Gender Development

Gender identity is the sense of oneself as male of female, which is different from a person’s assigned sex at birth. Gender dysphoria occurs when a person’s gender does not match their sex. Infants as young as 10 months old can form stereotypic associations between faces of women and men and gender-typed objects. By 18-24 months, most children can label gender groups and use gender labels in their speech. Children typically develop gender awareness of their own self around 18 months and declare a gender identity of male of female by age 5-6. It is normal for children to experiment with gender expression and roles. For the majority of pre-pubertal children, gender dysphoria does not persist into adolescence, with only a minority (15%) experiencing persistent gender dysphoria. (Levy, 1994; Martin, 2010; Steensma, 2011).

BF Skinner’s theory states that behavior is influenced by its consequences, which can be positive reinforcement, negative reinforcement, of punishment. The frequency and consistency of these consequences, as determined by different reinforcement schedules, can shape and maintain behavior in various ways. Common reinforcement schedules include continuous reinforcement, fixed interval, fixed ratio, variable interval, and variable ratio.

The liver plays a significant role in breaking down clozapine through the action of CYP450 enzymes, with CYP1A2, CYP3A4, and CYP2D6 being particularly involved in the process.

The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

Several notable psychiatrists have made significant contributions to the field of mental health. Jakob Kasanin, born in Russia in 1897, introduced the term schizoaffective psychosis in his 1933 paper published in the American Journal of Psychiatry. Karl Theodor Jaspers, a German psychiatrist and philosopher, distinguished between true delusions and delusional-like ideas. Karl Ludwig Kahlbaum, also a German psychiatrist, pioneered modern clinical practices in mental health and conducted research on catatonia. Kurt Schneider, another German psychiatrist, is known for his work on the diagnosis and understanding of schizophrenia, including his compilation of first-rank symptoms that are particularly characteristic of the disorder.

Imipramine antidepressant effects were discovered by Kuhn. Kane introduced clozapine into clinical practice after conducting a successful double-blind multicenter trial comparing it with chlorpromazine in treatment-resistant schizophrenia. Charpentier synthesized chlorpromazine, while Klein discovered the use of iproniazid. Cade discovered the beneficial effect of lithium in treating mania.

In the given scenario, the individual is exhibiting projective identification by attributing their negative response to another person’s perceived attitudes. This is different from projection, where one attributes their own unacceptable thoughts of impulses to someone else.

The individual is not engaging in acting out, which involves impulsively acting on unconscious impulses to avoid conscious awareness of their effects. Instead, they are unable to gratify their impulse.

Suppression, a mature defense mechanism where one postpones attention to conscious impulses, is not being utilized in this situation. The individual is unable to avoid their unconscious impulse.

Repression involves the unconscious forgetting of painful memories of unacceptable impulses. However, in this scenario, the individual is expressing their unacceptable impulses rather than repressing them.

Chunking is a strategy that involves dividing complex tasks into smaller, more manageable chunks of subtasks. This approach can help alleviate unpleasant feelings that arise when faced with a task that seems overwhelming of difficult to complete.

Cognitive Dissonance is a term used to describe the uncomfortable feeling that arises when there is a conflict between an individual’s attitudes, beliefs, of behaviors. This feeling can lead to a change in behavior of beliefs. The theory of cognitive dissonance suggests that people have an inner drive to maintain cognitive consistency and avoid dissonance. This drive can result in irrational of maladaptive behaviors. Dissonance can be reduced by changing attitudes, behaviors, of beliefs, acquiring new information, of reducing the importance of the cognitions. Overall, cognitive dissonance plays a significant role in shaping human behavior and decision-making.

The act of repeating phrases that one feels compelled to perform is considered a compulsion. Compulsions are actions, either physical or mental, that one feels driven to perform. Obsessions, on the other hand, are recurrent and intrusive thoughts, urges, of images. The urge to hoard, for example, is an obsession rather than a compulsion. Compulsions are not inherently pleasurable and are performed to reduce anxiety. It is important to note that in order to qualify as a compulsion under DSM-5, the behavior must be time-consuming (taking more than 1 hour per day) of cause significant distress of impairment in important areas of functioning. Therefore, the behavior that is most suggestive of a compulsion is one that meets these criteria.

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by the presence of either obsessions or compulsions, and often both. Obsessions are repetitive and persistent thoughts, images, of impulses that are intrusive and unwanted, while compulsions are repetitive behaviors of rituals that an individual feels driven to perform in response to an obsession of according to rigid rules. The symptoms can cause significant functional impairment and/of distress. To diagnose OCD, the essential features include the presence of persistent obsessions and/of compulsions that are time-consuming of result in significant distress of impairment in important areas of functioning. The symptoms cannot be attributed to another medical condition of the effects of a substance of medication on the central nervous system.

Depression, suicidality, and aggression have been linked to low levels of 5-HIAA in the CSF.

The Significance of 5-HIAA in Depression and Aggression

During the 1980s, there was a brief period of interest in 5-hydroxyindoleacetic acid (5-HIAA), a serotonin metabolite. Studies found that up to a third of people with depression had low concentrations of 5-HIAA in their cerebrospinal fluid (CSF), while very few normal controls did. This suggests that 5-HIAA may play a role in depression.

Furthermore, individuals with low CSF levels of 5-HIAA have been found to respond less effectively to antidepressants and are more likely to commit suicide. This finding has been replicated in multiple studies, indicating the significance of 5-HIAA in depression.

Low levels of 5-HIAA are also associated with increased levels of aggression. This suggests that 5-HIAA may play a role in regulating aggressive behavior. Overall, the research on 5-HIAA highlights its potential importance in understanding and treating depression and aggression.

White matter is the cabling that links different parts of the CNS together. There are three types of white matter cables: projection tracts, commissural tracts, and association tracts. Projection tracts connect higher centers of the brain with lower centers, commissural tracts connect the two hemispheres together, and association tracts connect regions of the same hemisphere. Some common tracts include the corticospinal tract, which connects the motor cortex to the brainstem and spinal cord, and the corpus callosum, which is the largest white matter fiber bundle connecting corresponding areas of cortex between the hemispheres. Other tracts include the cingulum, superior and inferior occipitofrontal fasciculi, and the superior and inferior longitudinal fasciculi.

Lurasidone may cause akathisia and sedation as common side effects, which can vary based on the dosage. Its metabolic profile is neutral. However, doses lower than 37 mg are unlikely to produce desired results.

Understanding Social Loafing

Social loafing is a common phenomenon that occurs when people work in groups. It refers to the tendency of individuals to exert less effort when working in a group than when working alone. This can be attributed to the diffusion of responsibility, where individuals feel less accountable for their actions when working in a group. As a result, they may not put in as much effort as they would if they were working alone. Social loafing can have negative consequences for group performance, as it can lead to a lack of motivation and a decrease in productivity. Therefore, it is important to understand the causes of social loafing and take steps to prevent it from occurring in group settings.

The percentage of women who experience specific phobia at some point in their lives is 13%. The percentage of people who experience obsessive compulsive disorder within a year is 2.1%. The percentage of women who experience agoraphobia without panic disorder within a year is 3.8%. The percentage of men who experience specific phobia at some point in their lives is 4%. The percentage of people in the US National Comorbidity study who experience social phobia within a year is 7.4%. All of these statistics are based on the diagnostic criteria outlined in DSM-III R.

The Heschl gyrus, also known as the transverse temporal gyrus, is a component of the primary auditory complex located in the temporal lobe. It is noteworthy that the left Heschl gyrus is typically larger than the right. This structure is responsible for processing incoming auditory information and is unique in its mediolateral orientation. The brain hemispheres exhibit structural differences, with the left hemisphere (in over 90% of right-handed individuals) specializing in language function. Another structure within the primary auditory complex, the planum temporale, is also typically larger on the left side (up to ten times larger). Conversely, the amygdala, caudate nucleus, cingulate sulcus, and hippocampus are typically larger on the right side.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

While quality adjusted life years (QALY) are a utilitarian measure, it would be extreme to suggest that individuals with illnesses that require expensive treatments should not be treated solely based on the cost-benefit analysis. The general population does not strictly adhere to utilitarian principles, and therefore, The National Institute for Health and Care Excellence (NICE) considers other factors such as justice and the availability of alternative treatments for a particular condition in addition to the cost per QALY when making recommendations.

Water intoxication can cause polyuria and dilutional hyponatremia, but it does not typically lead to renal impairment. It is important to differentiate this condition from nephrogenic diabetes insipidus, which can develop in a significant percentage of patients on long-term lithium therapy and may present with nocturia as an early sign. While elevated calcium levels may occur in some patients on lithium, hyperparathyroidism is not a common clinical symptom. Tubulointerstitial nephritis is a rare complication of lithium therapy. The syndrome of inappropriate ADH secretion is not typically associated with polyuria of renal impairment and is not commonly linked to lithium therapy.

Carbamazepine use can result in leucopenia, which is a reduction in white blood cell count, affecting 1 in 10 individuals. Although other side effects can occur with carbamazepine, they are rare of very rare. The decrease in WBC is believed to be due to the inhibition of colony-stimulating factor in the bone marrow. However, the co-administration of lithium, which stimulates colony-stimulating factor, may potentially reverse the effects of carbamazepine (Daughton, 2006).

Carbamazepine: Uses, Mechanism of Action, Contraindications, Warnings, and Side-Effects

Carbamazepine, also known as Tegretol, is a medication commonly used in the treatment of epilepsy, particularly partial seizures. It is also used for neuropathic pain, bipolar disorder, and other conditions. The drug works by binding to sodium channels and increasing their refractory period.

However, carbamazepine has notable contraindications, including a history of bone marrow depression and combination with monoamine oxidase inhibitors (MAOIs). It also carries warnings for serious dermatological reactions such as toxic epidermal necrolysis (TEN) and Stevens Johnson syndrome.

Common side-effects of carbamazepine include leucopenia, ataxia, dizziness, somnolence, vomiting, nausea, urticaria, and fatigue. Other side-effects include thrombocytopenia, eosinophilia, oedema, fluid retention, weight increase, hyponatraemia, and blood osmolarity decreased due to an antidiuretic hormone (ADH)-like effect, leading in rare cases to water intoxication accompanied by lethargy, vomiting, headache, confusional state, neurological disorders, diplopia, accommodation disorders (e.g. blurred vision), and dry mouth.

