Psych questions Flashcards
Describe the features of Section 2 (MHA)
Lasts for 28 days and is for a period of assessment
Can be instigated by a relative or approve mental health practitioner and 2 doctors
Features of Section 3 (MHA)
Lasts for 6 months and is intended for treatment
Instigated by relative, AMP and 2 doctors
Features of Section 4
Lasts 72 hours max and is intended for emergency assessment
1 doctor must say why a section 2 is not being used e.g. lack of staff
Section 5(2)
When pt is already on a hospital ward
Max of 72 hours
When 1 doctor is present
Outpatients/A&E do not count as wards
Section 5(4)
Pt is requiring detainment for a mental disorder
Max 6 hours
Can be instigated by a senior nurse
Define an obsession
An unwanted intrusive thought, image, or urge that repeatedly enters a person’s mine
Define a compulsion
Repetitive behaviours or mental acts that a person feels driven to perform
A compulsion can be either be overt and observable by others such as checking a door is locked
Or a covert mental act that cannot be observed such as repeating a certain phrase in one’s mind
RFs for OCD
FHx
Peak onset is between 10-20 years
Pregnancy/postnatal period
Hx of abuse, bulling, neglect
Give an example of severe OCD
A pt who spends >3 hours a day on their obsessions/compulsions
Has severe interference/distress and has very little control/resistance
Management of OCD if functional impairment is mild
Low-intensity psychological treatments
CBT including exposure and response prevention
If insufficient or can’t engage in psychological therapy then offer SSRI
Management of OCD if moderate functional impairment
Offer a choice of either SSRI or more intensive CBT including exposure and response prevention
Management of OCD if severe functional impairment
Refer to secondary care mental health team for assessment
Whilst awaiting assessment offer SSRI and CBT (including exposure and response prevention)
Once established how long should SSRIs be continued in a pt with OCD ?
12 months
What is the advice given if a clozapine dose is missed for more than 48 hours ?
Pt will need to re-titrate clozapine dose again slowly
Health checks for pt starting on antipsychotic medication
FBC, U&E, LFT
Lipids, weight
Fasting BG
Prolactin
BP
ECG
Cardiovascular risk assessment
What health checks are completed annually for pts on AP medication ?
FBC, U&E, LFTs
Lipids and weight
Fasting BG
Cardiovascular risk assessment
What type of medication is associated with sudden onset psychosis ?
Steroids e.g. prednisolone
Features of psychosis
Hallucinations (auditory, visual, sensational)
Delusions
Thought disorganisation e.g. alogia, tangentially, clanging or word salad
Associated features with psychosis
Agitation/aggression
Neurocognitive impairment e.g. memory, attention or executive function
Depression
Thoughts of self-harm
DD’s for psychotic symptoms
Schizophrenia - MC
Depression
Bi-polar
Puerperal psychosis
Brief psychotic disorder
Neurological conditions e.g. parkinson’s, huntingtons
Prescribed drugs e.g. corticosteroids
Illicit drugs e.g. cannabis
Between what ages is peak incidence of first episode of psychosis ?
15-30 years
Management for SAD
Same manner as mild depression
1st line psychological therapies
Follow up in 2 weeks to ensure that there has been no deterioration
2nd line SSRIs
Do not give sleeping tablets
What is the first line medication given for GAD ?
Sertraline
What is Parkinsonism ?
A side effect of AP medication e.g. chlorpromazine
Characterised by the presence of resting tremor, bradykinesia, rigidity and postural instability.
What is the pathophysiology of Parkinsonism ?
Due to the dopamine-blocking effects of these medications in the basal ganglia resulting in an imbalance between dopamine and ACh activity
Patients < 25 should be reviewed in how many weeks following SSRI treatment initiation ?
1 week
What is the key difference between mania and hypomania ?
Mania lasts for 7 days or more. Hypomania is usually 4 days or more
Psychotic symptoms occur only in mania
Mood stabilisers for bi-polar
Lithium
2nd line - sodium valproate
A patient is asked what they have eaten today. They begin by telling you a story about what they had for breakfast, then talks about their favorite cooking shows on tv, then about a time they were interviewed on a news problem and then explains that they had toast and jam for breakfast. What is this an example of ?
