Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Phase 3A 2021 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Describe the checklist overview for a psych assessment

A

Introduction, history of presenting complaint, past psychiatric history, family history, personal history, past medical history, medication/drugs/alcohol, forensic history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What should be included in personal history in psych assessment?

A

birth (normal?pregnancy complications?labour complications?)
early development (milestones, general small child life)
home environment
school-social, academic
qualifications
work-employment, redundancies
relationships and children

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What should be covered in forensic history?

A

Juvenile crime, court appearances, convictions, length of sentences, crimes against person/property, experiences of prison

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What should be included in a mental state examination?

A 
Appearance and behaviour
Speech-speed, spontaneous/monosyllabic, volume, language, neologisms, punning
Mood/affect
Thoughts-content, form, stream
Perceptions
Cognition
Insight
Risk assessment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

In formulation of a psych assessment, what are the 5Ps?

A 
Presenting problem
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are functional hallucinations?

A

for a specific stimulus there is a hallucination eg tap running and voices being heard. Both perceived simultaneously

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are reflex hallucinations?

A

normal stimulus provokes a hallucination in a different sensory modality eg voices only heard whenever lights are switched on

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are hypnagogic and hypnopompic hallucinations?

A

Hypnagogic=hallucinations occurring at transition from wakefulness to sleep
Hypnopompic=hallucinations occurring at transition from sleep to wakefulness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are extracampine hallucinations?

A

Hallucinations outside of normal sensory field or range ef sensation of seeing something behind you

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the disorders of stream of thought in terms of disorders of tempo?

A

Flight of ideas
Inhibition or slowness of thinking
Circumstantiality (non direct thinking that digresses from the main point of the conversation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the disorders of stream of thought in terms of disorders of continuity of thought?

A

Perseveration (repetition of a certain response, regardless of absence or cessation of a stimulus)
Thought blocking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the disorders of possession of thought?

A

Obsessions and compulsions

Thought alienation- thought insertion, withdrawal and broadcasting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe primary delusions

A

New meaning arises in connection with some other psychological event (original)
3 types=delusional mood, delusional perception and sudden delusional idea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe secondary delusion

A

Arising from some other morbid experience/ previous abnormal experience. Psychologically understandable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the possible contents of delusions?

A

Persecutory, infidelity, love, grandiosity, guilt, nihilistic, poverty

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the disorders of memory?

A 
Dissociative amnesia (during periods of extreme trauma)
Confabulation (falsification of memory a/w organic pathology-filling-in gaps in memory)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the disorders of emotion?

A

Anhedonia (loss of pleasure)
Apathy
Incongruity of affect (eg smiling when saying how upset about dog dying)
Blunting of affect

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Describe conversion and belle indifference

A

Conversion= unconscious mechanism of symptom formation, psychological symptom causing a somatic symptom eg paralysis of hand
Belle indifference= lack of concern and/or feeling of indifference about above disability or symptom

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the disorders of experience of self?

A

Depersonalisation
Derealisation
Passivity phenomenon (somatic passivity, made acts/feelings/drives)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is catatonia and provide examples?

A

Catatonia=excited or inhibited motor activity in absence of a mood or neurological disorder

Eg
Waxy flexibility-limbs when moved feel like lead pipe/wax and remain in the position in which they were left
Echolalia- automatic repetition of words heard
Echopraxia-automatic repetition by patient of movements made by the examiner
Logoclonia- repetition of last syllable of a word
Negativism- motiveless resistance to movement
Palilalia- repetition of a word over and again with increasing frequency
Verbigeration- repetition of one or several sentences or strings of fragmented words, often in a monotonous tone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

ICD-10 diagnostic criteria for depression/ key features

A

(at least 2) core symptoms: anhedonia, anergia, low mood

associated symptoms: change in sleep (normally early morning waking), change in appetite, change in libido, diurnal mood variation, agitation, loss of confidence, loss of concentration, guilt, hopelessness, suicidal ideation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is bipolar affective disorder?

Types?

A

Depression+ hypomania/mania
Bipolar I= mania and depression (sometimes only mania)
Bipolar II=more episodes of depression, milder hypomania
Rapid cycling bipolar=episodes only last a few hours or days (rarer)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is cyclothymia?

