the experience of a normal perception. If the patient is asked to recall the point when they became aware of the delusion and its significance to them, they will report that the delusional perception arose on seeing a normal percept (the percept is a real external object, not a hallucinatory experience). Delusional perception is a first-rank symptom of schizophrenia.

Answer 473

Digit span ## Footnote Working memory is synonymous is synonymous with short-term memory, which is responsible for the immediate recall of small amounts of verbal (as in digit span) or visuospatial information.

Answer 474

Mamillary body alpha-keto glutamate dysfunction ## Footnote Wernicke encephalopathy (WE) and Korsakoff psychosis, together termed Wernicke-Korsakoff syndrome, are distinct yet overlapping neuropsychiatric disorders associated with thiamine deficiency. Deficiency of thiamine can lead to decreased functioning of enzymes involved in the tricarboxylic acid cycle (alpha-keto glutamate dehydrogenase and pyruvate dehydrogenase), pentose phosphate pathway, and branched-chain amino acid metabolism. Mammillary body lesions are the classic autopsy sign in WE patients and are present in almost all cases.

Answer 475

REM ## Footnote Evidence for the role of REM sleep in consolidation of the emotional components of memory is relatively strong. The precise mechanisms by which REM sleep promotes consolidation of emotional memories remains unresolved, although there are some studies suggesting that long-term potentiation processes are activated in REM sleep. There is a large body of literature suggesting that theta oscillations, characteristic of REM sleep, play a role in memory consolidation, particularly in fear conditioning and emotional memories.

Answer 476

Alpha-synucleinopathy ## Footnote Multisystem atrophy (MSA), a family of Parkinson-plus diseases, includes a cerebellar type (formerly olivopontocerebellar degeneration) that is notable for ataxia and a subtype with pronounced autonomic dysfunction (formerly Shy-Drager syndrome). There is a common neuropathological finding of distinctive inclusion bodies in glial cells which contain alpha-synuclein, leading to the classification of MSA as a synucleinopathy. No mutations in the gene for alpha-synuclein have been found in MSA, which appears to exist only as a sporadic disorder.

Answer 477

APP ## Footnote Cerebrovascular homeostasis is maintained by the blood-brain barrier (BBB), a highly selective structure that separates the peripheral blood circulation from the brain and protects the central nervous system. Several recent studies have highlighted the importance of the physiological role of the beta-amyloid precursor protein (APP) in endothelial cell homeostasis, suggesting an important role of this protein in maintaining vascular stability.

Answer 478

2nd trimester ## Footnote Brain organoids are produced by the differentiation of pluripotent stem cells under three-dimensional culture conditions by adding neurodevelopment- related regulatory signals. They are similar to the cell composition and anatomical structure of the brain, and can reflect the developmental process of the bring, as well as their physiology, pathology, and pharmacology. In terms of their cellular and molecular composition, the current architecture of brain organoids can mimic the second- trimester human fetal brain.

Answer 479

Dopamine ## Footnote Although dopamine dysfunction has mainly been linked to positive psychotic symptoms, striatal dopamine signalling normally has widespread effects on cortical function, and its dysregulation can also cause cognitive symptoms. Many researchers believe that cognitive and some negative symptoms of schizophrenia may be due to a deficit of dopamine activity in mesocortical projections to the dorsolateral prefrontal cortex.

Answer 480

Insula ## Footnote The anterior insula cortex has been shown to be a core circuit for empathy.

Answer 481

Melatonin ## Footnote Recommended treatments for REM sleep behaviour disorder include clonazepam, melatonin, and pramipexole. Melatonin binds to the M1 and M2 receptors, suppressing REM sleep motor tone and renormalising other circadian features of REM sleep. Melatonin requires a prescription in the EU and the UK.