Circumstantiality
What is the definition of circumstantiality ?
Inability to answer a question without giving excessive unnecessary detail
What is tangentially ?
A thought disorder characterised by wandering from a topic without returning to it
What is a neologism ?
Where a new word is formed which might result from the combining of two words. Associated with thought disorders
What is clang association ?
When ideas are related to each other only by the fact that they sound similar or rhyme
What is word salad ?
Completely incoherent speech where words are strung together into nonsense sentences
What is knights move thinking ?
A severe type of loosening associations where there are unexpected and illogical leaps from one idea to another
Key feature of schizophrenia
What is a flight of ideas ?
A feature of mania
Where leaps from one topic to another occur with discernible links between them
What is preservation ?
Where repetition of ideas or words occurs despite an attempt to change a topic
What is echolalia ?
Repetition of someone eles’s speech including the questions that were asked
What is the MoA for TCAs ?
Inhibition of reuptake of neurotransmitters in the synaptic cleft increasing concentration and transmission of action potential
5-HT and NA
What is the pharmacological mechanism behind the SEs of TCAs ?
Affinity for histamine receptors - drowsiness
AChMRs - dry mouth, blurred vision, constipation and urinary retention
Adrenergic receptors - postural hypotension
Also lead to increasing of QT interval
Examples of TCAs
Amitriptyline - used in management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
Lofepramine (lower incidence of toxicity in overdose)
Examples of sedating TCAs
Amitriptyline
Clomipramine
Dosulepin
Trazodone
Examples of less sedative TCAs
Imipramine
Lofepramine
Nortriptyline
What kind of side effects are more common with imipramine ?
AChM side effects are more common
Therefore, blurred vision + dry mouth + urinary retention is more common
What is a conversion disorder ?
A psychiatric condition where psychological stress is unconsciously manifested as physical, neurological symptoms
What is acute stress disorder ?
Occurs following a life-threatening experience
Similar features as PTSG such as hyperarousal, re-experiencing, avoidance and distress
However occurs between 3 days to 4 weeks post-traumatic experience
What is a somatisation disorder ?
Multiple physical symptoms present at least 2 years
Patient refuses to accept reassurance or negative test results
Illness anxiety disorder/hypochondriasis
Persistent belief in the presence of an underlying serious disease e.g. cancer
Patient refuses to accept reassurance or negative test results
What is a dissociative disorder ?
The process of separating off certain memories from normal consciousness
This contrasts with conversion disorders as it involves psychiatric symptoms such as amnesia, fugue, stupor
Dissociative identity disorder is the new term for multiple personality disorder
What is the risk of developing schizophrenia in monozygotic twin
50%
What is the risk of developing schizophrenia with parent who is effected
10-15%
What is the risk of developing schizophrenia in sibling who is effected
10%
What is the risk of developing schizophrenia in a pt with no FHx of the condition
1%
RFs for schizophrenia
FHx
Black Caribbean ethnicity
Migration
Urban environment
Cannabis use
When assessing a conversation disorder what is the name of a sign that would suggest the condition is psychological ?
Hoover’s sign
4 key features of PTSH and timescale
4 weeks post incident
Re-experiencing
Avoidance
Hyperarousal
Emotional numbing
None-key but associated features of PTSH
Depression
Drug or alcohol misuse
Anger
Unexplained physical symptoms
Management of PTSD
Watch and weight for mild symptoms lasting 4 weeks
Trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR)
Drug treatment is not recommended as first line
If drugs are used then venlafaxine or SSRIs should be used
In severe cases then risperidone may be used
Acute dystonic reactions are seen most commonly with what type of medication ?
