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|Year : 2016
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. Posters. Indian J Psychiatry 2016;58, Suppl S1:122-64
Aripiprazole in The Treatment of Paliperidone Induced Tardive Dyskinesia.
Sameer Belvi Mangalwedhe, Vishwanatha Sham Alamela
Department of Psychiatry, Hubli, KIMS, Karnataka, India
Tardive dyskinesia (TD) is a potentially serious and irreversible side effect of anti-psychotic medications. It is characterized by choreiform movements, or rhythmic abnormal involuntary movements of the face, mouth, tongue, trunk, and limbs. Although no reliable treatment for tardive dyskinesia exists, atypical antipsychotics are associated with a significantly lower incidence of tardive dyskinesia than typical antipsychotics. Recent reports suggest that atypical antipsychotics may have a beneficial effect on tardive dyskinesia remission. We present a case of severe oro-bucco-lingual TD which was effectively managed with aripiprazole.
Keywords: Tardive Dyskinesia, Aripiprazole, Anti-psychotics.
A Study of Stigma in Relatives of Patients Attending Psychiatry OPD
Paschim Vihar, New Delhi , India
Background: Stigma is pervasive among families of individuals with psychiatric disorders and Includes both general and associative stigma, that is, the process by which a person is stigmatized by virtue of association with another stigmatized individual. These forms of stigma may present a barrier to help seeking.
Aims of study: To study the experiences of stigma undergone by relatives of patients having psychiatric illnesses.
Material and methods: A cross sectional study was done for a period of 18 months at the Sri Siddhartha Medical College and Research Centre, Tumkur.121 relatives of the patients attending Psychiatry OPD, fulfilling the inclusion criteria were included. The perception of the participants regarding their opinion about the stigma pertaining to their general perceptions about stigma and their perceptions about the associative stigma related to the patient and their illness were collected, using the Opinions about Mental Illness and the Family Experiences Interview Schedule.
Results: This study showed that the relatives experience significant stigma and discrimination due to the perception that most people would be reluctant to accept a former mental patient as a productive and socially functioning individual. In general, the relatives of the patients having Anxiety Disorder had comparatively lesser stigma than the relatives of the patients having either Psychotic or Mood Disorders.
Conclusion: Stigmatization does not stop at the person who has a mental illness: it spreads to the family and remains present across generations. They have documented public attitudes and subjective experiences of patients and their families. Understanding how stigma affects family members in terms of both their psychological response to the ill person and their contacts with psychiatric services will improve interactions with the family. Further studies are also needed to investigate possible ways of destigmatization.
Keywords: stigma, Psychotic or Mood Disorders
Influence of Depression, Anxiety and Stress on Migraine: an Urban Community Based Study from Kolkata
Neelanjana Paul*, Malay Kumar Ghosal, Avijit Hazra, Sujata Das, Biman Kanti Ray, Shyamal Kumar Das
Department of Psychiatry, ICARE Institute of Medical Sciences & Research, Haldia, West Bengal, India
Objective: Community studies on migraine are lacking from developing countries, though its epidemiology and economic burden has regional variations, with strong influences of social, financial and cultural factors. This comprehensive study assessed prevalence, clinical correlates and disability burden of migraine in an urban community, with a especially focusing on stress and psychiatric comorbidities.
Methods: This two-stage, cross-sectional study used validated, globally-accepted diagnostic criteria to study migraine in a representative sample aged 20 to 50 years, residing in an urban area of India. Sex- and age-matched controls without any history of headache were evaluated for putative risk factors. Subjective reactions to various situations were measured by Stress-Arousal Checklist. Co-existing depression and anxiety were assessed using 7 and 3 basic symptoms, respectively; depending on whether the respondents had ≥ 2 symptoms, different categories were assigned, as having depression, depressive symptoms, anxiety, anxiety symptoms, or symptoms of both anxiety and depression.
Results: Screening of 2421 individuals (52.17% females) revealed one-year prevalence of episodic headache of 18.01% (95% CI 16.48-19.54%), of whom migraine was diagnosed in 374 individuals. Lower educational status, adverse environmental exposures, long-distance travel and oral contraceptive drugs emerged as significant risk factors for developing migraine in our cohort. A descriptive analysis of comorbid depression and anxiety symptoms among cases and controls also showed their higher preponderance in the study group, which interacted with perception of stress to influence migraine attacks.
Conclusion: Migraine is influenced by external factors as well as individual's perception of stress and comorbid psychiatric symptoms, even though some of the latter may be sub-syndromal. Public health measures are essential for their proper management, as they entail significant burden, especially in the most productive age-groups.
Keywords: epidemiology, psychiatric comorbidities, migraine:
Prevalence of Bullying and Profile of Bullies and Victims Among Urban School Going Adolescents
Jagdish Vankar, Harshil A. Patel, Shail Shah, Tanvi Anand Patil, Ajay Phatak,Somashekhar Marutirao Nimbalkar
Department Of Psychiatry, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
Aims and Objective: Bullying can have short term and long term implications on physical as well as mental health, ranging from headache, abdominal pain, and nausea to clinical depression leading to suicidal tendencies. It is important to identify bullies as well as victims know the prevalence of bullying related involvement. Whether the prevalence of bullying warrants an intervention plan is not known in our region as there have been very few studies published from India and none from Gujarat.
Methods: A questionnaire was administered to 7th, 8th and 9th graders of 5 schools (n=1106) in two districts, Vadodara and Anand, which comprised of Peer Interaction In Primary Schools (PIPS) and Strength And Difficulty Questionnaire (SDQ) scales apart from demographic information. Descriptive statistics were used to portray characteristics of bullies and victims. ANOVA/Chi square test was applied to determine associations between socio-demographic variables and different traits.
Results: Prevalence of bullying related involvement was 49%. Prevalence of bullying others was 29.9% and prevalence of victimization was 29.7%. Boys were more likely to be bullies (p=0.03) and get bullied (p<0.001) vis-a-vis girls. Overweight/obese (p=0.02) and students having less friends (p= 0.001) were more likely to be victims. Significant association was found between victimization (p=0.014) and bullying behavior (p=0.026) with poor academic performance. Victimization and bullying varied across schools (p<0.001).
Conclusion: We found high prevalence of bullying in our region. One school had lower incidence and building an intervention and structure using the information from that school needs to be explored.
Keywords: Bullying; Victimization; Schools; Adolescent; Strength and Difficulty Questionnaire; Peer Interaction in Primary Schools.
To Describe Adverse Effect of Severe Tardive Dystonia After Small Dose Exposure of Atypical Antipsychotics for few Months
Nilanjan Chandra, Ritambhara Y Mehta , Shabina Sheth , Kamlesh Dave
New Civil Hospital, Gujarat, Surat, India
Objective: To emphasise caution before using small/casual use of low dose 2 nd generation antipsychotics in patient with hyperthymic temperament and borderline intellectual functioning.
Method: 19 year old male patient, presented with severe unilateral dystonic neck movements. Other siblings in family are educated with master degree and patient was also sent to school; but due to inattention, restlessness he did not pass 2 nd standard after 3 attempts and left the schooling. With preserved executive functioning, skill learning he worked as unskilled labourer, he was not suspected with intellectual disability. Since childhood patient is over famliar, moody, short tempered with inappropriate social judgement; for which sometimes friends make fun of him, harass him. In this background patient presented with occasional anger outburst, beating family members, fearfulness, sleep disturbance which was precipitated after fever, one friend might threaten him which made him scared, patient stopped going out of house which was interpreted as Psychosis with persecutory ideas. He was treated with Risperidone 4 mg and Trihexiphenidy l2 mg for 2 months and Olanzapine 5 mg for 6 months, which ended with side effects of cervical tardive dystonic movements. He was diagnosed borderline intellectual functioning with standard psychological test, tests like routine investigations, EEG, Fundus examination, cervical x-ray, MRI Brain are normal. After consultation with neurophysician, he was treated with Clonazepam 3mg, Tetrabenazine 75mg, Trihexiphenidy l2mg. After two months patient's symptoms improved around 40%.
Result and discussion: Patients with Borderline intellectual functioning and hyperthymic temperament are more prone to develop severe adverse effects like tardive dystonia with atypical antipsychotic like Risperidone and even with olanzapine5mg which has minimal extra pyramidal side effects. So injudicious use of antipsychotics without detail assessment should be kept in mind. Case discussions will be done at the time of presentation.
Attitudes Towards and Perceived Need for Learning Communication Skills in Fresher Undergraduate Medical Students
Jagdish Vankar, Anusha Prabhakaran, Suman Singh
Department Of Psychiatry, Pramukhswami Medical College, Karamsad, Anand, Gujarat. E-mail: firstname.lastname@example.org
Background: Revised Graduate Medical Education Regulation (2012) identifies patient-provider communication as a competency. From 2015, Medical Council of India would be implementing Attitude & Communications (AT-COM) module for addressing these needs in undergraduate medical students at Nodal and Regional centres. We undertook this study to determine undergraduate students' attitudes towards communication skills training (CST).
Methodology: An anonymous cross-sectional survey consisting of Likert-type questions rated from strongly agree to strongly disagree, was conducted amongst fresher I MBBS Students. Single questions assessing perception of need for CST, importance of CST and self-knowledge of communication skills (CS) were used. Attitudes toward learning communication skills were measured using modified version of communication skills attitude scale (CSAS). CSAS has two subscales. Subscale I measures positive attitude (PAS), subscale II measures negative attitude (NAS) with higher scores indicating stronger attitudes. We adapted some questions on Modified CSAS for use amongst I MBBS students.
Results: While two-thirds agreed, almost one-third of the students were unsure or disagreed with the importance and need for CST. Importance and need for CST were moderately to weakly correlated with CSAS attitudes. There were significant differences on CSAS positive and negative attitude subscale scores according to agreement on question for importance of CST and need for CST. While most students felt they should have good CS, many of them also felt that they can pass exam based on assessment of knowledge only.
Conclusion: Course implementers should be mindful in addressing positive and negative attitudes towards communication skills training while delivering the content of the course. Assessment of communication skills should be incorporated in all formative and summative evaluations and faculty development program in communication skills training and assessment are required.
Keywords: Communication Skills, attitude
Case Report on Neurofibromatosis With Major Depressive Disorder And Psychotic Features
Ravi Hareshkumar Shah, Nilanjan Chandra , Urvish Jaganiya, Ritambhara Mehta .Kmalesh Dave
A case report of a 30 year old suffering from Neurofibromatosis with skin lesions, cafι au lait spots and neurofibromas over face, chest region and back, patient didn't have any neurological signs presented with Severe Major Depression with Psychotic features.
Neurofibromatosis type 1 is often associated with psychiatric disorders. There are numerous reports about physical aspects of neurofibromatosis. However, information on psychological aspects is scanty and the reported findings are often based on highly selected groups of patients sometimes not assessed in a systematic manner with standardised measures.
Dysthymia (21%) has been reported as the most frequent diagnosis. There is also a high prevalence of depressive mood, anxiety, and personality disorders. Bipolar mood disorders or schizophrenia appear to be rare. However this is a case report in which psychotic features were seen along with depressive features at the time of presentation.
Conclusion: Neurofibromatosis leads to impaired quality of life and psychiatric component adds to the burden of illness. No direct neural pathology has been identified for psychiatric morbidities. Thus patients of neurofibromatosis presenting to psychiatric facility should be fully assessed for underlying psychiatric comorbidity, so early treatment can be given and worsening can be prevented.
Keywords: Neurofibromatosis, psychotic features
Trichotilomania In A Mentally Retarded Female: A Case Report
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe but potentially reversible neuropsychiatric illness. It is often missed due to its earlier presentation as a psychotic illness. Although, initially it was described mostly in young females with history of ovarian teratoma, now it is increasingly being reported in adult males and children without a history of neoplasm. Most patients with this illness follow a specific course that progresses from initial psychosis to seizures, memory disturbances and catatonia. Though such patients have high mortality if untreated, up to 75% of patients show good response to immunotherapy.
Here we present a case of 20 year old, unmarried female presented with a short duration illness of 7 days. Although initially she had symptoms of psychosis mainly fearfulness, persecutory ideas, referential ideas and fleeting nihilistic delusion that she is dead and the world around her is going to end, over next few days in the psychiatry ward, she developed symptoms of catatonia namely stereotypy, echolalia/echopraxia, waxy flexibility, bizarre posturing and complete mutism. She also had orofacial dyskinesias, choreoathetoid movements, memory disturbances and 2 episodes of complex partial seizures.
In view of this classical presentation along with normal MRI and non-specific EEG findings, autoimmune workup was carried out which showed positive serum anti NMDAR antibody and subsequently cerebrospinal fluid NMDAR antibody also came positive. Whole body PET scan ruled out systemic neoplasm. After starting steroids, patient showed a dramatic improvement in her symptoms with almost complete recovery at 3 month follow up and a near complete amnesia for the illness part.
This case showed classic progression of anti NMDAR encephalitis and also adds to the limited literature available. It also highlights some atypicalities like absence of systemic neoplasm and provides further support for potential reversibility of the condition with prompt treatment.
Keywords: Anti-N-methyl-D-aspartate receptor, neoplasm
A Case of REM Sleep Behaviour Disorder Due to Clomipramine
Abhinav Pandey, Sathya Prakash, Mamta Sood
Manohar Kunj, Gautam Nagar, New Delhi, India
Introduction/Background: Clomipramine is widely used in the treatment of Obsessive Compulsive Disorder (OCD). Side effects such as dry mouth, dizziness, constipation, seizures and myoclonus have been reported. Rarely, sleep related adverse effects have been reported.
Methods: We present an interesting case of REM sleep behaviour disorder (RBD) due to clomipramine.
Results: A 38 years old female presented with an ICD 10 diagnosis of OCD, mixed type and severe depressive episode without psychotic symptoms. She was initially treated with sertraline 200 mg. Due to inadequate response, clomipramine 25mg was subsequently added and increased to 75mg. However, within 24 hours of increasing clomipramine she started having disturbed sleep characterized by grimacing, verbalising, continuous movement of her limbs including jerky movements and multiple night time awakenings. It would appear as if she was doing various activities like giving instructions to her children in dreams. Physical examination, EEG and MRI brain did not reveal any abnormality. Clomipramine 75mg was tapered off in 3 days and within 24 hours of stopping it there was marked improvement in her sleep problems. The score on Naranjo Adverse Drug Reaction Probability scale was 7 suggesting high probability of the sleep disturbance being an adverse effect of clomipramine.
Discussion: RBD is a parasomnia of REM sleep. The disorder is due to lack of muscle atonia normally present in REM sleep. There is an active behaviour (dream enactment behaviour) leading to sleep disruption. RBD is a well known sleep disorder and its prevalence is 0.38-0.5% in general population. RBD occurring after starting of clomipramine has been rarely reported and are mostly from the era before RBD was described. In current case, RBD led to significant problems and impairment of quality of life in the patient and had to be discontinued. Thus, identifying this adverse effect of clomipramine is important.
Keywords: Clomipramine, RBD, Sleep Disorders
A Case of Frontotemporal Lobar Degeneration with Kluver- Bucy Syndrome
C.Agila, Mukesh J. Samani
PG hostel, near ruda building, Jamnagar road, Gujarat, Rajkot, India
A 39 year old male patient brought to our emergency by police personnel as he was being held custody for his inappropriate sexual behavior in public. Patient presented with marked irritability, forgetfulness, and impulsivity, and sleep disturbance, inability to sustain attention, abusiveness, and social disinhibition, for the last 3 years. Premorbidly he was good at work and had great inter-personal relationships. There were gradual changes in behavior. He became defaulter at work, had problems in relationships and had deterioration in expression of appropriate basic and social emotions. Sometimes depressed all day, unprovoked anger outbursts were observations by family members. He, frequently showed aggression on brother regarding minor conflicts, ran away from home, and demanded for food items and eatables. He progressively worsened in symptoms of disinhibition, impulsivity, inertia, hyperorality, loss of social awareness, neglect of personal hygiene, stereotyped behavior and utilization behavior. After consultation with private psychiatrist, he was treated with antipsychotics and ECT, but didn't show any improvement. No significant medical or surgical conditions were reported. Hemogram, urine routine and microscopic examination, liver and renal function tests, were normal. On Neuroimaging, marked changes of cerebral atrophy are noted predominantly involving bilateral frontal and median temporal lobes, mild cerebellar and midbrain atrophy with moderate to marked dilatation of ventricular system are noted. By DSM 5, he fulfilled the criteria for major neurocognitive disorder, probable frontotemporal lobar degeneration, with behavioral symptoms. Further diagnosis of Kluver Bucy Syndrome was made as he had presentation of forgetfulness, hyperorality, hypersexuality, lack of emotional response, hyperphagia. Severity of dementia was assessed by MMSE, Clinical dementia rating and Global Deterioration Scale. Patient was put on risperidone but follow-up was not possible as he was hospitalized in Hospital for mental health in another city.
Keywords: FRONTOTEMPORAL LOBAR, KLUVER- BUCY SYNDROME
Alexithymia, Anxiety and Depression Among Tinnitus Patients
Meenakshi Dayal, Ajay Kumar Bakhla , Rajni Bala
Department of ENT, Rajendra Institute of medical sciences, Ranchi, Jharkhand, India.
Context (Background): Tinnitus is a common auditory symptom and various studies supports its association to psychological distress, depression and anxiety, but literature lacks on association of tinnitus and alexithymia.
Aims: The aim of present study was to determine the prevalence and association of alexithymia, depression and anxiety among patients of tinnitus.
Materials and Methods: The study was conducted on patients of tinnitus at a medical college hospital. Study design was cross sectional, observational study. Patients were assessed with socio demographic data sheet, Hospital anxiety and depression scale, Tinnitus handicap inventory and Toronto alexithymia scale.
Statistical analysis: Data analysis included descriptive statistics and independent t - test to compare mean scores of alexithymia, anxiety and depression among high and low tinnitus handicap score subgroups.
Results: A total of 70 patients (55.7 % male and 44.3 % female) with mean age of 33.17 ± 12.24 years were finally analysed. The severity of tinnitus was mostly severe (34.3%) followed by moderate (20%), catastrophic (18.6%), mild (17.1%) and slight (10%). The prevalence of alexithymia, anxiety and depression among patients of tinnitus was found to be 64.2%, 37.1% and 20 % respectively. High tinnitus handicap group showed significant higher scoring on total alexithymia score, anxiety and depression compared to low tinnitus handicap group. On subscale analysis high tinnitus handicap group showed significant higher scoring with describing emotion and identification of emotion, but there was no difference for the subscale of externally oriented thinking.
Conclusions: The study found high prevalence of alexithymia, anxiety and depression among patients of tinnitus, and its association with problems of description and identification of emotion.
Keywords: Tinnitus, Alexithymia, Depression, Anxiety.
Executive Dysfunction in Depression
Shahbaaz Ali Khan, Ryali Vssr, Kalpana Srivastava, Khanam Shagufta, Jyoti Prakash , Bhat PS
Delhi cantt, Delhi, India.
Background: Executive dysfunction is common in Major depression and adds to the distress and disability associated with the disease. The relationship between executive function and major depression seems to be complex. This area has seen lot of research world over but there are very few such studies on Indian population.
Aim/Objective: To look for changes in executive functions in major depression. Compare the executive functions in first episode and recurrent depressives as well as with severity of the depressive episode.
Settings and Design: A cross sectional analytical controlled study
Methods and Material: Wisconsin Card Sorting Test (WCST) was administered for executive functions. Findings were compared with healthy matched controls. A subanalysis was done to compare these parameters across severity gradient of depression as well as between first episode depressives and those with a past burden of depressive illness.
Statistical analysis: statistical analysis was done using the SPSS version 17.
Results and Conclusions: Depressed patients performed poorly on several measures of executive functions. This dysfunction was not correlated significantly with depression severity or past burden of depressive illness.
Keywords: depression, executive functions, WCST
Predictors of Metabolic Syndrome in Patients Suffering from Schizophrenia in North- Western Region of Rajasthan
Vrinda Pareek, Naresh Nebhinani , SwapnilTripathi
Background: Metabolic syndrome (MS) is a cluster of disorders/risk factors including obesity, dyslipidaemia, insulin insensitivity, deranged glucose metabolism and hypertension.Schizophrenia in particular, is associated with increased riskof diabetes and metabolic syndrome (MS).
Objectives: The present research was aimed to study the prevalence and predictors of MS among outpatients with Schizophrenia in North western region of Rajasthan.
Materials and Methods: 29 patients suffering from Schizophrenia attending Psychiatry OPD at AIIMS Jodhpur were assessed for MS using International Diabetes Federation (IDF) criteria.
Results: Out of 29 subjects, 10 (34.5%) of thesubjects met the IDF criteria for MS. The commonest abnormality was decreased High Density Lipoprotein levels (HDL, 62.1%) followed by increasedwaist circumference (58.6%). 13 people were suffering from obesity (BMI≥25).Body mass index, and obesity weresignificant predictor of MS.
Conclusion: The findings of the present study suggest that metabolic syndrome is highly prevalent in subjects suffering from Schizophrenia.
Keywords: Schizophrenia, Metabolic Syndrome
A Lady Who Keeps on Sleeping
Panchmatia Ankit Parmanand, Nisheet Patel, Chintan Solanki, Nimesh Parikh
Nakoda Darshan Apt.,Nr. Lg Corner, Maninagar, Gujarat, Ahmedabad, India
Background: Excessive sleepiness can be idiopathic, or associated with sleep disorders such as narcolepsy, obstructive sleep apnea, and circadian rhythm disorders as well as be induced by insomnia disorder, insufficient sleep, or poor sleep hygiene. Primary (idiopathic) Hypersomnia of DSM-IV-TR is renamed as Hypersomnolence Disorder in DSM 5 & characterized by excessive sleepiness associated with recurrent periods of sleep within the same day, prolonged and non-restorative main sleep episode or sleep inertia. Excessive sleepiness is a risk factor for subsequent appearance of mood and substance use disorders, rather than medical or physical illnesses.
Objective: We report the case of a 35-year-old female that presented with 20 days' history of excessive sleep of 16-18 hours per day, and showed significant improvement with pharmacotherapy but developed depression in follow up.
Methodology: She was diagnosed as having Hypersomnolence Disorder based on subjective report of excessive sleep, which was confirmed from informants and objective observation as an indoor patient for one week, normal neurological examination and investigation reports, including polysomnography.
Results & Conclusion: Nocturnal polysomnography showed prolonged sleep duration, sleep efficiency of 96%, sleep latency of 16 min, normal REM sleep distribution and no apneic events. She was treated with Modafinil 200mg and methylphenidate SR 40mg with significant reduction in sleep duration to 7-8 hours per day within 10 days. After 15 days, she developed new onset depression that responded adequately to 40mg fluoxetine. Excessive sleepiness has a significant detrimental impact on psychological, social and vocational function and personal safety, thus adversely affecting quality of life. It must be recognized duly and given attention by clinicians.
Keywords: hypersomnolence disorder, polysomnography, modafinil, methylphenidate
Schizophrenia or Very Late Onset Schizophrenia Like Psychosis
Dr. Panjabrao memorial medical college, Amravati.
Introduction: The onset of schizophrenia generally occurs in late adolescence or early adulthood but few patients become ill in late adulthood. The diagnosis of very late-onset schizophrenia like psychosis has been proposed for patients who experience the onset of symptoms after the age of 60 years though neither DSM 5 nor ICD 10 has specific criteria of the age for diagnosis of schizophrenia. These patients present with characters similar to those of early-onset schizophrenia in terms of psychopathology, non-specific brain imaging abnormalities, course of illness, and treatment response. Importantly the emergence of psychotic symptoms for the first time in later life poses a diagnostic challenge for clinicians in assessment of elderly persons with mental illness as they are frequently confronted with issues relating to cognitive deficits, affective symptomatology, and physical illness. Most commonly, late onset delusions and hallucinations are associated with dementia and affective disorders; however, in a small but substantial number of cases these symptoms arise de-novo. Very late onset schizophrenia-like psychosis has an incidence of 1.5% in patients diagnosed with schizophrenia. Very few cases of late onset and very late onset schizophrenia have been reported.
Objective: We would like to present case of an 85 years old female with a classical history of very late onset schizophrenia like psychosis with interesting psychopathology and would like to discuss the issues related to the diagnosis, pathophysiology and treatment of this rare condition in geriatric psychiatry. This case is one of the few rare cases reported as to the best of our knowledge.
Keywords: late onset schizophrenia, psychopathology,
Too Much of Spice: A Case Reportof Fennel (Saunf) Abuse
Major Virendra Vikram Singh, Dy Comdt Rajendran A
Military Hospital , Jhansi, Uttar Pradesh, India
Under the F55 diagnostic category of ICD 10, abuse of non-dependence-producing substances is described. Various groups of substances have been listed. However published reports highlight mainly a few of them. Abuse of Specific herbal or folk remedies (F55.6) has rarely been reported. Fennel (Saunf सौंफ) is a common ingredient of spices and also used widely as mouth freshener in India. We report a female patient who was referred to Psychiatry OPD for management of her anxiety symptoms. A detailed evaluation revealed abuse of Fennel with features bordering dependence. We also highlight effects of Fennel and its psychotropic properties. To the best of our knowledge no such case has been reported in literature.
Keywords: Fennel (Saunf सौंफ), substances
Ethambutol induced psychosis - a case report.
Manjusha Pushparaj, Anisha Nakulan, Shiny John
Department of Psychiatry, Amala Institute of Medical Sciences, Thrissur.
Introduction: Most cases of anti tuberculous treatment (ATT) induced psychosis are due to isoniazid. 1,2,3 The following case report demonstrates the psychosis inducing potential of ethambutol.
Case Description: 72 year old lady on ATT with rifampicin, isoniazid and ethambutol for tuberculous lymphadenitis since 6 weeks presented with low mood, anhedonia, anergia since 5 weeks and delusion of guilt, restlessness and insomnia since 4 days. Physical examination showed enlarged cervical lymph nodes. Patient was restless with decreased speech output. She was depressed, had multiple depressive cognitions, delusion of guilt and lacked insight. Laboratory investigations showed elevated ESR. MRI Brain was normal. Possibility of isoniazid induced psychosis was considered as symptoms had temporal correlation with start of ATT. ATT regimen changed to rifampicin (450mg), pyrazinamide (1200mg) and ethambutol (800mg). Patient was started on olanzapine (7.5mg) as there was marked distress. Patient showed improvement of symptoms in 5 days but when olanzapine was tapered, psychotic symptoms relapsed within 1 week. A possibility of ethambutol induced psychosis was considered. Ethambutol was stopped and ATT regimen was changed to rifampicin, pyrazinamide and levofloxacin. Patient showed improvement of psychotic symptoms within 72 hrs. Patient was re-challenged with ethambutol with the consent of the relatives, to confirm diagnosis. She had relapse of symptoms within 24 hrs. Ethambutol was subsequently discontinued and patient showed improvement.
Discussion: Most cases of anti tuberculous agent-associated psychosis are caused by isoniazid (INH). Ethambutol associated psychosis is rare. 4.5 The mechanism of ethambutol induced psychosis is unclear. We rechallenged our patient with ethambutol to confirm our diagnosis, as it is a very cost effective and useful drug. Ethambutol is one of the most commonly used drugs in the treatment of tuberculosis. Though the principal side effect is retro bulbar neuritis, it is important to be aware that ethambutol can also induce psychosis.
Keywords: ethambutol, tuberculous,
Quality of the Reviews Submitted by Attendees of a Workshop on Peer Review
Samir Kumar Praharaj1, Shahul Ameen2
1 Kasturba Medical College, Manipal, Karnataka, 2 St. Thomas Hospital, Chethipuzha, Kerala, India.
Objective: To study the methodological quality and error detection of the review by the participants of a peer review workshop.
Methods: All participants of the workshop were invited to peer review a randomized controlled trial. The manuscript was emailed to them after introducing eight deliberate errors to it. Specific instructions and a deadline were provided. All the reviews were analyzed using Review Quality Instrument (RQI). Also, the rate and the type of errors identified were recorded.
Results: Of 25 participants (all were psychiatrists), 16 (64%) returned the reviews. The number of errors identified varied from 2 to 8 (median of 5), the most common being wrong conclusion (87.5%), randomization procedure (50%), written informed consent (50%), ethics committee approval (42.8%), and masking (31.2%). The mean total score on RQI was 20.62 (95% CI 18.73 to 22.51) out of 40; most of the reviewers did not discuss the importance of research question and the originality of the paper. Only 5 (31.2%) gave overall recommendation whether the manuscript should be accepted or not.
Conclusion: Major errors were readily identified by the reviewers; however, the review quality was modest and need further improvement.
Keywords: Peer Review, quality and error detection
Oedema Associated With Olanzapine - Case Series
Ram Rajesh, Mitalee Prajapati , Gopi Gajera , Kalpesh Chandrani
pg hostel, near ruda building, jamagar road, Rajkot, Gujarat, India
Olanzapine is a second generation atypical antipsychotic, a selectivemono- aminergic antagonist with high affinity to serotonin (5-HT 2A , 5-HT 2C ), dopamine (D 1-4 ), muscarinic (M 1-5 ), histamine (H 1 ) and adrenergic (α 1 )receptors; and weak affinity to GABA and beta-adrenergic receptors.It has been widely used in the management of major psychiatric illnesses like schizophrenia, bipolar-affective disorder, and major depressive disorder with psychotic features and has proven to be effective in the management of psychosis in demented patients. The most frequently reported side effects ofolanzapine include constipation, dyspepsia, weight gain, dry mouth, dizziness,somnolence and akathisia. Such trials have reported peripheral oedema as aninfrequent side-effect, affecting 3% of 532 actively treated subjects, comparedto 1% of 294 subjects on placebo, during a 6-week trial. In this report, wepresent a series of five cases of odema, taking olanzapine as a treatment for their psychiatric disorder, in the absence of other antipsychotic medication, attending the psychiatric OPD of P.D.U medical college, Rajkot. All the investigations appeared to be within normal limit and other medical conditions were ruled out. Thus we concluded that oedema may be associated with olanzapine. Also it was noted that it was transient and self-limiting which may not require additional treatment as reduction of the dosage or change of medication could be sufficient.
Pattern of Disability Referral to Psychiatry: A Three Year Chart Review
Priti Singh*,Pradeep Jain**, Pratibha Gehlawat***, Rajiv Gupta****
Urban estate 2, Hisar, Harayna , India
Disability in Psychiatry is related with two important entities: MR and mental illness.
PGIMS Rohtak being a tertiary care centre in Haryana gets disability referrals from every part of Haryana. These referrals are for the purpose of disability benefits, compensation in cases like RTA or legal issues like competence and capacity.
All the cases referred to Department of Psychiatry PGIMS from various sources for the purpose of disability assessment from the period of January 2011 to December 2013 were taken into study. The Sociodemographic profile and clinical variables were taken on a Performa designed for the purpose. The data was collected from the OPD and indoor files of Patients.
The assessment revealed younger age of consultation for boys, milder degree of disability in RTA cases along with motivated consultations. Further details are discussed in the presentation.
Predictors of Metabolic Syndrome in patients with Schizophrenia in North-Western India
Naresh Nebhinani 1 *, Swapnil Tripathi 2 , Vrinda Pareek 3 , Mukesh Gehlot 4
Department of Psychiatry, AIIMS Jodhpur, Rajasthan, India
Background: Very few studies have assessed predictors of metabolic syndrome (MS) in patients with Schizophrenia.
Aim: The study was aimed to assess theprevalence and predictors of MS and metabolic abnormalities in patients with schizophrenia.
Materials and Methods:By consecutive sampling, 49 patients with schizophrenia were recruited from psychiatric outpatient clinic at AIIMS Jodhpur and evaluated for the presence of MS using the modified National Cholesterol EducationProgram Adult Treatment Panel III (NCEP ATP-III) criteria.
Results: 10 patients (34.5%) had MS and other 17 patients (58.6%) had one or two metabolic abnormalities. Most common metabolic abnormalities were lower HDL in 18 patients (62%), followed by higher waist circumference in 17 patients (58.6%), and least common abnormality was raised blood pressure in 4 patients (13.8%). Nearly two-fifth of patients (13 patients, 44%) were obese. Duration of schizophrenia, body mass index and obesity were significant predictors of MS.
Conclusion: One-third of the patients had MS and rest half had one or two metabolic abnormalities. It calls for comprehensive physical and psychiatric care of the patients, with proper assessment, timely management and effective prevention of metabolic problems.
Keywords: Metabolic syndrome,metabolic abnormalities, schizophrenia, India
Assessment of Cognitive Function in Schizophrenia using MMSE
New PG Hostel, near ruda building, jamnagar road, Gujarat, Rajkot, India
Background: Schizophrenia is accompanied by impairments in several domains of cognitive function. (1) Most of the researches on cognition in schizophrenia have been done using advanced neuropsychological battery tests.
Aim: To report relationship between characteristics of schizophrenia based on PANSS and cognitive function based on MMSE, with aim of determining utility of MMSE to assess cognitive function in schizophrenia.
Material and methods: This was cross sectional study in clinical setting carried out in Department of Psychiatry, P.D.U Hospital, Rajkot.100 patients with DSM-5 diagnosis of Schizophrenia were taken for study. Socio demographic data was collected by structured proforma. Schizophrenia was diagnosed using DSM-5 criteria, PANSS was administered to study psychopathology and cognitive function was assessed with MMSE.
Results: 58% patients had some degree of cognitive impairment and 34% of them had moderate degree of cognitive impairment. Males had higher MMSE scores than females. Higher educational status and good compliance was associated with better MMSE scores. The mean positive, negative, general and total PANSS scores were 17.42, 20.91, 38.47 and 76.78 respectively. Negative correlation was found between MMSE scores and all the subscales of PANSS and total PANSS. Highest degree of negative correlation was found between negative symptoms and MMSE.
Conclusion: Cognitive function in schizophrenia is correlated with various domains of psychopathology, with negative symptoms affecting cognition in most significant manner. More advanced researches can correlate MMSE score with standard neuropsychological test scores and positive correlation can indicate that MMSE can be clinically useful instrument for screening cognitive function in schizophrenia.
Keywords: cognitive function, MMSE, PANSS
Quality of Life And Psychiatric Morbidity in Caregiver of Alcohol Dependence Patients
Shree Krishna Hospital, Karamsad, Gujarat, Anand, India
Background: Alcohol Dependence Syndrome could be considered as a disorder of the family. It has deleterious consequences not only on the patient with alcohol dependence but also on the members of his family. The caregiver of the patient with alcohol dependence is a key member of the family. They are most vulnerable to have significant psychiatric disorders like mood disorders, anxiety disorders and a higher prevalence of medical morbidity and psychosocial problems as well.
Aims: To evaluate the frequency and nature of psychiatric morbidity in caregivers of patients with Alcohol Dependence.
Materials and Methods: The study was carried out at Psychiatry OPD, P.D.U. Medical College & Hospital, Rajkot. In this cross-sectional study, 110 patients between ages 18-65, having alcohol dependence as per diagnostic criteria of DSM- 5 were studied. The data was collected using standard demographic data sheet and clinical evaluation. Leeds dependence scale, Q-LES-O-SF Scale, GHQ scale were used to assess severity of dependence, quality of life and mental health respectively. The results were tabulated and analyzed using chi (χ2) square test. Correlation coefficient was measured between all scales using Pearson's formula.
Results: Out of 110 caregiver, 40(36%) caregiver had dysthymia, 24(22%) had major depression, 9(8%) had unspecified anxiety disorder and 5(5%) had generalized anxiety disorder. Quality of life was found to be significantly poor among caregivers of alcohol dependence patients.
Conclusion: Psychiatric morbidity in caregivers was found to be significantly correlated with alcohol dependence patients. So we must not neglect to evaluate the caregiver of alcohol dependence patients for the presence of psychiatric illness.
Keywords: Psychiatric Morbidity, dysthymia
Background: The physical and emotional difficulties experienced by caregivers' of those with severe mental illness have been a topic of research since 1960s. This burden many a times is more than that in chronic medical illnesses. The different domains of this burden needs close introspection as it has a role in deciding the prognosis of the mental illness.
Aim: To study the different realms of burden experienced by caregivers of patients suffering from Schizophrenia in rural South India.
Objectives: (a) To establish existence of burden in care giving for those diagnosed with Schizophrenia. (b) To study the different domains of burden experienced by the caregivers of Schizophrenia.
Method: After taking informed consent, a semi-structured proforma was employed to collect the socio-demographic data of 43 consecutive caregivers of those with Schizophrenia, diagnosed under ICD-10 DCR, attending OPD of a tertiary hospital in a rural area in Karnataka. Burden was assessed using Burden Assessment Schedule (BAS).
Results: Significant burden existed in the lives of caregivers of Schizophrenia as shown in earlier studies. Among the 43 caregivers studied, 26 were males and 17 were females. There were 23 spouses, 12 parents, 7 children and 1 sibling. Male caregivers experienced higher burden than female counterparts. Highest burden existed in the domains- "Support of Patient" and "Taking responsibility". Lowest burden was found in "Spouse related domain".
Conclusion: Caregivers of those with Schizophrenia experience significant degree of physical and emotional burden, which may even disrupt the family equilibrium. The knowledge about the nature of this burden is relevant in improving family coping skills, planning social support and implementing required interventions to raise the quality of life of the family as a unit.
A Case Report of delusion of Pregnancy in a Male and Review of Literature
Varsha B G, Chandrashekar M , Srinivasa M
Spandana Nursing Home , Bengaluru, Karnataka, India
Introduction: Delusion of pregnancy is described as false and fixed belief of being pregnant without factual evidence of pregnancy. This psychopathology is relatively rare in men and more common in females. The presentation is similar to couvade syndrome where a man develops symptoms of pregnancy when his wife becomes pregnant but he is aware that he is not pregnant.
Case History: A 35year old married male hailing from rural background working as an agriculturist with no family history of psychiatric illness with 15 years h/o schizophrenia, not on medications since 2 months presented with h/o belief that he is gaining weight, giddiness in the morning, bloating sensation in the stomach which he attributed to pregnancy symptoms as he knew that females present with similar complaints during pregnancy. He continued to believe that he is being pregnant inspite of reassurance from family and doctors. He also had hearing voices in isolation. During this time he had impairment in activities of daily living and sociooccupational functioning. On MSE he had delusion of pregnancy, restricted affect, and 2nd PAH with impaired judgement and grade 1 insight. Patient was treated with risperidone 6mg per day and 6 sessions of modified ECTs. He responded with decreased conviction and no hallucinations at the time of discharge. He continued to manage well in subsequent follow ups.
Discussion: Development of delusion of pregnancy in men has been explained psychodynamically as his expression of frustrated creativity, infantile envy of his wife's ability to bear a child and dramatic expression of identification with his mother.Delusion of pregnancy is encountered in both psychiatric and organic disorders.As in our case it presented as symptom of schizophrenia. As reported delusion of pregnancy respond to medications in most of the cases even though very few patients may have delusion lasting for long.
Keywords: delusion of Pregnancy, couvade syndrome
Meditation Based Approaches for Addiction: A Review
Nimmy chandran, Anju Dhawan, Biswadip chatterjee
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
Background: Meditation based approaches are becoming more popular in all fields of medicine. There is also research related to this in the field of addiction. The purpose of this poster is to review meditation based approaches for the addiction, to study the effectiveness, benefits, proposed mechanism of action and limitations in existing research. Some popular meditation based techniques are studied in terms of their background, their mechanism of action and clinical application for substance use disorder.
Material and method: A review of literature was done using 4 electronic databases. A total of 40 studies were reviewed including 25 studies in the last 5 years and 5 reviews.
Result: Overall, the existing literature supports the effectiveness of meditation based techniques for assisting treatment of substance use disorder. However, there are many limitations of the studies in terms of small sample size, lack of enough Randomized Controlled Trials, and lack of enough longitudinal studies. Enough evidences available only for some types of meditation like mindfulness based methods. There is lack of instruments to measure the adherence to treatment. Finally, meditation can be used only by those patients who are interested in it.
Discussion: Further research has to be done to determine the effectiveness using well designed randomized controlled trials and longitudinal studies. The mechanism of action should be studied more extensively using neuroimaging and neurophysiology. There is also need to develop tools to objectively monitor self-practice, compliance, and adherence with the intervention.
Keywords: Substance use disorder, Meditation based approaches; Mindfulness meditation based therapies, Transcendental meditation, Sudarshankriya yoga
Managing a 59 Year Male Suffering from Bipolar Affective Disorder Type II: Highlighting Valproate Induced Thrombocytopenia
Lovee Dhawan*, Susanta Padhy**
Department of Psychiatry, PGIMER, Chandigarh
Case Description: PS, 58 years old married male suffers from an episodic mental illness characterized by episodes of similar and opposite polarity since year 1980; Since then the patient has been receiving on-off medications. H/o one admission in 2000 during which reportedly 10 ECTs were given and patient was discharged on Lithium 1050 mg and Imipramine 175mg as mentioned in one of the outpatient treatment record. The last episode was of the similar polarity (as the current) and it occurred in 2006 and was managed with Lithium and Imipramine in above mentioned doses. He continued with irregular OPD follow ups since then. Patient would have poor compliance for medications as he would take them unsupervised. He used to take his medications 3-4 times in a week. He however maintained well till November , 2012. Thereafter had another depressive episode managed with change of medications and frequent follow ups at PGIMER; on 17.05.2013 was started on Sodium Valproate at 1000 mg. There was a progressive gradual fall in the platelet level from 1.9 Lac/cu.mm to 56000/cu.mm within period of 2-3 months. As no cause could be found, Valproate was stopped and the platelet level normalized again progressively and gradually over 2-3 months of stopping
Discussion: VALPROATE INDUCED THROMBOCYTOPENIA (TCP) Chances of TCP increase as VPA levels above 100 - 130 microgram/ml.
Mechanism Unclear: Dose dependent suppression of Bone marrow; Production of Platelet antibody causing peripheral platelet destruction: Immune Thrombocytolysis
Keywords: Bipolar Affective Disorder, Thrombocytolysis
Gardner Diamond Syndrome: A Case Report and Brief Review
Mahadev Singh Sen 1 , Aseem Mehra 2 , Susanta Kumar Padhy 3
Department of Psychiatry, PGIMER, Chandigarh
Introduction: Gardner - Diamond syndrome, also known as auto-erythrocyte sensitization syndrome, is an uncommon and under-recognized psychiatric condition, with features of unexplained but predictable bruising. It does not find a mention in current diagnostic classification, and available literature is quite limited, especially from India.
Case description: A 42 year old female patient presented to the psychiatric unit at a tertiary care hospital with nine month history of menstrual disturbance with anxiety symptoms followed in 5 months by development of black coloured, raised patches associated with pain on her right arm initially, later involving the both legs and abdomen. She also developed ulcers in the mouth 2-3 weeks later. There was worsening of symptoms transiently when her son had left for army. With an impression of autoimmune disorder, she was thoroughly investigated with multiple medical/rheumatology/dermatology referrals. All investigations, including Prothrombin time, INR, ANA, anti-ds DNA, anti-smith antibody, antiphospholipid antibody, RNP, complement level, thyroid function test etc. all were normal (except a marginal decrease in haemoglobin). Psychometry for conflict assessment was done. No other major axis I psychiatric diagnosis noted. She was started on Tab. Mirtazapine and Pregabalin; taught relaxation exercise; underwent supportive psychotherapy and problem solving strategy. During therapy she could discover the association between stress and skin lesions; and vice-a-versa. She showed marked and dramatic improvement after initiation of Mirtazapine, with full remission of symptoms after 3 months.
Discussion: This case is discussed in light of limited available literature. It highlights the need for the psychiatrist and physician to suspect this entity and evaluate accordingly. More clinical and research attention towards this uncommon and elusive entity of Gardner - Diamond syndrome is needed.
Keywords: Diamond syndrome, Mirtazapine,
Psychiatric Morbidity Pattern in Patient After Earthquake at TUTH Nepal
Manisha Chapagai, Pratikchya Tulachan , Saraswati Dhungana
T.U. Teaching Hospital ,Maharajgung, Kathmandu, Nepal
Introduction: Earthquakes are natural disasters, causing long lasting physical, economical and mental trauma to survivors. There are numerous mental health conditions known to occur after earthquakes as they cause significant loss in various aspects of individual's life.
The basic aim of this study is explore sociodemographic characteristic and pattern of psychiatric morbidity in patient attending atTribhuvan University Teaching Hospital after earthquake.
Material and Method: A descriptive cross sectional study of clinical profile of patient attending to TUTH OPD was done. Psychiatric diagnoses were based on ICD-10 diagnostic criteria.
Result: Among 1057 cases who visited the outpatient services at Department of Psychiatry during first four and half months after major earthquake on 25 th April 2015, 109 were directly related to earthquake. The mean age was 37 ± 19. The most commonly diagnosed conditions were F 41.9 Anxiety Disorder Unspecified (16%), F43.2 Adjustment disorder (14 %), F 43.1 Post-traumatic stress disorder (8%) and Moderate depressive episode (7.4%). Two cases were referred with incidence of deliberate self harm.
Conclusion The commonest psychiatric morbidity in patient attending in this hospital based survey after earthquake are anxiety disorder unspecified followed by adjustment disorder. The rate of PTSD seems significant in earthquake survivors in our study. But finding has to be taken with consideration that this is a descriptive cross sectional study and sample is limited to a single hospital.
Keywords: Post-traumatic stress disorder, Adjustment disorder, Earthquake
A Study of Serum DHEA-sulphate/ Cortisol ratio in First-episode schizophrenia: Relationship to Aggression and Symptomatology
Ram K Solanki, Parag Sharma, Alok Tyagi, Suresh Gupta, Chitra Verma, Pankaj Borade, Wasim Gesawat, Dayaram Swami.
Department of Psychiatry, S.M.S Medical College & Associated Hospitals, Jaipur, India.
Background: Neuroactive steroids, such as cortisol, dehydroepiandrosterone (DHEA) and its sulfate ester (DHEA-S) have several notable roles in the central nervous system in improvement of mood, with increased energy, interest, confidence and activity levels. Recent studies have suggested the role of DHEA-S, in the symptomatology and pharmacotherapy of schizophrenia patients with negative symptoms, we investigated Cortisol and DHEA-S blood levels in individuals in their first-episode of Schizophrenia in order to exclude effects of age, chronic illness, long-term treatment and institutionalization.
Aim and objectives: To assess ratio of Serum DHEA-S and Cortisol. To ascertain correlation to aggression symptamatology and gender.
Methodology: A Study was conducted at S.M.S Medical College, Psychiatric centre, Jaipur. Those patients fulfilling the exclusion and inclusion criteria ,willing to participate in the study, diagnosed by ICD 10 and confirmed by consultants were recruited in the study. Socio-demographic and illness characteristics recorded in semi structured performa. Positive and Negative symptoms Scale (PANSS) was used for symptomatology. A control group of 20 healthy individuals other than 1 st degree relatives of Schizophrenia patients were recruited as control. Aggression was assessed using the aggression subscale of Buss-Durkee Hostility Inventory.
Blood collection: Sample taken between 8.30 a.m. to 09.30 am in calm and comforting environment for assessment of Serum Cortisol and DHEA-S simultaneously. Blood levels for DHEA-S and cortisol were obtained for 30 first-episode schizophrenia subjects, controls and correlated with a range of clinical rating scales. Patients were free of any antipsychotic medication.
Results & Discussion: In all the subjects, ratio of DHEA sulphate and Cortisol correlated with symptomatology, gender and aggression. Findings recorded and suitable statistics applied and discussed.
Conclusion- Serum DHEA-S/Cortisol ratio was associated with symptomatology and aggression.
Keywords: dehydroepiandrosterone (DHEA), Schizophrenia patients
Vijay Sitaram Pawar, Rahul Bagle, Sagar Karia, Devavrat Harshe, Avinash Desousa, Nilesh Shah
Department of psychiatry, Sion hospital, Maharashtra, Mumbai, India
Introduction: Opium has been cultivated in India as well being imported via the ancient trade routes passing through India. India currently holds the most number of opium users in South Asia. "Bhukki" (poppy husk) has been called the poor man's addiction. With the recent police crackdown on bhukki smugglers leading to disruption of supply, thousands now are seeking deaddiction treatment. Its use is particularly culturally accepted amongst Truck Drivers. Due to increase in rates of buying them in black market, many of them decided to quit this habit. So there was a sudden surge of these patients in our hospital. Hereby is the paper on demographic factors of these patients.
Methodology: All the out patient department papers of these patients were analysed from period of June 2014 to September 2014 and data was entered in excel sheet and analysed with computer software.
Results: There were in all 265 patients, (264 males & 1 female), with age group ranging from 19 to 85 years. About 44% were using only Bhukki, 25% Afim and 30% both. 67% had no other comorbid substance use. There was statistically significant difference in mean age and education status amongst truck driver and non- truck driver groups.
Conclusion: Thus we need to look into the socio-cultural aspects of addiction, wherein many substances might have been culturally accepted to be abused. And these results in lot of our population addicted.
Keywords: bhukki, truck drivers, afim, cultural.
Audit Cycle of Use of Antipsychotics to Deal with Behavioural and Psychological Symptoms of Dementia
Raman Sharma, Sara Cunningham,
Southway Clinic, 50 Inchkeith Road, Plymouth ,Plymouth Community Health Care UK
Introduction: Using antipsychotics to treat BPSD in dementia is controversial with increased risk of morbidity and mortality. Their use is limited to persistent aggression in moderate to severe Alzheimer's dementia when non pharmacological methods have failed. Risperidone is the only licenced drug in the UK for treating Behavioural and Psychological symptoms of dementia. It is indicated for maximum 6 weeks with the maximum dose required of 1 mgs twice daily. (Ref- Taylor D et al. Maudsley prescribing guidelines in Psychiatry 11th edition 2012; 509-518)
Methods: We reviewed drug charts and clinical notes of all patients admitted in a Dementia ward in Plymouth on 18/11/14 and re-audited on 26/6/15. Recommendations were made to improve practice after initial audit and results were re-analysed six months later to monitor practice.
Audit Standards: Maudsley prescribing guidelines in Psychiatry 11 th Edition March 2012 and British national formulary (BNF) 68, Sept 2014-March 2015 were used as gold standards.
Results: Eight patients with dementia were audited each time. There was a reduction in the number of patients on regular anti-psychotic medications (5/8 vs 3/8) and improved documentation of indication of use of antipsychotics 0/5 vs 2/3. Use of the indicated anti-psychotic risperidone improved, where they were indicated 2/5 vs 2/3, it was more often within BNF upper limits 1/2 vs 2/2 and there was a reduction in use of other antipsychotics 3/5 vs 1/3. No improvement in prescribing Risperidone for 6 weeks or less 0/2 vs 0/2 or in documentation of reasons for using another antipsychotics other than Risperidone 0/3 vs 0/1.
Conclusion: Service improvement was evident in most parameters as a result of this audit. This audit can be extended to look into use of antipsychotics in patients who are living in Care homes in Plymouth and nationally with diagnosis of Dementia.
Keywords: antipsychotics , Dementia
A Case of Normalisation of Risperidone Induced Hyperprolatinemia with The Addition of Aripiprazole
M. Hemalatha mutthagari-yemineni, R.S.Swaroop Chary* V. Sharbandh Raj***
SVS Medical College and Hospital, Mahabubnagar, India.
Background: Hyperprolactinemia can be a complication of conventional
Neuroleptics as well as with some atypical anti psychotic agents. These
medications offer the advantage of improved efficacy in the treatment of positive and negative symptoms of psychosis, as well as a better side effect profile over the older agents . Hyperprolactinemia is clinically defined as a plasma prolactin level of >20ng/ml for men and >25ng/ml for women.
Aim: To report a case of normalization of hyperprolactinemia induced by risperidone with addition of Aripiprazole.
Case: A 30 year old female diagnosed with paranoid schizophrenia, was being treated with Risperidone , patient developed hyperprolactinemia after 3 months of treatment. Gradually Aripiprazole was started and cross tapered with Risperidone which led to resolution of hyperprolactinemia.
Further details of the case will be discussed at the conference.
Keywords: Risperidone, Hyperprolactinemia, Paranoid schizophrenia, Aripiprazole
An Assessment of Anxiety Disorders in Children Attending Paediatric and Psychiatric Opd in a Tertiary Care Hospital
Shatabdi Saha, Saswati Nath, Sayanti Ghosh
R.g.Kar Medical College, 1, Khudiram Bose Sarani, West Bengal, Kolkata
Background: Child and adolescent anxiety disorders are the most prevalent forms of childhood psychopathology, affecting about 10-20% of children and adolescents at some point in their lives . Separation anxiety and specific phobias are more common in preadolescent children. Female children and adolescents have higher rates of anxiety disorder.
Objective: To estimate the extent and severity of anxiety disorder in children and assesment of effectiveness of psychiatric interventions in children with anxiety disorder
Method: All consecutive new children aged between 6-12 year age, attending psychiatric and pediatric OPD from 01/07/2014 to 31/12/2014 who are not suffering from mental retardation, epilepsy or any gross neurological disorder, are screened with CBCL. Detailed assessment is done by a semi-structured interview schedule and final diagnosis is done by according to DSM 5- criteria. Severity of anxiety in children is assessed by PARS at the beginning i.e before intervention and at 6 months after intervention. Statistical analysis is done with SPSS version 20. Paired- t-test is done to assess the effectiveness of intervention.
Result: 20(2.22%) out of 900 children attended at pediatric OPD and 13(9.02%) out of 144 children attended psychiatric OPD is found with anxiety disorder. Anxiety disorder is more in female child (72.73%) than male child (27.27%) and more found in children belongs to nuclear family. 54.55% & 45.45% of anxious children are Hindu & Muslim. 66.67% & 33.37% of anxiety disorder children reside in rural and urban area. 27.27% of anxiety children are from low socioeconomic family. The decrease in PARS score after psychiatric intervention for 6 months is statistically significant ( p < 0.05, CI= 95%, α=0.5).
Conclusion: A significant number of children is detected with anxiety disorder not only in psychiatric OPD but in pediatric OPD also. After necessary intervention , psychotherapy and pharmacotherapy for 6 months ,it is found that there is statistically significant improvement of anxiety symptoms in children.
Keywords: ANXIETY DISORDERS, CBCL.
Successful use of Lithium in a female with Kleine Levin Syndrome: A case report and review of female cases reported in world literature
Department of Psychiatry, AIIMS Jodhpur, Rajasthan, India
E-mail: Correspondence: email@example.com
Kleine-Levin Syndrome (KLS) is a rare disorder which mainly affects adolescent boys and rarely reported in females. It is characterized by recurrent episodes of hypersomnia and other symptoms and it is a really challenging for the physician, since itscauses are not yet clear, and available treatment options are not having adequate support. Though several medications (stimulants, lithium, valproate, antipsychotics, and antidepressants) have been reported to provide variable benefit in different symptoms,with lithium being the most widely used drug.
Here we are reporting a female case with KLS, who initially improved with lithium monotherapy but later we have to add armodafinil and sertralinefor complete remission. We will highlight case details and also review the female cases with KLS reported in the world literature.
Keywords: Kleine-Levin Syndrome, KLS in female, lithium, India
Effectiveness of Stress Management Training among Medical Students
Naresh Nebhinani 1* , Mamta 2
Department of Psychiatry, College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
Background: Medical curriculum recommends mastery on multiple domains, which generates significant stress and pressures. This study was aimed to assess the impact of stress management skill training among first year medical students.
Methods: After ethical approval and informed consent we recruited 100 first year medical students and imparted Comprehensive stress management skill training. Outcomes were evaluated through serial measurements of their stress, stressors, burnout, and coping at baseline, one and three months.
Results: Baseline stress was higher among girls (academic, interpersonal, teaching-learning, group activities related stressors and total stress score), and students from nuclear family and urban locality. The comprehensive stress management skill training has significantly reduced their stress scores (in academic, intrapersonal, interpersonal, and teaching-learning related stressors), and burnout levels (for exhaustion) at 1 and 3 months after skill training.
Conclusion: The comprehensive stress management program was effective in reducing medical students' stress and burnout in a short-term period.
Keywords: stress management, , burnout
Ajinkya Sureshrao Ghogare Ashish Saboo , Shrikant Deshmukh , Parth Deshmukh
Shree Colony, Daryapur , Amravati, Maharashtra, India
It is considered as culture bound syndrome , more common in Malay males, Muslim religion, low education and rural origin, who are between ages of 20 and 45 years. It is dissociative episode that is characterized by period of depression followed by outburst of violent, aggressive or homicidal behavior.Episodes caused by perceived insult and accompanied by persecutory ideas, automatism, amnesia and exhaustion.Classical four stages are largely present:(a)brooding and withdrawal,(b) homicidal paroxysm,(c) continuation of homicidal behavior until killed,restrained or falling into stupor of exhaustion,(d) complete or partial amnesia.
Episode is composed of following elements -
- Exposure to stressful stimulus or subacute conflict ; eliciting in subject feeling of anger,loss,shame and lowered self esteem. Stressor-Minor: example - argument with coworker,verbal insult.
Major: example - death of loved one.
Period of social withdrawal and brooding over precipitating conflict,often involves aimless wandering and sometimes accompanied by visual perceptual alterations. Indiscriminate selection of victims,who may or may not symbolically represent original actors in inflict.Occasionally subject also attacks animals or objects in his path or wounds himself,sometimes severely. Cessation may be spontaneous but usually results from being overpowered or killed or exhaustion. Subsequent partial or total amnesia and report of unconsciousness or description of "darkened vision"(mata gelap)during acute episode.
Risk factors for Running Amok -
- History of violent behavior and / or threats.
- Prior suicide attempts.
- Significant interpersonal stress. Example - Loss of loved one, financial stress .
- Personality disorder - paranoid, antisocial, narcissistic or borderline.
- History of psychosis & violent behavior during a mood disorder.
- Psychotic disorder with persecutory themes and history of acting on them.
- Delusional (paranoid) disorder.
- Psychotic disorder with violent command hallucinations.
- Employment problems such as sudden job loss,termination, or employee conflicts.
