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.

Mahler’s Separation-Individuation theory of child development proposes that personality development occurs in distinct stages. The first stage, the Autistic phase, occurs during the first few weeks of life, where the child is mostly sleeping and cut off from the world. The second stage, the Symbiotic phase, lasts until around six months of age, where the child sees themselves and their mother as a single unit. The third stage, Separation-Individuation, has four subphases. The first subphase, Differentiation, occurs between six to ten months, where the child begins to see themselves as an individual and experiences separation anxiety. The second subphase, Practicing, occurs between ten to sixteen months, where the child explores connections with the external world and people other than the mother. The third subphase, Rapprochement, occurs between sixteen to twenty-four months, where the child struggles to balance their desire for independence and proximity to the mother, often resulting in tantrums and the use of transitional objects. The fourth subphase, Object constancy, occurs between twenty-four to thirty-six months, where the child accepts the idea of object constancy and is more comfortable with the mother being separate for periods of time.

It is important to differentiate between verbigeration and vorbeirden. Verbigeration involves the senseless repetition of words of phrases, while vorbeirden occurs when a patient comprehends a question but provides an obviously incorrect answer. This phenomenon is commonly observed in Ganser’s syndrome, a type of dissociative psychosis that often affects incarcerated individuals awaiting trial.

– 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.

Melanin

Melanin is a pigment found in various parts of the body, including the skin, hair, and eyes. It is produced by specialized cells called melanocytes, which are located in the skin’s basal layer. The function of melanin in the body is not fully understood, but it is thought to play a role in protecting the skin from the harmful effects of ultraviolet (UV) radiation from the sun. Additionally, melanin may be a by-product of neurotransmitter synthesis, although this function is not well established. Overall, the role of melanin in the body is an area of ongoing research.

Types of Tremor

Essential Tremor

Otherwise known as benign essential tremor, this is the most common type of tremor. It is not associated with any underlying pathology. It usually begins in the 40’s, affects mainly the hands, and is slowly progressive. It tends to worsen with heightened emotion. It usually presents with unilateral upper limb involvement then progresses to both limbs.

Parkinsonian Tremor

This tremor is associated with Parkinson’s disease. It is classically described as ‘pill rolling’ due to the characteristic appearance of the fingers.

Cerebellar Tremor

Otherwise known as an intention tremor. This is a slow, coarse tremor which gets worse with purposeful movement. This is seen in lithium toxicity (note that the tremor seen as a side effect of long term lithium is fine and classed as physiological).

Psychogenic Tremor

Also known as a hysterical tremor. This type of tremor tends to appear and disappear suddenly and is hard to characterise due to its changeable nature. It tends to improve with distraction.

Physiologic Tremor

This is a very-low-amplitude fine tremor that is barely visible to the naked eye. It is present in every normal person while maintaining a posture of movement. It becomes enhanced and visible in many conditions such as anxiety, hyperthyroidism, alcohol withdrawal, and as drug induced side effects.

It is useful to have a basic idea about the frequencies of different types of tremor.

Type of Tremor Frequency

Intention 2-3Hz

Parkinsonian 5Hz

Essential 7Hz

Physiological 10Hz

Psychogenic variable

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.

Association fibres refer to axons that link different cortical areas within the same hemisphere of the brain. The middle longitudinal fasciculus is a white matter tract that connects the inferior parietal lobule to the temporal cortices. The uncinate fasciculus is a relatively short pathway that connects the anterior temporal areas to the inferior frontal areas. The inferior longitudinal fasciculus and inferior fronto-occipital fasciculus fibre pathways are believed to connect the occipital cortices to the anterior temporal and inferior frontal cortices (note that the inferior fronto-occipital fasciculus pathway is also known as the inferior occipitofrontal fasciculus). The cingulum is a group of white matter fibres that extend from the cingulate gyrus to the entorhinal cortex, facilitating communication between different parts of the limbic system.