A

Having highs and lows but much milder and so doesn’t fit the criteria for bipolar affective disorder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Describe features of hypomania

A 
Lasting for at least 4 days
Elevated mood (euphoric/dysphoric/angry)
Increased energy
Increased talkativeness 
Poor concentration
Mild reckless behaviour eg overspending
Sociability/overfamiliarity
Increased libido/sexual disinhibition 
Increased confidence
Decreased need for sleep
Change in appetite
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Describe features of mania

A 
Lasting for over a week
Extreme elation-uncontrollable
Overactivity
Pressure of speech
Impaired judgement
Extreme risk taking behaviour eg spending spree
Social disinhibition
Inflated self-esteem and grandiosity
Can have psychotic symptoms
Mood congruent or incongruent
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What are the psychoses?

A

Schizophrenia, delusional disorder, schizotypal disorder, depressive psychosis, manic psychosis, organic psychosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Epidemiology of schizophrenia and prognosis

A

Lifetime risk of 1%
Onset typically in 2nd to 3rd decade of life but a 2nd smaller peak of incidence in late middle age
M:F 1:1
Stable incidence globally
Overall die 25 years earlier than the general population

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is schizophrenia?

A

Splitting of thoughts or loss of contact with reality. Affects thoughts, perceptions, mood, personality, speech, volition, sense of self

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Describe the symptoms of schizophrenia?

A

First rank symptoms (need at least 1): thought alienation, passivity phenomena, 3rd person auditory hallucinations, delusional perception

Secondary symptoms (at least 2): delusions, 2nd person auditory hallucinations, hallucinations in other modality, thought disorder, catatonic behaviour, negative symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What are positive symptoms?

A

Hallucinations, delusions, passivity phenomena, thought alienation, lack of insight, disturbance in mood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What are negative symptoms?

A

Blunting of affect, amotivation, poverty of speech and thought, poor non-verbal communication, deterioration in functioning, self neglect, lack of insight

In a smaller proportion of people with schizophrenia this can be seen after a prolonged period of living with the disorder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Features of generalised anxiety disorder?

A

Lasting for over 6 months, tiredness, poor concentration, irritability, muscle tension, disturbed sleep (initial insomnia rather than EMW), anxiety across different situations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Features of panic disorder

A

Physical; palpitations, chest pain, choking, tachypnoea, dry mouth, urgency of micturition, dizziness, blurred visions, paraesthesia

Psychological; feeling of impending doom, fear of dying, fear of losing control, depersonalisation, derealisation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Features of OCD

A

Obsessive thoughts or images-often unpleasant (death/sexual/blasphemous), repetitive, intrusive, irrational, recognised as patient’s own thoughts

Compulsions-checking, washing, counting, symmetry, repeating certain words or phrases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

DSM classification of a personality disorder

A

DSM IV: enduring pattern inner experience and behaviour, deviates from cultural expectations, pervasive and inflexible, onset in adolescence/early adulthood, stable over time, leads to distress

DSM V added: impairments in self and interpersonal functioning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What personality disorders are in cluster A?

A

‘Odd/eccentric’

Schizoid, paranoid, schizotypal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What personality disorders are in cluster B?

A

‘Dramatic/erratic’

EUPD/BPD, histrionic, narcissistic, antisocial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What personality disorders are in cluster C?

A

‘Anxious/fearful’
Obsessive-compulsive (anankastic)
Dependent
Avoidant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Features of emotionally unstable personality disorder?

A

EUPD/Borderline personality disorder/BPD

Impulsivity-acting without thought of consequences, substance misuse, disordered eating, sexual behaviours, risk-taking behaviour, self harm, overspending
Intense unstable relationships
Fear of and attempts to avoid abandonment
Unstable mood
Chronic feelings of emptiness
Thoughts of self harm and suicide
Uncertainty around self-image, aims and preferences
May also experience transient stress induced paranoia or dissociation-can include hearing voices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Key differentials of EUPD?

A

BAD (bipolar affective disorder)- more episodic mood changes, mood changes sustained over days/weeks, presence of biological symptoms, may be mood congruent/delusions
Neurodevelopmental disorders eg ADHD and autism
Psychosis- schizophrenia, schizoaffective disorder
Complex PTSD

41
Q

How to manage BPD?

A

Psychological therapies- dialectical behaviour therapy, therapeutic communities, mentalisation based therapy
No place for pharmacy

42
Q

What impairment of functioning do you see in people with BPD?

A 
High levels of anxiety and family stress
Difficulty keeping jobs
Overemotional
Self injurious behaviour
Stormy interpersonal relationships
43
Q

Main principles of CAT?