In summary, carbamazepine is a medication with multiple uses, but it also carries significant contraindications, warnings, and side-effects that should be carefully considered before use.

Development: Erikson and Marcia

Erikson’s theory of psychosocial development outlines eight stages of ego growth, each marked by a specific crisis that must be resolved for positive development. These stages range from trust vs. mistrust in infancy to integrity vs. despair in old age. Successful resolution of each crisis leads to positive growth and development.

Marcia expanded on Erikson’s theory, focusing on identity formation during adolescence. He described four separate identity statuses, which represent the four possible combinations of commitment and exploration. Identity confusion/diffusion occurs when adolescents neither explore nor commit to any identities. Foreclosure occurs when an individual commits to an identity without exploring options. A moratorium is a state in which adolescents are actively exploring options but have not yet made commitments. Individuals who have explored different options, discovered their purpose, and have made identity commitments are in a state of identity achievement.

Overall, both Erikson and Marcia’s theories emphasize the importance of positive resolution of developmental crises and the role of exploration and commitment in identity formation.

Dissociative seizures, also known as pseudoseizures of functional seizures, are abnormal paroxysmal manifestations that resemble epileptic seizures but are not related to abnormal epileptiform discharges. They can be caused by physical factors such as hypoglycemia of cardiac dysfunction, but more commonly result from mental of emotional processes. Dissociative seizures are more common in females and tend to have an onset in late adolescence. Distinguishing between true seizures and pseudoseizures can be challenging, but a rise in serum prolactin levels after a seizure is a helpful diagnostic tool. Treatment options for psychogenic nonepileptic seizures are limited, with cognitive-behavioral therapy being the most studied and effective intervention.

The symptoms experienced during discontinuation can be similar to those of anxiety and depression, leading to the possibility of misinterpreting them as a relapse.

Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

Flumazenil: A Selective GABAA Receptor Antagonist

Flumazenil is a medication that selectively blocks the effects of benzodiazepines on the GABAA receptor. It is used to reverse the sedative effects caused by benzodiazepines, either partially or completely. Flumazenil works by competitively interacting with benzodiazepine receptors, which can reverse the binding of benzodiazepines to these receptors. It is administered intravenously and has a short half-life of about 60 minutes. The effects of flumazenil are usually shorter than those of benzodiazepines, and sedation may recur. Flumazenil also blocks non-benzodiazepine-agonists like zopiclone. However, it has no effect on other drugs such as barbiturates, ethanol, of other GABA-mimetic agents unless they act on the benzodiazepine receptor site. The hypnosedative effects of benzodiazepines are rapidly blocked within 1-2 minutes after intravenous administration, and the duration of action ranges from 20 to 50 minutes.

Brain Anatomy

The brain is a complex organ with various regions responsible for different functions. The major areas of the cerebrum (telencephalon) include the frontal lobe, parietal lobe, occipital lobe, temporal lobe, insula, corpus callosum, fornix, anterior commissure, and striatum. The cerebrum is responsible for complex learning, language acquisition, visual and auditory processing, memory, and emotion processing.

The diencephalon includes the thalamus, hypothalamus and pituitary, pineal gland, and mammillary body. The thalamus is a major relay point and processing center for all sensory impulses (excluding olfaction). The hypothalamus and pituitary are involved in homeostasis and hormone release. The pineal gland secretes melatonin to regulate circadian rhythms. The mammillary body is a relay point involved in memory.

The cerebellum is primarily concerned with movement and has two major hemispheres with an outer cortex made up of gray matter and an inner region of white matter. The cerebellum provides precise timing and appropriate patterns of skeletal muscle contraction for smooth, coordinated movements and agility needed for daily life.

The brainstem includes the substantia nigra, which is involved in controlling and regulating activities of the motor and premotor cortical areas for smooth voluntary movements, eye movement, reward seeking, the pleasurable effects of substance misuse, and learning.

The prevalence of dementia among individuals aged 60 and above, adjusted to the western Europe population by global burden of disease region, is greatest in Latin America, with a rate of 8.5%. The prevalence rates for other regions are as follows: Central Europe – 5.8%, East Asia – 5%, Sub-Saharan Africa, east – 4%, and Sub-Saharan Africa, west – 2.1%.

Understanding Grief: Normal and Abnormal Phases

Grief is a natural response to loss, and it is a complex process that can take different forms and durations. John Bowlby and Kubler-Ross have proposed models to describe the typical phases of grief, which can vary in intensity and duration for each individual. Bowlby’s model includes shock-numbness, yearning-searching, disorganization-despair, and reorganization, while Kubler-Ross’s model includes denial-dissociation-isolation, anger, bargaining, depression, and acceptance.

However, some people may experience abnormal grief, which can be categorized as inhibited, delayed, of chronic/prolonged. Inhibited grief refers to the absence of expected grief symptoms at any stage, while delayed grief involves avoiding painful symptoms within two weeks of loss. Chronic/prolonged grief is characterized by continued significant grief-related symptoms six months after loss.

It is important to distinguish between normal grief and major depression, as a high proportion of people may meet the criteria for major depression in the first year following bereavement. Some features that can help differentiate between the two include generalized guilt, thoughts of death unrelated to the deceased, feelings of worthlessness, psychomotor retardation, and prolonged functional impairment.

Overall, understanding the phases and types of grief can help individuals and their loved ones navigate the grieving process and seek appropriate support and resources.

Thought insertion is a symptom commonly experienced by individuals with schizophrenia, where they believe that their thoughts are not their own and have been placed in their head from an external source. This is one of the many first rank symptoms of schizophrenia, which also include delusional percept, audible thoughts, third person auditory hallucination, running commentary, thought withdrawal, thought broadcast, passivity of affect, passivity of impulses, passivity of volition, and somatic passivity. Third person auditory hallucinations involve hearing multiple voices discussing the patient as a third person. Thought broadcast is a passivity experience where the patient believes their thoughts are being widely broadcasted after being taken away from their head. Thought withdrawal is the belief that one’s thoughts are being taken away from their head against their will. Somatic passivity is a delusional belief that one’s body is being controlled from outside, which is different from haptic hallucination.

The Emergence of Social Smiling in Infants

Wormann (2014) discusses the emergence of social smiling in infants, which is usually interpreted as the first positive expression directed towards a cause. This occurs when an infant with an initially expressionless face examines the face of another person, and their face and eyes light up while the corners of their mouth pull upward. The age of the first appearance of the social smile varies across cultures, ranging from the fifth to seventh week. Additionally, there are differences in its duration and frequency between the second and seventh month of life. Understanding these milestones is important for a basic understanding of normal child development.

Child Development Milestones:
4 weeks Responds to noise (either by crying, of quieting), follows an object moved in front of eyes
6 weeks Begins social smiling*
3 months Holds head steady on sitting
6 months Rolls from stomach to back, starts babbling
7 months Transfers objects from hand to hand, looks for dropped object
9 months Sits unsupported, begins to crawl
12 months Cruising (walking by holding furniture)
18 months Walks without assistance, speaks about 10-20 words
2 years Runs, climbs up and down stairs alone, makes 2-3 word sentences
3 years Dresses self except for buttons and laces, counts to 10, feeds themself well
4 years Hops on one foot, copies a cross
5 years Copies a triangle, skips

Ethical theory and principles are important in medical ethics. There are three key ethical theories that have dominated medical ethics: utilitarianism, deontological, and virtue-based. Utilitarianism is based on the greatest good for the greatest number and is a consequentialist theory. Deontological ethics emphasize moral duties and rules, rather than consequences. Virtue ethics is based on the ethical characteristics of a person and is associated with the concept of a good, happy, flourishing life.

More recent frameworks have attempted to reconcile different theories and values. The ‘four principles’ of ‘principlism’ approach, developed in the United States, is based on four common, basic prima facie moral commitments: autonomy, beneficence, non-maleficence, and justice. Autonomy refers to a patient’s right to make their own decisions, beneficence refers to the expectation that a doctor will act in a way that will be helpful to the patient, non-maleficence refers to the fact that doctors should avoid harming their patients, and justice refers to the expectation that all people should be treated fairly and equally.

Assessment tools are commonly used in clinical research to diagnose and evaluate various conditions. The abnormal involuntary movement scale (AIMS) is one such tool that assesses the range of extrapyramidal side effects caused by neuroleptic medication. Another tool, Conors, is used to diagnose ADHD in children, while DIVA is used for the same purpose in adults. DISCO, on the other hand, is an assessment tool used to diagnose ASD at any age. Finally, the Hamilton depression rating scale, also known as HAM D-17, is used to evaluate the severity of depression in patients. Proper use of these assessment tools can aid in accurate diagnosis and effective treatment of various conditions.

Culture bound illnesses are psychiatric conditions that are specific to one particular culture. There are many different types of culture bound illnesses, including Amok, Shenjing shuairuo, Ataque de nervios, Bilis, colera, Bouffee delirante, Brain fag, Dhat, Falling-out, blacking out, Ghost sickness, Hwa-byung, wool-hwa-byung, Koro, Latah, Locura, Mal de ojo, Nervios, Rootwork, Pibloktoq, Qi-gong psychotic reaction, Sangue dormido, Shen-k’uei, shenkui, Shin-byung, Taijin kyofusho, Spell, Susto, Zar, and Wendigo.

Some of the most commonly discussed culture bound illnesses include Amok, which is confined to males in the Philippines and Malaysia who experience blind, murderous violence after a real of imagined insult. Ataque de nervios is a condition that occurs in those of Latino descent and is characterized by intense emotional upset, shouting uncontrollably, aggression, dissociation, seizure-like episodes, and suicidal gestures. Brain fag is a form of psychological distress first identified in Nigerian students in the 1960s but reported more generally in the African diaspora. It consists of a variety of cognitive and sensory disturbances that occur during periods of intense intellectual activity. Koro is a condition that affects Chinese patients who believe that their penis is withdrawing inside their abdomen, resulting in panic and the belief that they will die. Taijin kyofusho is a Japanese culture bound illness characterized by anxiety about and avoidance of interpersonal situations due to the thought, feeling, of conviction that one’s appearance and actions in social interactions are inadequate of offensive to others. Finally, Wendigo is a culture bound illness that occurs in Native American tribes during severe winters and scarcity of food, characterized by a distaste for food that leads to anxiety and the belief that one is turning into a cannibalistic ice spirit.