Answer 482

Narcolepsy ## Footnote Orexin/hypocretin neurons are localised exclusively in certain hypothalamic areas (later hypothalamic area, perifornical area, and posterior hypothalamus). These hypothalamic neurons degenerate in narcolepsy, and loss of these neurons causes the inability of orexin to be produced and released downstream on wake-promoting neurotransmitter centres and thus lack of stabilising wakefulness.

Answer 483

Priors ## Footnote The account of predictive processing has emerged as an alluring computational model to explain how brain processes information about the world. In the higher brain centers, expected predictions and pre-existing beliefs (known as priors) are said to be combined with observed sensory data (referred to as likelihood) to compute a posterior probability (referred to as the posterior). This posterior probability is said to represent the most probable perception, considering both the prior beliefs and the sensory evidence. In cases where there is a disparity between the prior expectations and the sensory evidence (likelihood), a prediction error is generated. This error signal initiates the necessity to revise the brain's current model and adjust its prior beliefs accordingly. To express it formally, a prediction error quantifies the difference between the means of the prior and likelihood distributions, taking into account their respective precisions (inverse variance).

Answer 484

Tau positive, amyloid negative ## Footnote The classification of frontotemporal dementias is based on the type of protein inclusions observed in neurons as well as the mutational status, if known. The inclusions contain predominantly or exclusively one of three markers: tau; TDP-43, a DNA/RNA-binding protein; and FUS (fused in sarcoma). Atypical frontotemporal lobar degeneration with ubiquitin-positive inclusion is a relatively rare cause of FTD characterised by FUS-positive inclusions.

Answer 485

7 times ## Footnote Receptors linked to G proteins all have the structure of seven-transmembrane regions, meaning that they span the membrane seven times.

Answer 486

The tendency for a group to make a more extreme decision than its individual members would have done initially ## Footnote Group polarisation is defined within social psychology as the tendency for groups to move towards a more extreme version of their initial beliefs following group discussion, e.g. being more risky if they were originally inclined to be, and more cautious if this was their initial inclination.

Answer 487

Reactive attachment disorder ## Footnote In ICD-11, reactive attachment disorder is characterised by grossly abnormal behaviours in early childhood, occurring in the context of a history of grossly inadequate child care. Even when an adequate primary caregiver is newly available, the child does not turn to the primary caregiver for comfort, support, and nurture, rarely displays security-seeking behaviours towards any adult, and does not respond when comfort is offered.

Answer 488

Informational ## Footnote According to French & Raven, informational power stems from the logical or persuasive content of the communication between the influencing agent and the target. Informational power is used when campaigns explain the reasons for recommended behaviours, indicating how such behaviours would contribute to improved heath.

Answer 489

Retrospective falsification ## Footnote Retrospective falsification refers to the unintentional distortion of memory that occurs when it is filtered through a person's current emotional, experiential, and cognitive state. It is often found in those with depressive illness who describe all past experiences in negative terms due to the impact of their current mood. Any psychiatric illness can lead to retrospective falsification, which is related to insight of the patient as well as to suggestibility.

Answer 490

Proximity ## Footnote Proximity is one of the four original grouping laws of Gestalt psychology that explain the organisation of parts into whole by the visual system. According to the law, elements close together tend to be grouped perceptually, so that the array 00 00 00 00 tends to be perceived as four pairs rather than eight separate elements.

Answer 491

Cerebellum ## Footnote Cerebellar hypoplasia was an early documented change in brain morphology in ASD (autism spectrum disorder). The finding of cerebellar hypoplasia in ASD has been replicated and has been associated with the loss of cerebellar Purkinje cells in the posterior lobe whose degenerated myelinated axons contribute to reduced cerebellar volume.

Answer 492

Authoritative ## Footnote The authoritative parenting style is characterised as high in responsiveness and demandingness. Authoritative parents provide not only support and warmth, but also clearly defined rules and consistent discipline.

Answer 493

Selective auditory attention ## Footnote The cocktail party phenomenon involves selective attention in speech perception that enables a listener to attend to one among several equally loud conversations occurring simultaneously, factors such as voice quality and directional cues facilitating the task. Recordings of conversations under similar circumstance are very much harder to understand. The term was introduced in 1957 by the British telecommunications engineer Colin Cherry.