Cognitive analytic therapy

A

Cognitive analytical therapy:
Through early experience we develop patterns of relating, including thinking, acting and feeling that can be adaptive at the time but later may become problematic

Three Rs of CAT: reformulation, recognition, revision

44
Q

Who normally forms the care coordinator role in psychological and psychosocial management?

A

Community mental health nurse (CMHN)

BUT can be OT/psychologist/psychiatrist

45
Q

Describe the bio-psycho-social model for formulation

A

Predisposing (vulnerability), precipitating (triggers), prolonging (maintaining), protective (strengths) for each of biological, psychological and social factors

46
Q

Two examples for Biological factors at each stage in bio-psycho-social model for formulation

A

Predisposing: genetics, developmental disabilities, perinatal, neonatal, physical and sensory impairments

Precipitating: hormones, physical illness, head injury, adolescence, drug use

Prolonging: non-adherence to medication, neurological impairment, alcohol and drug use

Protective: physical health, diet and exercise, adherence to medication, intact cognitive functions, sleep hygiene

47
Q

Two examples for psychological factors at each stage in bio-psycho-social model for formulation

A

Predisposing=personality, early trauma, temperament, abuse/neglect, core beliefs, emotional deregulation

Precipitating= life events, transitions and life stages, emotional deregulation

Prolonging= unhelpful coping strategies, lack of insight, beliefs and appraisals, destructive behaviour

Protective= insight, motivation for change, desire to understand phenomena, positive coping strategies, resilience and distress tolerance

48
Q

Two examples for social factors at each stage in bio-psycho-social model for formulation

A

Predisposing= formative relationships, schooling and peer groups, security, culture

Precipitating= identity, social roles, bullying, relationships/bereavements, social isolation, offending

Prolonging= destructive patterns in relationships, social isolation, non-engagement with support

Protective= supportive relationships, engagement with services, self care, spirituality, community involvement

49
Q

Describe psychodynamic (psychoanalytic) therapy

A

Based off Freud

Make connections between past and present and help patient become more aware of unconscious processes which are giving rise to symptoms

Around 1 year with weekly sessions

Therapeutic relationship with therapist is central

50
Q

Describe cognitive behavioural therapy (CBT)

A

1st wave=behaviour therapy
2nd wave=cognitive therapy
3rd wave=combine mindfulness and acceptance techniques with 1st and 2nd waves

Break scenarios down into thoughts, feelings, physical and behavioural impacts for unhelpful and helpful categories of each

Structured 12-20 sessions (may be longer). Focus on here and now and day to day problems

51
Q

Principles of counselling?

A

Normally within primary care
Help patient be clearer about their problems and come up with their own answers
Help to cope with recent events they’ve found difficult, doesn’t aim to change them as a person

52
Q

Principles of CAT?

A

NICE approved for depression and personality disorders

Patient describes how problems have developed from events in their life and personal experiences

Coping mechanisms and how to improve

53
Q

Principles of interpersonal therapy?

A

For mild to moderate depression

Help patient understand how problems may be connected to the way their relationships work

Helps identify how to strengthen relationships and find better ways of coping

54
Q

Principles of DBT?

A

For BPD
Individual and group sessions combined as a program
Regular sessions over a period of 12-18 months
Help patients learn to manage difficult emotions by experience, recognition and acceptance
Balance acceptance and change
Combines behavioural and 3rd wave CBT

55
Q

Principles of family therapy?

A

Family attend together
Often used in CAMHS
Work with a family’s strengths to help members think about different ways of behaving with each other

56
Q

Principles of marital therapy?

A

1 or 2 therapists meet with a couple

May deal with problems between the partners of stresses both partners are facing

57
Q

Name the classes of antidepressants

A

MAO (monoamine oxidase) inhibitors eg iproniazid
Tricyclic eg amitriptyline
SSRIs (selective serotonin reuptake inhibitor) eg sertraline, fluoxetine
SNRIs (serotonin noradrenaline reuptake inhibitor) eg mirtazapine, duloxetine

58
Q

Side effects of MAO inhibitors?

A 
Cheese effect (cheese contains substantial amount of tyramine, which can lead to hypertensive crises as more tyramine is absorbed when on MAOi)
Drug interactions
59
Q

Side effects of TCAs?

How do they work?

A

Anticholinergic effects (can’t pee, can’t see, can’t spit, can’t shit), alpha-1 adrenergic antagonism, antihistaminergic, overdose (lethal), seizures

Block 5-HT and NA transporters

60
Q

Side effects of SSRIs?