Keywords: Running Amok , culture bound syndrome
A Study of Insight and Quality of Life in Patients of OCD
Tanuj verma, Anju Agarwal , Shantanu Bharti Gupta , Ajay Kohli , Anshuman Tiwari , Abdul Jilani
Tanuj Nursing Home,Katra Road,Civil Lines,Pratapgarh,(U.P), India Era's Lucknow, Medical College,Lucknow
Introduction: Obsessive compulsive disorder is a chronic disease with a prevalence of 2-3% in the general population. Insight in OCD can vary from a patient having good insight into his/her illness to a poor insight. Patients with poor insight could easily be misdiagnosed as having psychosis,leading to management problems .Quality of life refers to general wellbeing of a person. OCD tends to markedly impair a person's quality of life.
Objectives: The aim of the study was to investigate the insight and quality of life in patient of OCD at Department of Psychiatry ,ELMCH, Lucknow
Method: The sample size consisted of 40 subjects with diagnosis of OCD as per the ICD-10 criteria. A detailed history of illness was taken including symptom profile and levels of insight,along with Sociodemographic data. Data were collected on semistructured proforma and Y-BOCS scale was used to assess the levels of insight,with Global assessment of functioning(GAF) scale used to assess the quality of life.
Results: Out of the total sample ,most of the patients (n=38) were found to have a fair insight; with 2 of the patients having a poor insight into their illness. In terms of quality of life;most were found to have severe impairment( GAF score between 41-50.)
Keywords: quality of life , Obsessive compulsive disorder
A Case of Heller's Syndrome
Neilofor Hussain, R. S. Swaroop Chary*, V. Sharbandh Raj***
Department of Psychiatry, Svs Medical College and Hospital, Mahbubnagar, Telangana, India
Background: Heller's syndrome , also known as Childhood Disintegrative Disorder, a part of Autism Spectrum Disorders is a rare condition ( incidence - 0.002%) characterized by a late onset (2-10 years) loss of previously acquired language and social skills and results in persistent delay in these areas, in addition to restricted, repetitive, or stereotyped patterns of behaviour and other behavioural abnormalities.
Case Discussion: We present the case of a 9 year old male child. The patient had normal development till the age of 5 years, then he started to develop regression of previously acquired language and social skills along with repetitive, stereotyped behavior and behavioral abnormality in the form of aggression suggestive of Heller's syndrome.
The aim is to report a case of Heller's syndrome in detail.
The details of the case will be presented at the conference.
Keywords: Heller's syndrome, Childhood Disintegrative Disorder, Autism Spectrum Disorders
Periodic Catatonia-A challenging diagnosis
Nisheet M Patel , Asim Musa , Nimesh C Parikh , Chintan K Solanki
Psychiatry Ward,V S General Hospital
Introduction: Periodic catatonia is a rare type of catatonic syndrome having frequently and constantly repeated catatonic episodes. In the pathogenesis of catatonia, several mechanisms have been suggested. Benzodiazepines and electroconvulsive therapy (ECT) have been used as first line treatment in catatonia. Outcome variability is ranging from Schizophrenia and organic condition to currently more towards mood disorders.
Objective: We report a case of 17-year male patient presented with periodic catatonia with underlying bipolar mood disorder.
Methodology: Neurological assessment, Buch Francis Catatonia Rating Scale (BFCRS), Brain imagine and laboratory investigations, DSM-5, NICE guideline
Conclusion: Our case report shows improvement of periodic catatonia with benzodiazepines and ECT. Our study also makes future direction about variable outcome of periodic catatonia.
Keywords: Periodic catatonia (PC), bipolar mood disorder, BFCRS
Strategies to improving Medication Administration in Mental Health Care setting; Literature Review.
Sanam Zulfiqar Mcnojia, SanamZulfiqarMcnojia
Al-Azhar Garden, Sector 35/B, KDA Scheme 33,Sindh,Karachi-75280, Pakistan. E-mail: firstname.lastname@example.org
Introduction: Nurses are primarily involved in medication administration phase across all settings. Medication safety has been is a significant issue in psychiatric hospitals. Numerous practice issues in regards of medication administration are being rising in tertiary hospitals.
Background: In mental health care setting where direct observation technique of medication administration should be followed. However, poor medication adherence, low compliance,lack of staffing, unfavorable working conditions, lacking professional responsibilities and not any proper supervision from administration side, may have a serious consequence on mentally ill patients.
Method: In systemic literature review of 10 articles of last 7 years, studies showing the importance and alternative forms used in medication administration in mental health setting.
Results: According to Australian Commission on Safety and Quality in Health Care (ACSQHC) nurses uphold the use of standard identification band used to identify patients during routine medication administration in psychiatric inpatient units. Furthermore, technical and interpersonal approaches (as cited in Kelly, Roper, Elsom& Gaskin, 2011), direct observation technique, assessment of before and after the medication administration and covertly medication administration to incapacitated patients to avoid aggression and agitation (Haw & Stubbs, 2010) are proven strategies to improve practices of nurses in medication administration. Literature also highlights the nurse-patient relationship in psychiatric in enhancing compliance and building insight in long term medication regimen.
Conclusion: Therefore, Nurses needed to hold accountability in providing standards of practices, focusing the best interest of patient and take step ahead to improve the quality of care given to mentally ill patients.
Keywords: Medicine administration , review of literature
A Comparative Study on Attitude Towards Mental Illness of First and Third Year Medical Students of Alappuzha Medical College, Kerala
Sharon Raj Eliza, Post Graduate student, Sobha A,
Dept of Community Medicine, Govt TD Medical College, Alappuzha
Introduction: Over the past decade, mental illness has emerged as an important cause of disease burden in both developed and developing countries. The number of psychiatrists or others with specialist training are insufficient to effectively deal with this growing crisis. It requires motivating and training medical undergraduates to either take up psychiatry as a career, or be willing to and capable of treating common psychiatric disorders in general practice or within their specialties.
Objective: To compare the attitude of first year and third year MBBS student (who was exposed to psychiatric theory, methods and practice) toward mental illness in Alappuzha Medical College, Kerala.
Methodology: A cross sectional study was conducted among first year and third year MBBS students of Govt T D Medical College Alappuzha using a validated questionnaire "Attitude towards Mental Illness" modified from a study by Swaran P Singh et al in 1998. There were 15 questions. The items were scored on a five point Likert scale with a higher score suggesting a more favorable attitude. The scoring on some of the items was reversed to avoid response bias. Total score was 75.A score of 45 was taken as neutral attitude. Total sample size obtained was 256(129 first years and 127 third years).Data was analyzed using SPSS version 16.
Results: MBBS students show a positive attitude toward mental illness. The mean score for first years were 47.94(SD+/_4.508) and third years were 48.32 (SD+/_5.031).This difference was not statistically significant.
Recommendation: The above study recommends increase in the number of hours of Psychiatry training for MBBS students
Keywords: ATTITUDE, psychiatric disorders
Exploration of Nomophobia among Professionals at Workplace
Hemant Kumar Gupta, Manoj Kumar Sharma
Acamh&Ns, Nimhans, Karnataka, Banglore, India
Background: Recent years have seen increase in mobile phone use for metting day to day needs, leisure as well as for professional purpose. Beside s these usages, it is also used for chatting, visiting adult sites, involvement in online relationship, gambling, shopping, games & web surfing. It usage pattern has shown compulsion to carry the mobile as well as subjective manifestation of anxiety for not carrying /losing the mobile phone. There is not published work for its exploration at workplace in Indian context. The present study assessed the pattern of mobile phone use as well as assessment of nomophobia at workplace. (Methods& Materials)250(males/females) were assessed using background datasheet , problematic phone questionnaire as well as screening questions for assessment of nomophobia. Administration was carrying in group setting.(Results) Results indicated the presence of problematic use of mobile phone and 167 acknowledgement of presence of anxiety for not carrying the mobile/losing the mobile as well as postponing important offline activities for accessing mobile phone. Majority carry the mobile with them during night and check their mobile as a first activities after waking up.(Conclusion) The study showed the presence of nomophobia and has implications for promotion of alternative offline leisure activities.
Keywords: Nomophobia professionals
Association of Internet Addiction With Anxiety and Quality of Life Among Medical Students
Nidhi Nagori, A.U.Vala, Imran J.ratnani, Kinjal Vasava.
Objective: Internet addiction or excessive Internet use is characterized by excessive or poorly controlled preoccupations, urges or behaviours regarding computer use and Internet access that lead to impairment or distress in individual's psychological state. This study was aimed to assess the frequency of internet addiction and its possible association with anxiety severity and quality of life among medical students.
Methods: This was an observational, cross sectional, single-centred, self-assessable questionnaire based study administrated among 525 consenting medical students. The participants were assessed by proforma containing demographic details, other variables related with internet use, questionnaires of IAT (Internet Addiction Test for Internet Use), BAI (Beck's Anxiety Inventory for severity of anxiety) and WHOQOL-BREF (World health organization quality of life assessment scale for quality of life). Statistical data were analysed by Graph Pad InStat version 3.06. Proportions were compared by using Chi-square test, IAT, BAI and WHOQOL- BREF scores were compared by Mann-Whitney test followed by Dunn post test multiple comparison and correlation was assessed by spearman's rank correlation. P value of <0.05 was considered to be statistically significant.
Results: Frequency of problematic users among students was 9.3 % with frequency of internet addiction 0.9%. Males were more likely to experience internet addiction than females. Participants with problematic internet use were likely to experience high severity of anxiety (p<0.0001) and poorer quality of life in psychological (p= 0.01) and environmental domain (p=0.03) of WHOQOL-BREF. Severity of anxiety is positively correlated with internet addiction (r 2 = 0.085, p<0.0001).
Conclusion: Participants with problematic internet use were more likely to experience anxiety symptoms and quality of life and vice a versa.
Keywords: Internet Addiction, Anxiety, Quality of Life
Psychosis Due to Levetiracetam in a Child
Parvesh Batra, Susanta Kumar Padhy,
Department of Psychiatry, PGIMER, Chandigarh, India
Background: Levetiracetam has been increasingly preferred by physicians for treating seizure disorders in both adults and children. Behavioural side effects are seen in about 37.6% of pediatric patients on levetiracetam treatment. The commonly reported psychiatric adverse-reactions include agitation, anxiety, emotional lability, apathy, depersonalization, hostility, hyperkinesias and irritability. Psychosis is reported infrequently in less than 1% of cases. Risk factors for developing side effects include paediatric age group, prior cognitive defects, status epilepticus pre-existing psychotic disorder, rapid titration and underlying neurological disease. Despite this, its awareness among psychiatrists, paediatricians and neurologists seems limited.
Case Description: We present a case of 8 year child who developed psychotic symptoms within 1 st week of starting levetiracetam. The child initially presented with status epilepticus following 3 days of fever. He was treated for acute meningoencephalitis. As adequate doses of phenytoin and valproate could not control seizures, levetiracetam was added. With this though seizures subsided but the child developed visual hallucinations, hallucinatory behaviour, formal thought disorder, disorganised behaviour, fearfulness, persecutory ideation and sleep disturbances after 5 days of initiating levetiracetam. Consciousness and orientation was intact. Neuroimaging, EEG, drug levels and CSF studies were normal. Initially minimal improvement with risperidone 1 mg/day was noticed, but there was significant decrease in psychotic symptoms after stopping levetiracetam. Subsequently two episodes of seizures occurred which were controlled by adding clobazam. Provisional diagnosis of levetiracetam induced psychosis was considered after carefully ruling out post-ictal psychosis, meningo-encephalitis associated behavioural change and delirium.
Discussion: Points in favour for considering Levitercitam induced psychosis are: presence of risk factors, onset of psychotic symptoms after leviteracetam initiation, appreciable improvement in the same after stopping leviteracetam and carefully ruling out other possible causes. The risk factors, diagnostic dilemmas, follow-up status and brief review of psychosis due to levetiracetam are discussed.
Keywords: psychosis , levetiracetam , seizures.
Valproate Associated Hyperammonemia: A Case Report
Indu Surendran, Dr Sandeep Grover
Department of Psychiatry, PGIMER Chandigarh.
Background: Hyperammonemia is an uncommon side effect of valproate, diagnosis of which required high level of clinical suspicion. Aim: To present a case of valproate associated hyperammonemia and discuss the risk factors and management of same. Method (Case Description): A 57 year old man, suffering from Bipolar Affective Disorder, Tobacco and alcohol dependence for 20 years presented with delirium characterised by disorientation, poor attention concentration, memory disturbances and marked anxiety while receiving Valproate 2000 mg/day along with Risperidone 6 mg/day. Further exploration of history revealed that patient was diagnosed with diabetes mellitus, benign prostatic hyperplasia, hydrouretero-nephrosis and chronic kidney disease few months back. Additionally he was experiencing marked constipation. On investigation his hemogram, blood biochemistry, liver function test were within normal limits. However he had deranged renal function tests, raised fasting blood glucose levels and Hba1c. In view of constipation and use of high doses of valproate, hyperammonemia was suspected and on investigation patient was found to have high ammonia levels (159 Umol/l). In view of this, patient was managed conservatively with stoppage of valproate, intense management of blood glucose levels and syrup lactulose. Stoppage of valproate led to improvement in delirium and his cognitive functions improved. Later he was managed with carbamazepine for prophylaxis of bipolar affective disorder along with close monitoring of serum ammonia levels, which normalized after a few weeks Conclusion: Valproate can lead to hyperammonemia and patients receiving high doses of valproate, especially those with chronic medical illnesses, should be closely monitored for the same.
Keywords: Valproate , Hyperammonemia , medical illness
A Study of Depression and Quality of Life in Patients with Oral Cancer
Archana S.Kantak B.N. Panchal , Arvind Sisodiya , Ashok U. Vala , Sarandha Srivastava
PG-2 Hostel, Sir T.hospital Campus, Gujarat, Bhavnagar
Objectives: Head and neck cancer (HNC) is one of the 10 most frequently occurring cancers worldwide, with estimates of over 500,000 new cases annually and one of the 10 leading causes of cancer mortality.Head and neck cancer (HNC) patients experience among the highest rates of major depressive disorder (MDD) of all oncology patients. The incidence of depression in HNC patients ranges between 15% and 50%.The aim of this study was to find out frequency of major depressive disorder (MDD) and its association with quality of life in patients with Oral Cancer.
Methods: This was a single-center, cross sectional, observational, questionnaire based study. Seventy consecutive patients, who attended Oncology outpatient department of tertiary care hospital with diagnosis of Oral cancer were included. Diagnosis of Major Depressive Disorder was done by clinically administered interview as per DSM V. The patients were further assessed for demographic details, HADS-A(Hospital Anxiety and Depression scale for Anxiety),HADS-D (Hospital Anxiety and Depression scale for Depression), FACT H&N QOL (Functional Assessment of Cancer Therapy Head and Neck Quality of Life Scale).Data were analyzed by GraphPad InStat version 3.06. Proportions were compared by using Chi-square test, HADS-A, HADS-D and FACT H&N QOL scores were compared by Mann-Whitney U test or Kruskar Wallis test followed by Dunn post test multiple comparison .P value <0.05 was considered to be statistically significant.
