MRCPsych Paper I/II Practice Session

1. MRCPsychPaper I/II Practice Session drscotthall@doctors.net.uk

2. Paper I • General Adult (history and mental state examination, cognitive assessment, neurological examination and classification) • Basic Psychopharmacology • Psychology • Descriptive psychopathology (naming weird and wonderful symptoms) • History of psychiatry (naming people who discovered things and dates they did) • Basic ethics and philosophy of psychiatry • Stigma and culture • Don’t ignore the “sitgma and culture” and “ethics” bits at the end of the list, there will be questions about it. The culture bit includes knowing the names of some very random but interesting ‘Culture Bound Syndromes’. Wikipedia is helpful for these!

3. Paper II • General Adult • General principles of psychopharmacology (pharmacokinetics, pharmacodynamics) – including drugs, their uses, side effects etc. • Neuropsychiatry (physiology, endocrinology, chemistry, anatomy, pathology) • Genetics • Epidemiology • Advanced Psychological Processes and Treatments

4. Anxious (avoidant) PD • The World Health Organization's ICD-10 lists avoidant personality disorder as (F60.6) Anxious (avoidant) personality disorder.[2] • It is characterized by at least 3 of the following: • persistent and pervasive feelings of tension and apprehension; • belief that one is socially inept, personally unappealing, or inferior to others; • excessive preoccupation with being criticized or rejected in social situations; • unwillingness to become involved with people unless certain of being liked; • restrictions in lifestyle because of need to have physical security; • avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection. • Associated features may include hypersensitivity to rejection and criticism. • It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.

5. Trance and possession disorders • Trance and Possession Disorder Possession trance is characterized by a transient alteration in identity whereby one's normal identity is temporarily replaced (possessed) by a spirit, ghost, deity, or other person. The experience of being "possessed" by another entity, such as a person, god, demon, animal, or inanimate object, holds different meanings in different cultures and therefore the diagnosis for this disorder may be culturally bound. While possession is a common experience in many cultures, in Western industrialized cultures, such experiences are not the norm. • Associated Features: Loss of control over one's actions.Behavior change or acting differently.Loss of awareness of surroundings.Loss of personal identity.Difficulty distinguishing reality from fantasy at the time of the possession.Change in tone of voice.Wandering attention.Trouble concentrating.Loss of sense of time.Loss of memory.Belief that one's body changed in appearance.

6. Miller and Cohen 2001 'We assume that the PFC serves a specific function in cognitive control: the active maintenance of patterns of activity that represent goals and the means to achieve them. They provide bias signals throughout much of the rest of the brain, affecting not only visual processes but also other sensory modalities, as well as systems responsible for response execution, memory retrieval, emotional evaluation, etc. The aggregate effect of these bias signals is to guide the flow of neural activity along pathways that establish the proper mappings between inputs, internal states, and outputs needed to perform a given task.'

7. Cognition in Bipolar disorder • individuals with bipolar disorder have impaired executive function, attentional processing, and verbal memory; these deficits seem to be independent of mood state, and persist during euthymia; attentional and executive dysfunctions appear to be familial in bipolar patients; deficits in executive function and attentional processing seem to be especially related to poor functional outcome, independent of depressive symptoms (Osuji et al 2005)

10. Dysbindin Harrison, P.J., and Owen, M.J. 2003. Genes for schizophrenia? Recent findings and their pathological implications. Lancet. 361:417–419.

13. Heritability • The concept of heritability plays a central role in the psychology of individual differences. Heritability has two definitions. The first is a statistical definition, and it defines heritability as the proportion of phenotypic variance attributable to genetic variance. The second definition is more common "sensical". It defines heritability as the extent to which genetic individual differences contribute to individual differences in observed behavior (or phenotypic individual differences). You should memorize both of these definitions. • Because heritability is a proportion, its numerical value will range from 0.0 (genes do not contribute at all to phenotypic individual differences) to 1.0 (genes are the only reason for individual differences). For human behavior, almost all estimates of heritability are in the moderate range of .30 to .60. • The quantity (1.0 - heritability) gives the environmentability of the trait. Environmentability has an analogous interpretation to heritability. It is the proportion of phenotypic variance attributable to environmental variance or the extent to which individual differences in the environment contribute to individual differences in behavior. If the heritability of most human behaviors is in the range of .30 to .60, then the environmentability of most human behaviors will be in the range of .40 to .70.