A

nausea, headache, GI upset.
agitation, akathisia, anxiety
sexual dysfunction, insomnia, hyponatraemia

61
Q

Description of monoamine hypothesis of depression

Arguments for and against

A

Depression is due to deficit of monoamines (noradrenaline, dopamine, serotonin)

For: all antidepressants increase NA and 5-HT function, amphetamines and cocaine elevate mood, 50% depressed patients have low CSF 5HIAA (breakdown product of serotonin)

Against: amphetamine and cocaine less effective in depressed people, alpha and beta blockers have no effect on BAD, time to therapeutic effect is long, other treatments effective in depression (ketamine, ECT, TMS)

62
Q

Description of neuroplasticity hypothesis

A

Stress (elevation of cortisol) is very neurotoxic and induces glutamate release, this decreases neuronal neuroplasticity

Antidepressants cause slow increase in BDNF (neuroprotective chemicals) via GPCRs

Antidepressants decrease glutamate release

May also directly increase plasticity in hippocampal neurones

Antidepressants help recovery by protecting brain from further stress and allow for different neural pathways to be formed

63
Q

What is serotonin syndrome?

How to treat?

A

Triad of neuromuscular abnormalities, altered mental state, autonomic dysfunction

Tx: ranges from supportive to use of cyproheptadine

64
Q

Positive and negative symptoms of psychosis?

A

Positive=hallucinations and delusions

Negative=flattened affect, cognitive difficulties, poor motivation, social withdrawal

65
Q

What pathways are in the dopaminergic system?

A

Mesolimbic, nigrostriatal, mesocortical, tuberoinfundibular

66
Q

Involvement of mesolimbic pathway in psychosis?

A

Overactivity in mesolimbic pathway
This pathway is associated with reward and pleasure centre, runs from VTA (ventral tegmented area) to nucleus accumbens
Aberrant salience hypothesis- misattribution of salience - responsible for positive symptoms
Blocking this pathway reduces positive symptoms of psychosis but might reduce ability to feel pleasure

67
Q

Role of mesocortical pathway in psychosis?

A

Underactivity in mesocortical pathway
Arises from VTA, fibres spread throughout neocortex
Required for executive function and cognitive control of emotions
Relative underactivity in schizophrenics - ‘neuroleptic dysphoria’ and responsible for some of the negative symptoms

68
Q

Role of nigrostriatal pathway and D2 antagonists

A

Nigrostriatal pathway: fibres from substantia nigra which innervate striatum in basal ganglia
Causes movement
Neurological effects caused by D2 antagonists (1st gen antipsychotics)= extrapyramidal symptoms;

69
Q

Motor side effects which can be caused by first generation antipsychotics?

A 
(Extrapyramidal side effects)
Tremor
Acute dystonia 
Akathesia
Tardive dyskinesia (irreversible side effect)
70
Q

Relation of antipsychotics to tuberoinfundibular pathway?

A

This pathway links hypothalamus to pituitary
Dopamine inhibits prolactin release in this pathway
D2 blockade will increase prolactin levels! (infertility, irregular periods, loss of libido, lactation, breast pain)

71
Q

Ways in which atypical antipsychotics work?

A

Bind less tight than typical eg haloperidol remains bound after 24 hours whereas quetiapine is only for 2-4 hours

Act as a partial agonist eg aripiprazole on D2 receptors

Do other things, rather than just D2 blockade (fewer extrapyramidal side effects)

72
Q

Downsides of second generation/ atypical antipsychotics?

A

Metabolic side effects
5HT2C and H1 receptor blockade known to increase appetite and weight eg olanzapine=14kg in 12 months
Disordered glucose handling and hypertriglyceridaemia
Can lead to postural hypotension, impotence and long QT

73
Q

What is neuroleptic malignant syndrome?

How to treat?

A

Slower onset than serotonin syndrome
Tremor, muscle cramps, fever, autonomic instability, delirium
Raised Ck can progress to rhabdomyolysis

Tx: dopamine agonists eg bromocriptine

74
Q

When is clozapine used?

Cautions?

A

Used in treatment resistance when 2 or more other treatments unsuccessful
Can cause hypersalivation and constipation
Can cause agranulocytosis-frequent blood tests for monitoring

75
Q

How long should you be on antispychotics?