Answer 494

Bystander effect ## Footnote The 'bystander effect' (also known as the 'Genovese syndrome') is the reluctance of bystanders to intervene in an emergency, especially when a person appears to be in distress, or a crime is being committed. Scores of experiments have shown that people are much less likely to intervene in an emergency, and are generally slower to respond, when other people are present than when they are alone, and this phenomenon is sometimes called 'group inhibition of helping' or 'bystander apathy effect'.

Answer 495

Grief reactions are influenced by developmental levels and concepts of death ## Footnote Grief reactions in children are influenced by developmental levels and concepts of death and may not resemble adult reactions. Family bereavement has continuous, cumulative effects on children's emotional and social well-being, long after bereavement happens. Grief is not an illness, but it does increase the risk of mental health difficulties, both in childhood and later life. Around 1/3 of bereaved children reach clinical levels of emotional/behavioural difficulties in the two years following a parent's death. Around 1 in 29 school-age children and young people (5-16) in the UK are bereaved at some point in their childhood of a parent or sibling.

Answer 496

Group conflict and cooperation ## Footnote Realistic group conflict theory is the notion that group conflict and hostility are caused chiefly by competition for resources and power, as proposed by psychologist Muzafer Sherif and several colleagues in the Robbers Cave experiment. The field experiment involved two groups of white, middle-class eleven-year-old boys, and was named after the Robbers Cave State Park where the experiment took place.

Answer 497

Halo effect ## Footnote The halo effect is a generalisation from the perception of one prominent or salient characteristic, trait, or personality attribute to an impression of the whole, leading to inflated correlations between rated items.

Answer 498

Hawthorne effect ## Footnote The Hawthorne effect refers to improvement in the performance or productivity of workers or students resulting from the introduction of new working methods or conditions, irrespective of the nature of the changes, the effect often being attributed to the feeling of being under concerned observation.

Answer 499

Negative behaviours in adolescence are normative ## Footnote A primary aspect of the 'storm and stress' characterisation of adolescence is that adolescents exhibit more negative, or undesirable, characteristics in the domains of externalising, internalising, and parent-adolescent relationships than do younger and older individuals. The original characterisation by Hall (in 1904) who spoke of behaviour such as 'cruelty, laziness, lying, and thievery' as normative, is now seen as inaccurate and does not specify percentages of adolescents who are expected to display specific negative behaviours. Nevertheless, this characterisation has influenced the public opinion and is often referred to in the context of risk behaviour, mood disruption, and parent-child conflicts.

Answer 500

Observing an adult aggressor receive punishment reduces the probability of aggressive behaviour in children ## Footnote Key findings of Bandura's experiments on aggressive in children include the following: 1) Observation of an aggressive model is sufficient to elicit aggressive behaviour in the young child. 2) If the adult model is punished for their aggressive behaviour, the probability that the child will show aggressive behaviour is reduced. 3) Positive reinforcement or no reinforcement of the adult model's aggression leads to increased aggression on the part of the child (vicarious/indirect learning). 4) Children who watch a film showing aggressive people or cartoons tend to imitate this behaviour. 5) Children transfer, by means of generalisation, aggression into new, different contexts, even when the aggressive model is no longer present (delayed imitation).

Answer 501

Perception involves making inferences about past experiences ## Footnote Richard Gregory was a pioneer of cognitive psychology whose scientific work involved the development and interpretation of visual illusions, which he used as a tool to work out the perceptual mechanisms involved in the way that the visual world is normally perceived. Gregory's account of perception requires not only information from the retina but also knowledge-based processes required for top-down or indirect construction of perception: past experience, assumptions, and active processing. An alternative approach was advocated by the psychologist James Gibson who argued that depth and form are obtained directly from the visual image. Gibson also argued that an object's affordance is what it can offer the viewer in terms of potential action.