Results: Frequency of MDD in Oral Cancer patients was 40%. The patients having Major Depressive Disorder showed higher HADS-A (p<0.0001), HADS-D(p<0.0001) scores and poorer quality of life in all domains of FACT H&N QOL.
Conclusion: The patients with Oral Cancer have higher rates of depression and poor quality of life.
Keywords: Oral Cancer, Depression, Quality of life.
"Pseudoparasitic Dysethesia"-the relentless pursuit for mind bugs
Arun Ayyappan, sri saipriya , christina George,
Dr smcsi medical college, Kerala, Thiruvananthapuram, INDIA
Dermatozoenwahn or Delusional infestation or Delusional parasitosis is a common condition in dermatology practice but is uncommon in psychiatry. It was first described as Acarophobia by G Thibierge in 1890's (ekbaums syndrome). Delusional parasitosis can be denovo, secondary or organic. Walling et al suggested "Pseudo parasitic dysethesia" as an alternate name to reduce the stigma. Delusional parasitosis in paranoid schizophrenia has been reported.
58 yr old female, a case of paranoid schizophrenia presented with 6 year history of expressing the belief that others were throwing bugs over her head, experiencing sensations of insects crawling all over her head and face which she picked with her right thumb & index finger. She showed pieces of skin as insects, started cutting her hair & repeatedly washed her hair in an attempt to get rid of these. She described the colour of insects as black. She was seen primarily by psychiatrist for these complaints since her paranoid symptoms started first but was non compliant. There was no history suggestive of cognitive decline. On examination sideburn areas showed hyperpigmentation, hyperkeratotic plaques and callus formation in the right thumb. Multiple cut hair was present over scalp.
Mental status examination revealed blunted affect, delusions of persecution, delusion of infestation, tactile hallucination, memory intact, impaired insight. MMSE was attempted but patient was not cooperative. All relevant investigations including haemoglobin, lymphocyte count, ESR, thyroid function test, blood sugar levels, vitamin B12 assay were found to be within normal limits. She was diagnosed as a case of paranoid schizophrenia -continuous course(ICD -10) and delusional parasitosis (secondary). She didn't respond to an adequate trial of risperidone. Her symptoms improved with chlorpromazine, haloperidol combination and are currently undergoing treatment in our institution.
This case highlights that delusional parasitosis can occur secondary to paranoid delusions.
Keywords: Dermatozoenwahn , paranoid delusions.
Atypical Antipsychotic Induced Delirium in an Elderly Patient
Kavitha M S, Sumersh Balachandran , Druhin A V,
Vasantham, Kunnakkavu PO, Cherukara via, Kerala, Perinthalmanna, India
Background: Antipsychotics are known to have a number of adverse effects. Compared with conventional antipsychotics, atypical antipsychotics are less likely to cause extra-pyramidal symptoms and are better tolerated in the elderly and can also be good treatment option for delirium. However, these medications do not represent a homogeneous class, given their differences in effect size regarding both alleviation of clinical symptoms and their potential for inducing side effects.
Objective: To describe the case of an 80 year old man, who developed delirium, after starting Risperidone for Persistent Delusional Disorder.
Case Report: 80 year old married gentleman from a LSES family with past history of DM, with family history suggestive of psychosis, personal history of nicotine dependence, premorbidly well adjusted, presented with 35 years duration of delusion of parasitosis with tactile hallucination and delusion of persecution and exacerbation of symptoms for past 1 week associated with sleep disturbance. MSE was corroborative. All investigations were normal. Started him on trihexyphenydyl 2mg/day and Risperidone 1 mg. Risperidone dose was titrated to 2 mg/day. He developed delirium 2 days after the dose of Risperidone was increased to 2.5 mg. Anticholenergic medication was stopped. Repeated FBS values were higher, hence started him on Insulin. Risperidone dose was tapered and stopped by day 15, Haloperidol 0.25 mg was started. Patient gradually improved.
Result: In case of developing adverse effects like delirium with atypical antipsychotics, changing to typical antipsychotics result in better outcome.
Conclusion: Although Risperidone appears to be a safe treatment option for elderly psychiatric patients, particular caution is advised in the presence of metabolic disorders. Successful treatment in the elderly requires appropriate multidimensional assessment of the patient, knowledge of possible co-morbidities, complexities of polypharmacy, age-dependent changes in pharmacokinetics and pharmacodynamics, and drug-drug interactions in this age group.
Keywords: Atypical antipsychotics, delirium, elderly
Flexion-contracture in Both Knee and Hip Joints in a Schizophrenic Patient Restrained by Family Members for 15 years
Rajkumar 1, Rajat Oswal2, Aamir Khan Pathan3
Medical College Baroda
Psychotic patients were restrained at home and even in asylums in the past due to poor awareness and lack of effective community based treatment for chronic psychotic illness. In recent times, due to improving awareness and better psychiatric treatment facilities, patients are being treated earlier and are usually not restrained. Few cases come to hospital these days that have been restrained for years.
Here we present a case of a 35 years old married separated male from lower socio-economic status belonging to rural background having continuous psychiatric illness for 15 years. Fifteen years ago he had a history of acute onset of hallucination, delusion of persecution, aggression, poor self-care, sleep disturbance and running away from home. He was taken to a private psychiatrist where he was given ECT and showed improvement but discontinued treatment due to financial problems.
After one week, the patient started worsening. Due to his aggressive behavior his family members kept him in chains outside their home in a temporary shade since then. His mother was the only person asking to him to provide food and change his clothes in which he used to pass urine and stool. Gradually patient stopped talking and would remain withdrawn. He would sit in a squatting position throughout the day.
His story appeared in newspapers after which the village administration brought him to Government Medical College, Psychiatry unit for treatment. Patient was diagnosed as suffering from Schizophrenia and was started on antipsychotics. On examination it was found that he had developed flexion-contracture in both knee and hip joints and referred to an Orthopedic surgeon who diagnosed him as suffering from flexion-contracture of both hip and knee joints with arthritic changes. Patient was advised NSAIDs and physiotherapy.
Patient was discharged after 70 days and showed remakable improvement in his symptoms and he can now walk with support.
Association of Stigma and Self-esteem in Patients Suffering from Psychiatric Illness
Gopi Gajera, Rajesh Ram, Kalpesh Chandrani
Raijinagar, Opp. Motibag, Junagadh, India
Persons with psychiatricillnesses may internalize stigma and experience diminished self-esteemwhich proves to be one of the greatest barriers to regaining a normal lifestyle and health. There is growing evidence of the negative effects of stigma on the self-esteem of such patients.
Aims: To determine the association between stigma and self-esteem in patients suffering from psychiatric illness.
Method: The study sample consisted of 41 psychiatrically ill outpatients, including (29%) femalesand(71%) males, divided into 6 categories i.e. schizophrenia(17%), bipolar(34%), depression(17%), anxiety(10%), obsessive-compulsive(7%) and substance use(15%). Assessment instruments included the Stigma Scale by King et al and the Rosenberg Self-Esteem Scale. Data were analyzed using Pearson co-relation co-efficient.
Results: Patients with substance use disorder experienced maximum stigma (Mean=78.7, SD=10) and least self-esteem (Mean=15.2, SD=7) as compared to others. Stigma is more negatively co-related with self-esteem in female patients(r= -0.9) as compared to males(r= -0.52), and moderately negatively co-related in patients of depression(r= -0.81), schizophrenia(r= -0.77) and bipolar (r= -0.65). Overall co-relation between stigma and self-esteem was moderate and negative(r= -0.67), i.e. as the stigma increases, self-esteem decrease and vice-versa.
Conclusions: Low self-esteem increases the susceptibility for development of stigma for psychiatric illness, and the presence of stigma for psychiatric illness, in turn, lowers self-esteem. Enhancing psychological resources, by increasing self-esteem and the ability to cope with symptoms, can be targeted to diminish the stigma.
Keywords: stigma, self-esteem, psychiatric illness
Case report: Acute Hyperglycaemia Associated with Psychotic Symptoms
*Swapnajeet Sahoo, **Aseem Mehra, **Sandeep Grover,
*Senior Resident, ** Associate Professor, PGIMER, Chandigarh
Aim: To present a case of psychosis, in which patient had short lasting episodes of psychosis (in the absence of altered sensorium and cognitive disturbances) were associated with acute hyperglycaemic episodes in a young female patient presented with type I diabetes mellitus.
Case report: A 36 year old female, belonging to a Sikh nuclear family, from urban background with type 1 diabetes mellitus, who was pre-morbidly well-adjusted with no family history of mental illness, presented with an illness of acute onset, 4 months duration precipitated by poor compliance to insulin therapy, characterized by smiling and muttering to self, abusive behaviour, decreased self-care, anger outbursts, delusion of persecution, delusion of grandiosity, excessive grooming, increased religiosity, decreased sleep, decreased appetite, emotional liability, mood incongruent delusion. Patient's relatives who would be monitoring her blood sugar reported a temporal correlation of onset and progression of psychotic symptoms with rise in fasting blood glucose levels from 200 to 300 mg/dl. Past history revealed a similar episode 7 years back which lasted for 20 days, when she had become non-compliant to insulin. A diagnosis of Acute and transient Psychotic disorder was considered. However, in the follow-ups she had 2 similar episodes and was brought to emergency with violent behaviour and on investigation was found to have hyperglycaemia (FBS-300-515 mg/dl, PP(s)- 398 mg/dl). Further, adequate management of hyperglycaemia over the next 15 days, along with use of Tab. Trifluoperazine 15 mg/day, Tab. Clonazepam 0.5 mg/day led to improvement in the psychotic symptoms. Later the psychotropics were stopped and patient was educated about the importance of compliance with insulin. Since then patient is complaint with insulin and did not have any relapse of psychotic symptoms. Conclusions: Poor glycaemic control can precipitate psychotic symptoms in patients with diabetes mellitus.
Keywords: Hyperglycemia, psychosis, type I diabetes mellitus
Clozapine Induced Eosinophilia: A Case Report
Anish Shouan, Vijay Prakash, Sandeep Grover
Department of Psychiatry, PGIMER, Chandigarh
Background: There is limited information on eosinophilia occurring in patients on clozapine. There are few case reports. Aim: To present the case of 32 year male with undifferentiated schizophrenia and obsessive compulsive symptoms managed with clozapine, fluoxetine and maintenance ECT for further management and revealed eosinophilia on further investigations. Methodology (Case description): A 32 years old married male, presented with an insidious onset and continuous illness from the age of 16 years characterised by apathy, social withdrawal, avolition, laughing and muttering to self, delusion of persecution towards family members, decreased sleep, decreased appetite, poor self-care and disturbed bio-functions. For this he was taken to many faith healers and private practitioners and was started on atypical antipsychotics and mood stabilizers but did not show any improvement. This continued till he was 31 years of age then he started to wash his hands repeatedly and doing this even after repeated stoppage and would not think it to be normal. After about 6 months he was admitted in psychiatry ward in PGIMER, Chandigarh. ECT was started and after 2 adequate trials of atypical anti-psychotics, he was started on clozapine and gradually increased to 225 mg and Fluoxetine 40 mg and weekly CBC monitoring was done and on DLC he was found to have eosinophilia. All the alternate causes of eosinophilia was ruled out by sending stool microscopy, sputum analysis, ruling out auto-immune causes by IgE levels, HRCT-Thorax and all of which was found to be normal. After that it was concluded that Eosinophilia was due to Clozapine. Dose was not increased further and patient was continued on fortnightly ECT and there is 50-60% improvement in symptoms. Conclusion: Close CBC monitoring should be done.
Keywords: Clozapine, eosinophilia
Psychiatric Comorbidities in a Patient with Lissencephaly
Ruchita Shah, Indu Surendran, Soumya Jhanda, Nidhi Chauhan
Department of Psychiatry, Post Graduate Institute of Medical Education and Research
Background: Lissencephaly is a rare disease that is associated with absence (agyria) or incomplete development (pachygyria) of the ridges or convolutions of the outer surface of the brain, associated with significant psychiatric comorbidities Aim: To present a case of intellectual disability, autism, ADHD and seizure disorder with lissencephaly-pachygyria complex in a 6 year old female child Method (Case Description): Patient was born of a full term delivery without perinatal complications, through cesarean section following suspected fetal distress. Had significant developmental delay; would not follow objects with eyes, smile, roll-over or babble even by 8 months of age; would just move her limbs at times; would not even cry when hungry/ passed stools or urine. At 8 months, she developed episodes of loss of consciousness with initial loud shrieking with up-rolling of eyes, trembling of body with abnormal EEG; controlled with Sy. Carbamazepine 3 ml BD. She attained neck-holding and smiling at 1.5 years, sitting without support at 3-4 years, babbling and walking without support at 4-5 years. Had no stranger anxiety nor eye-contact. By 4-5 years of age, she would walk around continuously, picking up objects and putting them in her mouth, rubbing them against her teeth, chewing them without swallowing and enjoying same, screaming, kicking, banging her head or biting self, if people tried to stop her. She would move onto a new object after hours of playing with one; search continuously for new objects; assault her family members at times without any reason. She would not indicate bowel or bladder habits and would at times touch her stools and play with same. She was managed with risperidone and clonidine; psychoeducation of parents regarding type of illness, causation, severity was done and parental concerns were addressed; behavioral analysis was done, taking into account the antecedents, problem behaviors and consequences. Also child's strengths were evaluated and accordingly behavioral therapy with components of positive reinforcement, limit-setting, prompting, modelling, ignoring and shaping were started. Conclusion: Lissencephaly can result in significant impairments in the growth and intellectual development and has to be managed symptomatically to ensure a satisfactory outcome and improved quality of life.