A

At least 6 months after event.
Ideally more like 18 months
Sudden discontinuation associated with relapse

76
Q

Define mental disorder (legal term)

A

Any disorder or disability of the mind, excluding alcohol and drug use

77
Q

Who is AMHP and S12 approved doctor?

A

AMHP= approved mental health professional- normally social worker
Section 12 approved doctor= usually psychiatrist

78
Q

Describe section 2 of the MHA 1983?

A

28 days detention for assessment
Cannot be renewed, can give treatment without patient consent
Needed to be signed by 2 doctors (1 S12 approved) and 1 AMHP

Evidence required: signs and symptoms (not diagnosis) of mental disorder, health and safety concerns

79
Q

Describe section 3 of MHA 1983?

A

6 months detention for treatment
Can be renewed
2 doctors and 1 AMHP

Evidence: diagnosis of MHD, tx in best interests, tx available

80
Q

Describe section 4 of MHA 1983?

A

Emergency order
72 hours- only when waiting for a second doctor would lead to undesirable delay
1 doctor and 1 AMHP

Evidence: health and safety, evidence of MHD for assessment, not enough time for 2nd doctor to attend

81
Q

Describe section 5(4) of MHA 1983?

A

Patient already admitted, but wanting to leave
Nurses’ holding power until doctor can attend
6 hours
Cannot be treated coercively under this section

82
Q

Describe section 5(2) fo MHA 1983?

A

Patient already admitted, but wanting to leave
Doctors’ holding power
72 hours
Allows time for section 2 or 3 assessment
Cannot be coercively treated under this section

83
Q

Describe section 135/136 of MHA 1983?

A

Police section
S136= person suspected of having mental disorder in a public place
S135= court order to access patient’s home and remove them to place of safety (local psych unit or police cell)

84
Q

DSM criteria for delirium?

A

All 4 features must be present;
Fluctuating confusion over a short period of time,
Disturbance in consciousness,
Change in cognition or perceptual disturbance,
Evidence from history/examination/investigations consistent with delirium

85
Q

What are the subtypes of delirium?

A

Hyperactive eg inappropriate behaviour, hallucinations, agitation
Hypoactive eg lethargy, reduced concentration and appetite
Mixed-signs and symptoms of both of above

86
Q

What is involved in a delirium screen?

A

Urinalysis, sputum, FBC, folate and B12, U+E, HbA1c, Calcium, LFT, inflammatory markers, drug levels, TFTs, CXR, ECG

87
Q

Potential precipitating factors of delirium?

A

PINCHES ME
Pain, infection, nutrition, constipation, hydration, endocrine and electrolyte, stroke, medication and alcohol, environmental

Also psychological factors like stress, visual/hearing impairment, sleep deprivation

88
Q

What is OCD?

A

Obsessive compulsive disorder
Obsessions=unwelcome thoughts/images that are intrusive and cause distress
Compulsions=repetitive activities carried out to reduce the anxiety that can be caused by obsession

89
Q

How to manage OCD?

A

Talking therapies- CBT, ERP (exposure and response prevention), cognitive therapy
Potential medications=SSRIs and clomipramine (TCA, 2nd line)

90
Q

What is psychosis?

A

Number of symptoms associated with significant alterations to a person’s perception, thoughts, mood and behaviour

91
Q

Name 3 first generation/typical antipsychotics

A

Haloperidol, benperidol, chlorpromazine, flupentixol, levomepromazine, promazine, sulpiride

92
Q

Name 3 second generation/atypical antipsychotics

A

Amisulpride, clozapine, olanzapine, risperidone, quetiapine

93
Q

What is schizoaffective disorder?

A

Combination of schizophrenia symptoms and mood disorder symptoms
Bipolar type or depressive type

94
Q

What are the different types of delusions?

A

Erotomanic, grandiose, jealous, persecutory, somatic, mixed

95
Q

What are the somatoform disorders?

A

Somatisation disorder, hypochondriasis, conversion disorder, body dysmorphic disorder, pain disorder

96
Q

What is somatisation disorder?

A

Physical symptoms caused by mental or emotional factors
Many physical symptoms from different parts of the body eg headaches, abdo pain, period problems, sexual dysfunction
Wax and wane in severity

97
Q

What is hypochondriasis?

A

Minor symptoms thought to be caused by some serious disease

98
Q

What is conversion disorder?

A

Symptoms suggestive of a serious neurological disease eg total loss of version, but developed due to a stressful situation

Phase 3A 2021 (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions