Risk, Capacity & Safeguarding — MCQs
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During a suicide risk assessment, which of the following questions is most appropriate for exploring suicidal ideation when no spontaneous disclosure has been made?
A 31-year-old woman with severe anorexia nervosa (BMI 13.5 kg/m²) is admitted medically for refeeding. She refuses nasogastric feeding, stating she would rather die than gain weight. Mental capacity assessment finds she cannot weigh the risks and benefits due to the overwhelming influence of her anorexia. She is not detained under the Mental Health Act. Under which legal framework should nasogastric feeding proceed?
A 74-year-old woman with moderate Alzheimer's dementia (MMSE 16/30) lives in a care home. She is assessed for capacity to consent to influenza vaccination. She understands it is an injection to prevent flu, but when asked why it is recommended, she states 'because my daughter said so' and cannot explain the risks or benefits. What is the correct interpretation of this capacity assessment?
A 26-year-old man is brought to the Emergency Department by police following threats to jump from a bridge. He has borderline personality disorder and reports chronic suicidal ideation. He describes detailed plans to purchase a firearm illegally. He is currently calm and denies immediate intent. A urine drug screen is positive for cocaine. What is the most appropriate immediate management?
A 39-year-old man with acute psychosis is detained under Section 2 of the Mental Health Act. He requires dental extraction for a severely infected tooth causing facial swelling but refuses, believing the dentist is trying to poison him. He becomes agitated when staff approach. He has capacity to refuse treatment for the dental problem. What is the legal framework for proceeding with the dental extraction?
A 47-year-old woman with recurrent depressive disorder is admitted following an overdose of 50 paracetamol tablets taken with clear suicidal intent. She has been treated with N-acetylcysteine and her liver function is improving. She now states she regrets the attempt and wants to go home to her family. Her husband reports this is her fourth attempt in 2 years. During risk assessment, which factor most strongly predicts future completed suicide in this patient?
A 68-year-old man with newly diagnosed frontotemporal dementia is assessed for capacity to make decisions about his financial affairs. He can state his assets and understand explanations about why he needs help managing finances. However, he immediately forgets the information and cannot use it to make decisions. Which component of the Mental Capacity Act assessment does this specifically demonstrate he lacks?
A 55-year-old man with no psychiatric history presents to his GP describing feeling 'very low' for 3 months. During assessment, which of the following features, if present, would most significantly increase his immediate suicide risk?
An 82-year-old woman with vascular dementia (MMSE 14/30) is admitted with a fractured neck of femur requiring surgical fixation. The orthopaedic team requests a capacity assessment as she is refusing surgery, stating 'I just want to go home'. She cannot explain the consequences of not having surgery. Her daughter has Lasting Power of Attorney for Health and Welfare and consents to the operation. What is the most appropriate next step?
A 41-year-old woman with emotionally unstable personality disorder presents to the Emergency Department following superficial cuts to her forearms after an argument with her partner. She has presented 15 times in the past year with similar presentations. She is currently calm and requesting discharge. She denies suicidal intent and states she was trying to 'release tension'. What is the most appropriate management approach?
Risk, Capacity & Safeguarding UK Medical PG Practice Questions and MCQs
Question 131: During a suicide risk assessment, which of the following questions is most appropriate for exploring suicidal ideation when no spontaneous disclosure has been made?
- A. 'You're not thinking of doing anything silly, are you?'
- B. 'Have things ever got so bad that you've thought about ending your life?' (Correct Answer)
- C. 'Do you have any plans to harm yourself in the next few days?'
- D. 'You don't have any suicidal thoughts, do you?'
- E. 'Are you feeling suicidal at the moment?'
