Questions: EMIs
NEUROSCIENCES: NEUROANATOMY
Theme: Functional neuroanatomy
Options for questions: 1–3
- Acquired sociopathy
- Akinetic mutism
- Amnesia
- Amusia
- Anomia
- Dysprosody
- Motor aphasia
- Prosopagnosia
For each of the following areas of localisation, select the single most appropriate symptom or sign. Each option may be used once, more than once or not at all.
1. Basal forebrain
2. Orbital cortex
3. Right side areas 44 and 45 (non-dominant)
NEUROSCIENCES: NEUROENDOCRINOLOGY
Theme: Endocrine tests and their clinical use
Options for questions: 4–7
- Dexamethasone suppression test
- Fasting plasma glucose
- 24-hour urinary vanillylmandelic acid
- Oral glucose tolerance test with levels of growth hormone
- Plasma and urine osmolarity
- Plasma aldosterone and renin measurement
- Parathyroid hormone
- Short adrenocorticotropic hormone stimulation test
- Thyroid antibodies
- Thyroid-stimulating hormone
For each of the following cases, select the single most appropriate endocrinological test. Each option may be used once, more than once or not at all.
4. A 30-year-old man was diagnosed with Cushing's disease.
5. A 32-year-old man was started on olanzapine. After 2 months, he was diagnosed with diabetes mellitus.
6. A 40-year-old woman was diagnosed with a phaeochromocytoma.
7. A 32-year-old man presented with soft-tissue overgrowth, and big jaws, hands and feet.
PSYCHOPHARMACOLOGY: PHARMACODYNAMICS
Theme: Mechanism of side effects of antipsychotics
Options for questions: 8–10
- α1-adrenergic receptor blockade
- Asymmetrical σ1-receptor activation in frontal cortex
- Decreased density of neuronal nicotinic cholinergic receptors
- Dopamine D4-receptor activation in the hippocampus
- Dopamine receptor super sensitivity
- High dopamine D2-receptor occupancy in striatum
- Low dopamine D2-receptor occupancy in striatum
For each of the following side effects, select the single most appropriate mechanism. Each option may be used once, more than once or not at all.
8. Postural hypotension
9. Parkinsonism
10. Tardive dyskinesia
PSYCHOPHARMACOLOGY: PHARMACOKINETICS
Theme: Mechanism of action of psychotropic drugs
Options questions: 11–13
- Amisulpride
- Aripiprazole
- Buspirone
- Chlorpromazine
- Duloxetine
- Galantamine
- Moclobemide
- Reboxetine
For each of the following mechanisms of action, select the single most appropriate drug. Each option may be used once, more than once or not at all.
11. D2-Receptor partial agonist
12. 5-Hydroxytryptamine 1A partial agonist
13. Noradrenaline selective reuptake inhibitor
Theme: Adverse drug reactions of antidepressants
Options for questions: 14–16
- Citalopram
- Clomipramine
- Fluroxamine
- Maprotiline
- Mirtazapine
- Paroxetine
- St John's wort
- Tranylcypromine
- Venlafaxine
For each of the following descriptions, select the single most appropriate medication. Each option may be used once, more than once or not at all.
14. This drug showed no advantage over selective serotonin reuptake inhibitors (SSRIs) in low doses. It is often used in patients with hypersomnia and atypical presentation of depressive disorder. It has possibly more rapid onset of action than SSRIs, but is poorly tolerated at medium-to-high doses. Withdrawal effects are common.
15. This drug is often used in depressed patients with anxiety and severe sleep disturbance. Sedation may be inversely related to dose prescribed. Its side-effect profile is predominantly histamine 1 (H1) receptor antagonism.
16. This drug is a potent inhibitor at cytochrome CYP450-2D6 and inhibits its own metabolism. It is well tolerated by patients with panic and mixed anxiety and depressive disorders. Its abrupt withdrawal may cause gastrointestinal disturbance and movement disorders.
Theme: Mechanisms of action of psychotropic drugs
Options for questions: 17–20
- Agomelatine
- Atomoxetine
- Bupropion
- Buspirone
- Duloxetine
- Milnacipran
- Mirtazapine
- Trazodone
- Venlafaxine
- Ziprasidone
For each of the following mechanisms of action, select the single most appropriate medication that acts via that mechanism. Each option may be used once, more than once or not at all.
17. 5-Hydroxytryptamine 1A (5-HT1A) partial agonist
18. Selective noradrenaline re-uptake inhibitor
19. 5-HT2A antagonist and 5-HT reuptake inhibitor
20. Melatonin receptor agonist
PSYCHOPHARMACOLOGY: ADVERSE REACTIONS
Theme: SSRI-induced side effects
Options for questions: 21–23
- Stimulation of 5-hydroxytryptamine 2A (5-HT2A) and 5-HT2C in limbic cortex
- Stimulation of 5-HT2A in basal ganglia
- Stimulation of 5-HT2A in brain stem
- Stimulation of 5-HT2A in GI tract
- Stimulation of 5-HT2A in mesocortical centres
- Stimulation of 5-HT2A in spinal cord
- Stimulation of 5-HT3 in basal ganglia
- Stimulation of 5-HT3 in hypothalamus
- Stimulation of 5-HT3 in limbic cortex
For each of the following adverse effects of SSRI drugs, select the single most appropriate explanation of mechanism. Each option may be used once, more than once or not at all.
21. Myoclonus
22. Delayed ejaculation
23. Decreased libido
GENETICS
Theme: Genetic tests and their clinical use
Options for questions: 24–27
- Chromatin remodelling
- Guthrie's test
- Hardy–Weinberg equilibrium
- Imprinting genes
- Phenotypic equilibrium
- Polymerised chain reaction
- Quadruple test
- Small RNAs (micro-RNAs, small interfering RNAs)
- Southern blotting technique
- Western blotting test
For each of the following descriptions, select the single most appropriate genetic test. Each option may be used once, more than once or not at all.
24. Nucleosomes in the DNA have dynamic properties, thus affecting the transcription. It is a form of epigenetic modification of DNA.
25. A screening test to be done in a newborn who later presented with a learning disability, microcephaly, epilepsy, fair hair and skin, eczema, hyperactivity and autistic features.
26. This test has serum inhibin-A assay as its component.
27. This test is associated with cognitive dysfunction.
Theme: Genes involved in schizophrenia
Options for questions: 28–30
- COMT
- DAOA
- DISC1
- DISC2
- PRODH2
- Dysbindin
- Neuregulin
For each of the following chromosome locations, select the single most appropriate gene that is situated at this location. Each option may be used once, more than once or not at all.
28. Chromosome 1q42.1
29. Chromosome 6p22.3
30. Chromosome 8p21-22
Theme: Authors associated with terminology in genetics
Options for questions: 31–34
- DNA
- Gene
- Genetics
- Genome
- Genotype
- Nucleus
- Polygene
- RNA
For each of the following authors, select the terminology/terminologies with which he or she is associated according to further instructions. Each option may be used once, more than once or not at all.
31. GK Mather (select ONE options)
32. Maurice Wilkins (select ONE option)
33. Wilhelm Johannsen (select TWO options)
34. William Bateson (select ONE option)
EPIDEMIOLOGY: SURVEYS ACROSS LIFE SPAN AND MEASURES
Theme: Statistical tests in clinical research
Options for questions: 35–37
- Angoff's method
- Area under the curve
- Bonferroni's method
- Likelihood ratio
- Mann–Whitney U-test
- Receiver operating characteristic curve
- Tchaikovsky's method
- The paired t-test
For each of the following descriptions, select the single most appropriate term that best describes it. Each option may be used once, more than once or not at all.
35. This method is used to identify the best compromise between sensitivity and specificity of a test.
36. This process is used when a number of hypothesis are being evaluated using p values.
37. In this approach, a group of experts are consulted to obtain a raw cut score.
Theme: Sampling methods in clinical research
Options for questions: 38–40
- Cluster sampling
- Progressive sampling
- Quota sampling
- Random sampling
- Simple sampling
- Snowball sampling
- Stratified sampling
- Systemic sampling
For each of the following descriptions, select the single most appropriate sampling method. Each option may be used once, more than once or not at all.
38. Every twentieth name on a school admission list
39. To determine rates of depression in white and Asian people
40. To determine rates of schizophrenia in black ethnic and illegal immigrants
ADVANCED PSYCHOLOGICAL PROCESSES AND TREATMENTS
Theme: Normative and non-normative shifts
Options for questions: 41–43
- Being employed
- Bereavement
- Receiving an award in school
- Getting a driving licence
- Growth spurt
- Going on holiday
- Illness
- Increasing autonomy and responsibility
- Learning a foreign language
- Menarche
- Parental divorce
- Physical strength
- Right to vote acquired
- Self-harm
For each of the following shifts, according to Kloep and Hendry, select the most appropriate transition/transitions as per further instructions. Each option may be used once, more than once or not at all.