First generation (typical) APs
E.g. haloperidol
What is acute dystonic reactions
Characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures
Give examples of dystonic reactions
Torticollis
Opisthotonus
Dysarthria
Oculogyric crisis
Common sized effects of atypical antipsychotics
DM
Dyslipidaemia
Osteoporosis
Weight gain
What is the mechanism of action of mirtazapine ?
Noradrenergic and specific serotonergic antidepressant (NsSSAs)
Increases the release of neurotransmitters by blocking alpha2 adrenoreceptors
2 common SEs for mirtazapine
Sedation
Increased appetite
What kind of medication is duloxetine ?
SSRI
What is Charles-Bonnet Syndrome ?
Visual hallucinations associated with eye disease
The most common hallucinations are faces, children and wild animals
Occurs in patients of increasing age
Risk factors for Charles-Bonnet ?
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairment
Most common ophthalmological conditions associated with Charles-Bonnet ?
1st - macular degeneration
2nd - glaucoma
3rd - cataract
What investigation should be organised for elderly patients with sudden onset psychosis ?
CT head to rule out organic causes
When do symptoms of alcohol withdrawal usually manifest ?
6-12 hours
When do alcohol withdrawal linked seizures usually occur ?
36 hours
When does delirium tremens usually occur post alcohol withdrawal ?
72 hours
Factors that would suggest depression over dementia
Short Hx, rapid onset
Biological symptoms e.g. weight loss, sleep disturbance
Pt insight into poor memory
Global memory loss (vs dementia with recent memory loss)
First rank symptoms of schizophrenia
Auditory hallucinations
Thought disorders
Passivity phenomena
Delusional perceptions
What auditory hallucinations tend to occur in patients with schizophrenia
Two or more voices discussing the patient in the 3rd person
Thought echo
Voices commenting on the pts behaviour
What thought disorders are common in patients with schizophrenia
Thought insertion
Thought withdrawal
Thought broadcasting
What is thought insertion ?
The delusion that one’s thoughts are not one’s own, but rather belong to someone else and have been inserted into one’s mind
What is thought withdrawal ?
The delusional belief that thoughts have been ‘taken out’ of the patient’s mind, and the patient has no power over this
What is thought broadcasting ?
A type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence.
The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet.
What is passivity phenomena and what condition is it associated with ?
Bodily sensations being controlled by external influence
Actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Negative symptoms of schizophrenia
Incongruity/blunting of affect
Anhedonia
Alogia - poverty of speech
Avolition - poor motivation
Social withdrawal
(Catatonia)
What medication could be given to manage acute dystonia secondary to AP medication ?
Procyclidine
What is tardive dyskinesia
A condition where a pts face, body or both make sudden, irregular movements which cannot be control
E.g. lip smacking, difficulty swallowing and excessive blinking
What are 2 key features of lewy body dementia ?
Visual hallucinations
Motor impairment (similar to Parkinson’s)
What condition will bulimic pts often present to ED with ?
Metabolic alkalosis
Low Cl will suggest that this is due to the loss of HCL from the stomach
Hypokalaemia will show ECG changes (Tall P waves, flattened T waves, palpitations)
What is bulimia nervosa
A type of eating disorder characterised by episodes of binge-eating followed by intentional vomiting or other purgative behaviours such as use of laxatives or diuretics or exercising
Recurrent vomiting my lead to erosion of the teeth or Russell’s sign
What is Russell’s sign ?
Calluses on the knuckles on the back of the hand due to repeated self-induced vomiting
How can long term lithium use cause hyperkalaemia ?
Hyperparathyroidism
SEs of lithium
Hyperparathyroidism → Hyperkalaemia
Benign leukocytosis
Cardiac, renal and neurological damage
Hypothyroidism - MC
What are somatic symptoms of depression
Early morning waking and changes in appetite and weight
Loss of libido
Loss of emotional reactivity
Diurnal mood variation
Anhedonia
Psychomotor agitation or retardation
What are atypical features of depressed patients
Increased appetite
Hypersomnia
Core features of depression
Low mood
Anhedonia
Fatigue/low energy
Depression screening questions
During the last month have you often been bothered by feeling down, depressed or hopeless ?
During the last month, have you often been bothered by having little interest in doing things ?
Depression assessment tools ?
Hospital anxiety and depression scale (HAD)
Patient health questionnaire (PHQ-9)
What scores indicate what in a HAD assessment ?
0-7 normal
8-10 borderline
11+ = case
What scores indicate what in a PHQ-9 assessment
0-4 none
5-9 mild
10-14 moderate
15-19 moderately severe
20-27 severe
Which psychiatric medication can cause overflow incontinence ?
TCAs e.g. amitriptyline
Which psychiatric medication can lower seizure threshold ?
Clozapine
Risk factors for GAD
Age 35-54
Being divorced or separated
Living alone
Being a lone parent
Protective factors for GAD
Age 16-24
Being married or cohabiting
Which physical health conditions can present similarly to GAD
Hyperthyroid disease
Atrial fibrillation
What is the most common endocrine disorder occurring following long term lithium treatment ?
Hypothyroidism
What type of medication is rasagiline ?
MOA
Features of SSRI discontinuation syndrome
Dizziness
Electric shock sensations
Anxiety
What medication can be used to manage severe tardive dyskinesia ?
Tetrabenzine
What side effects are common with typical - first generation APs
Akathisia
Galactorrhoea
Parkinsonism
Tardive dyskinesia
Which APs are partially associated with weight gain
Atypical but partially olanzapine and clozapine
This is due to antagonism of 5-HT2C and H1 receptors resulting in increase appetite and reduced satiety
Features of Mania
Lasts from at least 7 days
Causes severe functional impairment in social and work setting
May require hospitalisation due to risk of harm to others or self
May present with psychotic symptoms
Features of hypomania
Lesser version of mania
Last > 7 days - typically 3-4 days
Can be high functioning and does not impair functional capacity to be social or work
Unlikely to require hospitalisation
Does not exhibit any psychotic symptoms
Features common to both mania and hypomania
Elevated or irritable mood
Pressured speech
Flight of ideas, rapid speech with frequent changes in topic based on associations, distractions or word play
Poor attention
Insomnia, loss of inhibitions e.g. sexual promiscuity, overspending and risk taking
Increased appetite
Classic features of a schizoid personality disorder
Little interest in friends or relationships
Tool to assess the severity of an alcohol withdrawal
Clinical Institute Withdrawal Assessment (CIWA-Ar)
How might agranulocytosis/neutropenia appear on a blood test of a pt taking Clozapine ?
Decreased leukocytes (??)
What should be checked before titrating venlafaxine
Blood pressure
What common SE are SNRIs associated with ?
HTN
What would you want to assess before starting citalopram ?
Cardiac function - ECG
QT interval
What would you assess before starting on an SSRI ?
U&Es - signs of hyponatraemia
For at risk pts monitor before initiation, 2-4 weeks post and every 3 moths thereafter
Which AP is associated with deranged blood glucose results ?
Olanzapine
What is akathisia ?
A sense of inner restlessness and inability to keep still
What risks of APs in elderly should one be aware of ?
Stroke and VTE
What is delusional parasitosis ?
A psychiatric condition where people have the mistaken belief that they are parasitized by bugs, worms, or other creatures
What is caphras delusion ?
That a friend or family member has been replaced by an identical imposter
What is Hoover’s sign ?
When pressure is felt under the paretic leg when lifting the non-paretic leg against pressure due to the involuntary contralateral extension of the hip
What change in a patients hair would support a diagnosis of anorexia nervosa
Lanugo hair
Fine downy hair growth in response to loss of body fat
Physical Features of anorexia nervosa
Failure of secondary sexual characteristics
Bradycardia
Cold-intolerance
Yellow tinge on skin (hypercarotenemia)
What medication may be used in OCD as an alternative to SSRIs
Clomipramine
Under ICD-10 criteria how long do symptoms need to last to count as depression ?