Answer 502

Persuasive communication ## Footnote Assimilation-contrast theory is a theory of judgement and attitude change. A consequence of this theory is that an extreme and ego-involving judgement or attitude tends to be polarised (to become even more extreme) in response to most types of information or persuasive communication.

Answer 503

Systematic desensitisation ## Footnote Systematic desensitisation (Wolpe) is frequently used in the treatment of phobic anxiety disorders. It is based on the behavioural principle of reciprocal inhibition (i.e. anxiety and relaxation cannot coexist).

Answer 504

This period is extended in children with autism spectrum disorder ## Footnote The prelinguistic stage is viewed as the period between birth and when an individual begins to use words/signs meaningfully. It is a time when children typically increase their ability to communicate with others, first using eye gaze, attending, and social-emotional affect and later adding gestures and other nonverbal means to communicate. Individuals with significant intellectual disability, including autism spectrum disorder, can have substantially protracted prelinguistic periods of communication and language development. For some, a singular reliance on prelinguistic communication may continue into adolescence or adulthood. The skills typically learned during this stage are critical to effective communication throughout the lifespan.

Answer 505

Attributing personal factors for others' behaviours ## Footnote Fundamental attribution error is a pervasive tendency to underestimate the importance of external situational pressures and to overestimate the importance of internal motives and dispositions in interpreting the behaviour of others.

Answer 506

Discrimination ## Footnote Allport identified the following processes operating during conflicts between the minority and the majority: 1. Antilocution 2. Avoidance 3. Discrimination: Minority group is discriminated against by denying them opportunity and equality. 4. Physical attack 5. Extermination.

Answer 507

Are nitrogen-containing compounds ## Footnote A purine is an aromatic heterocycle composed of carbon and nitrogen. Eukaryotes, bacteria, and archaea are all able to carry out de-novo biosynthesis of purines. Purines include adenine and guanine, which participate in DNA and RNA formation. Purines are also constituents of other important biomolecules, such as ATP, GTP, cyclic AMP, NADH, and coenzyme A. Other important purines include hypoxanthine, xanthine, theobromine, caffeine, uric acid, and isoguanine. Cytosine, thymine, and uracil are pyrimidines.

Answer 508

DISC1 and NRG1 ## Footnote DISC1 is one of the most important candidate genes for schizophrenia. It is one of the most researched genes in schizophrenia, alongside the COMT AND NRG1 genes. DISC1 is a protein that performs many functions, including neuronal migration, intracellular transport, synaptic maintenance, and stabilisation. NRG1 is one of the most important proteins for the variety of functions in which it is involved. Among them are the growth and development of the epidermis and development of the nervous system (synaptic plasticity).

Answer 509

Oxytocin ## Footnote Oxytocin is a crucial regulator of human social behaviour. Individual differences within the oxytocin system - assessed through hormonal levels, epigenetic modification, or genetic variation - have been linked to differential sensitivity to social cues, prosocial behaviours, and stress responsiveness in adults. Early experience in maternal care predicts epigenetic change within the infant oxytocin system, levels of which are in turn reflective of infant temperament.

Answer 510

Constructional apraxia (Gestalt) ## Footnote Symptoms arising from non-dominant hemisphere injury tend to be subtle, and predominantly neuropsychologic. The cause is usually a structural lesion, such as trauma, stroke, or malignant tumour, that has rapidly developed in the non-dominant parietal or frontal lobe cortex. Neuropsychological deficits include constructional apraxia (Gestalt), dressing apraxia, and anosognosia.

Answer 511

Inferior parietal lobe ## Footnote The default mode network is an integrated system of cortical areas that are active in a person who is in a state of wakeful rest, daydreaming, reminiscing, or contemplating future events, but not focused on a specific task involving the sensory (especially visual) input. It includes the medial prefrontal cortex, the posterior cingulate gyrus, and angular gyrus, and the medial, lateral, and inferior parietal lobe (IPL), and parts of the parahippocampal gyrus.