41. Normative society-dependent shift (select TWO options).
42. Normative maturational shift (select THREE options).
43. Non-normative shift (select THREE options).
Theme: Effects of family adversities
Options for questions: 44–46
- Child abuse is more common
- Child has negative peer interactions even before separation
- There is an established causal link to developing a psychotic illness in adulthood
- There is a higher prevalence in children reared by homosexual couples
- School performance is usually unaffected
- Sons are usually compliant to mothers
- The relationship between mother and daughter is affected in mothers who do not remarry
- There are links to adolescent criminal behaviour
- Weight loss is usually the first indicator of adversity
For each of the following family adversities, select the single most appropriate effect associated with it. Each option may be used once, more than once or not at all.
44. Marital conflict
45. Lone parents
46. Childhood physical abuse
Theme: Therapy models in children and adolescents
Options for questions: 47–48
- Art therapy
- Cognitive–behavioural therapy
- Eye-movement desensitisation and reprocessing
- Desensitisation
- Play therapy
- Psychodynamic psychotherapy
- Systemic family therapy
For each of the following cases, select the single most appropriate intervention. Each option may be used once, more than once or not at all.
47. A 12-year-old boy presented with problems in childhood that resulted from inappropriate family structure and organisation.
48. A 14-year-old adolescent girl presented with depression.
Answers: EMIs
1. C Amnesia
Amnesia is defined as memory impairment after a brain injury, neurological illness, or iatrogenic or psychological trauma. Individuals with amnesia may have normal short-term or immediate memory. Lesion in either side of basal forebrain can give rise anterograde, retrograde amnesia and confabulation.
2. A Acquired sociopathy
Individuals with acquired sociopathy can present with memory impairement, lack of concern, disinhibited behaviour and lability of mood. Acquired sociopathy is also known as pseudo-psychopathic disorder. Lesion in either side of the orbital cortex can give rise to acquired sociopathy.
3. F Dysprosody
A lesion in the non-dominant (right-side) areas 44 and 45 can give rise to dysprosody (Table 6.1).
4. A Dexamethasone suppression test
Cushing's syndrome is caused by hypercortisolism. In this condition patients may present with comorbid neuropsychiatric symptoms and signs of depression, psychosis, mania and confusion. The dexamethasone suppression test is used to demonstrate the continued production of endogenous cortisol despite the administration of an exogenous steroid.
Second-generation antipsychotic medication is associated with metabolic syndrome. It can cause an alteration in blood glucose levels and could be responsible for causing diabetes mellitus. The most useful test to diagnose diabetes mellitus is a fasting plasma glucose test.
6. C 24-hour urinary VMA
Phaeochromocytoma is one of the rare catecholamine-producing tumours. In this condition, the patient presents with episodic hypertension, anxiety and chest tightness. Glycosuria during the attacks is present in about 30% of patients. A 24-hour urine collection for vanillylmandelic acid is the screening test for diagnosis of a phaeochromocytoma. In addition, metanephrines and catecholamines can also be checked in the plasma for diagnosis.
7. D Oral glucose tolerance test with levels of growth hormone
Acromegaly is a rare disease, which is caused by hypersecretion of growth hormone (GH) from a pituitary tumour. It usually presents between ages of 30 and 50 years. It is characterised by excessive soft-tissue growth. Patients may present with the psychological effects of their disease which include mood swings, low self-esteem, body image distortion, social withdrawal and anxiety. The definite test for diagnosis is the oral glucose tolerance test with GH levels.
In case of diabetes insipidus, patient may present with polyuria, polydipsia, and dehydration. Investigations that are useful to diagnose the condition are urea and electrolytes, calcium, plasma and urine osmolality. Plasma osmolality should be high and urine osmolality should be low in order to assist this diagnosis.
8. A α1-Adrenergic receptor blockade
Postural hypotension is commonly associated with antipsychotic drugs that are antagonist at postsynaptic adrenergic α1-receptors. Clozapine, chlorpromazine, quetiapine and risperidone are associated with postural hypotension. In addition, some drugs are antagonists at presynaptic α2-adrenergic receptors, which can lead to increased release of noradrenaline, increased vagal activity and vasoconstriction.