Aphasia is a language impairment that affects the production of comprehension of speech, as well as the ability to read of write. The areas involved in language are situated around the Sylvian fissure, referred to as the ‘perisylvian language area’. For repetition, the primary auditory cortex, Wernicke, Broca via the Arcuate fasciculus (AF), Broca recodes into articulatory plan, primary motor cortex, and pyramidal system to cranial nerves are involved. For oral reading, the visual cortex to Wernicke and the same processes as for repetition follows. For writing, Wernicke via AF to premotor cortex for arm and hand, movement planned, sent to motor cortex. The classification of aphasia is complex and imprecise, with the Boston Group classification and Luria’s aphasia interpretation being the most influential. The important subtypes of aphasia include global aphasia, Broca’s aphasia, Wernicke’s aphasia, conduction aphasia, anomic aphasia, transcortical motor aphasia, and transcortical sensory aphasia. Additional syndromes include alexia without agraphia, alexia with agraphia, and pure word deafness.

Individuals who have ever experienced manic or hypomanic episodes should not be diagnosed with a ‘single episode depressive disorder’ (ICD-11 6A70).

Depression is diagnosed using different criteria in the ICD-11 and DSM-5. The ICD-11 recognizes single depressive episodes, recurrent depressive disorder, dysthymic disorder, and mixed depressive and anxiety disorder. The DSM-5 recognizes disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder, and premenstrual dysphoric disorder.

For a diagnosis of a single depressive episode, the ICD-11 requires the presence of at least five characteristic symptoms occurring most of the day, nearly every day during a period lasting at least 2 weeks. The DSM-5 requires the presence of at least five symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood of loss of interest of pleasure.

Recurrent depressive disorder is characterized by a history of at least two depressive episodes separated by at least several months without significant mood disturbance, according to the ICD-11. The DSM-5 requires at least two episodes with an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode.

Dysthymic disorder is diagnosed when a person experiences persistent depressed mood lasting 2 years of more, according to the ICD-11. The DSM-5 requires depressed mood for most of the day, for more days than not, for at least 2 years, along with the presence of two or more additional symptoms.

Mixed depressive and anxiety disorder is recognized as a separate code in the ICD-11, while the DSM-5 uses the ‘with anxious distress’ qualifier. The ICD-11 requires the presence of both depressive and anxiety symptoms for most of the time during a period of 2 weeks of more, while the DSM-5 requires the presence of both depressive and anxious symptoms during the same 2-week period.

Overall, the criteria for diagnosing depression vary between the ICD-11 and DSM-5, but both require the presence of characteristic symptoms that cause significant distress of impairment in functioning.

Mini Mental State Exam (MMSE)

The Mini Mental State Exam (MMSE) was developed in 1975 by Folstein et al. Its original purpose was to differentiate between organic and functional disorders, but it is now mainly used to detect and track the progression of cognitive impairment. The exam is scored out of 30 and is divided into seven categories: orientation to place and time, registration, attention and concentration, recall, language, visual construction, and attention to written command. Each category has a possible score, and the total score can indicate the severity of cognitive impairment. A score equal to or greater than 27 indicates normal cognition, while scores below this can indicate severe, moderate, of mild cognitive impairment. The MMSE is a useful tool for detecting and tracking cognitive impairment.

Mania often presents with flight of ideas, and most cases are of unknown origin, resulting in a diagnosis of primary bipolar disorder. However, in some cases, manic, hypomanic, of mixed episodes may occur after an organic insult, such as a stroke, traumatic brain injury, of tumor. The most common locations for these lesions are the thalamus, hypothalamus, basal ganglia, and frontal and temporal cortices. According to a systematic review and pooled lesion analysis by Barahona-Corrêa (2020), right-sided brain lesions are more prevalent among patients with lesional mania.

Formal Thought Disorders

In formal thought disorders, changes in the speed, coherence, and cogency of thought can be observed from a patient’s speech. These disorders can also be self-reported and may be accompanied by enhanced use of nonverbal language. One possible indication is a lack of an adequate connection between two consecutive thoughts, which is called ‘asyndesis’.

There are several types of formal thought disorders, including inhibited thinking, retarded thinking, circumstantial thinking, restricted thinking, perseverative thinking, rumination, pressured thinking, flight of ideas, tangential thinking, thought blocking, disruption of thought, incoherence/derailment, and neologisms.

Inhibited thinking is about the subjective experience of the patient, who may feel that their thinking process is slowed down of blocked by an inner wall of resistance. Retarded thinking, on the other hand, is about the observed quality of thought as inferred through speech, where the flow of thought processes is slowed down and sluggish.

Circumstantial thinking refers to an inability to separate the essential from the unessential during a conversation without rendering the conversation incoherent. Restricted thinking involves a limited range of thought content, fixation on one particular topic of a small number of topics only, and a stereotyped pattern of thinking.

Perseverative thinking is characterized by the persistent repetition of previously used words, phrases, of details to the point where they become meaningless in the context of the current stage of the interview. Rumination is the endless mental preoccupation with, of excessive concern over, mostly unpleasant thoughts.

Pressured thinking, also known as crowding of thought, is when the patient feels helplessly exposed to the pressures of floods of different ideas of thoughts. Flight of ideas involves an increasing multitude of thoughts and ideas which are no longer firmly guided by clear goal-directed thinking.

Tangential thinking occurs when the patient appears to understand the contents of the questions addressed to them but provides answers which are completely out of context. Thought blocking of disruption of thought refers to sudden disruption of an otherwise normal flow of thought of speech for no obvious reason.

Incoherence of derailment is when the interviewer is unable to establish sensible connections between the patient’s thinking and verbal output, which is sometimes also called derailment. Neologisms involve the formation of new words of usage of words which disregard normal conventions and are generally not easily understandable.

The medial temporal lobe, comprising the hippocampus and parahippocampal gyrus, exhibits the earliest neuropathological alterations.

Alzheimer’s disease is characterized by both macroscopic and microscopic changes in the brain. Macroscopic changes include cortical atrophy, ventricular dilation, and depigmentation of the locus coeruleus. Microscopic changes include the presence of senile plaques, neurofibrillary tangles, gliosis, degeneration of the nucleus of Meynert, and Hirano bodies. Senile plaques are extracellular deposits of beta amyloid in the gray matter of the brain, while neurofibrillary tangles are intracellular inclusion bodies that consist primarily of hyperphosphorylated tau. Gliosis is marked by increases in activated microglia and reactive astrocytes near the sites of amyloid plaques. The nucleus of Meynert degenerates in Alzheimer’s, resulting in a decrease in acetylcholine in the brain. Hirano bodies are actin-rich, eosinophilic intracytoplasmic inclusions which have a highly characteristic crystalloid fine structure and are regarded as a nonspecific manifestation of neuronal degeneration. These changes in the brain contribute to the cognitive decline and memory loss seen in Alzheimer’s disease.

Enzymes called RNA polymerases, not transferases, transcribe RNA from DNA.

Genomics: Understanding DNA, RNA, Transcription, and Translation

Deoxyribonucleic acid (DNA) is a molecule composed of two chains that coil around each other to form a double helix. DNA is organised into chromosomes, and each chromosome is made up of DNA coiled around proteins called histones. RNA, on the other hand, is made from a long chain of nucleotide units and is usually single-stranded. RNA is transcribed from DNA by enzymes called RNA polymerases and is central to protein synthesis.

Transcription is the synthesis of RNA from a DNA template, and it consists of three main steps: initiation, elongation, and termination. RNA polymerase binds at a sequence of DNA called the promoter, and the transcriptome is the collection of RNA molecules that results from transcription. Translation, on the other hand, refers to the synthesis of polypeptides (proteins) from mRNA. Translation takes place on ribosomes in the cell cytoplasm, where mRNA is read and translated into the string of amino acid chains that make up the synthesized protein.