Keywords: COMORBIDITIES , LISSENCEPHALY
Lycanthropy and Cotard syndrome - A rare Combination
KHH Suchandra, Ruchita Shah, Aseem Mehra,
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, INDIA
Background: Clinical lycanthropy is defined as a rare psychiatric syndrome involving the unusual belief that the affected person can transform into, or has transformed into an animal or behaviour suggestive of such belief. A review of literature till now listed only few cases of lycanthropy mainly describing transformations into wolves, one single report about transformation into pig and no cases describing metamorphosis into ahorse. Cotard's syndrome is another rare condition in which the patient has nihilistic delusions and ideation of immortality.Existence of both these syndromes simultaneously in a patient is very rarely reported. Also in the literature, not much has been discussed regarding itstreatment. Aim: We present a case of psychotic depression presenting with phenomenology oflycanthropy and cotard'ssyndrome simultaneously and treated successfully with ECT. Case description: A 53-year-old female patient presented to the outpatient clinic with symptoms of severe depression following a stressor (son marrying against her wish and followed by separation) and intentional self harm. On careful exploration, she had symptoms over 3 years characterized by anhedonia, worthlessness, suicidal plans, guilt, passivity, persecution, delusional belief of parts of self being metamorphosed into those of a horse and delusional belief of own body parts are getting rotten away. She believed that this metamorphosis was a result of the wrath of Goddess Kali (goddess of destruction amongst other things) and was associated with delusion of sin. She was on atypical antipsychotic and antidepressants with poor treatment response. Later she was treated with electroconvulsive therapy (8 ECTs) along with venlafaxine and trifluperazine, with which both her mood and psychotic symptoms improved completely.Conclusion: Co-existence of lycanthropy and cotard's syndrome is rare and ECT proves to be effective. Further studies are required to understand these syndromes psychodynamically and transculturally which might have therapeutic importance
Keywords: lycanthropy, cotard syndrome, ECT
A Rare Case of Cotrad Syndrome in an Adult Male: A Case Report
KHH Suchandra, Subodh BN, AseemMehra
Department of Psychiatry, Postgraduate Institute of Medical Education and Research
Background: Cotard's Syndrome is a very rare neuropsychiatric condition in which the sufferer holds a delusional beliefthat he or she is dead, does not exist, is putrefying or haslost his/her blood or internal organs. It is seen in subjects with depression, schizophrenia and organic syndromes. Cotard's syndrome is in general reported to be morecommon in females and older age groups with rare occurrence in adult male.
Aim: To present the case of psychotic depression with cotard's syndrome in an adult male.
Methodology(case report):A 22 year old male presented to the outpatient clinic with symptoms of severe depression following a stressor(difficulty in job). Exploration of history revealed that he had anhedonia, hopelessness, low energy, decreased appetite, somnolence and guiltover eight months. As depression worsened, he started believing that his inner body parts are getting rotten away leaving a foul smell. He had the delusional belief that his head is empty and his brain went missing. Also he could not feel the presence of his other body parts like eyes and neck, to which he repeatedly kept checking for their presence. These symptoms worsened over a period of six months. He was earliertreated on adequate trials of risperidone, sertraline without much improvement. On Hamilton Depression Rating Scale-21(HDRS-21) he scored 32. He was later started on electroconvulsive therapy and medications like olanzapine, escitalopram. A total of 8 ECTs were given along with medications to which he responded completely(HDRS-21 score decreased to 7) over three months.
Conclusion: Cotard's syndrome is a rare condition, very rarely seen in adult males. Electroconvulsive therapy has proved to be effective.
Keywords: Cotard syndrome, ECT, depression
Blood in Tears as Presenting Symptom in a Pregnant Woman with Dysthymia
Nimeesha. Nekkanti1 , R Rama Krishna Raju2, M Vijaya Gopal3
Department Of Psychiatry, GSL Medical College, Rajahmundry, Andhra Pradesh
Abstract: Depression at all ages is common, it is the 3 rd leading cause of morbidity at present and is expected to be the 2 nd leading cause by the year 2020. Depression is not only having low mood, worthlessness and hopelessness it also coexists with many different physical symptoms. Here we report an atypical presentation in a 24 year old pregnant woman complaining of bleeding from both the eyes at 32 weeks of gestation. History revealed, persistent low mood, decreased interest and concentration in daily activities and low self esteem since 2010. There was one episode in 2013 with increased intensity of symptoms and associated crying spells, worthlessness, hopelessness, mild aggressiveness, worsening of suicidal ideas, disturbed sleep and appetite, when she was sent to her maternal aunt where she grew up after her parents death.They didn't attend any psychiatrist instead went to a local faith healer, partial remission of symptoms was observed in 6months. In 2015 july, she presented with bloody tears from both the eyes associated with mild depressive symptomatology. Patient on her hospital stay developed repeated bleeding episodes. Bleeding sample was investigated for haemoglobin, peripheral smear, clotting time and cross-matched. MRI brain was normal, nasolacrimal duct was patent on ultrasonography. After detailed evaluation she was diagnosed as Persistant Mood Disorder-Dysthymia. Patient was started on SSRI and Psychoeducated about the illness. Improvement in symptomatology was noted after 4weeks of treatment and complete remission of bloody tears at the end of 2 months was observed. This case is reported for the rarity of its presentation.
Keywords: Bloody tears, Dysthymia.
Risperidone for Behavioral Problems in JCNL: A Case Report
Riteeka S Dikshit
The neuronal ceroidlipofuscinoses (NCL) are progressive neurodegenerative disorders in which various psychiatric symptoms like anxiety, depression and psychosis are common. Here we present a case of 7 year old child diagnosed as having juvenile neuronal ceroidlipofuscinoses and responded to risperidone for his behavioral issues. We started him on syrup Risperidone 0.5mg twice a day for control of his behavioral problems and was gradually increased to 2mg in divided doses. Also tab. Trihexiphenidyl 2mg was added once risperidone was increased to 2mg. He is much better and is on regular follow up with us. It is important for pediatricians to look for behavioral problems in children having JCNL. Treating these comorbid conditions can reduce the burden of family members to some extent in handling these children.
Keywords: Risperidone, neuronal ceroidlipofuscinoses (NCL) , Behavioral Problems
"A Study On Excessive Daytime Sleepiness and Its Correlation with Psychopathology in Patients with Schizophrenia
Riteeka S Dikshit
Introduction: Excessive daytime sleepiness (EDS) and sleep problems are common in patients with schizophrenia. The symptom of EDS when dissected in schizophrenia can be attributed to various causes including neurobiological changes, sleep disorders, medication or as a symptom of schizophrenia itself. The prevalence of sleep disorders and sleep problems in first episode and chronic schizophrenia has been understudied.
Aims and Objectives: The objective of this study was to study the prevalence of excessive daytime sleepiness in patients with first episode and chronic schizophrenia and to correlate with various psychopathological parameters.
Materials and Methods: In this cross-sectional study with ambulatory patients suffering from schizophrenia, sleep quality was evaluated with the Pittsburgh Sleep Quality Index (PSQI), and excessive daytime sleepiness by the Epworth Sleepiness Scale (ESS). Severity of illness was assessed by PANSS and cognition by Frontal Assessment Battery and Trail Making Test A and B.
Results: 100 patients (72 male and 28 female) aged 17 to 64 years (mean age 30.63) were studied. Poor sleep quality (PSQI>6), exhibited by 83% patients. Excessive daytime sleepiness (ESS>7) was found in 32% patients. There was not much statistically significant differences in various parameters according to the age, duration of illness or gender based.
Conclusion: Thus there was a high prevalence of sleepiness and poor sleep quality in the sample but it did not have much correlation with age, gender or duration of illness nor it had major impact on various cognitive tests.
Keywords: Daytime Sleepiness , Psychopathology , Schizophrenia
Pica associated with Risperidone use: A Case Report
Nishtha Chawla 1, Saurabh Kumar2, Raman Deep Pattanayak3
All India Institute of Medical Sciences, New Delhi
Introduction: Pica is defined as the persistent intake of non-nutritional substances, in an inappropriate way from an evolutionary perspective, which is not culturally sanctioned. There has been one previous case report of Pica following oral Olanzapine among atypical antipsychotics. We present a case of Risperidone associated pica, which persisted during the initiation of treatment.
Case Description: A 50 year old female, married, educated upto 10 th , diagnosed as a case of 'other nonorganic psychotic disorders' as per ICD-10 for duration of 25 years, characterized by delusion of persecution, delusion of reference and disorganised behavior. There was no history of medical/surgical diseases, eating disorders, drug abuse or other psychiatric history. She was not compliant on treatment and currently off medication for past 7 years. She followed up after 7 years with relapse of her symptoms for past one year. She was started on Tab.Risperidone 1mg/day built to 4mg/day. After 1-2 weeks of starting of Risperidone, she developed an irresistible urge for eating raw rice several times in a day. On occasions, she would get up in the middle of the night in order to eat raw rice. This symptom gradually remitted over 3-4 weeks although Risperidone was continued at similar dosage. There was complete remission of her psychotic symptoms too within a month of starting antipsychotic.
Conclusion: Although the exact underlying mechanism of pica is not known, it has been proposed that the craving for eating non-nutritional material could be considered as an obsessive-compulsive spectrum disorder. Limited literature suggests that pica may occur during the use of second generation antipsychotics, which is similar to obsessive-compulsive symptoms. The observation that pica lasted only for a relatively brief time, it may be missed during the course of use of atypical antipsyhotics. Further studies are warranted to explore the relationship between pica and second generation antipsychotics.
Profile of Patient Presenting with Alcohol Related Seizures at a Rural Tertiary Care Hospital
Jagdish Vankar, Chinmaye Sapre, Soaham Desai Himasnshu Pandya,
Department Of Psychiatry, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
Background: Alcohol-related seizures are defined as adult-onset seizures that occur in the setting of chronic alcohol dependence. Alcohol related seizures are most commonly attributed to alcohol withdrawal syndrome (AWS) but studies show various other causes such as epilepsy and structural brain lesions.
Methodology: Patients coming to hospital with history of seizures and alcohol use without previous diagnosis of epilepsy were included. Data collected consisted of socio-demography, alcohol use profile [Quantity x Frequency measure of alcohol use (QF), AUDIT, CIWA, DSM-IV-TR diagnosis of alcohol dependence], presence of AWS, last intake of alcohol. Motivation for drinking was measured using Drinking motive questionnaire (DMQ-R). Metabolic workup was done for all patients. Imaging study (CT and/or MRI) and EEG were done based on clinical judgment of treating team and patient affordability.
Results: Thirty-eight patients were included and analyzed. IMFL was the most frequent type of alcohol used, with Frequent-Low pattern (≥4 times/wk & ≤6 drinks per occasion) being most common. Coping was the highest endorsed reason for drinking. Alcohol withdrawal seizures (n=13) & Dual diagnosis (n=4) were collated and compared with other causes (n=21). QF, Last intake ≤72 hrs and presence of alcohol withdrawal on presentation were significantly associated with alcohol withdrawal seizures. Abnormal metabolic workup was significantly associated with other diagnosis. No significant difference in the groups on comparison of presence or absence of abnormal findings on Imaging and EEG was found.
Conclusion: QF measure of alcohol consumption, time since last intake of alcohol, history of alcohol withdrawal on presentation and metabolic workup are good indicator to differentiate alcohol withdrawal seizure from other causes. EEG and imaging should be used when patient presents with history of first known seizure or when time since last intake is >72hrs.
Keywords: alcohol withdrawal syndrome, seizures
A Case Report of Seizure / Pseudo-seizure Disorder
Shivraj P 1 , Anu K 2 , Vijay G 3 , Shobha N 4 , Mazumdar K 5 , .Aditi C 6 , Divya R 7 .
Dept of Psychiatry, BARC Hospital, Anushakti Nagar, Mumbai.
Background: Seizure disorder often has co-existing pseudo seizures also as accompanying co-morbidity. Distinguishing pseudo-seizures from true seizures is of paramount importance to psychiatrist to prevent over-utilisation of medical facilities be it neuroimaging or Electroencephalography (EEG).
Case History: An 18yr old Engineering undergraduate diagnosed case of Seizure disorder (Complex Partial seizures) 3 years back on treatment from Neurologist reported to psychiatric OPD with c/o negative thinking and anxiety. He also continued to experience episodes with head turning sideways, asynchronous movements of upper limbs and utterances of expletives. This would happen more so in presence of people and never had he fallen down or injured self during such episodes. At times these episodes happened even during night time. He will be unaware of such behaviour but never lost consciousness during these episodes.
On MSE: Pt was kempt and tidy touch with surroundings, Affect was Dysphoric with pre-occupation about his altered behaviour and also exhibiting Anticipatory anxiety about when the next episode may occur again.
Investigations: MRI didn't reveal any significant abnormality. EEG was showing abnormal slowing over left temporal region. Psychological assessment was also done in which for Rosarch testing he was very much guarded so became invalid due to very few responses. MMPI was administered whose findings were suggestive of Hysteria.
Conclusions: Psychogenic Non Epileptic Seizures (PNES) also called as Pseudo seizures are an important accompaniment of True seizures in quite a few patients. But it's important to differentiate between true seizures from pseudo-seizures as patients insist for having CT Scan/MRI and EEG done frequently along with Neurological opinion. This helps in reducing the unnecessary utilisation of costly health care resources.
Keywords: Psychogenic Non Epileptic Seizures (PNES), seizures
A Case Report of Wilson's Disease Presenting with Psychiatric Manifestations
Praveen s g 1 , Anil T 2 , D.Vijayalakshmi 3 , P.Himakar 4
department of psychiatry Andhra medical college. Vishakhapatnam
Wilson's disease is an autosomal recessive genetic disorder with hepatic, neurological and psychiatric manifestations. When patient initially present with psychiatric manifestations, it can obscure the primary diagnosis and therefore the diagnosis of Wilson's disease should be kept in mind. Here we present the case of a 22 year old male initially presented with behavioural abnormalities and later was diagnosed to be Wilson's disease. In addition the patient also presented with renal tubular abnormalities and an incidental finding of azygos anterior cerebral artery.
Introduction: Dr. Wilson published description of 12 patients who presented with extrapyramidal motor disease and an autopsy demonstrating softening of lenticular nucleus and cirrhosis. It was also noted that two of the patients presented with schizophrenia like psychoses.Psychiatric symptoms ranging from major depression, mania, antisocial behaviour to psychoses were observed in cases with Wilson's disease. It is later found to be a genetic disorder transmitted through autosomal recessive mode and involving copper metabolism characterised by excessive deposition of copper in liver, brain and other tissue.genetic defect was localised to short arm of chromosome 13 affecting ATPase(ATP7B) 1 gene in liver presenting with hepatic manifestations(40%), neurologic manifestations(40%) ,psychiatric manifestations occur in one fifth 2 .Life time prevalence of psychiatric disorders may vary from 30-100% 3-5 .
We present a case report in which the patient initially presented with psychotic features, who on investigations found to have Wilson's disease.
Case report: Mr. p.s 22 year old male born out of non-consanguineous marriage presenting with c/o behavioural abnormalities of 2 year duration with exacerbation of symptoms since 15 days. The behavioural abnormalities are in the form of talking to self, laughing to self, wandering behaviour, abusive and aggressive behaviour towards family members and villagers, impulsive behaviour .The patient had an episode of attempting suicide by stabbing himself over a trivial altercation and was hospitalised for the same for a period of about one month during which a psychiatric referral was advised. He was reportedly being treated for aggression with haloperidol for few days before he came to us.
Physical examination revealed normal vital parameters with no icterus. Higher mental functions revealed impaired attention span. He was well oriented to time, place, person and his recent/immediate/remote memory were found to be intact with impaired abstract abilities .His neurological examination revealed no abnormalities in cranial nerves, sensory system and no cerebellar signs with motor system revealing tremors on out stretched hand.