Explanation: ***'Have things ever got so bad that you've thought about ending your life?'***- This approach is **open, non-judgmental**, and uses a **graduated technique** that normalizes the inquiry by acknowledging the patient's level of distress.- It uses **clear, unambiguous language** ("ending your life") while avoiding a confrontational tone, facilitating disclosure.*'You're not thinking of doing anything silly, are you?'*- This phrasing is **dismissive and judgmental**, using 'silly' to trivialize the patient’s potential pain and discourage honest communication.- It is a **leading question** with negative framing that makes it difficult for a patient to disclose suicidal thoughts for fear of judgment.*'Do you have any plans to harm yourself in the next few days?'*- This question jumps too quickly to **specific plans and intent** without first establishing the presence of suicidal ideation.- Effective risk assessment requires a **stepped approach**, starting with general ideation before moving to specific timelines or methods.*'You don't have any suicidal thoughts, do you?'*- This is a **closed, leading question** that implicitly invites a 'No' response, making it challenging for the patient to disagree.- It suggests **discomfort or a negative bias** from the interviewer, which can hinder therapeutic rapport and disclosure.*'Are you feeling suicidal at the moment?'*- While direct, this question can be **too abrupt and confrontational** as an opening query when no spontaneous disclosure has been made.- It focuses strictly on the **present moment**, potentially missing a history of ideation or thoughts that have occurred recently but not at the exact time of the question.
Question 132: A 31-year-old woman with severe anorexia nervosa (BMI 13.5 kg/m²) is admitted medically for refeeding. She refuses nasogastric feeding, stating she would rather die than gain weight. Mental capacity assessment finds she cannot weigh the risks and benefits due to the overwhelming influence of her anorexia. She is not detained under the Mental Health Act. Under which legal framework should nasogastric feeding proceed?
- A. Mental Health Act Section 63 for treatment of mental disorder
- B. Mental Capacity Act best interests decision-making with Deprivation of Liberty Safeguards (Correct Answer)
- C. Common law doctrine of necessity as a life-saving emergency
- D. Inherent jurisdiction of the High Court
- E. Mental Health Act Section 3 must be implemented first before any treatment
Explanation: ***Mental Capacity Act best interests decision-making with Deprivation of Liberty Safeguards*** - The patient has been assessed as **lacking capacity** to make the decision regarding feeding due to her anorexia, which is a core requirement for invoking the **Mental Capacity Act (MCA) 2005**. - Since the proposed treatment (nasogastric feeding) is against her expressed wishes and constitutes a **deprivation of liberty** (due to restraint or continuous supervision), **Deprivation of Liberty Safeguards (DoLS)** authorization is necessary to ensure the intervention is lawful and in her **best interests**. *Mental Health Act Section 63 for treatment of mental disorder* - **Section 63** of the **Mental Health Act (MHA)** permits treatment for mental disorders without consent, but only if the patient is **detained** under the MHA. - The scenario explicitly states that the patient is **not detained** under the Mental Health Act, rendering Section 63 inapplicable in this situation. *Common law doctrine of necessity as a life-saving emergency* - The **doctrine of necessity** is typically used in **immediate, life-threatening emergencies** where a formal capacity assessment is not feasible or time-sensitive action is paramount. - In this case, a **mental capacity assessment** has already been conducted, and the **Mental Capacity Act** provides a specific statutory framework for making decisions for individuals who lack capacity, superseding common law. *Inherent jurisdiction of the High Court* - The **High Court's inherent jurisdiction** acts as a "safety net" for complex cases involving **vulnerable adults** where statutory frameworks might not fully apply, or there are significant disputes. - It is not the primary framework for cases where a patient is found to lack capacity and the **Mental Capacity Act** clearly provides the appropriate legal mechanism for decision-making in their **best interests**. *Mental Health Act Section 3 must be implemented first before any treatment* - While **Section 3** of the **MHA** could provide a basis for compulsory treatment for anorexia nervosa, it is not a prerequisite before any treatment can be initiated if the patient lacks capacity under the **MCA**. - The **MCA** allows for best interests decisions and treatment for those who lack capacity without necessarily needing to formally detain them under the **MHA**, often being considered less restrictive.
Question 133: A 74-year-old woman with moderate Alzheimer's dementia (MMSE 16/30) lives in a care home. She is assessed for capacity to consent to influenza vaccination. She understands it is an injection to prevent flu, but when asked why it is recommended, she states 'because my daughter said so' and cannot explain the risks or benefits. What is the correct interpretation of this capacity assessment?