The process of translation involves messenger RNA (mRNA), transfer RNA (tRNA), and ribosomal RNA (rRNA). Transfer RNAs, of tRNAs, connect mRNA codons to the amino acids they encode, while ribosomes are the structures where polypeptides (proteins) are built. Like transcription, translation also consists of three stages: initiation, elongation, and termination. In initiation, the ribosome assembles around the mRNA to be read and the first tRNA carrying the amino acid methionine. In elongation, the amino acid chain gets longer, and in termination, the finished polypeptide chain is released.

De Clérambault’s syndrome is characterized by amorous delusions where the patient believes that a person of higher social status, often a public figure, is in love with them. These delusions are not based on any actual contact of encouragement from the subject. Patients with this syndrome may also experience delusions of persecution. Due to their strong belief in the reality of their delusions, patients often lack insight and may not seek help. Treatment can include psychotherapy and antipsychotics. Other syndromes with delusional symptoms include Capgras syndrome, Cotard’s syndrome, Ekbom’s syndrome, and Othello’s syndrome.

The presence of repetitive questioning is not commonly seen in cases of global psychogenic amnesia and may indicate transient global amnesia instead.

Psychogenic Amnesia: A Non-Neurological Syndrome

Psychogenic amnesia is a rare condition where patients experience severe retrograde amnesia without any known brain injury of disorder. This syndrome is also known as hysterical amnesia, dissociative amnesia, and functional retrograde amnesia. It can be difficult to distinguish from malingered amnesia. There are two types of psychogenic amnesia: global and situation-specific. Global psychogenic amnesia can manifest as psychogenic fugue, psychogenic focal retrograde amnesia, of multiple personality disorder. Situation-specific amnesia refers to a gap in memory for a traumatic incident and can arise in various circumstances, such as PTSD of being the victim of an offense. The amnesia in global psychogenic amnesia often follows a reversed gradient, with earlier memories preferentially affected. Three factors have been identified as predisposing factors for global psychogenic amnesia: a severe precipitating stress, a history of depressed mood and suicidal ideas, and a previous history of a transient neurological amnesia.

The duration of an illness is determined by multiplying its incidence by its prevalence. If a curative treatment for the disease is discovered, the duration of the illness will decrease. The remaining answer choices will lower the incidence of the illness.

Familiarity with neuropsychological scales is necessary for the MRCPsych exams, including knowledge of the purpose of the test, whether it requires a trained observer, and the approximate duration of the test. For example, the Cornell scale assesses depression in dementia, while the Alzheimer’s disease assessment scale (ADAS) consists of eleven sections for cognitive function and ten for non-cognitive functions, taking 45 minutes with a trained observer. The abbreviated mental test score (AMTS) takes three minutes and is scored out of ten, while the clock drawing test takes two minutes and is often used in conjunction with the MMSE as a screening tool for mild-moderate dementia. The MMSE is a widely used scale with a maximum score of 30.

This scenario illustrates the concept of projection, where the athlete is projecting their own feelings of hatred onto their team mate. However, it does not involve projective identification as there is no indication of how the team mate is internalizing of reacting to the projection.

Intermediate Mechanism: Rationalisation

Rationalisation is a defense mechanism commonly used by individuals to create false but credible justifications for their behavior of actions. It involves the use of logical reasoning to explain away of justify unacceptable behavior of feelings. The individual may not be aware that they are using this mechanism, and it can be difficult to identify in oneself.

Rationalisation is considered an intermediate mechanism, as it is common in healthy individuals from ages three to ninety, as well as in neurotic disorders and in mastering acute adult stress. It can be dramatically changed by conventional psychotherapeutic interpretation.

Examples of rationalisation include a student who fails an exam and blames the teacher for not teaching the material well enough, of a person who cheats on their partner and justifies it by saying their partner was neglectful of unaffectionate. It allows the individual to avoid taking responsibility for their actions and to maintain a positive self-image.

Overall, rationalisation can be a useful defense mechanism in certain situations, but it can also be harmful if it leads to a lack of accountability and an inability to learn from mistakes.

The combination of the patient’s symptoms and medical history strongly suggests the presence of neuromuscular malignant syndrome. To confirm the diagnosis, a serum creatine kinase test would be the most beneficial investigation to conduct. Although creatine kinase is a highly sensitive marker for muscle tissue damage, it is not specific to this condition and may also be elevated in other conditions such as acute alcohol intoxication of acute psychosis.

Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

A fenestrated cavum septum pellucidum is linked to dementia pugilistica.

Dementia Pugilistica: A Neurodegenerative Condition Resulting from Neurotrauma

Dementia pugilistica, also known as chronic traumatic encephalopathy (CTE), is a neurodegenerative condition that results from neurotrauma. It is commonly seen in boxers and NFL players, but can also occur in anyone with neurotrauma. The condition is characterized by symptoms such as gait ataxia, slurred speech, impaired hearing, tremors, disequilibrium, neurobehavioral disturbances, and progressive cognitive decline.

Most cases of dementia pugilistica present with early onset cognitive deficits, and behavioral signs exhibited by patients include aggression, suspiciousness, paranoia, childishness, hypersexuality, depression, and restlessness. The progression of the condition leads to more prominent behavioral symptoms such as difficulty with impulse control, irritability, inappropriateness, and explosive outbursts of aggression.

Neuropathological abnormalities have been identified in CTE, with the most unique feature being the abnormal accumulation of tau in neurons and glia in an irregular, focal, perivascular distribution and at the depths of cortical sulci. Abnormalities of the septum pellucidum, such as cavum and fenestration, are also a common feature.

While the condition has become increasingly rare due to the progressive improvement in sports safety, it is important to recognize the potential long-term consequences of repeated head injuries and take steps to prevent them.

The Dunning-Kruger effect refers to a phenomenon where individuals with lower levels of skill of knowledge tend to overestimate their abilities, leading them to believe they are more competent than they actually are.

The Flynn Effect is the term used to describe the increase in standardised intelligence test scores over time. Research conducted by Flynn showed that IQ scores increased by 13.8 points between 1932 and 1978, which equates to a 0.3-point increase per year of approximately 3 points per decade. More recent studies have also supported the Flynn effect, with IQ score gains observed between 1972 and 2006. This means that an individual is likely to achieve a higher IQ score on an earlier version of a test than on the current version. In fact, the test will overestimate an individual’s IQ score by an average of 0.3 points per year between the year in which the test was normed and the year in which the test was administered.

The Milan systemic family therapy examines multigenerational family patterns and how family members interact and struggle over several generations. It is based on the general systems theory, which views families as systems where every action produces a reaction in one of more members. Interpersonal therapy focuses on the scientific study of people and their interpersonal processes, rather than just the mind, brain, of society. Rational emotive therapy, developed by Albert Ellis, is a short-term therapy that aims to restructure cognition and is similar to cognitive behavioural therapy. Family education therapy is related to psychoeducational interventions and is different from the methods described above. Dialectical behaviour therapy (DBT) is an integrative therapy that draws from behavioural, cognitive, and psychodynamic therapies, as well as eastern philosophy and meditation techniques.

All preganglionic neurons in both the sympathetic and parasympathetic nervous system secrete acetylcholine. The postganglionic neurotransmitter of the parasympathetic nervous system in all neurons is acetylcholine. Postganglionic fibers of the sympathetic nervous system mainly secrete Noradrenalin and Adrenalin but at sweat glands and erector pili muscles the postganglionic neurotransmitter is acetylcholine.

Dura Mater

The dura mater is one of the three membranes, known as meninges, that cover the brain and spinal cord. It is the outermost and most fibrous layer, with the pia mater and arachnoid mater making up the remaining layers. The pia mater is the innermost layer.

The dura mater is folded at certain points, including the falx cerebri, which separates the two cerebral hemispheres of the brain, the tentorium cerebelli, which separates the cerebellum from the cerebrum, the falx cerebelli, which separates the cerebellar hemispheres, and the sellar diaphragm, which covers the pituitary gland and forms a roof over the hypophyseal fossa.