9. F High dopamine D2-receptor occupancy in striatum
Parkinsonism results from the antagonistic action of antipsychotics at dopamine D2-receptors in the basal ganglia including the corpus striatum.
10. E Dopamine receptor supersensitivity
Tardive dyskinesia can present with choreiform, athetoid, dystonic, stereotypic or a combination of these movements. High-risk groups who may develop tardive dyskinesia include women, elderly patients, or someone with an underlying brain disease, mood disorder or diabetes mellitus. Its mechanism is considered to be receptor up-regulation, which is described as an increase in the postsynaptic receptors and supersensitivity due to chronic pharmacological antagonism.
This is a partial dopamine agonist with high affinity for dopamine D2- and D3-receptors. It has affinity for 5-hydroxytryptamine 1A (5-HT1A) receptors as partial agonist but without much affinity for D1-receptors. It possesses antagonist affinity for 5-HT2A-, 5-HT6- and 5-HT7-receptors.
12. C Buspirone
This is a partial serotonin 5-HT1A- receptor agonist, dopamine D2- and D3-receptor agonist, D4-receptor antagonist and partial α1-receptor agonist. It is used in short- and long-term treatment of generalised anxiety disorder.
13. H Reboxetine
This is a selective noradrenaline reuptake inhibitor. Although weight gain and sedation are unusual with reboxetine, side effects such as β insomnia, anxiety, agitation, sexual dysfunction, dry mouth, urinary retention, hypotension and constipation can occur.
14. I Venlafaxine
This has a dual action on serotonin and noradrenaline receptors. At higher doses it acts in dopamine as well. Its pharmacological properties resemble those of clomipramine to some extent. However, unlike clomipramine and other tricyclic antidepressants, it has a negligible affinity for other neuroreceptor sites. Hence, it lacks sedative and anticholinergic effects.
15. E Mirtazapine
This is an analogue of mianserin and has a similar pharmacological property. However, it has weaker affinity for α1-adrenoreceptors. This permits mirtazapine to activate serotonin as well as noradrenaline-neurons. It is known as a noradrenaline and serotonin-specific antidepressant. It has a sedative profile and can be used in depressed patients with sleep disturbance.
16. F Paroxetine
This is absorbed slowly and its peak plasma level is achieved after 4–8 hours. It has a half-life of 20–30 hours. Extrapyramidal side effects such as parkinsonism and akathisia are more common with selective serotonin reuptake inhibitors than tricyclic antidepressants. In particular, paroxetine is associated with acute dystonias in the first few days of treatment.
17. D Buspirone
This is a short acting 5-HT1A partial agonist which is used for anxiety disorders but not as an anxiolytic. It is administered twice or thrice daily. It is also used in combination with selective serotonin reuptake inhibitors (SSRIs) to augment its action. It would act on somatodendritic 5-HT1A autoreceptors to replete serotonin levels and SSRIs can block 5-HT reuptake. It does not cause sexual dysfunction, unlike SSRIs.
18. B Atomoxetine
Reboxetine and atomoxetine are selective noradrenaline reuptake inhibitors. Atomoxetine is primarily used to treat attention deficit hyperactivity disorder. As a result of selective action, they 113lack the additional undesirable properties of tricyclic antidepressants. However, for the same reason they are not considered as strong or effective as other agents that have multiple actions.
19. H Trazodone
Trazodone and nefazodone are 5 (5-HT2A) antagonist and 5-HT reuptake inhibitors (serotonin antagonist/reuptake inhibitor). They block 5-HT2A, 5-HT2C and serotonin transporters. All three mechanisms are responsible for the antidepressant action. They also block α1-receptors leading to undesirable effects.
20. A Agomelatine
This is a melatonin receptor agonist. It is the first antidepressant that acts on melatonergic receptors. It is a 5-HT2C and 5-HT2B antagonist.
21. C Stimulation of 5-HT2A in the brain stem
SSRIs stimulate 5-HT2A receptors in the brain stem resulting in myoclonus and slow-wave sleep disturbance.