Answer 512

0.5 ## Footnote The evidence for linkage between two loci depends on the recombination frequency between them. Recombination frequency is measured by the recombination fraction, equal to the genetic distance between the two loci. 1% recombination equals 1 centimorgan (cM) in the genetic distance and, on average, covers a physical distance of about 1 megabase of DNA. Genes are said to independently assort, when they are apart at a distance of 50 cM or more. Thus, a recombination fraction of 0.5 or 50% indicates that two loci are not linked but rather that they are segregating independently.

Answer 513

Anterior limb of internal capsule ## Footnote Deep brain stimulation is best regarded as an experimental treatment for OCD and depression. DBS involves implantation of bilateral electrodes under stereotactic guidance and MRI confirmation. Targets for DBS in OCD include the anterior limb of the internal capsule and, for depression, the subgenual cingulate gyrus.

Answer 514

Calcium ## Footnote Genetic association studies of schizophrenia have consistently demonstrated a convergence of genetic risk upon sets of genes with synaptic functions, including discrete signal transduction pathways such as voltage-gated calcium channel complexes and glutamate receptor complexes. The relationship between the expression of genes involved in voltage-gated cation channel activity and association with schizophrenia has been shown to be strongest for the subset of genes related to calcium channel activity.

Answer 515

DNA fragment sequence ## Footnote Developed by and named after Edward Southern, a Southern blot is used to identify if a known DNA sequence is present in a sample by using a specific probe to identify the sequence in a large mixture of other DNA fragments. Southern blots were traditionally used to validate the successful introduction or removal of DNA sequences in the genome of genetically modified animals. Now, modern PCR techniques are more sensitive and a faster alternative to identifying a DNA fragment.

Answer 516

Fragile X syndrome ## Footnote Fragile X syndrome (FXS)-affected individuals display a spectrum of neurologic, psychiatric and developmental issues which often manifest with less severity in full-mutation (FM) females as a result of X-chromosome inactivation or skewed or adverse Lyonization. Random inactivation (or Lyonisation) of either the paternal or the maternal X chromosomes occurs in each cell in female embryos, resulting in a mosaic expression of X-linked genes in females with 50:50 expression of maternal and paternal alleles. However, in the presence of a structural abnormality such as fragile X chromosome, a deviation from the 50:50 ratio, known as skewed or adverse Lyonization, may occur wherein the inactivation of the unaffected X chromosome is favored. This leads to the clinical expression of FXS in some women (30-50% of the Fragile X chromosome carriers). In general, the X-chromosome inactivation ratio is considered skewed if it is ≥65:35.

Answer 517

Hippocampus ## Footnote The dentate gyrus is a subregion of the hippocampus. Encoding spatial information as well as pattern separation are seen as its major functions, among many other roles relevant to human memory.

Answer 518

IL-6 ## Footnote Biomarkers of inflammation in patients with depression include elevated blood levels of IL-1 beta, IL-6, TNF, and CRP. Of these, prospective associations of depression and inflammatory biomarkers are observed in both directions, particularly for IL-6.

Answer 519

Noradrenergic ## Footnote CNS norepinephrine (noradrenaline) synthesis takes place primarily in the locus coeruleus, which is located in the dorsal portion of the pons. While the locus coeruleus gives rise to norepinephrine tracts, the raphe nucleus gives rise to serotonin tracts.

Answer 520

PET ## Footnote PET relies on positron-emitting, biologically active radioisotopes (radioligands) incorporated into organic molecules. The radioligands, inhaled or injected intravenously, undergo metabolism in the brain and emit positrons. The reaction between positrons and electrons yields photons that PET detects and transforms into images. Most PET studies measure the metabolism of a substitute for glucose, fluorine-18-labeled fluorodeoxyglucose (FDG).

Answer 521

PET ## Footnote Dynamic positron emission tomography (PET) with appropriate neuroreceptor ligands permits the measurement of neurotransmitter release in the human brain with appropriate pharmacological or behavioural challenge. This imaging technique has been used for more than two decades to probe the neurochemical underpinnings of cognitive and motivational functions in normal and neuropathological conditions. PET is the only technology to date that has the capability to reveal the metabolism of molecules, receptors, and neurotransmitters in vivo with the appropriate radioligands and precursor.

Answer 522

Lithium ## Footnote Lithium use during pregnancy has a well-known association with the cardiac malformation, Ebstein anomaly. Of note, however, is that more recent data suggest that the magnitude of the effect is much smaller than previously estimated.

Answer 523

41-43% ## Footnote In the CATIE trial, metabolic syndrome prevalence was 41% and 43%, respectively, using the National Cholesterol Education Program (NCEP) and AHA (fasting glucose threshold of 100mg/dl) derived criteria.

Answer 524

5HT2 ## Footnote Hallucinogens such as LSD, psilocybin, and mescaline are 5HT2A agonists. When these agents stimulate 5HT2A receptors on glutamatergic pyramidal neurons in the prefrontal cortex, this causes overactivation of the glutamate neuron. The resultant release of glutamate into the ventral tegmental area causes hyperactivity of the mesolimbic dopamine pathway, resulting in delusions and auditory hallucinations. Excessive glutamate release in the visual cortex can cause visual hallucinations.

Answer 525

Carbamazepine ## Footnote Some drugs have a narrow therapeutic index (a small increase in dose can cause toxicity and a small reduction in dose can cause a loss of therapeutic action). The most commonly prescribed ones are digoxin, warfarin, theophylline, phenytoin, carbamazepine, and lithium.

Answer 526

Oxazepam ## Footnote Oxazepam is a short-acting benzodiazepine and one of the most frequently prescribed anxiolytic drugs. It is also the active metabolite of a wide range of other benzodiazepines, such as diazepam, ketazolam, temazepam, and chlordiazepoxide.

Answer 527

Antagonist at D2, 5HT2A, and 5HT7 ## Footnote Lurasidone is a 5HT2A/D2 antagonist. It also potently blocks 5HT7 receptors, which may be beneficial for mood, sleep, cognitive impairment, and negative symptoms in schizophrenia, and also in bipolar disorder and major depressive disorder. Lurasidone lacks potent actions at D1, M1, and H1 receptors, theoretically suggesting less propensity for inducing cognitive impairment, weight gain, or sedation compared to other agents with these properties.

Answer 528

0.8 ## Footnote The incidence of EPS is significantly correlated with the D2 receptor occupancy in the substantia nigra and striatum areas. Approximately 75-80% blockade of D2 receptors by antipsychotics can lead to the induction of EPS. Notably, this does not apply to D2 partial agonists as they show high D2R occupancies but still lower odds of EPS.

Answer 529

Diplopia ## Footnote Serotonin syndrome is characterised by altered mental state, agitation, tremors, shivering, diarrhoea, hyperreflexia, myoclonus, ataxia, and hyperthermia. Autonomic signs and symptoms include hyperthermia (that may be secondary to prolonged seizure activity, rigidity, or muscular hyperactivity), Gl upset (including nausea and diarrhoea), mydriasis, tachycardia, and hyper/hypo-tension.

Answer 530

G protein coupled ## Footnote Metabotropic receptors are linked to G proteins. Metabotropic receptors get their name from the fact that the movement of ions through them depends on certain metabolic processes. While they do not have ion channels included in their own structure (they are monomeric proteins with an extracellular neurotransmitter binding domain), the activation of intermediate molecules called G-proteins (an intracellular domain) enable eventual ion movement.

Answer 531

Galantamine ## Footnote Galantamine is an inhibitor of the enzyme acetylcholinesterase (AChE). Central cholinergic neurons are important for regulation of memory, and thus, in the central nervous system, the boost of acetylcholine caused by AChE blockade contributes to improved cognitive functioning.

Answer 532

Increased glomerular filtration rate (GFR) ## Footnote Increased cardiac output of pregnancy is accompanied by an increase in renal blood flow, which, in conjunction with haemodilution and a reduction in oncotic pressure from reduced plasma proteins, increases the GFR. Albumin concentrations are 70-80% lower compared to non-pregnancy. Consequently, drugs that are highly protein bound will typically have greater free fractions in pregnancy. Fluid volume increases in pregnancy. Depending on a number of factors, the volume of distribution for hydrophilic medications may be as large as the volume of total body water. In pregnancy, the increase in total body water (and thus volume of distribution) leads to reduced plasma and tissue concentrations for the same initial dose compared to the nonpregnant state.

Answer 533

Non-competitive NMDA antagonism ## Footnote Memantine is a non-competitive, low-affinity NMDA receptor antagonist. It also has weak 5HT-3 antagonist properties.

Answer 534

Parasympathetic ganglia ## Footnote Muscarinic acetylcholine receptors are G-protein coupled metabotropic receptors. Various subtypes are distributed predominantly in the CNS. Iin the peripheral nervous system, they are found primarily on autonomic effector cells innervated by postganglionic parasympathetic nerves.

Answer 535

Reduces the risk of misuse/diversion ## Footnote A buprenorphine/naloxone preparation (suboxone) may reduce the risk of diversion. The different sublingual and parenteral absorption profiles of buprenorphine and naloxone are the key factors: if used sublingually, the naloxone will have negligible effects. However, if the combined preparation is injected, the naloxone will have a substantial effect and will attenuate the effects of buprenorphine in the short term and is also likely to precipitate withdrawal in opioid-dependent individuals on full opioid agonists.

Answer 536

Senna ## Footnote Stimulant laxatives (senna, bisacodyl or sodium picosulfate) are the first-line treatments for clozapine-induced constipation, if the individual has not passed a bowel movement in two days, after excluding intestinal obstruction. If the laxative is not working after 24 hours, consider adding an osmotic laxative (macrogols or lactulose) or emollient stool softeners (docusate sodium). Regular lactulose and plenty of fluids is important part of management. Avoid bulk-forming laxatives because the cause of constipation in this case is gastric hypomotility. Faecal impaction may require treatment with high dose macrogol or repeated doses of suppositories.

Answer 537

Lesch-Nyhan Syndrome ## Footnote Lesch-Nyhan syndrome is related to a defect in hypoxanthine guanine phosphoribosyl-transferase (HGPRT) leading to an accumulation of uric acid. This is an X-linked recessive condition leading to intellectual disability. Partial HGPRT deficiency results in gout. Compulsive self-mutilation is an important behavioural phenotype seen in this condition, which is very distressing to these children. Often severe self-biting behaviour is noted (finger/lip biting, with self-splinting in an attempt to prevent the behaviour). The mean age at onset of self-injury is 3.5 years. Men with this syndrome are reported to hit, spit, swear and even become aggressive towards their caregivers. Kidney failure secondary to infection or uric acid deposition (urate stones) is the cause of death in most subjects.

Answer 538

Triad of infantile spasms, spike-wave complex and intellectual disability ## Footnote Lennox-Gastaut syndrome is one of the most severe epileptic encephalopathies of childhood onset. It can occur secondary to an underlying brain disorder or idiopathic (i.e., has no known cause). Although Lennox-Gastaut syndrome is commonly characterised by a triad of signs, which include multiple seizure types, slow spike-wave complexes on EEG, and significant learning disability. The children suffer frequent fits of many different types, starting with infantile spasms that often evolve into full-blown syndrome; the age of onset is from 1 to 8 years, peaking at 3 to 5 years. However, unlike isolated infantile spasms, Lennox-Gastaut syndrome tends to be a lifelong epileptic encephalopathy

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