- A. She has capacity as she understands the basic nature of the intervention
- B. She lacks capacity as she cannot weigh the information to make a decision (Correct Answer)
- C. She has capacity as she is able to communicate a clear decision
- D. She lacks capacity as she is relying on her daughter's opinion rather than her own judgement
- E. The assessment is incomplete and requires psychiatric specialist opinion
Explanation: ***She lacks capacity as she cannot weigh the information to make a decision***- Under the **Mental Capacity Act (MCA)**, capacity requires a patient to **understand**, **retain**, **use or weigh** relevant information, and **communicate** their decision.- Although she understands the basic nature of the injection, her inability to explain **risks or benefits** or process why the vaccine is needed demonstrates a failure to **weigh information** as part of the decision-making process.*She has capacity as she understands the basic nature of the intervention*- **Understanding** the basic nature of a procedure is only one of four functional criteria; a patient must also be able to **use and weigh** that information to have capacity.- In this case, her deficit in clinical reasoning regarding **consequences and alternatives** outweighs her simple recognition of what an injection is.*She has capacity as she is able to communicate a clear decision*- Being able to **communicate** a choice is a necessary component but is not sufficient on its own to confirm capacity.- A patient can state a preference while having a total **impairment of the mind** that prevents them from understanding the basis of that preference.*She lacks capacity as she is relying on her daughter's opinion rather than her own judgement*- Relying on the advice of others is common and does not automatically signal a lack of capacity, provided the person can still **process the information** themselves.- The primary reason she lacks capacity here is not the influence of the daughter, but her **functional inability** to explain the rationale or weigh the clinical benefits.*The assessment is incomplete and requires psychiatric specialist opinion*- **Capacity assessments** for routine medical interventions like vaccinations are the responsibility of the **treating clinician** and do not routinely require a psychiatrist.- The assessment described provides sufficient evidence of functional impairment to make a clinical determination of **incapacity** without further referral.
Question 134: A 26-year-old man is brought to the Emergency Department by police following threats to jump from a bridge. He has borderline personality disorder and reports chronic suicidal ideation. He describes detailed plans to purchase a firearm illegally. He is currently calm and denies immediate intent. A urine drug screen is positive for cocaine. What is the most appropriate immediate management?
- A. Discharge with crisis team referral as he denies immediate intent
- B. Admit informally for overnight observation until cocaine effects resolve
- C. Arrange urgent outpatient review within 48 hours with community mental health team
- D. Detain under Section 2 of the Mental Health Act for assessment and treatment
- E. Admit informally with one-to-one observation and reassess after drug effects resolve (Correct Answer)
Explanation: ***Admit informally with one-to-one observation and reassess after drug effects resolve*** - Informal admission preserves the **therapeutic alliance** in patients with **Borderline Personality Disorder** while ensuring safety during a high-risk period of **cocaine intoxication**. - **One-to-one observation** is necessary due to the high risk factors, including **detailed suicidal plans** and recent police intervention, allowing for a thorough reassessment once the patient is sober. *Discharge with crisis team referral as he denies immediate intent* - Discharge is unsafe because **cocaine intoxication** significantly increases **impulsivity** and impairs judgment, making his denial of intent unreliable until the drug clears. - The presence of a **specific suicide plan** (purchasing a firearm) constitutes a high-risk factor that cannot be safely managed in the community immediately following a crisis. *Admit informally for overnight observation until cocaine effects resolve* - General overnight observation lacks the necessary **enhanced supervision** (one-to-one) required for a patient who was just deterred from a high-lethality suicide attempt. - Standard observation levels may not prevent further self-harm attempts within the ward environment for a patient with **chronic suicidal ideation** and acute intoxication. *Arrange urgent outpatient review within 48 hours with community mental health team* - Outpatient follow-up is insufficient for an acute crisis where the patient was found on a **bridge** and is currently **intoxicated**. - The risk of **suicide completion** is highest in the immediate hours following cocaine use, necessitating a more secure and supervised environment than the community can provide. *Detain under Section 2 of the Mental Health Act for assessment and treatment* - **Section 2** is generally considered a last resort; because the patient is currently calm and cooperative, **informal admission** (the least restrictive option) must be attempted first. - Compulsory detention is often counter-productive in **Borderline Personality Disorder** unless the patient refuses essential care and is at immediate risk to life.
Question 135: A 39-year-old man with acute psychosis is detained under Section 2 of the Mental Health Act. He requires dental extraction for a severely infected tooth causing facial swelling but refuses, believing the dentist is trying to poison him. He becomes agitated when staff approach. He has capacity to refuse treatment for the dental problem. What is the legal framework for proceeding with the dental extraction?