22. F Stimulation of 5-HT2A in the spinal cord
SSRIs are known to cause sexual side effects such as decreased libido, anorgasmia and erectile dysfunction. Stimulation of serotonin and its release in the brain and spinal cord leads to a decrease in noradrenaline and dopamine. This results in sexual side effects including delayed ejaculation.
23. E Stimulation of 5-HT2A in mesocortical centres
The undesirable side effects of SSRIs seem to involve not only specific 5-HT-receptor subtypes but also the action of serotonin at the receptors in specific areas of the body, including the brain, spinal cord and gut. Different side effects and their causation, depending on the receptor subtype and site of action, are mentioned in Table 6.2. In a patient treated with SSRIs, who experienced agitation, anxiety, apathy and sexual dysfunction, it could be really difficult to know whether this represents incomplete recovery from depression or the side effects of SSRIs. In this case, adding or switching to a different class of drugs that acts on dopamine, noradrenaline or GABA may be required. Many other antidepressants that act through a separate mechanism have different side-effect profiles. For example, mirtazapine blocks 5-HT2A, 5-HT2C and 5-HT3-receptors, and therefore lacks many of the side effects caused by SSRIs. The same applies to nefazodone which blocks 5-HT2A.
24. A Chromatin remodelling
DNA is packed in chromatin in a repeat of histone DNA complexes, which are called nucleosomes. DNA has to get rid of the nucleosomes so that it is available for the transcription factors and RNA polymerase for transcription. Nucleosomes have dynamic properties that ultimately affect the transcription and, as with DNA methylation, are heritable and in fact another form of epigenetic modification of DNA. Histones are proteins and present in nucleosomes cores. Chromatin remodelling involves either the movement of the nucleosome along the length of the DNA molecule, a process known as ‘nucleosome sliding’, or by chromatin remodellers, which cause disruption and reorganisation of the nucleosome core, making the DNA available for transcription.
Phenylketonuria is the third most common cause of learning disability after Down's syndrome and fragile X syndrome. It is an autosomal recessive condition and occurs in 1:14,000 live births. There is absence of an enzyme called phenylalanine hydroxylase, which is responsible for the conversion of phenylalanine to tyrosine. Guthrie's test detects β-subtilis, the multiplication of which depends on phenylalanine. It is carried out 6–14 days after birth. The deficiency of phenylalanine hydroxylase can lead to severe learning disabilities and this can be avoided if phenylalanine is excluded from the diet. Sufferers may present with autistic behaviour, cerebral palsy, a characteristic mousy odour, fits, eczema, fair hair, blue eyes, etc.
26. G Quadruple test
This is a screening blood test for Down's syndrome and spina bifida. It can detect women who are at higher risk of their baby having either of these conditions. It cannot tell whether the fetus has or doesn't have Down's syndrome or spina bifida. The test measures four hormones in the blood: α-fetoprotein, β-human chorionic gonadotrophin, inhibin-A and oestriol.
27. D Imprinting genes
Intellectual disabilities that are present in ‘imprinting’ disorders such as Prader–Willi syndrome, Angelman's syndrome, Rett's and Turner's syndromes are due to imprinting genes.
Hardy–Weinberg equilibrium states that the allele (say if the alleles are either C or T) and genotype (genotypes will be CC, CT, TT) frequencies in a large population remain constant, i.e. in equilibrium in any population over generations in the absence of migration, mutation, assortative mating (or random mating), and natural selection. It is almost impossible that the Hardy–Weinberg equilibrium exists in nature (i.e. not evolving). The importance of the Hardy–Weinberg model is that it enables scientists to compare a change in a population's genetic structure over a period of time. If a population's genetic structure stays in Hardy–Weinberg equilibrium it will indicate a state of ‘no evolution’.
28. C DISC 1
This gene is located in chromosome 1q42.1. It encodes for a protein called disrupted in schizophrenia 1. It is implicated in disorders such as schizophrenia, depression and bipolar disorder.
29. F Dysbindin
Dystrobrevin-binding protein-1, also known as dysbindin, is located on chromosome 6p22.3. A strong association has been noticed between dysbindin expression and schizophrenia. Hermansky–Pudlak syndrome type 7 is an autosomal recessive condition that is caused by mutation in the dysbindin gene.
30. G Neuregulin
This is situated on chromosome 8p21-22.
COMT gene is located in chromosome 22q11. DAOA, known as D-amino acid oxidase activator, or G72 is located in 1224.11.