2 weeks
What are other symptoms of depression not counting the big 3
Reduced concentration and attention
Decreased self-esteem and confidence
Feelings of worthlessness and guilt
Bleak and pessimistic view of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Weight loss and diminished appetite
Psychomotor agitation or retardation
Marked loss of libido
What counts as mild depression under diagnostic criteria ?
At least 2 of the main 3 symptoms
Minimum duration of 2 weeks
Symptoms are distressing but do not limit function
What counts as moderate depression under diagnostic criteria ?
At least 2 of the main 3 symptoms of depression, and at least 3 of the other symptoms
Minimum duration for 2 weeks
Considerable difficulty with normal work and social function
What counts as severe depression under diagnosis criteria ?
All 3 of the main symptoms and at least 4 other symptoms of which some will be severe intensity
Minimum 2 weeks but if symptoms are partially severe then they may prompt early diagnosis
Psychotic symptoms may present
Severe distress and/or agitation
What is another name for illness anxiety disorder
Hypochondriasis
What are the features of sleep paralysis and what medication can be used ?
Paralysis - usually occurring on waking up but can also occur before falling asleep
Hallucinations - images or speaking that appear during the paralysis
Can be managed with clonazepam is partially troublesome
Which personality disorder is associated with strange speech ?
Schizotypical
Factors that are associated with a poor prognosis in schizophrenia
Strong FHx
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
Which AP is best suited to treating the negative symptoms of schizophrenia
Clozapine
What are the negative features of schizophrenia
Incongruity/blunting of affect
Anhedonia
Alogia - poverty of speech
Avolition - poor motivation
Social withdrawal
When is electroconvulsive therapy (ECT) indicated ?
In a catatonic patient with life-threatening depressive disorder
When should patients be reviewed whilst starting SSRIs ?
Under 25 or suicide risk then 1 week
Over 25s then 2 weeks
How long should SSRI’s be reduced when ceasing treatment ?
4 weeks
Except fluoxetine
Which SSRI has the highest incidence of discontinuation syndrome ?
Paroxetine
What are the features of SSRI discontinuation syndrome ?
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI symptoms e.g. pain, cramping, diarrhoea, vomiting
Paraesthesia
What is the most common adverse effect of electroconvulsive therapy ?
Retrograde amnesia
Which SSRI is useful for post MI depression ?
Sertraline
Which SSRI is associated with adverse ECG changes ?
Citalopram - increased QT interval - should not be used if pre-existing issues
Which medications should SSRIs not be used with ?
NSAIDs - add PPI
Warfarin/heparin → Avoid SSRI try mirtazapine
Triptans and MAOIs - serotonin syndrome
SSRIs and pregnancy
Increase risk of congenital heart defects in 1st trimester
Increase risk of persistent pulmonary hypertension of newborn if used in 3rd trimester
SEs of atypical APs
Weight gain
Hyperprolactinaemia
Stroke and VTE in elderly
Extrapyramidal SEs can occur but reduced compared to typical
Which AP carries an increased risk of dyslipidemia and obesity
Olanzapine
Which AP has a decreased side effect profile partially reduced hyperprolactinaemia
Aripiprazole
Under what circumstances can clozapine be prescribed ?
Only if 2+ APs have been used for eat least 6-8 weeks with no effect
Weekly FBCs
Baseline ECG
Full side effect profile of clozapine
Agranulocytosis 1%
Neutropenia 3%
Reduced seizure threshold
Constipation
Myocarditis
Hypersalivation
What lifestyle change could cause the dose of clozapine to be changes ?
Smoko start or cessation
Suicide RFs
Male sex
Hx of self harm
Alcohol/drug use
Hx of psych illness partially depression or schizophrenia
Hx of chronic illness
Unemployed
Social isolation
Unmarried, divorced or widowed
Risk of completed suicide
Efforts to avoid discovery
Planning
Leaving written note
Violent method
Final acts e.g. sorting finances
Protective Factors for suicide risk
Family support
Children at home
Religious belief
What extrapyramidal side effects can occur with AP use ?
Parkinsonism
Acute dystonia - sustained and uncontrolled muscle contractions e.g. torticollis/oculogyric crisis
Akathisia
Tardive dyskinesia - abnormal and involuntary movements e.g. clenching or chewing of the jaw
What other non-extrapyramidal side effects can occur with AP use
Antimuscarinic - dry mouth, blurred vision, urinary retention, constipation
Sedation/weight gain
Raised prolactin - galactonrrhoea
Impaired glucose tolerance tests
Reduced seizure threshold
Prolonged QT - partially haloperidol
Neuroleptic malignant syndrome
What is neuroleptic malignant syndrome ?
A life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction
What are the typical presentations of Anorexia nervosa
Low BMI, bradycardia, hypotension
Increased salivary gland size
Hypokalemia
Low FSH, LH, oestrogen and testosterone
Increased GC and growth hormone
Hypercholesterolaemia
Hypercarotinaemia
Low T3
Think most low but G and C high
What is the therapeutic range of lithium
0.4-1.0 mmol/L
Common SEs with lithium use
Nausea, vomiting, diarrhoea
Fine tremor
Nephrotoxicity - polyuria secondary to nephrogenic DI
Thyroid enlargement - may lead to hypo
ECG - T wave flattening/inversion
Weight gain
Idiopathic intracranial hypertension
Leukocytosis
Hyperparathyroid → hypercalcaemia
What monitoring dose lithium use require
Check 12 hours post dose
After starting check levels weekly until therapeutic range is stable
Once stable check every 3 months
Weekly check is dose changes
Thyroid and renal function check every 3 months
Capgras syndrome
Friends and family replaced by imposter
Contards syndrome
Belief that the pt is dead
De Clerambault syndrome
Delusional disorder where a patient believes that another individual is infatuated with them
Charles Bonnet Syndrome
Pt with significant vision loss have recurrent visual hallucinations
SEs of electroconvulsive therapy
Headache
Nausea
Short term memory impairment (retrograde amnesia)
Cardiac arrhythmia
(only contraindication is raised ICP)
(ADs should be reduced but not stopped proper to ECT)
Cluster A PDs
Odd and eccentric
Paranoid
Schizoid
Schizotypical
Features of a paranoid PD
Hypersensitive and unforgiving attitude when insulted
Unwarranted tendency to question the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on character
Features of a schizoid PD
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness - few interests
Few friends or confidants other than family
Features of a schizotypical PD
Ideas of reference
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd eccentric behaviour
Lack of close friends other than family
Odd speech !
Cluster B PDs
Antisocial
Borderline/EU
Histonic
Narcisstic
Features of antisocial PD
Failure to confirm to social norms e.g. laws
More common in men
Deceptive
Impulsive/reckless
Irritable and aggressive
Lack of remorse
Borderline/EU
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealisation and devaluation
Unstable self-image
Impulsivity
Recurrent suicidal behaviour
Affect instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
Features of Histonic PD
Inappropriate sexual seductiveness
Need to be centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention
Impressionistic speech lacking detail
Self-dramatization
Relationships considered to be more intimate than they are
Features of a Narcissistic PD
Grandiose sense of self-importance
Preoccupation with fantasies of unlimited success power or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy - need for admiration
Chronic envy
Arrogant and haughty attitude
Cluster C PDs
Anxious and fearful
Avoidant
Dependent
OCD PD
Avoidant PD
Avoids occupational activities which involve significant interpersonal contact due to fear of criticism or rejection
Unwillingness to be involved unless certain of being liked
Restraint in intimate relationships due to fear of being ridiculed
Reluctance to take on personal risk due to fear of embarrassment
Views self as inept and inferior to others
Dependent
Difficulty making everyday decisions without reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement
Lack of initiative
Unrealistic fear of being left to care for themselves
Urgent search for relationship as a source of care and support when a close relationship ends
OCD
Preoccupation and insistence on details, rules, lists, order and organisation; perfectionism that interferes with completing tasks; excessive doubt and exercising caution; excessive conscientiousness, as well as rigidity and stubbornness.