- A. Treatment can proceed under Section 63 of the Mental Health Act as it relates to mental disorder
- B. Treatment cannot proceed as he has capacity to refuse and detention only applies to psychiatric treatment (Correct Answer)
- C. Treatment can proceed under common law doctrine of necessity as an emergency
- D. Treatment requires authorisation from the Second Opinion Appointed Doctor (SOAD)
- E. Treatment can proceed under Deprivation of Liberty Safeguards authorisation
Explanation: ***Treatment cannot proceed as he has capacity to refuse and detention only applies to psychiatric treatment***- Detention under **Section 2** of the **Mental Health Act (MHA)** only authorizes medical treatment for the **mental disorder** itself, not for unrelated physical conditions.- Since the patient has been assessed as having **capacity** to refuse the dental extraction, his autonomy must be respected regardless of his detention status for psychosis.*Treatment can proceed under Section 63 of the Mental Health Act as it relates to mental disorder*- **Section 63** of the MHA allows for treatment of the **mental disorder** for which a patient is detained, and related physical health issues directly caused by the mental disorder.- A **dental infection** is generally considered an independent physical health issue, and the MHA does not provide authority to override the refusal of a patient with **capacity** for such a treatment.*Treatment can proceed under common law doctrine of necessity as an emergency*- The **doctrine of necessity** allows for emergency treatment of patients who **lack capacity** when it's immediately necessary to save life or prevent serious deterioration.- Since the patient **has capacity** to refuse this specific treatment, the common law doctrine of necessity cannot be invoked to override his decision.*Treatment requires authorisation from the Second Opinion Appointed Doctor (SOAD)**- **Second Opinion Appointed Doctors (SOADs)** are involved under the MHA to authorize specific psychiatric treatments (e.g., long-term medication, ECT) for detained patients, particularly when the patient lacks capacity or objects.- A SOAD's authority does not extend to compelling physical health treatments, such as a **dental extraction**, especially when the patient has **capacity** to refuse.*Treatment can proceed under Deprivation of Liberty Safeguards authorisation*- **Deprivation of Liberty Safeguards (DoLS)** applies to individuals who **lack mental capacity** and whose liberty is being deprived in their best interests in a hospital or care home setting.- This patient **has capacity** to refuse the dental treatment, and he is already detained under the MHA for his mental disorder, making DoLS inapplicable for this specific decision.
Question 136: A 47-year-old woman with recurrent depressive disorder is admitted following an overdose of 50 paracetamol tablets taken with clear suicidal intent. She has been treated with N-acetylcysteine and her liver function is improving. She now states she regrets the attempt and wants to go home to her family. Her husband reports this is her fourth attempt in 2 years. During risk assessment, which factor most strongly predicts future completed suicide in this patient?
- A. Multiple previous suicide attempts (Correct Answer)
- B. Expressed regret about the current attempt
- C. Current engagement with psychiatric services
- D. Female gender
- E. Support from family members
Explanation: ***Multiple previous suicide attempts***- A **history of previous self-harm** or suicide attempts is the single strongest clinical predictor of **completed suicide** in the future.- The risk is compounded by the **frequency and lethality** of attempts; having four attempts in two years indicates a high-risk escalating pattern.*Expressed regret about the current attempt*- While expressed regret can be a positive sign, it is often **unreliable** in predicting long-term safety, especially in patients with **recurrent impulsive behavior**.- It may be a transient reaction to the **immediate medical consequences** rather than a resolution of the underlying suicidal ideation.*Current engagement with psychiatric services*- Engagement is generally considered a **protective factor**, as it allows for professional monitoring and pharmacological management of **depressive disorder**.- However, in this patient, previous engagement has not successfully prevented **repeated life-threatening episodes**, making it less predictive of safety than the history of attempts.*Female gender*- While women have higher rates of **suicide attempts** (parasuicide), men are statistically more likely to **complete suicide**.- Therefore, being female is not a stronger predictor of completed suicide compared to a **chronic history of self-destructive behavior**.*Support from family members*- Family support and having a spouse are recognized **protective factors** that can reduce overall social isolation.- In this case, despite having a husband, the patient has still made **multiple serious attempts**, indicating that social support alone is insufficient to mitigate her high risk.
Question 137: A 68-year-old man with newly diagnosed frontotemporal dementia is assessed for capacity to make decisions about his financial affairs. He can state his assets and understand explanations about why he needs help managing finances. However, he immediately forgets the information and cannot use it to make decisions. Which component of the Mental Capacity Act assessment does this specifically demonstrate he lacks?
- A. Ability to understand information relevant to the decision
- B. Ability to retain information long enough to make a decision (Correct Answer)
- C. Ability to weigh information as part of decision-making
- D. Ability to communicate his decision by any means
- E. Ability to appreciate the consequences of his decision
Explanation: ***Ability to retain information long enough to make a decision*** - The patient's immediate forgetting of the explained information directly demonstrates a deficit in the ability to **retain** it, a key component of the Mental Capacity Act assessment. - For a person to have capacity, they must be able to hold the relevant information in their mind for long enough to make a **reasoned decision**, which is impaired in this case due to **frontotemporal dementia**. *Ability to understand information relevant to the decision* - The case clearly states the patient "can state his assets and **understand explanations**," indicating that the initial comprehension of information is preserved. - This component assesses whether the person can grasp the basic facts presented, which is distinct from the ability to keep those facts in mind over time. *Ability to weigh information as part of decision-making* - The ability to **weigh or use** information logically presupposes the ability to first **retain** it; if the information is immediately forgotten, it cannot be effectively weighed. - The primary deficit is not in the process of evaluation itself, but in the necessary memory function that precedes it. *Ability to communicate his decision by any means* - There is no indication in the scenario that the patient has any difficulty in **communicating** a decision, whether verbally, through gestures, or by any other means. - This component addresses the physical or cognitive ability to express a choice, which is not the problem described. *Ability to appreciate the consequences of his decision* - **Appreciating the consequences** is an aspect of weighing information; it involves understanding the potential outcomes of a decision. - However, the fundamental barrier here is the inability to **retain** the information needed to even begin considering its consequences, making retention the more specific lack.
Question 138: A 55-year-old man with no psychiatric history presents to his GP describing feeling 'very low' for 3 months. During assessment, which of the following features, if present, would most significantly increase his immediate suicide risk?
- A. Sleep disturbance with early morning wakening
- B. Recent diagnosis of metastatic pancreatic cancer (Correct Answer)
- C. Feelings of guilt about past actions
- D. Anhedonia and reduced motivation
- E. Weight loss of 5kg over 3 months
Explanation: ***Recent diagnosis of metastatic pancreatic cancer***- A **life-threatening physical illness**, particularly one with a terminal prognosis like pancreatic cancer, is one of the most significant external risk factors for **immediate suicide**.- This diagnosis significantly heightens feelings of **hopelessness**, loss of control, and a sense of being a **burden** to others, which are critical drivers of suicidal intent.*Sleep disturbance with early morning wakening*- This is a common **biological symptom** of clinical depression known as **diurnal variation**, indicating a more severe depressive episode.- While it reflects the severity of the mental state, it does not carry the same **acute elevation in suicide risk** as a terminal physical illness.*Feelings of guilt about past actions*- Guilt is a core psychological symptom used to diagnose **major depressive disorder** and can range from mild to delusional levels.- Although it contributes to the overall clinical picture, it is less predictive of **immediate risk** compared to catastrophic life events or terminal diagnoses.*Anhedonia and reduced motivation*- **Anhedonia** (the inability to feel pleasure) is a primary diagnostic criterion for a depressive episode.- While these symptoms impair functioning, they are not as specifically associated with an **escalated suicide risk profile** as serious physical illness is.*Weight loss of 5kg over 3 months*- Significant **weight loss** is considered a somatic symptom of depression and is part of the objective assessment of severity.- It indicates the **chronicity** or physiological impact of the depressive state but is not an independent marker of **high immediate suicide risk**.
Question 139: An 82-year-old woman with vascular dementia (MMSE 14/30) is admitted with a fractured neck of femur requiring surgical fixation. The orthopaedic team requests a capacity assessment as she is refusing surgery, stating 'I just want to go home'. She cannot explain the consequences of not having surgery. Her daughter has Lasting Power of Attorney for Health and Welfare and consents to the operation. What is the most appropriate next step?
- A. Proceed with surgery based on the daughter's consent under the LPA
- B. Apply for a Court of Protection order to authorise surgery
- C. Assess whether she lacks capacity and if surgery is in her best interests (Correct Answer)
- D. Respect her refusal as she has clearly communicated her wishes
- E. Sedate her and proceed with surgery as an emergency life-saving intervention
Explanation: ***Assess whether she lacks capacity and if surgery is in her best interests*** - Under the **Mental Capacity Act 2005**, a formal **capacity assessment** must be documented for the specific decision at hand before acting on anyone else's behalf. - Once incapacity is established, the clinician must determine if the intervention is in the patient's **best interests**, incorporating the views of the **LPA holder** and any previously expressed values. *Proceed with surgery based on the daughter's consent under the LPA* - An **LPA for Health and Welfare** only becomes active once the patient is formally assessed as **lacking capacity** for that specific decision. - Clinical documentation of the patient's **inability to weigh information** or understand consequences must precede accepting proxy consent. *Apply for a Court of Protection order to authorise surgery* - The **Court of Protection** is generally reserved for complex, disputed cases or where no legal surrogate exists; it is unnecessary when a **valid LPA** is in place. - For standard clinical procedures like fracture fixation, the **LPA holder** provides the necessary legal authority once incapacity is confirmed. *Respect her refusal as she has clearly communicated her wishes* - Simply communicating a wish does not mean the patient has **decision-making capacity**, especially if they cannot demonstrate an understanding of the **clinical consequences**. - If the refusal is made without capacity due to **vascular dementia**, clinicians have a duty of care to act in her **best interests** to prevent harm. *Sedate her and proceed with surgery as an emergency life-saving intervention* - Emergency intervention without assessment is only legally protected under **Section 5** of the MCA if there is an **immediate threat to life** and no time for assessment. - While a hip fracture is serious, there is sufficient time to perform a **formal capacity assessment** and consult the **LPA** before proceeding.
Question 140: A 41-year-old woman with emotionally unstable personality disorder presents to the Emergency Department following superficial cuts to her forearms after an argument with her partner. She has presented 15 times in the past year with similar presentations. She is currently calm and requesting discharge. She denies suicidal intent and states she was trying to 'release tension'. What is the most appropriate management approach?
- A. Admit informally to psychiatric ward for extended observation
- B. Perform brief risk assessment and facilitate discharge with crisis team follow-up (Correct Answer)
- C. Arrange immediate referral to dialectical behaviour therapy programme
- D. Detain under Mental Health Act Section 2 for assessment
- E. Prescribe PRN benzodiazepines for future episodes of distress
Explanation: ***Perform brief risk assessment and facilitate discharge with crisis team follow-up***- This approach aligns with best practice for **Emotionally Unstable Personality Disorder (EUPD)** in crisis, emphasizing **autonomy** and avoiding unnecessary hospitalization that can reinforce **maladaptive coping mechanisms**.- Given the patient denies **suicidal intent**, is calm, and uses self-harm for **tension release**, community-based support via a **crisis team** is the most appropriate management, focusing on ongoing risk assessment and support.*Admit informally to psychiatric ward for extended observation*- **Extended inpatient admission** for EUPD is generally discouraged as it can lead to **regression**, increased dependency on services, and may not be therapeutic for patients presenting with non-suicidal self-harm.- While brief crisis admissions can occur, in this case, the patient is calm and requesting discharge, and her self-harm is for **tension relief**, not acute suicidal ideation.*Arrange immediate referral to dialectical behaviour therapy programme*- **Dialectical Behaviour Therapy (DBT)** is the gold-standard long-term treatment for EUPD, but it is an intensive **outpatient therapy** that requires a stable environment and patient commitment.- An **immediate referral** from the Emergency Department is not practical as DBT involves a structured programme and assessment, which should be arranged through **routine community mental health pathways**.*Detain under Mental Health Act Section 2 for assessment*- Detaining a patient under the **Mental Health Act (MHA)** Section 2 requires evidence that they are suffering from a mental disorder warranting detention for their own **health or safety** or for the **protection of others**.- This patient denies **suicidal intent**, is calm, and appears to have **capacity**, meaning the legal threshold for **compulsory detention** is not met in this acute presentation.*Prescribe PRN benzodiazepines for future episodes of distress*- **Benzodiazepines** are generally **contraindicated** in EUPD because they can cause **disinhibition**, potentially increasing impulsivity and the risk of self-harm.- They also carry a high risk of **dependence** and do not address the underlying pathology of **emotional dysregulation** central to EUPD.
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