15. Arch. Gen Psych, Vol. 61 No. 3, March 200

22. Vaillant (1977) • In George Eman Valliant’s (1977) categorization, defences form a continuum related to their psychoanalytical developmental level. Vaillant's levels are: • Level I - pathological defences (i.e. psychotic denial, delusional projection) • Level II - immature defences (i.e. fantasy, projection, passive aggression, acting out) • Level III - neurotic defences (i.e. intellectualization, reaction formation, dissociation, displacement, repression) • Level IV - mature defences (i.e. humour, sublimation, suppression, altruism, anticipation)

23. Medical Ethics

24. Piaget’s Theory of Cognitive Development

30. Pinel (1745-1826) • Mania without delirium • Mania with delirium • Melancholia • Dementia • Idiotism • “Mental Alienation”/moral treatment

31. Kraepelin (1856-1926) • Manic depression • Dementia preacox • Patterns of genetics • Course and outcome

32. Bleuler (1857-1939) • Scz • 4 As • “Catastrophic Schizophrenia” *

33. Jaspers (1883-1969) • Biographical method • General psychopathology • Allgemeine Psychopathologie (1913) • Form before content (like Schneider) • Autochthonous delusions • “Un-understanable” • 3 criteria

34. Object relations theory • Fairbairn, Winnicott, Guntrip, Mahler • Attachment, frustration, rejection

39. Monothetic/Polythetic • Monothetic concepts specify necessary and sufficient conditions for class membership. Necessary conditions: any individual case, in order to qualify as an instance of the concept, would necessarily have to exhibit all the attributes enumerated in the concept • Polythetic concepts list a number or the attributes which members or the class may have without specifying any of these attributes as necessary for class membership. E.g. borderline personality disorder is diagnosed from a list or eight criteria: patients are borderline if they match up to five of these eight items, but no particular item is necessary for the diagnosis.

41. Dreams • The operations include: • Condensation — one dream object stands for several associations and ideas; thus "dreams are brief, meagre and laconic in comparison with the range and wealth of the dream-thoughts". • Displacement — a dream object's emotional significance is separated from its real object or content and attached to an entirely different one that does not raise the censor's suspicions. • Representation — a thought is translated to visual images. • Symbolism — a symbol replaces an action, person, or idea.

42. Paper II

43. Most common • The most common X-linked recessive disorders are:[2] • Red-Green color blindness; a classic example of an X-linked trait because it is easy to explain the phenotype and it's relatively common [3] (7% to 10% of men are carriers making the above calculations predict 0.49% to 1% for women). Its commonness may be attributable to its not being a serious disability in most cases and an actual advantage in some situations (for example, not being distracted by some of the color in color based camouflage).It is also known as daltonism. • Hemophilia A; another famous example because it was found in European royal families who intermarried and were famous enough that their pedigrees could be established and offered in textbooks as a "famous example" of an X-linked trait that had been documented in history books before mendelian genetics was understood. • Fragile X syndrome; resulting in a spectrum of characteristic physical, intellectual, emotional and behavioural features which range from severe to mild in manifestation. The syndrome is associated with the expansion of a single trinucleotide gene sequence (CGG) on the X chromosome, and results in a failure to express the FMR-1 protein which is required for normal neural development. • Duchenne muscular dystrophy; muscular dystrophy associated with mutations in the dystrophin gene, characterized by rapid progression of muscle degeneration, eventually leading to loss in ambulation, respiratory failure and death. • Becker's muscular dystrophy; milder form of Duchenne, causes slowly progressive muscle weakness of the legs and pelvis. • Hemophilia B; a blood clotting disorder caused by a mutation of the Factor IXgene, leading to a deficiency of Factor IX. It is rarer than haemophilia A. It's also called Christmas disease • X-linked ichthyosis; a skin condition (ichthyosis) caused by the hereditary deficiency of the steroid sulfatase (STS) enzyme that affects 1 in 2000 to 1 in 6000 males.[4] • X-linked agammaglobulinemia (XLA); affects the body's ability to fight infection (origin of the name: A=no, gammaglobulin=Antibody). XLA patients do not generate mature B cells.[5] B cells are part of the immune system and normally manufacture antibodies (also called immunoglobulins) which defends the body from infections (thehumoral response). Patients with untreated XLA are prone to develop serious and even fatal infections.[6] • Glucose-6-phosphate dehydrogenase deficiency; may exhibit nonimmune hemolytic anemia in response to a number of causes, most commonly infection or exposure to certain medications or chemicals. • Less common disorders • Theoretically, a mutation in any of the genes in the Category:Genes on chromosome X may cause disease, but below are some notable ones, with short description of symptoms: • Adrenoleukodystrophy; leads to progressive brain damage, failure of the adrenal glands and eventually death. • Alport syndrome; glomerulonephritis, endstage kidney disease, and hearing loss. • Androgen insensitivity syndrome; variable degrees of undervirilization and/or infertility in XY persons of either gender • Barth syndrome; metabolism distortion, delayed motor skills, stamina deficiency, hypotonia, chronic fatigue, delayed growth, cardiomyopathy, and compromised immune system. • Centronuclear myopathy; where cell nuclei are abnormally located in skeletal muscle cells. In CNM the nuclei are located at a position in the center of the cell, instead of their normal location at the periphery. • Charcot-Marie-Tooth disease (CMTX2-3); disorder of nerves (neuropathy) that is characterized by loss of muscle tissue and touch sensation, predominantly in the feet and legs but also in the hands and arms in the advanced stages of disease. • Coffin-Lowry syndrome; severe mental retardation sometimes associated with abnormalities of growth, cardiac abnormalities, kyphoscoliosis as well as auditory and visual abnormalities. • Fabry disease; A lysosomal storage disease causing anhidrosis, fatigue, angiokeratomas, burning extremity pain and ocular involvement. • Hunter's Syndrome; potentially causing hearing loss, thickening of the heart valves leading to a decline in cardiac function, obstructive airway disease, sleep apnea, and enlargement of the liver and spleen. • Hypohidrotic ectodermal dysplasia, presenting with hypohidrosis, hypotrichosis, hypodontia • Kabuki syndrome; multiple congenital anomalies and mental retardation. • Kennedy disease; muscle cramps and progressive weakness • Lesch-Nyhan syndrome; neurologic dysfunction, cognitive and behavioral disturbances including self-mutilation, and uric acid overproduction (hyperuricemia) • Lowe Syndrome; hydrophthalmia, cataracts, intellectual disabilities, aminoaciduria, reduced renal ammonia production and vitamin D-resistant rickets • Menkes disease; sparse and coarse hair, growth failure, and deterioration of the nervous system • Nonsyndromic deafness and X-linked nonsyndromic deafness; hearing loss • Norrie disease; cataracts, leukocoria along with other developmental issues in the eye • Occipital horn syndrome; deformations in the skeleton • Ornithine transcarbamylase deficiency; developmental delay and mental retardation. Progressive liver damage, skin lesions, and brittle hair may also be seen • Siderius X-linked mental retardation syndrome; cleft lip and palate with mental retardation and facial dysmorphism, caused by mutations in the histone demethylase PHF8 • Simpson-Golabi-Behmel syndrome; coarse faces with protruding jaw and tongue, widened nasal bridge, and upturned nasal tip • Spinal muscular atrophy caused by UBE1 gene mutation; weakness due to loss of the motor neurons of the spinal cord and brainstem • Wiskott-Aldrich syndrome; eczema, thrombocytopenia, immune deficiency, and bloody diarrhea • X-linked Severe Combined Immunodeficiency (SCID); infections, usually causing death in the first years of life • X-linked sideroblastic anemia; skin paleness, fatigue, dizziness and enlarged spleen and liver.

44. Mitochondrial • Diabetes mellitus and deafness (DAD) • this combination at an early age can be due to mitochondrial disease • Diabetes mellitus and deafness can also be found together for other reasons • Leber's hereditary optic neuropathy (LHON) • visual loss beginning in young adulthood • eye disorder characterized by progressive loss of central vision due to degeneration of the optic nerves and retina • Wolff-Parkinson-White syndrome • multiple sclerosis-type disease • affects 1 in 50,000 people in Finland • Leigh syndrome, subacute sclerosing encephalopathy • after normal development the disease usually begins late in the first year of life, although onset may occur in adulthood • a rapid decline in function occurs and is marked by seizures, altered states of consciousness, dementia, ventilatory failure • Neuropathy, ataxia, retinitis pigmentosa, and ptosis (NARP) • progressive symptoms as described in the acronym • dementia • Myoneurogenic gastrointestinal encephalopathy (MNGIE) • gastrointestinal pseudo-obstruction • neuropathy • Myoclonic Epilepsy with Ragged Red Fibers (MERRF) • progressive myoclonic epilepsy • "Ragged Red Fibers" – clumps of diseased mitochondria accumulate in the subsarcolemmal region of the muscle fiber and appear as "Ragged Red Fibers" when muscle is stained with modified Gömöri trichrome stain • short stature • hearing loss • lactic acidosis • exercise intolerance • Mitochondrial myopathy, encephalomyopathy, lactic acidosis, stroke-like symptoms (MELAS)

45. AD • Huntingtons • NF1 • Marfan • Fam hyperchol. • PCOS

46. AR (often IEM) • Tay sachs • PKU • N-P

50. Grading of Evidence • Ia: systematic review or meta-analysis of randomised controlled trials • Ib: at least one randomised controlled trial • IIa: at least one well-designed controlled study without randomisation • IIb: at least one well-designed quasi-experimental study, such as a cohort study • III: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case–control studies and case series • IV: expert committee reports, opinions and/or clinical experience of respected authorities