Risk Factors for Suicide

A family history of suicide is a significant risk factor for suicide, even if there is no family history of psychiatric disorder. Asking someone about suicidal thoughts does not cause them to have those thoughts, and individuals who self-harm regularly are at a higher risk of suicide. In fact, studies have shown that 1-6% of individuals who present to the hospital after non-fatal self-poisoning of self-injury die by suicide within the first year. It is also important to note that 90% of people who die by suicide have a psychiatric disorder. These risk factors should be taken seriously and addressed in order to prevent suicide.

Patients may feel that they have lost control over their thoughts, which can manifest as passivity of thought. This refers to the belief that an external agency is controlling one’s thoughts. Passivity can take different forms, such as thought withdrawal, thought insertion, and thought broadcasting.

Ego (Boundary) Disturbances

Ego (boundary) disturbances refer to experiences where there is a disturbance in the perception of self as distinct from the environment of the integrity of self. It also includes instances where bodily processes, personal thought processes, feelings, and actions are experienced as being externally directed. These phenomena are referred to as passivity phenomena, and some of the symptom characteristics are classified as bizarre delusional phenomena in the DSM.

Derealization is when a patient experiences their surroundings of time as if they are unreal and changed, losing all feelings of familiarity and trust in the environment. People, objects, and surroundings appear unreal, unfamiliar, of spatially altered. The sensations may be intense of weak in nature.

Depersonalization is when a patient perceives themselves as alien, unreal, changed, of as a stranger. The disturbances of depersonalization may be of a transient nature only of become more persistent over a longer period of time. It is generally felt to be both strange and unpleasant.

Thought broadcasting is when a patient’s personal thoughts are experienced as no longer belonging to the patient alone but accessible by others who will know what the patient is thinking (mind reading). Thought withdrawal is when a patient’s thoughts are being removed of stripped from them. Thought insertion is when patients experience their thoughts and ideas as being externally influenced, made externally, controlled, directed, entered/ of externally imposed.

Other feelings of alien influence refer to feelings, intentions, behavior, of bodily functions that are experienced as externally controlled of made by others (passivity phenomena). The patient feels externally compelled to say something specific, to scream, to act of behave in a particular way, to attack someone, to throw a tantrum, etc.

If mild cognitive impairment (MCI) does not affect driving, there is no need to inform DVLA. However, if there are concerns about the impact of MCI on driving, DVLA should be notified to conduct an investigation.

DVLA guidelines state that assessing driving ability in individuals with dementia is challenging. Those with poor short-term memory, disorientation, lack of insight, and judgment are likely to be unfit to drive. The varying presentations and progression rates of dementia are recognized, and attention disorders can also impair driving ability. Medical reports are typically used to determine fitness to drive. In cases of early dementia where sufficient skills are retained and progression is slow, a license may be granted, subject to annual review. A formal driving assessment may be necessary.

Understanding Incentive Salience and its Role in Addiction and Grief

Incentive salience is a process that drives the brain to desire certain things, such as drugs, and is mediated by mesolimbic dopamine systems. This process is separate from the experience of pleasure, and a person can want something they don’t necessarily like. Desire is amplified by brain states that heighten dopamine reactivity, such as stress, emotional excitement, relevant appetites, of intoxication. This state-dependent amplification of incentive salience is one reason why many addicts find it difficult to stop at just one hit.

Interestingly, grief has been hypothesized to be underpinned by a very similar process as drug addiction, referred to as the ‘incentive salience theory of grief’. Understanding the distinction between liking and wanting can help us better understand addiction and grief, and how the brain processes these experiences.

Alcohol Dependence Blood Profile

Alcohol dependence can have a significant impact on an individual’s blood profile. Several markers tend to be elevated in individuals with alcohol dependence, including GGT, AST, MCV, and ALT. Among these markers, GGT is considered the most reliable indicator of recent alcohol use. This means that elevated levels of GGT in the blood can suggest that an individual has consumed alcohol recently.

It is important to note that these blood markers may not be elevated in all individuals with alcohol dependence, and other factors can also contribute to changes in blood profile. However, monitoring these markers can be useful in assessing an individual’s alcohol use and identifying potential health risks associated with alcohol dependence. Healthcare professionals can use this information to develop appropriate treatment plans and support individuals in managing their alcohol use.

The First Pass Effect in Psychiatric Drugs

The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

Phenelzine belongs to a class of antidepressants called Monoamine Oxidase Inhibitors (MAOIs). However, it is contraindicated in patients with phaeochromocytoma, a rare tumor that secretes catecholamines, as MAOIs inhibit the breakdown of catecholamines and can lead to hypertensive crises, brain hemorrhage, and even death in such patients.

While antidepressants are generally considered to have a negligible effect on seizure activity in epileptics, caution should be exercised when using MAOIs in patients with thyroid disease. Additionally, as with all antidepressants, MAOIs may precipitate mania and should be used with caution in bipolar disorder, although they are not contraindicated.

Hyponatremia, a condition characterized by low sodium levels, is a potential side effect of most antidepressants, including MAOIs. However, MAOIs are not considered high risk compared to other antidepressant drugs. If sodium levels fall below 125 mmol/L, antidepressants should be stopped.

Reference:
Taylor, D., Paton, C., & Kapur, S. (2018). The Maudsley Prescribing Guidelines in Psychiatry (13th ed.). John Wiley & Sons.

Gedankenlautwerden is a symptom of schizophrenia where one hears their own thoughts spoken just before of at the same time as they occur. It is different from écho de la pensée, which refers to hearing one’s own thoughts spoken aloud after they have occurred. Functional hallucinations are triggered by an external stimulus in the same modality, while thought broadcasting involves the belief that someone of something has access to the patient’s thoughts. Extracampine hallucinations are those perceived as coming from outside the sensory field, such as hearing astronauts speaking on the moon.

Neo-Freudians were therapists who developed their own theories while still retaining core Freudian components. Some important neo-Freudians include Alfred Adler, Carl Jung, Erik Erickson, Harry Stack Sullivan, Wilfred Bion, John Bowlby, Anna Freud, Otto Kernberg, Margaret Mahler, and Donald Winnicott. Each of these individuals contributed unique ideas to the field of psychology. For example, Carl Jung introduced the concept of the persona and differentiated between the personal and collective unconscious, while Erik Erickson is known for his stages of psychosocial development. Margaret Mahler developed theories on child development, including the three main phases of autistic, symbiotic, and separation-individuation. Donald Winnicott introduced the concept of the transitional object and the good enough mother. Overall, neo-Freudians expanded upon Freud’s ideas and helped to shape modern psychotherapy.

The majority of Turner syndrome cases are not inherited and occur due to a failure in the separation of chromosomes during cell division, known as nondisjunction.

Understanding Turner Syndrome

Turner syndrome is a genetic disorder that affects only females. It occurs when one of the two X chromosomes is missing of partially missing. This happens randomly and does not increase the risk of the condition in future siblings. Although X-inactivation occurs in females, having only one X chromosome can cause issues as not all genes are inactivated in the inactivated X chromosome.

The features of Turner syndrome include short stature, a webbed neck, a broad chest with widely spaced nipples, gonadal dysfunction leading to amenorrhea and infertility, congenital heart disease, and hypothyroidism. Despite these physical characteristics, girls with Turner syndrome typically have normal intelligence, with a mean full-scale IQ of 90. However, they may struggle with nonverbal, social, and psychomotor skills. It is important to understand the symptoms and effects of Turner syndrome to provide appropriate care and support for affected individuals.

Individuals with hepatic impairment should avoid taking agomelatine and duloxetine due to contraindications. It is recommended to avoid sedative TCAs, such as trimipramine, imipramine, dothiepin, and amitriptyline.

Hepatic Impairment: Recommended Drugs

Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

Mood stabilizers: Lithium

Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

Fortnightly injections are required for Risperidone depot antipsychotic. Flupenthixol decanoate injections can be given every two to four weeks. Fluphenazine decanoate injections can be given every 14-35 days. Olanzapine embonate and paliperidone injections are given every four weeks.

Clinical Trials: Phases and Objectives

Clinical trials are conducted in four phases to evaluate the safety and efficacy of drugs of treatments. In Phase I, a small group of healthy individuals (15-20) is given the drug to determine its safety, dosage range, and side effects. Phase II involves a larger group (100-300) to assess the drug’s effectiveness and safety. In Phase III, the drug is given to a larger population (1,000-3,000) to confirm its efficacy, compare it with existing treatments, and collect data for safe use. Phase IV, also known as post-marketing trials, is conducted after the drug is licensed to gather additional information on safety and potential uses. These trials are crucial in determining the safety and efficacy of drugs and treatments before they are made available to the public.

Multiple Sclerosis: An Overview

Multiple sclerosis is a neurological disorder that is classified into three categories: primary progressive, relapsing-remitting, and secondary progressive. Primary progressive multiple sclerosis affects 5-10% of patients and is characterized by a steady progression with no remissions. Relapsing-remitting multiple sclerosis affects 20-30% of patients and presents with a relapsing-remitting course but does not lead to serious disability. Secondary progressive multiple sclerosis affects 60% of patients and initially presents with a relapsing-remitting course but is then followed by a phase of progressive deterioration.

The disorder typically begins between the ages of 20 and 40 and is characterized by multiple demyelinating lesions that have a preference for the optic nerves, cerebellum, brainstem, and spinal cord. Patients with multiple sclerosis present with a variety of neurological signs that reflect the presence and distribution of plaques. Ocular features of multiple sclerosis include optic neuritis, internuclear ophthalmoplegia, and ocular motor cranial neuropathy.

Multiple sclerosis is more common in women than in men and is seen with increasing frequency as the distance from the equator increases. It is believed to be caused by a combination of genetic and environmental factors, with monozygotic concordance at 25%. Overall, multiple sclerosis is a predominantly white matter disease that can have a significant impact on a patient’s quality of life.

REM sleep is facilitated by the presence of acetylcholine (Ach), while dopamine, histamine, noradrenaline, and serotonin act as inhibitors of sleep.

Modes of Inheritance

Genetic disorders can be passed down from one generation to the next in various ways. There are four main modes of inheritance: autosomal dominant, autosomal recessive, X-linked (sex-linked), and multifactorial.

Autosomal Dominant Inheritance

Autosomal dominant inheritance occurs when one faulty gene causes a problem despite the presence of a normal one. This type of inheritance shows vertical transmission, meaning it is based on the appearance of the family pedigree. If only one parent is affected, there is a 50% chance of each child expressing the condition. Autosomal dominant conditions often show pleiotropy, where a single gene influences several characteristics.

Autosomal Recessive Inheritance

In autosomal recessive conditions, a person requires two faulty copies of a gene to manifest a disease. A person with one healthy and one faulty gene will generally not manifest a disease and is labelled a carrier. Autosomal recessive conditions demonstrate horizontal transmission.

X-linked (Sex-linked) Inheritance

In X-linked conditions, the problem gene lies on the X chromosome. This means that all males are affected. Like autosomal conditions, they can be dominant of recessive. Affected males are unable to pass the condition on to their sons. In X-linked recessive conditions, the inheritance pattern is characterised by transmission from affected males to male grandchildren via affected carrier daughters.

Multifactorial Inheritance

Multifactorial conditions result from the interaction between genes from both parents and the environment.

If the individual were to experience impaired consciousness during the attack, this would be classified as a complex partial seizure. However, based on the current symptoms, it appears to be a simple partial seizure with retained consciousness.

Intervention-Causation Fallacy

The intervention-causation fallacy is a common mistake where people assume that a cure proves a cause. For instance, if antidepressants alleviate symptoms of depression, it does not necessarily mean that depression has a biological cause. It is important to note that just because a treatment works, it does not necessarily mean that it is addressing the root cause of the problem. Therefore, it is crucial to be cautious when making assumptions about causation based on interventions. By avoiding this fallacy, we can ensure that we are accurately identifying the underlying causes of problems and developing effective solutions.

Munchausen syndrome, also known as factitious disorder, is a condition where individuals intentionally fabricate of induce illness to assume the patient role. It was named by London physician Richard Asher in 1951, who observed patients reporting false symptoms such as abdominal pain, bleeding, and headaches. Conversion disorder, also known as dissociative disorder, is another term used to describe this condition. Ganser’s syndrome, which is not specifically mentioned in the ICD-11, was previously listed as a dissociative disorder and is often seen in forensic psychiatry. It is characterized by symptoms such as approximate answers, hallucinations, clouded consciousness, and insensitivity to pain, and is usually acute and self-limiting. Patients may not remember experiencing the syndrome.

Somatoform and dissociative disorders are two groups of psychiatric disorders that are characterised by physical symptoms and disruptions in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behaviour. Somatoform disorders are characterised by physical symptoms that are presumed to have a psychiatric origin, while dissociative disorders are characterised by the loss of integration between memories, identity, immediate sensations, and control of bodily movements. The ICD-11 lists two main types of somatoform disorders: bodily distress disorder and body integrity dysphoria. The former involves bodily symptoms that the individual finds distressing and to which excessive attention is directed, while the latter involves a disturbance in the person’s experience of the body manifested by the persistent desire to have a specific physical disability accompanied by persistent discomfort of intense feelings of inappropriateness concerning current non-disabled body configuration. Dissociative disorders, on the other hand, are characterised by involuntary disruption of discontinuity in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behaviour. The ICD-11 dissociative disorders include dissociative neurological symptom disorder, dissociative amnesia, trance disorder, possession trance disorder, dissociative identity disorder, partial dissociative identity disorder, depersonalization-derealization disorder, and other specified dissociative disorders. Each disorder has its own set of essential features and diagnostic criteria.

Prescribing medication for elderly individuals requires consideration of their unique pharmacokinetics and pharmacodynamics. As the body ages, changes in distribution, metabolism, and excretion can affect how medication is absorbed and processed. For example, reduced gastric acid secretion and motility can impact drug absorption, while a relative reduction of body water to body fat can alter the distribution of lipid soluble drugs. Additionally, hepatic metabolism of drugs decreases with age, and the kidneys become less effective, leading to potential accumulation of certain drugs.

In terms of pharmacodynamics, receptor sensitivity tends to increase during old age, meaning smaller doses may be needed. However, older individuals may also take longer to respond to treatment and have an increased incidence of side-effects. It is important to start with a lower dose and monitor closely when prescribing medication for elderly patients, especially considering the potential for interactions with other medications they may be taking.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

If serum clozapine levels remain elevated, it is recommended to add anticonvulsant cover due to the increased risk of seizures and EEG changes. While some clinicians may advocate for higher clozapine levels, there is limited evidence to support this practice. Amisulpride can be used to augment clozapine, but it is not necessary in this situation. Beta-blockers are used to treat persistent tachycardia caused by clozapine, while hyoscine hydrobromide is used to manage clozapine-associated hypersalivation. Loperamide is unlikely to be needed as clozapine is known to cause constipation.

CYP3A4 is responsible for metabolizing the majority of benzodiazepines in the liver.

Benzodiazepines: Effective but Addictive

Benzodiazepines are a class of drugs that are commonly used to treat anxiety. They are divided into two categories: hypnotics, which have a short half-life, and anxiolytics, which have a long half-life. While they can be effective in reducing anxiety symptoms, they are also highly addictive and should not be prescribed for more than one month at a time.

Benzodiazepines are particularly effective as hypnotics, but they do have some negative effects on sleep. They suppress REM sleep, and when they are discontinued, a rebound effect is often seen. This means that people may experience more vivid dreams and nightmares when they stop taking the medication. It is important for doctors to carefully monitor patients who are taking benzodiazepines to ensure that they are not becoming addicted and that they are not experiencing any negative side effects.

Functions of the Hypothalamus

The hypothalamus is a vital part of the brain that plays a crucial role in regulating various bodily functions. It receives and integrates sensory information about the internal environment and directs actions to control internal homeostasis. The hypothalamus contains several nuclei and fiber tracts, each with specific functions.

The suprachiasmatic nucleus (SCN) is responsible for regulating circadian rhythms. Neurons in the SCN have an intrinsic rhythm of discharge activity and receive input from the retina. The SCN is considered the body’s master clock, but it has multiple connections with other hypothalamic nuclei.

Body temperature control is mainly under the control of the preoptic, anterior, and posterior nuclei, which have temperature-sensitive neurons. As the temperature goes above 37ºC, warm-sensitive neurons are activated, triggering parasympathetic activity to promote heat loss. As the temperature goes below 37ºC, cold-sensitive neurons are activated, triggering sympathetic activity to promote conservation of heat.

The hypothalamus also plays a role in regulating prolactin secretion. Dopamine is tonically secreted by dopaminergic neurons that project from the arcuate nucleus of the hypothalamus into the anterior pituitary gland via the tuberoinfundibular pathway. The dopamine that is released acts on lactotrophic cells through D2-receptors, inhibiting prolactin synthesis. In the absence of pregnancy of lactation, prolactin is constitutively inhibited by dopamine. Dopamine antagonists result in hyperprolactinemia, while dopamine agonists inhibit prolactin secretion.

In summary, the hypothalamus is a complex structure that regulates various bodily functions, including circadian rhythms, body temperature, and prolactin secretion. Dysfunction of the hypothalamus can lead to various disorders, such as sleep-rhythm disorder, diabetes insipidus, hyperprolactinemia, and obesity.

Attitude scales are used to measure a person’s feelings and thoughts towards something. There are several types of attitude scales, including the Thurstone scale, Likert scale, semantic differential scale, and Gutman scale. The Thurstone scale involves creating a list of statements and having judges score them based on their negativity of positivity towards an issue. Respondents then indicate whether they agree of disagree with each statement. The Likert scale asks respondents to indicate their degree of agreement of disagreement with a series of statements using a five-point scale. The semantic differential scale presents pairs of opposite adjectives and asks respondents to rate their position on a five- of seven-point scale. The Gutman scale involves a list of statements that can be ordered hierarchically, with each statement having a corresponding weight. Respondents’ scores on the scale indicate the number of statements they agree with.

White matter is the cabling that links different parts of the CNS together. There are three types of white matter cables: projection tracts, commissural tracts, and association tracts. Projection tracts connect higher centers of the brain with lower centers, commissural tracts connect the two hemispheres together, and association tracts connect regions of the same hemisphere. Some common tracts include the corticospinal tract, which connects the motor cortex to the brainstem and spinal cord, and the corpus callosum, which is the largest white matter fiber bundle connecting corresponding areas of cortex between the hemispheres. Other tracts include the cingulum, superior and inferior occipitofrontal fasciculi, and the superior and inferior longitudinal fasciculi.

The Cerebral Cortex and Neocortex

The cerebral cortex is the outermost layer of the cerebral hemispheres and is composed of three parts: the archicortex, paleocortex, and neocortex. The neocortex accounts for 90% of the cortex and is involved in higher functions such as thought and language. It is divided into 6-7 layers, with two main cell types: pyramidal cells and nonpyramidal cells. The surface of the neocortex is divided into separate areas, each given a number by Brodmann (e.g. Brodmann’s area 17 is the primary visual cortex). The surface is folded to increase surface area, with grooves called sulci and ridges called gyri. The neocortex is responsible for higher cognitive functions and is essential for human consciousness.

Aripiprazole and olanzapine are preferred over haloperidol due to its high impact on the QTc interval. Risperidone can also be considered as a viable option in cases where the QTc interval is elevated.

Amantadine and QTc Prolongation

Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

The Thematic Apperception Test is a personality test that falls under the category of projective tests, which involve describing rather than measuring a specific aspect.

Personality Testing

There are two main types of personality tests: projective and objective. Projective tests aim to assess unconscious material by presenting subjects with ambiguous pictures of phrases to elicit an unconscious response. Examples of projective tests include the Rorschach Inkblot, Thematic Apperception Test, Draw-A-Person test, and sentence completion tests. On the other hand, objective tests have structured and clear questions and aims. Examples of objective tests include the Minnesota Multiphasic Personality Inventory, Sixteen Personality Factor Questionnaire (16PF), NEO Personality Inventory, and Eysenck Personality Test (EPQ).

Inhibited Mania

Inhibited mania is one of the six mixed affective states identified by Kraepelin. It is characterized by symptoms of both mania and depression, but with a predominance of depressive features. Patients with inhibited mania may experience feelings of sadness, guilt, and worthlessness, as well as decreased energy and motivation. At the same time, they may also exhibit symptoms of mania, such as increased activity, impulsivity, and irritability.

Inhibited mania is considered an autonomous mixed episode, meaning that the patient consistently experiences symptoms of both mania and depression. This type of mixed state is associated with a poorer prognosis compared to those occurring between transitions from one mood state to another.

Treatment for inhibited mania typically involves a combination of mood stabilizers, antidepressants, and psychotherapy. It is important for clinicians to carefully monitor patients with inhibited mania, as they may be at increased risk for suicide and other adverse outcomes.

Compared to other antidepressants, agomelatine has a lower likelihood of causing sexual dysfunction. This is because other antidepressants can cause various changes in the body, such as sedation, hormonal changes, and disruption of the cholinergic/adrenergic balance, which can lead to sexual dysfunction. Additionally, other antidepressants may inhibit nitric oxide and increase neurotransmission, which can also contribute to sexual dysfunction. However, agomelatine does not act through the serotonergic of alpha adrenergic systems and has a lower propensity for causing these changes, resulting in less sexual dysfunction.

Frontal lobe pathology can result in the elicitation of frontal release signs, such as palmomental reflexes. Ataxia may be present in conditions like normal pressure hydrocephalus, while cogwheel rigidity is commonly found in extrapyramidal syndromes. Contralateral hemisphere dysfunction can lead to postural arm drift. These signs occur when the frontal lobe’s normal inhibition of these responses is released. For more information, see Kipps and Hodges’ article Cognitive assessment for clinicians.

Pathology Findings in Psychiatry

There are several pathology findings that are associated with various psychiatric conditions. Papp-Lantos bodies, for example, are visible in the CNS and are associated with multisystem atrophy. Pick bodies, on the other hand, are large, dark-staining aggregates of proteins in neurological tissue and are associated with frontotemporal dementia.

Lewy bodies are another common pathology finding in psychiatry and are associated with Parkinson’s disease and Lewy Body dementia. These are round, concentrically laminated, pale eosinophilic cytoplasmic inclusions that are aggregates of alpha-synuclein.

Other pathology findings include asteroid bodies, which are associated with sarcoidosis and berylliosis, and are acidophilic, stellate inclusions in giant cells. Barr bodies are associated with stains of X chromosomes and are inactivated X chromosomes that appear as a dark staining mass in contact with the nuclear membrane.

Mallory bodies are another common pathology finding and are associated with alcoholic hepatitis, alcoholic cirrhosis, Wilson’s disease, and primary-biliary cirrhosis. These are eosinophilic intracytoplasmic inclusions in hepatocytes that are made up of intermediate filaments, predominantly prekeratin.

Other pathology findings include Schaumann bodies, which are associated with sarcoidosis and berylliosis, and are concentrically laminated inclusions in giant cells. Zebra bodies are associated with Niemann-Pick disease, Tay-Sachs disease, of any of the mucopolysaccharidoses and are palisaded lamellated membranous cytoplasmic bodies seen in macrophages.

LE bodies, also known as hematoxylin bodies, are associated with SLE (lupus) and are nuclei of damaged cells with bound anti-nuclear antibodies that become homogeneous and loose chromatin pattern. Verocay bodies are associated with Schwannoma (Neurilemoma) and are palisades of nuclei at the end of a fibrillar bundle.

Hirano bodies are associated with normal aging but are more numerous in Alzheimer’s disease. These are eosinophilic, football-shaped inclusions seen in neurons of the brain. Neurofibrillary tangles are another common pathology finding in Alzheimer’s disease and are made up of microtubule-associated proteins and neurofilaments.

Kayser-Fleischer rings are associated with Wilson’s disease and are rings of discoloration on the cornea. Finally, Kuru plaques are associated with Kuru and Gerstmann-Sträussler syndrome and are sometimes present in patients with Creutzfeldt-Jakob disease (CJD). These are composed partly of a host-encoded prion protein.

Fragile X is a genetic syndrome that results in mental retardation, an elongated face, large protruding ears, and enlarged testicles (in males). Individuals with this syndrome tend to be shy, have difficulty making eye contact, and struggle with reading facial expressions. They may also exhibit stereotypic movements such as hand flapping. The cause of fragile X is a mutation in the FMR1 gene, which is crucial for neural development and functioning. This gene is located at Xq27, and in individuals with fragile X, there are excessive trinucleotide repeats (CGG) at this gene. Similar to other trinucleotide repeat disorders (such as Huntington’s, myotonic dystrophy, Friedreich’s ataxia, and spinocerebellar ataxia), the severity of the condition increases with the number of repeats.

Trinucleotide Repeat Disorders: Understanding the Genetic Basis

Trinucleotide repeat disorders are genetic conditions that arise due to the abnormal presence of an expanded sequence of trinucleotide repeats. These disorders are characterized by the phenomenon of anticipation, which refers to the amplification of the number of repeats over successive generations. This leads to an earlier onset and often a more severe form of the disease.

The table below lists the trinucleotide repeat disorders and the specific repeat sequences involved in each condition:

Condition Repeat Sequence Involved
Fragile X Syndrome CGG
Myotonic Dystrophy CTG
Huntington’s Disease CAG
Friedreich’s Ataxia GAA
Spinocerebellar Ataxia CAG

The mutations responsible for trinucleotide repeat disorders are referred to as ‘dynamic’ mutations. This is because the number of repeats can change over time, leading to a range of clinical presentations. Understanding the genetic basis of these disorders is crucial for accurate diagnosis, genetic counseling, and the development of effective treatments.

The Role of the Ventral Tegmental Area in Reward and Pleasure

The midbrain contains a cluster of dopaminergic cells known as the ventral tegmental area (VTA), which plays a crucial role in the experience of reward and pleasure. These cells are involved in the release of dopamine, a neurotransmitter that is associated with feelings of pleasure and motivation. The VTA is activated in response to various stimuli, such as food, sex, and drugs, and is responsible for the pleasurable sensations that accompany these experiences. Dysfunction in the VTA has been linked to addiction and other disorders related to reward processing. Understanding the role of the VTA in reward and pleasure is essential for developing effective treatments for these conditions.

Confirmation of lithium toxicity cannot be solely based on a normal serum lithium level. EEG is a more reliable method, as it can detect diffuse slowing and triphasic waves, which are characteristic features of lithium toxicity. CT and MRI brain scans are not helpful in confirming lithium toxicity. While ECG may show changes such as arrhythmias and flattened of inverted T-waves, they are not sufficient to confirm lithium toxicity. A lumbar puncture can rule out an infectious cause for the symptoms but cannot confirm lithium toxicity.

There are four different bases in DNA, and since a codon consists of three bases, there are 64 potential combinations of bases in a codon due to the formula 4 * 4 * 4.

Codons and Amino Acids

Codons are made up of three bases and each codon codes for an amino acid. There are 64 different triplet sequences, with three of them indicating the end of the polypeptide chain. The start codon always has the code AUG in mRNA and codes for the amino acid methionine. This leaves 61 codons that code for a total of 20 different amino acids. As a result, most of the amino acids are represented by more than one codon. Amino acids are the building blocks of proteins, which can form short polymer chains called peptides of longer chains called polypeptides of proteins.

Lesions of the vagus nerve commonly result in the following symptoms: a raspy of weak voice, difficulty swallowing, absence of the gag reflex, deviation of the uvula away from the affected side, and an inability to elevate the palate.

Overview of Cranial Nerves and Their Functions

The cranial nerves are a complex system of nerves that originate from the brain and control various functions of the head and neck. There are twelve cranial nerves, each with a specific function and origin. The following table provides a simplified overview of the cranial nerves, including their origin, skull exit, modality, and functions.

The first cranial nerve, the olfactory nerve, originates from the telencephalon and exits through the cribriform plate. It is a sensory nerve that controls the sense of smell. The second cranial nerve, the optic nerve, originates from the diencephalon and exits through the optic foramen. It is a sensory nerve that controls vision.

The third cranial nerve, the oculomotor nerve, originates from the midbrain and exits through the superior orbital fissure. It is a motor nerve that controls eye movement, pupillary constriction, and lens accommodation. The fourth cranial nerve, the trochlear nerve, also originates from the midbrain and exits through the superior orbital fissure. It is a motor nerve that controls eye movement.

The fifth cranial nerve, the trigeminal nerve, originates from the pons and exits through different foramina depending on the division. It is a mixed nerve that controls chewing and sensation of the anterior 2/3 of the scalp. It also tenses the tympanic membrane to dampen loud noises.

The sixth cranial nerve, the abducens nerve, originates from the pons and exits through the superior orbital fissure. It is a motor nerve that controls eye movement. The seventh cranial nerve, the facial nerve, also originates from the pons and exits through the internal auditory canal. It is a mixed nerve that controls facial expression, taste of the anterior 2/3 of the tongue, and tension on the stapes to dampen loud noises.

The eighth cranial nerve, the vestibulocochlear nerve, originates from the pons and exits through the internal auditory canal. It is a sensory nerve that controls hearing. The ninth cranial nerve, the glossopharyngeal nerve, originates from the medulla and exits through the jugular foramen. It is a mixed nerve that controls taste of the posterior 1/3 of the tongue, elevation of the larynx and pharynx, and swallowing.

The tenth cranial nerve, the vagus nerve, also originates from the medulla and exits through the jugular foramen. It is a mixed nerve that controls swallowing, voice production, and parasympathetic supply to nearly all thoracic and abdominal viscera. The eleventh cranial nerve, the accessory nerve, originates from the medulla and exits through the jugular foramen. It is a motor nerve that controls shoulder shrugging and head turning.

The twelfth cranial nerve, the hypoglossal nerve, originates from the medulla and exits through the hypoglossal canal. It is a motor nerve that controls tongue movement. Overall, the cranial nerves play a crucial role in controlling various functions of the head and neck, and any damage of dysfunction can have significant consequences.

The sole anticholinergic side effect is memory impairment, while the remaining choices are instances of cholinergic side effects.

Receptors and Side-Effects

Histamine H1 Blockade:
– Weight gain
– Sedation

Alpha 1 Blockade:
– Orthostatic hypotension
– Sedation
– Sexual dysfunction
– Priapism

Muscarinic Central M1 Blockade:
– Agitation
– Delirium
– Memory impairment
– Confusion
– Seizures

Muscarinic Peripheral M1 Blockade:
– Dry mouth
– Ataxia
– Blurred vision
– Narrow angle glaucoma
– Constipation
– Urinary retention
– Tachycardia

Each receptor has specific effects on the body, but they can also have side-effects. Histamine H1 blockade can cause weight gain and sedation. Alpha 1 blockade can lead to orthostatic hypotension, sedation, sexual dysfunction, and priapism. Muscarinic central M1 blockade can cause agitation, delirium, memory impairment, confusion, and seizures. Muscarinic peripheral M1 blockade can result in dry mouth, ataxia, blurred vision, narrow angle glaucoma, constipation, urinary retention, and tachycardia. It is important to be aware of these potential side-effects when using medications that affect these receptors.

Trait Theory: Understanding Personality Traits

Trait theory is a psychological approach that seeks to understand personality by identifying and categorizing specific traits. The theory was first introduced by Gordon Allport, who classified personality traits into three levels.

At the highest level, we have cardinal traits. These are traits that are so pervasive that they dominate a person’s behavior and activities. Only a few people possess cardinal traits, but for those who do, these traits are the ruling force of their personality. Cardinal traits are usually evident to most people who know the individual.

The second level of traits is central traits. These are easily detected characteristics within a person, traits that all people have a certain number of, usually around five to ten on average. Central traits are the building blocks of personality and help to define a person’s overall character.

Finally, we have secondary traits. These are less evident and only manifest in select circumstances. They are not as important as central of cardinal traits, but they still play a role in shaping a person’s behavior and personality.

Overall, trait theory provides a useful framework for understanding personality and how it develops over time. By identifying and categorizing specific traits, psychologists can gain insights into why people behave the way they do and how they can change their behavior to achieve their goals.

Bilateral infarction in the territory supplied by the distal posterior cerebral arteries can lead to cortical blindness with preserved pupillary reflex. This condition is often accompanied by Anton’s syndrome, where patients are unaware of their blindness.

, coma, respiratory depression (rare)

While adherence, compliance, and capacitance all refer to how well a patient follows a doctor’s instructions, they do not have the same meaning as concordance, which specifically refers to the agreement between patient and doctor on a treatment plan.

The critical period for development of attachment and social skills is between 6 and 36 months of age. During this time, infants and toddlers are particularly sensitive to their caregivers’ responses and interactions, which can shape their emotional and social development. This period is crucial for establishing secure attachments and developing social skills that will influence their relationships throughout their lives.

Attachment Theory and Harlow’s Monkeys

Attachment theory, developed by John Bowlby, suggests that children have an innate tendency to form relationships with people around them to increase their chance of survival. This attachment is different from bonding, which concerns the mother’s feelings for her infant. Children typically single out a primary caregiver, referred to as the principle attachment figure, from about 1-3 months. The quality of a person’s early attachments is associated with their adult behavior, with poor attachments leading to withdrawn individuals who struggle to form relationships and good attachments leading to socially competent adults who can form healthy relationships.

Bowlby’s attachment model has four stages: preattachment, attachment in the making, clear-cut attachment, and formation of reciprocal attachment. The time from 6 months to 36 months is known as the critical period, during which a child is most vulnerable to interruptions in its attachment. Attachments are divided into secure and insecure types, with insecure types further divided into avoidant and ambivalent types.

Harlow’s experiment with young rhesus monkeys demonstrated the importance of the need for closeness over food. The experiment involved giving the monkeys a choice between two different mothers, one made of soft terry cloth but provided no food and the other made of wire but provided food from an attached baby bottle. The baby monkeys spent significantly more time with their cloth mother than with their wire mother, showing the importance of attachment and closeness in early development.

Parapraxis: A Freudian Slip of the Tongue

A parapraxis, commonly known as a ‘slip of the tongue’, is a Freudian concept that suggests that these slips reveal important information about the repressed content of the unconscious mind. According to Freud, these mistakes are not accidental but rather a manifestation of the unconscious mind’s desires and thoughts. For instance, a person may accidentally call their boss by their partner’s name, revealing an underlying attraction of resentment towards their boss. Freud believed that these parapraxes could provide valuable insights into a person’s psyche and help uncover repressed memories of emotions. Therefore, he considered them an essential tool in psychoanalysis. Today, parapraxes are still studied and analyzed by psychologists and therapists to gain a better understanding of their patients’ unconscious thoughts and feelings.

Huntington’s Disease: Genetics and Pathology

Huntington’s disease is a genetic disorder that follows an autosomal dominant pattern of inheritance. It is caused by a mutation in the Huntington gene, which is located on chromosome 4. The mutation involves an abnormal expansion of a trinucleotide repeat sequence (CAG), which leads to the production of a toxic protein that damages brain cells.

The severity of the disease and the age of onset are related to the number of CAG repeats. Normally, the CAG sequence is repeated less than 27 times, but in Huntington’s disease, it is repeated many more times. The disease shows anticipation, meaning that it tends to worsen with each successive generation.

The symptoms of Huntington’s disease typically begin in the third of fourth decade of life, but in rare cases, they can appear in childhood of adolescence. The most common symptoms include involuntary movements (chorea), cognitive decline, and psychiatric disturbances.

The pathological hallmark of Huntington’s disease is the gross bilateral atrophy of the head of the caudate and putamen, which are regions of the brain involved in movement control. The EEG of patients with Huntington’s disease shows a flattened trace, indicating a loss of brain activity.

Macroscopic pathological findings include frontal atrophy, marked atrophy of the caudate and putamen, and enlarged ventricles. Microscopic findings include neuronal loss and gliosis in the cortex, neuronal loss in the striatum, and the presence of inclusion bodies in the neurons of the cortex and striatum.

In conclusion, Huntington’s disease is a devastating genetic disorder that affects the brain and causes a range of motor, cognitive, and psychiatric symptoms. The disease is caused by a mutation in the Huntington gene, which leads to the production of a toxic protein that damages brain cells. The pathological changes in the brain include atrophy of the caudate and putamen, neuronal loss, and the presence of inclusion bodies.

Attachment (Ainsworth)

Psychologist Mary Ainsworth developed the ‘Strange Situation procedure’ to study and categorize attachment in children aged 12 to 18 months. The procedure involves seven steps, including two separations and two reunions, and takes place in one room. The child’s attachment is classified into one of three styles: secure, anxious-resistant, and anxious-avoidant. A fourth category, disorganized, is sometimes observed. Ainsworth suggested that the child’s attachment style is determined by the primary caregiver’s behavior.

Mary Main later developed the Adult Attachment Interview and identified four categories of attachment in adults that correspond to those observed in the strange situation. The distribution of adult attachment styles correlates with those of the strange situation, with 70% of children and adults having secure attachment. Attachment styles also seem to be passed on to subsequent generations.

Attachment Theory and Harlow’s Monkeys

Attachment theory, developed by John Bowlby, suggests that children have an innate tendency to form relationships with people around them to increase their chance of survival. This attachment is different from bonding, which concerns the mother’s feelings for her infant. Children typically single out a primary caregiver, referred to as the principle attachment figure, from about 1-3 months. The quality of a person’s early attachments is associated with their adult behavior, with poor attachments leading to withdrawn individuals who struggle to form relationships and good attachments leading to socially competent adults who can form healthy relationships.

Bowlby’s attachment model has four stages: preattachment, attachment in the making, clear-cut attachment, and formation of reciprocal attachment. The time from 6 months to 36 months is known as the critical period, during which a child is most vulnerable to interruptions in its attachment. Attachments are divided into secure and insecure types, with insecure types further divided into avoidant and ambivalent types.

Harlow’s experiment with young rhesus monkeys demonstrated the importance of the need for closeness over food. The experiment involved giving the monkeys a choice between two different mothers, one made of soft terry cloth but provided no food and the other made of wire but provided food from an attached baby bottle. The baby monkeys spent significantly more time with their cloth mother than with their wire mother, showing the importance of attachment and closeness in early development.

Mitgehen is a type of extreme cooperation that is observed in catatonia, where the patient moves their body in the direction of even the slightest pressure. It is crucial that the patient has been instructed to resist manipulation. This phenomenon is also referred to as the ‘angle poise lamp sign’ and is a form of automatic obedience. Catalepsy is another sign seen in catatonia, where patients maintain unusual postures for extended periods of time. In contrast, cataplexy is a sudden loss of muscle tone that leads to collapse and is commonly observed in narcolepsy. Gegenhalten is an involuntary resistance to passive movements. Mitmachen is a milder form of automatic obedience, where the patient’s body can be moved into any position without resistance when instructed to resist manipulation. Mitmachen is less severe than mitgehen, as the pressure required to elicit movements in mitgehen is very minimal.

Graves’ disease is a specific type of hyperthyroidism that is characterized by unique signs such as lid lag and retraction, exophthalmos, and pretibial myxoedema. Other signs of hyperthyroidism include low body weight and hyperactivity. However, signs such as periorbital edema, dry skin, and hoarse voice are associated with hypothyroidism.

To encourage patients to express themselves freely, doctors use various techniques such as validation, confrontation, clarification, facilitation, and open-ended questions. Validation involves making patients feel more comfortable by normalizing their thoughts, feelings, of behaviors. Confrontation involves pointing out something that the patient may be missing of denying. Clarification is used to clarify something that the patient has said. Facilitation involves using verbal and non-verbal cues to encourage patients to continue sharing. Open-ended questions are used to prompt patients to respond in their own words, rather than with a simple yes or no answer.

There is controversy surrounding the question, likely due to its poor wording. However, some sources suggest that the correct answer is EEG. This may be based on a one-time recommendation in the Frith Prescribing Guidelines from 2005, which suggests that an EEG is necessary before starting lithium due to its potential to lower the seizure threshold, which is particularly relevant for individuals with LD who are prone to seizures. However, this recommendation has not been supported by NICE, the BNF, of the Maudsley Guidelines, so it should be viewed with caution. NICE and the Maudsley do recommend that all individuals have an ECG before starting lithium, so choosing that answer would be a safe choice.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

There are several different types of personality assessments available. The personality assessment inventory (PAI) is a self-report test with 344 items and 22 scales, using a Likert-type format. Likert items ask respondents to rate their level of agreement of disagreement with a statement. The 16 personality factor questionnaire (16 PF) is a self-report questionnaire with true/false format, measuring 16 different personality dimensions. The Minnesota multiphasic personality inventory (MMPI) is an objective measure of personality in adults, with 566 true/false items. The Beck depression inventory is a self-report inventory with 21 multiple choice questions, used to measure the severity of depression. Finally, the thematic apperception test (TAT) is a projective measure of personality, using 20 stimulus cards depicting scenes of varying ambiguity.

Attitude scales are used to measure a person’s feelings and thoughts towards something. There are several types of attitude scales, including the Thurstone scale, Likert scale, semantic differential scale, and Gutman scale. The Thurstone scale involves creating a list of statements and having judges score them based on their negativity of positivity towards an issue. Respondents then indicate whether they agree of disagree with each statement. The Likert scale asks respondents to indicate their degree of agreement of disagreement with a series of statements using a five-point scale. The semantic differential scale presents pairs of opposite adjectives and asks respondents to rate their position on a five- of seven-point scale. The Gutman scale involves a list of statements that can be ordered hierarchically, with each statement having a corresponding weight. Respondents’ scores on the scale indicate the number of statements they agree with.

The assessment of theory of mind is conducted through the Sally Ann test, while executive function is evaluated through the tower of London test. Projective personality tests include the tell-me-a-story test and the Rorschach test. Ammons Quick Test is utilized to aid in the evaluation of premorbid intelligence.

The Sally-Anne Test and the Theory of Mind

The Sally-Anne test, conducted by Simon Baron-Cohen, led to the development of the theory of mind idea. The experiment involved several groups of children, including those with autism. During the test, a skit was performed where Sally put a marble in a basket and left the room. Anne then removed the marble from the basket and placed it in a box. When Sally returned, the children were asked where she would look for her marble.

The results showed that most non-autistic children correctly identified the basket, while most autistic children pointed to of named the box. This led the researchers to conclude that the autistic children who chose the box lacked the ability to understand that Sally did not know the marble was in the box. The Sally-Anne test thus became a crucial tool in understanding the theory of mind, which refers to the ability to attribute mental states to oneself and others.

Understanding Incentive Salience and its Role in Addiction and Grief

Incentive salience is a process that drives the brain to desire certain things, such as drugs, and is mediated by mesolimbic dopamine systems. This process is separate from the experience of pleasure, and a person can want something they don’t necessarily like. Desire is amplified by brain states that heighten dopamine reactivity, such as stress, emotional excitement, relevant appetites, of intoxication. This state-dependent amplification of incentive salience is one reason why many addicts find it difficult to stop at just one hit.

Interestingly, grief has been hypothesized to be underpinned by a very similar process as drug addiction, referred to as the ‘incentive salience theory of grief’. Understanding the distinction between liking and wanting can help us better understand addiction and grief, and how the brain processes these experiences.

Several scales are utilized to assess the positive and negative symptoms of schizophrenia, including the assessment of positive symptoms (SAPS) and assessment of negative symptoms (SANS). These scales are commonly used in research to evaluate the effectiveness of new medications. The global assessment of functioning scale is used by clinicians to determine a patient’s overall level of functioning. The Hamilton rating scale for depression (HAM-D) is a useful tool for monitoring the severity of depression and measuring the impact of treatment. Additionally, the schedule for affective disorders and schizophrenia (SADS) was created to standardize the diagnostic evaluation of psychiatric symptoms and reduce variability in information.

Catecholamines are a group of chemical compounds that have a distinct structure consisting of a benzene ring with two hydroxyl groups, an intermediate ethyl chain, and a terminal amine group. These compounds play an important role in the body and are involved in various physiological processes. The three main catecholamines found in the body are dopamine, adrenaline, and noradrenaline. All of these compounds are derived from the amino acid tyrosine. Overall, catecholamines are essential for maintaining proper bodily functions and are involved in a wide range of physiological processes.

Culture-bound disorders are mental health conditions that are specific to certain cultural settings and may be related to other diagnostic categories such as anxiety disorders of psychosis. Examples of these disorders include windigo and brain fag, which are depressive states, latah and piblokto, which are hysterical states, and amok, which is a dissociative state.

Brain fag is commonly observed in West African students and is a reaction to extreme stress, often related to school work. Symptoms include difficulty concentrating, memory problems, low mood, and sometimes pain around the head and neck, and blurred vision.

Amok is a dissociative state that is more prevalent in Malaysia. It is characterized by symptoms such as neurasthenia, depersonalization, rage, automatism, and violent acts.

Latah is a condition similar to Tourette’s syndrome, where an exaggerated startle response leads to abnormal behavior such as screaming, cursing, dancing movements, and uncontrollable laughter. Upon provocation, affected individuals may also shout obscene utterances, imitate a word, gesture, of action, of automatically obey commands that they would not normally follow.

Piblokto, traditionally found among Eskimo women, presents with attacks of screaming, crying, and running naked through the snow.

Wendigo is a depressive condition characterized by the delusion that one has become cannibalistic. It is mostly observed in Native Americans.

FTDP-17 is a type of frontotemporal dementia that results from a mutation in the MAPT gene found on chromosome 17. The MAPT gene is responsible for producing Tau protein.

Genes Associated with Dementia

Dementia is a complex disorder that can be caused by various genetic and environmental factors. Several genes have been implicated in different forms of dementia. For instance, familial Alzheimer’s disease, which represents less than 1-6% of all Alzheimer’s cases, is associated with mutations in PSEN1, PSEN2, APP, and ApoE genes. These mutations are inherited in an autosomal dominant pattern. On the other hand, late-onset Alzheimer’s disease is a genetic risk factor associated with the ApoE gene, particularly the APOE4 allele. However, inheriting this allele does not necessarily mean that a person will develop Alzheimer’s.

Other forms of dementia, such as familial frontotemporal dementia, Huntington’s disease, CADASIL, and dementia with Lewy bodies, are also associated with specific genes. For example, C9orf72 is the most common mutation associated with familial frontotemporal dementia, while Huntington’s disease is caused by mutations in the HTT gene. CADASIL is associated with mutations in the Notch3 gene, while dementia with Lewy bodies is associated with the APOE, GBA, and SNCA genes.

In summary, understanding the genetic basis of dementia is crucial for developing effective treatments and preventive measures. However, it is important to note that genetics is only one of the many factors that contribute to the development of dementia. Environmental factors, lifestyle choices, and other health conditions also play a significant role.

Types of Shared Psychotic Disorders

There are different types of shared psychotic disorders, also known as folie à deux. Folie induite occurs when one person with psychosis adopts the delusions of another person with psychosis. On the other hand, folie imposée happens when a healthy individual takes on the delusions of a psychotic person. Folie simultanée is when two people with psychotic illnesses develop identical delusions at the same time. Meanwhile, folie communiqué is when a healthy individual eventually adopts the delusions of a person with psychosis after initially resisting them. It is important to note that a healthy individual who mimics the delusions of a psychotic person for attention is not considered to have a delusional disorder.

Dysarthria is a speech disorder that affects the volume, rate, tone, of quality of spoken language. There are different types of dysarthria, each with its own set of features, associated conditions, and localisation. The types of dysarthria include spastic, flaccid, hypokinetic, hyperkinetic, and ataxic.

Spastic dysarthria is characterised by explosive and forceful speech at a slow rate and is associated with conditions such as pseudobulbar palsy and spastic hemiplegia.

Flaccid dysarthria, on the other hand, is characterised by a breathy, nasal voice and imprecise consonants and is associated with conditions such as myasthenia gravis.

Hypokinetic dysarthria is characterised by slow, quiet speech with a tremor and is associated with conditions such as Parkinson’s disease.

Hyperkinetic dysarthria is characterised by a variable rate, inappropriate stoppages, and a strained quality and is associated with conditions such as Huntington’s disease, Sydenham’s chorea, and tardive dyskinesia.

Finally, ataxic dysarthria is characterised by rapid, monopitched, and slurred speech and is associated with conditions such as Friedreich’s ataxia and alcohol abuse. The localisation of each type of dysarthria varies, with spastic and flaccid dysarthria affecting the upper and lower motor neurons, respectively, and hypokinetic, hyperkinetic, and ataxic dysarthria affecting the extrapyramidal and cerebellar regions of the brain.

Professionalism and UK Regulation

Oaths and declarations are important in establishing trust and credibility for professions. The Hippocratic Oath, dating back to 425 BC, is a part of the Western medical tradition and emphasizes the teaching of medicine, patient’s best interests, confidentiality, and abstinence from harmful practices. However, it does not mention concepts such as autonomy of justice and forbids surgery. The Declaration of Geneva (1948) and the Declaration of Helsinki (1964) are modern-day versions of the Hippocratic Oath, emphasizing the patient’s health and interests over science and society. These declarations arose from the concern of the medical community’s complicity with the Nazi party during World War II.

In the UK, doctors must register with the General Medical Council (GMC), which sets professional standards and maintains a register of licensed doctors. It is illegal to practice medicine without a license in the UK. The GMC’s Good Medical Practice and the Good Medical Practice: Framework for Appraisal and Revalidation document emphasizes the duty of doctors to be honest and trustworthy, with dishonesty viewed harshly. Confidentiality is an important legal and ethical duty, but it is not absolute. Breaches of confidentiality may occur in emergencies, in the interests of others, when required by statute of the courts, of when required by the Driver and Vehicle Licensing Agency (DVLA). Sexualized relationships with current patients are prohibited, and accepting unsolicited gifts from patients is allowed but must not affect the way doctors prescribe, advise, treat, refer, of commission services.

Antipsychiatry is a movement that emerged in the 1960s and challenges the traditional medical model of mental illness. It argues that mental illnesses are not biological of medical conditions but rather social constructs that reflect deviations from social norms. The movement has been associated with several famous figures, including Thomas Szasz, R.D. Laing, Michel Foucault, and Franco Basaglia. These individuals have criticized the psychiatric profession for its use of involuntary hospitalization, medication, and other forms of coercion in the treatment of mental illness. They have also advocated for alternative approaches to mental health care, such as community-based care and psychotherapy. Despite its controversial nature, the antipsychiatry movement has had a significant impact on the field of mental health and continues to influence the way we think about and treat mental illness today.

Kluver-Bucy syndrome is a neurological disorder that results from dysfunction in both the right and left medial temporal lobes of the brain. This condition is characterized by a range of symptoms, including docility, altered dietary habits, hyperorality, and changes in sexual behavior. Additionally, individuals with Kluver-Bucy syndrome may experience visual agnosia, which is a condition that impairs their ability to recognize and interpret visual stimuli.

Antipsychotics can be classified in different ways, with the most common being typical (first generation) and atypical (second generation) types. Typical antipsychotics block dopamine (D2) receptors and have varying degrees of M1, Alpha-1, and H1 receptor blockade. Atypical antipsychotics have a lower propensity for extrapyramidal side-effects and are attributed to the combination of relatively lower D2 antagonism with 5HT2A antagonism. They are also classified by structure, with examples including phenothiazines, butyrophenones, thioxanthenes, diphenylbutylpiperidine, dibenzodiazepines, benzoxazoles, thienobenzodiazepine, substituted benzamides, and arylpiperidylindole (quinolone). Studies have found little evidence to support the superiority of atypicals over typicals in terms of efficacy, discontinuation rates, of adherence, with the main difference being the side-effect profile. The Royal College also favors classification by structure.

Mental State Exam – Mood and Affect

Affect is a term used to describe a patient’s present emotional responsiveness, which is indicated by their facial expression and tone of voice. It can be described as being within normal range, constricted (where the affect is restricted in range and intensity), blunted (similar to constricted but a bit more so), of flat (where there are virtually no signs of affective expression). Mood, on the other hand, is a more prolonged prevailing state of disposition. A feeling is an active experience of somatic sensation of a passive subjective experience of an emotion, while an emotion is best thought of as a feeling and memory intertwined. Apathy is the absence of feeling. It is important to distinguish between affect and mood, as affect is momentary and mood is more prolonged.

The doctor is adhering to the principle of respecting the patient’s autonomy, allowing them to make their own decisions about their treatment. The four principles of medical ethics, as proposed by Tom Beauchamp and James Childress, include nonmaleficence (avoiding harm), justice (fair distribution of resources), and beneficence (acting in the patient’s best interest).

Within the psychodrama setting, the patient takes on the role of the protagonist and actively delves into their emotional conflict. This therapeutic approach was created by Jakob Moreno and involves the dramatisation of emotional struggles in a group setting. The group leader of therapist, known as the director, plays an active role in guiding the process.

Some significant SNRIs (Serotonin Noradrenaline reuptake inhibitors) are Venlafaxine and Duloxetine.

Mechanisms of Action of Different Drugs

Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

Mendelian Inheritance (Pedigrees)

Mendelian inheritance refers to the transmission patterns of genetic conditions caused by a mutation in a single gene. There are four types of Mendelian inheritance patterns: autosomal dominant, autosomal recessive, X-linked recessive, and X-linked dominant. Each pattern follows a predictable inheritance pattern within families.

Autosomal dominant conditions are expressed in individuals who have just one copy of the mutant allele. Affected males and females have an equal probability of passing on the trait to offspring. In contrast, autosomal recessive conditions are clinically manifest only when an individual has two copies of the mutant allele. X-linked recessive traits are fully evident in males because they only have one copy of the X chromosome, while women are rarely affected by X-linked recessive diseases. X-linked dominant disorders are clinically manifest when only one copy of the mutant allele is present.

Common examples of conditions with specific inheritance patterns include neurofibromatosis type 1 and 2, tuberous sclerosis, achondroplasia, Huntington disease, Noonan’s syndrome for autosomal dominant; phenylketonuria, homocystinuria, Hurler’s syndrome, galactosaemia, Tay-Sach’s disease, Friedreich’s ataxia, Wilson’s disease, cystic fibrosis for autosomal recessive; vitamin D resistant rickets, Rett syndrome for X-linked dominant; and cerebellar ataxia, Hunter’s syndrome, Lesch-Nyhan for X-linked recessive.

ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

Operant Conditioning: Reinforcement, Punishment, and More

Operant conditioning, also known as instrumental learning, is a theory of learning developed by B.F. Skinner. It suggests that people learn by interacting with their environment. Reinforcement and punishment are key concepts in operant conditioning. A reinforcer is a stimulus of event that increases the likelihood of a behavior being repeated. Reinforcement can be positive of negative. Positive reinforcement occurs when a behavior is strengthened by adding a rewarding stimulus, while negative reinforcement occurs when a behavior is strengthened by removing an unpleasant stimulus. A punisher is a stimulus that decreases the likelihood of a behavior being repeated. Positive punishment occurs when a behavior is reduced in frequency by adding an unpleasant stimulus, while negative punishment occurs when a behavior is reduced in frequency by removing a pleasant stimulus.

Primary reinforcers are instinctual desires such as food, water, social approval, and sex. Secondary reinforcers, also known as conditioned reinforcers, are not innately appreciated and people have to learn to like them through classical conditioning of other methods. Secondary reinforcers include things such as money. Different patterns of reinforcement have different influences on the response. There are five main reinforcement schedules: fixed interval, variable interval, fixed ratio, variable ratio, and random. Variable ratio schedules are most resistant to extinction.

Shaping and chaining are techniques used when an exact behavior cannot be performed and so cannot be rewarded. Shaping involves rewarding successive, increasingly accurate approximations to the behavior, while chaining involves breaking a complex task into smaller, more manageable sections. Escape conditioning refers to a situation whereby an aversive situation is removed after a response. It is a form of negative reinforcement. Habituation refers to the phenomenon whereby there is a decrease in response to a stimulus over time. Covert sensitization is a technique used whereby someone learns to use mental imagery to associate a behavior with a negative consequence.

The term paramnesia refers to memory disorders where fantasy and reality are confused. There are various types of paramnesias, including déjà vu, jamais vu, confabulation, reduplicative paramnesia, retrospective falsification, and cryptomnesia. Reduplicative paramnesia is a subset of delusional misidentification syndromes, which include Capgras delusion, the Fregoli delusion, and others. A review of reduplicative paramnesia was conducted by Politis in 2012.

DBS is primarily used to treat Parkinson’s disease by targeting the Globus pallidus interna and subthalamic nucleus. However, for treatment-resistant depression (TRD), the subcallosal cingulate was the first area investigated for DBS, while vagal nerve stimulation has also been used. Psychosurgical treatment for refractory OCD and TRD involves targeting the anterior limb of the internal capsule. Although the caudate nucleus is part of the basal ganglia and associated with Parkinson’s disease, it is not a primary target for DBS.

Discontinuation symptoms are frequently observed in patients taking antidepressants with a shorter half-life, especially venlafaxine of paroxetine. These symptoms can be unsettling, and even patients who are aware of the cause may experience them for several days of longer if they do not resume taking the medication. Malignant hypertension is improbable since the blood pressure is not significantly elevated. Venlafaxine is not typically linked to neuroleptic malignant syndrome.

Although first rank symptoms are commonly associated with schizophrenia, they are not considered diagnostic of pathognomonic of the disorder, as they can also be present in other conditions. It is important to note that these symptoms were not originally designed for diagnostic purposes, but rather as a screening tool.

First Rank Symptoms: Their Significance in Identifying Schizophrenia

First rank symptoms were introduced by Kurt Schneider in 1938 as a practical tool for non-psychiatrists to identify schizophrenia. While they are highly suggestive of schizophrenia, they are not pathognomonic and can also be seen in affective and personality disorders. Additionally, there is no evidence to support their prognostic significance.

A systematic review in 2015 found that first rank symptoms differentiated schizophrenia from nonpsychotic mental health disorders with a sensitivity of 61.8% and a specificity of 94.1%. They also differentiated schizophrenia from other types of psychosis with a sensitivity of 58% and a specificity of 74.7%.

The first rank symptoms include running commentary, thought echo, voices heard arguing, thought insertion, thought withdrawal, thought broadcast, delusional perception, somatic passivity, made affect, and made volition. While they can be helpful in identifying schizophrenia, they should not be relied upon as the sole diagnostic criteria.

Lithium – Pharmacology

Pharmacokinetics:
Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

Ebstein’s:
Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

Contraindications:
Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

Side-effects:
Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

Lithium-induced diabetes insipidus:
Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

Toxicity:
Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

Pre-prescribing:
Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Monitoring:
Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

The TCAs that are considered the most hazardous in overdose are amitriptyline and dosulepin (dothiepin).

Tricyclic Antidepressants: Uses, Types, and Side-Effects

Tricyclic antidepressants (TCAs) are a type of medication used for depression and neuropathic pain. However, due to their side-effects and toxicity in overdose, they are not commonly used for depression anymore. TCAs can be divided into two types: first generation (tertiary amines) and second generation (secondary amines). The secondary amines have a lower side effect profile and act primarily on noradrenaline, while the tertiary amines boost serotonin and noradrenaline.

Some examples of secondary amines include desipramine, nortriptyline, protriptyline, and amoxapine. Examples of tertiary amines include amitriptyline, lofepramine, imipramine, clomipramine, dosulepin (dothiepin), doxepin, trimipramine, and butriptyline. Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, and urinary retention.

Low-dose amitriptyline is commonly used for neuropathic pain and prophylaxis of headache. Lofepramine has a lower incidence of toxicity in overdose. However, amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose. It is important to consult with a healthcare provider before taking any medication and to follow their instructions carefully.