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.

Agomelatine (Valdoxan) is a novel antidepressant that functions as an agonist at both MT1 and MT2 receptors, while also acting as a 5HT2C antagonist. Unlike most other antidepressants, it does not affect monoamine uptake.
First-generation antipsychotics work by antagonizing D2 receptors.
Benzodiazepines exert their effects by potentiating GABA.
Noradrenaline reuptake inhibition is a common mechanism of action for many antidepressants, including SNRIs and tricyclics.
SSRI (and other) antidepressants function by inhibiting the reuptake of serotonin.

Understanding Compound Questions in Interview Techniques

When conducting interviews, it is important to be aware of compound questions. These are questions that combine multiple inquiries into what appears to be a single question. Compound questions can be confusing for the interviewee and may lead to inaccurate of incomplete responses.

To avoid compound questions, it is important to break down inquiries into separate, clear questions. This allows the interviewee to fully understand what is being asked and provide a thoughtful response. Additionally, it is important to avoid using conjunctions such as and of of when asking questions, as this can create compound questions.

By using clear and concise language and avoiding compound questions, interviewers can ensure that they are receiving accurate and complete responses from their interviewees. This can lead to a more successful and informative interview process.

The cautious use of combined antidepressants can be considered for depression management, taking into account their mechanism of action. NICE suggests the combination of mirtazapine and SSRI for treatment-resistant depression. However, other combinations should be avoided due to the risk of interaction.

The child’s reasoning demonstrates an understanding that actions are evaluated as either positive of negative by others, and that the appropriate course of action is one that is deemed positive (of not negative) by the society.

Kohlberg’s Six Stages of Moral Development

Kohlberg’s theory of moral development consists of six stages that can be categorized into three levels. The first level is the preconventional stage, which is characterized by obedience and punishment orientation, where the focus is on the direct consequences of actions and unquestioning deference to power. The second stage is the self-interest orientation, where right behavior is defined purely by what is in the individual’s own interest.

The second level is the conventional stage, which is characterized by interpersonal accord and conformity, where the focus is on how the individual will appear to others. The behavior should accord with a consensus view on what is good. The second stage is the authority and social order obedience driven, where what is lawful is judged to be morally right. Right behavior is dictated by societal rules, and there is a greater respect for social order and the need for laws.

The third level is the postconventional stage, which is characterized by the social contract orientation, where individual rights determine behavior. The individual views laws and rules as flexible tools for improving human purposes. The fourth stage is the universal ethical principles orientation, where the right action is the one that is consistent with abstract reasoning using universal ethical principles.

It is important to note that the age ranges for Kohlberg’s developmental stages are rough guides, and sources vary widely. Kohlberg developed his stage theory following an experiment he conducted on 72 boys aged 10-16. However, the theory is criticized as sexist as it only included boys.

Blurred vision, recurrent infections (especially of the skin), lethargy, and polyuria are other possible symptoms that may indicate the development of diabetes, with type II diabetes typically presenting milder symptoms.

Antipsychotic Medication and Diabetes Risk

Individuals with schizophrenia are already at a higher risk for developing diabetes. However, taking antipsychotic medication can further increase this risk. Among the various antipsychotics, clozapine and olanzapine are associated with the highest risk. To mitigate this risk, the Maudsley recommends using amisulpride, aripiprazole, of ziprasidone for patients with a history of predisposition for diabetes. It is important for healthcare providers to carefully consider the potential risks and benefits of antipsychotic medication when treating patients with schizophrenia.

To receive a diagnosis of bipolar II, it is necessary to never have experienced a manic episode. Rapid cycling can be present in both bipolar I and II. Most individuals who experience mania will have recurring mood episodes. A diagnosis of bipolar I only requires the presence of mania, not depression. Cyclothymia is characterized by mood instability lasting for at least two years.

Bipolar Disorder Diagnosis

Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.