GK Mather coined the term ‘polygene’. When a certain phenotypic trait is influenced by two or more non-allelic genes, it can lead to polygenic inheritance. Eye colour is determined by two or more genes and hence is polygenic in nature.
32. A DNA
Watson, Crick and Wilkins received the noble prize in physiology or medicine in 1953 for determination of the structure of DNA.
33. B, E Gene. Genotype
Wilhelm Johannsen coined the term ‘gene’. He has also coined the terms ‘genotype’ and phenotype’.
34. C Genetics
William Bateson coined the term ‘genetics’.
35. F Receiver operating characteristic curve (ROC)
Theoretically, the most desirable balance between the values of sensitivity and specificity to be possessed by a test can be determined by a lengthy procedure involving measurement of the sensitivity and specificity values at different cut-off points, using a gold standard as reference. The sensitivity and specificity value obtained for cut-off points can also be presented graphically on an ROC. The closest point on the ROC to the ideal state represents the best sensitivity and specificity compromise, and the total area under the curve (AUC) of a test represents the probability of that test correctly identifying true positives and true negatives, i.e. test accuracy.
36. C Bonferroni's method
This method is an example of a closed test procedure. It controls the family-wise error rate for all the K hypotheses. Suppose that there are K new hypotheses each with a p value to be tested and the overall type 1 error rate is α, then all the p values < α / K are rejected.
37. A Angoff's method
In this approach, a group of experts is used to obtain a raw cut score. In this approach, a group of experts are used to obtain a raw cut score. It is a study that is used by examination or test setters to determine a cut-off for pass and fail results. The Royal College of Psychiatrists uses Angoff's method to set a standard for pass marks for theory papers 1, 2 and 3.
By combining the sensitivity and specificity values of a test, a more versatile and readily applicable measure of test validity may be derived. This measure is called a likelihood ratio and can be calculated for every possible result category of a test. It is a measure of the probability of a test result being seen in an individual with a disorder relative to it being seen in an unaffected individual.
38. H Systematic sampling
A random sample of the whole population should represent the whole population. The systematic sample involves arranging the target population according to some ordering scheme and then selecting elements at regular intervals through that ordered list.
This is the process of dividing members of the population into homogeneous subgroups before sampling and, for example, it is used for culture and racial studies.
40. F Snowballing sampling
This method recruits future participants from among their acquaintances. In other words, the sample group appears to grow like a rolling snowball. Cluster sampling is used when natural groupings are evident in a studied population.
41. D, M Getting a driving licence. Right to vote acquired
The shifts involved in a transition can be captured as ‘normative’ and ‘non-normative’ shifts. These were described by Hendry and Kloep in 1999.
42. E, H, J Growth spurt. Increasing autonomy and responsibility. Menarche
The normative maturational shift includes physical and cognitive changes that occur during adolescence in the individual, e.g. menarche, growth spurt, voice breaking and becoming more independent. The normative society-dependent shift includes transitions that occur in the environment around the individual, e.g. acquiring the right to vote and moving from primary to high school, starting an occupation (not merely being employed) and getting a licence to drive.
43. B, G, K Bereavement. Illness. Parental divorce
The non-normative shifts include changes to which the individual is subjected to as a result of adversity and self or the environment, e.g. parental divorce, illness, physical/learning disability or bereavement.
44. B Child has negative peer interactions even before separation
The effects of marital conflict are seen on children even before divorce or separation. The children are likely to have more stress and negative peer interactions. The effects on the child vary depending on the age of the child at the time of divorce or separation. The relationship between the mother and son is affected in mothers who do not remarry. There are no similar findings between the mother–daughter relationships. Sons are usually non-compliant to mother's control.
45. A Child abuse is more common
Child abuse occurs more commonly with lone parents. The effects of childhood physical abuse include adolescent criminal behaviour and violence as an adult (familial and non-familial). Childhood sexual abuse can have long-term effects on mental health.
Evidence suggests clear links to criminal behaviour in this situation. Research to date on children reared by homosexual couples does not show that the children develop significantly differently in any way.
47. G Systemic family therapy
Salvador Minuchin developed systemic family therapy, in the 1960s. It looks at structure and subsystems within the family. Therapy focuses on action more than insight and is based on normative family models with clear boundaries and hierarchies. The therapy views the presentation of the problems of the child as a result of dysfunction within the family system.
48. B Cognitive–behavioural therapy