At the time of admission he had increased PMA with excessive speech,did not maintain eye contact and content of thought revealing delusions of reference and delusions of persecution,he exhibited hallucinatory behaviour with irritable mood and had no insight into his illness. Routine blood investigations like CBC,LFT ,S.Creatine ,urine routine were done and found to be normal.
He was provisionally diagnosed as a case of paranoid schizophrenia and was initially started on oral risperidone and injectable antipsychotics. The patient started having abnormal movements after the start of antipsychotics, later the parents revealed a history of abnormal movements of limbs without loss of consciousness at which point a differential diagnosis of Wilsons disease and epilepsy with psychosis were considered. Further he was referred to regional eye hospital for slit lamp examination which revealed KF ring and urinary analysis revealed elevated urinary copper levels of 105 ug/24 hrs and ceruloplasmin levels of .46 g/l. The patients was also evaluated for increased frequency of urination which was reported during the hospital stay (his 24 hour urine collection was more than 4 litres a day) and urine examination revealed slightly positive anion gap , normal serum anion gap with normal renal parameters and was advised a regular nephrology follow up.
MRI scan brain was done which was found to be normal and MR angiogram of Brain revealed "azygos anterior cerebral artery" which is an uncommon to rare variant seen in .4% of general population.
He was maintained on 4mg of risperidone, 2mg of trihexyphenidyl and .5 mg of clonazepam were added as patient developed tremors. He improved symptomatically with the treatment,was discharged with the same treatment.
Discussion: Wilson's disease is an autosomal recessive disorder characterised by inability of liver to transport and store normally absorbed dietary copper resulting in abnormal deposition of copper in basal ganglia, eyes, liver and other tissues. This is an unusual presentation of Wilson's disease. Here the patient had a history of abnormal behaviour for 2 years and developed abnormal movements of limbs and trunk with use of antipsychotics during which time a differential diagnosis of Wilson's disease was considered and on further evaluation he was diagnosed with Wilson'sdisease . in addition to the above complaints he reported polyuria and was evaluated in order to rule out renal tubular acidosis which can occur in Wilson's disease( v tesar et al 1991) 6 and as the lab reports were inconclusive , was advised regular follow up.an incidental and rare finding of azygos anterior cerebral artery 7 was found during the workup. The patient was controlled on 4mg of risperidone. Some authorities believe that neurological and behavioural symptoms can be relieved with use of pencillamine(modaiet al 1985) 7 .some reports stated antipsychotic use as inadvisable.(Tu 1987) 8 There are reports of effectiveness of clozapine in management of wilsons disease(krim et al 2001) 9 .
There is further need to study the efficacy of various antipsychotics and chelating agents in the management of Wilson's disease and study on relationship between renal complications and psychiatric manifestations.
Keywords: psychiatric manifestations, autosomal recessive genetic disorder
A Case Report of Unusual Presentation of Early Onset Schizophrenia/ Obsessive Compulsive Disorder: Diagnostic Dilemma
Pooja M, Anu K, Vijay G, Shobha N, Mazumdar K, Aditi C, Divya R
BARC Hospital, Anushakti Nagar, Mumbai
Background: Schizophrenia is a common, chronic, and frequently devastating neuropsychiatric disorder, affecting about one percent of the world's general population. Schizophrenia patients with onsets after the age of 13 are usually divided into early-onset schizophrenia (EOS; onset 13-18 years) and adult-onset schizophrenia (AOS; onset after the age of 18). Findings from a recent study on pediatric OCD suggest that the prognosis of children with poor insight is worse than that of children with good insight.
Case History: A 15 year old girl brought by father with c/o fearfulness, seeing vivid images along with hearing voices for last 4 years. She would often see person hurting themselves like jumping from building or stabbing themselves, hanging from fan and she would also feel like doing the same. These experiences would happen quite often and lasting for 2-3 min's at times and more so during her exam period. These phenomenons dramatically improved after her exams got over speculating if these were Dissociative hallucinations. She had good improvement with Risperidone a earlier but unable to tolerate it, subsequently started on Fluvoxamine that brought excellent improvement speculating whether these were Obsessive imagery.
On MSE: Pt was kempt and tidy touch with surroundings, Affect was preserved and had auditory and visual hallucinations (Fantastic hallucinations)/ ? Obsessive images. Judgement was impaired with Grade 1 Insight.
Investigations: MRI indicated multiple SWI hypo intensities in left temporo parietal subcortical and deep white matter suspicious for calcific granulomas/petechial haemorrhages. EEG was showing abnormal potential epileptogenic discharges bilateral parietal and right temporal region.
Conclusions: There was plethora of psychopathology having some biological underpinnings in this unusual case. The phenomenology also was fluctuating with good improvement to SSRI's along with SGA's. Other critical facets of the case will be discussed in great detail during presentation.
Keywords: neuropsychiatric disorder, Risperidone
Hyperkinetic Conduct Disorder with Early Onset Bipolar Disorder: A Case Report
Ruchita Shah 1 , Soumya Jhanda 2* , Mahadev Singh Sen 3 , Nidhi Chauhan 4
DEPT. OF PSYCHIATRY, NEHRU HOSPITAL, PGIMER CHANDIGARH , UT , India
Introduction: Hyperkinetic Conduct disorder has been recognized as a prevalent co-morbidity in children and adolescents patients with bipolar disorder, however this co-morbidity is less well understood.
Aim: To demonstrate the clinical picture of a 15 year male with infantile hemiparesis, hyperkinetic conduct disorder and bipolar disorder.
Case Description (Methodology): A 15 year male presented with history of right sided hemiparesis since six months of age, with normal developmental milestones. Since three years of age he was observed to be an overactive child, would have difficulty sitting, would always be observed to be fidgety; would frequently lose his belongings at school and could not wait for his turn. Parents were liberal and attended to all the demands the patient made; often ignored the complaints regarding patient disturbing the class environment. Gradually he started engaging fights with peers, used abusive language, started bunking classes, would make excuses in class, would talk back to the teachers, throw and break household articles with no guilt for the same. He maintained the same till 15 years of age when he was observed to remain more irritable than his usual self. His sleep reduced yet would appear more energetic than before. After two weeks, appeared predominantly cheerful, would talk excessively often jump from one topic to another, would meet unfamiliar people and talk to them, started demanding for expensive articles, would make plans of future and helping the poor. He was treated with Olanzapine 5mg increased to 15 mg/day.MRI: Infarct in left lentiform nucleus. After initial improvement there was increase in symptoms , Lithium was started 300mg increased to 900mg with which he improved completely.
Conclusion: Long termmedication should be initiated in patients with Juvenile Bipolar Disorder even when it is the first episode.
Discussion: ADHD and Bipolar Disorder.
Keywords: Bipolar Disorder, Hyperkinetic Conduct disorder
Prevalence of Dementia Among Elderly in Rural Population of Coastal Karnataka.
Kasturba Hospital, Manipal, Karnataka, India
Objective: To study the prevalence of dementia among elderly population using a screening tool .
Type of study: cross-sectional study
No. of subjects: 2000
Inclusion criteria: Age more than 60 years. Both males and females
Exclusion criteria: Any visual or hearing deficits. Any known psychiatric disorders.
Tools: Hindi MMSE translated into Kannada.
Methodology: all the elderly population of udyavara village, udupi dist, Karnataka were identified from panchayat registers. Field worker who was trained in administration of the tool visited each home and identified the elderly population. Subjects who satisfied inclusion and exclusion criteria were recruited into the study and after taking written consent Hindi MMSE was administered.
Results: data collection over, statistical analysis is going on. Results of the study will be presented at the conference.
Keywords: the prevalence of dementia,
Maintenance Lorazepam for Recurrent Catatonia associated with Hyponatremia in Bipolar Disorder
Gaurav Uppal*, Samir Kumar Praharaj, PSVN Sharma
Department of Psychiatry, Kasturba medical College, Manipal, Karnataka
Background: Catatonia has been reported to occur with both unipolar and bipolar disorder, and responds to benzodiazepines and ECT. Recurrent episodes of catatonia may rarely occur with bipolar disorder that requires long term maintenance with benzodiazepines. We report an elderly with bipolar disorder presenting with recurrent catatonia associated with hyponatremia that required maintenance lorazepam.
Case report: A 61-year-old married Hindu female, diagnosed with bipolar disorder with diabetes mellitus and hypertension, presented with catatonic symptoms in emergency department. There was family history of bipolar disorder and alcohol dependence. Investigations showed raised blood pressure and hyponatremia. Catatonia resolved with lorazepam and correction of hyponatremia. Several previous episodes also had similar presentations with catatonia, associated with hyponatremia. She is maintaining well on a combination of lamotrigine 300 mg and lorazepam 4 mg.
Conclusion: Recurrent catatonia associated with hyponatremia can be a presentation in bipolar disorder, which may require long term benzodiazepines as maintenance to prevent catatonia.
Right Parietal Meningioma: A Diagnostic Dilemma
Praveenkumar Dontula, Swarna Buddha Nayok, Samir K Praharaj, Rajesh Krishna Bhandary , Psvn Sharma, Rishikesh V Behere
KMC Manipal, Karnataka, INDIA
Background: Meningiomas are the common benign brain tumors accounting for 13-26% of intracranial tumors. Incidence rate in females are twice to males. Most of them are found incidentally and only 25% are believed to be symptomatic.
Case report: We report a 40 year old female presenting with gradual onset decline in socio-occupational functioning with minimal positive symptoms, who was found to have a large meningioma in right parietal area. Physical examination revealed mild drug induced EPS and prominent papilledema. He was referred to neurosurgery for tumor removal.
Conclusion: Atypical presentations of psychosis with minimal positive symptoms should lead to investigations to rule out organic basis for the symptoms.
Keywords: Meningioma , Atypical presentation
A Rare Case of Kluver Bucy Syndrome
Parvathy. S, Keshavankutty nayar, Sreekumar
Department of Psychiatry,Amrita institute of medical sciences , Kochi
Kluver-bucy syndrome is a rare neurobehavioral symptom complex with poor prognosis, first described in 1939 by Heinrich Kluver and Paul Bucy, in monkeys with bilateral temporal lobe surgery. This syndrome in humans can be seen in associated with a variety of neurological conditions was first reported by Terzian and Ore in 1955(2). Symptoms include inability to recognize people, lack of fear reaction, lack of rage reaction, hyper sexuality, hypermetamorphosis, memory deficits and placidity. Among these the most common manifestations in humans are hyperorality with changes in dietary habits, hyper sexuality, visual agnosia and seizures(3). We report a case of Kluver-bucy syndrome in a 52 yr old male who presented with hyperorality, Hypersexuality, pica, visual agnosia, loss of normal fear and anger responses, distractibility, seizures, and memory impairment of 15months duration following herpes simplex meningoencephalitis. On MSE the patient was agitated, aggressive and had a hostile attitude. He had a restricted emotional affect with lack of emotional reactivity. His speech was monotonous with increased volume, irrelevant and incoherent, often in 3-4 words. Higher mental status examination showed impaired judgement, impaired recent and remote memory, and difficulty in performing the executive functioning. The patient was started on antipsychotics Aripiprazole and slowly titrated to a dose of 15mg. Benzodiazepines were used only in case of aggression. He showed 40-50% improvement in his symptoms after 2 weeks and was maintained on this dose subsequently.
Keywords: Kluver-bucy syndrome, Hypersexuality,
A Study of Executive Functions and Quality of Life in Patients with Obsessive Compulsive Disorder
Kamalika Mandal, Dharmesh S.Gohil, Bharat N Panchal, A U Vala
Background: Though the prevalence of Obsessive Compulsive Disorder(OCD) is high, there are less number of studies regarding Executive Functions(EF) , Quality of life(QOL) and their association with each other in patients of OCD. This study is conducted to find EF and QOL in patients of OCD and associations among duration of illness, severity of OCD, EF and QOL in patients of OCD.
Methods: This is a single-center, cross sectional, case control designed, hospital based study. Fifty consecutive patients of age 18-50 years, who attended psychiatry outpatient department diagnosed as OCD according to DSM-5, having at least 5 years of formal school education & duration of OCD for more than 1year, were included. Controls were sociodemographically matched non- blood-related attendants of the patients. Tools used are Y-BOCS (Yale Brown Obsessive Compulsive Severity rating scale), WHOQOL-BREF, Executive function tests like FAB (Frontal Assessment Battery), TMT-A (Trail Making Test-A), TMT-B(Trail Making Test-B), CDT(Clock Draw Test).Data were analyzed by Graph Pad In Stat version 3.06. Proportions were compared by using Chi-square test.Y-BOCS,FAB,TMT-A,TMT-B and WHOQOL- BREF scores were compared by Mann-Whitney test .
Results: Significant differences were found between patients and control groups in FAB(p<0.0001),TMT-A(p<0.0001),TMT-B(p<0.0001),CDT(p<0.0001) and WHOQOL-BREF (p<0.0001) .The severity of illness had a correlation with performance on EF tests(p value<0.0001), and Quality of Life parameters ie physical (p=0.0031),psychological(p<0.0001),Social(p=0.0235) and Environmental domains( p=0.0260). There were positive correlation between Executive dysfunction and poorer quality of life.
Conclusions: Impairments in response inhibition, cognitive set shifting, working memory, and visuospatial deficits were present in patients of OCD and was related to severity but not with duration of illness. Quality of life was lower in patients with OCD than in healthy subjects & was related to executive dysfunctions and the severity of illness.
Keywords: OCD, Executive Function, Quality of life.
Neuropsychiatric Manifestation Following Acute Organophosphate Poisoning
Udit Kumar Panda, Satyakam Mohapatra
Mental Health Institute, SCB Medical College, Odisha, India
Background: Organophosphate (OP) poisoning is a significant cause of morbidity and mortality in developing countries including India. The most commonly encountered toxic effects in human are peripheral (muscarinic and nicotinic side effects). But central nervous system effects of OP exposure have received less attention in the medical literature than peripheral effects.
Aim and objectives: We are reporting a case of 22 year old male who developed psychotic features and motor neuropathy following acute OP poisoning.
Methods: Mr. A, a 22-year-old male presented with complaints of fearfulness, suspiciousness, irritability, decreased sleep for last 7 days and difficulty in walking, weakness of both lower extremities for last 5 days. On evaluation there was history of accidental ingestion of OP insecticide chlorpyrifos 10 days before the onset of psychiatric symptoms. His serum cholinesterase levels were low (760 U/L; normal: 3500-8500 U/L). Nerve conduction studies revealed large fiber axonal degeneration predominantly motor type of both lower limbs. He was treated with tablet olanzapine 10 mg per day and his psychotic symptoms improved significantly within next 10 days. For his weakness of lower limbs physiotherapy was done and he improved partially within next 8 weeks.
Conclusion: Careful monitoring of these neuropsychiatric changes may positively reduce the morbidity and mortality, particularly in many developing countries where adequate protective measures are lacking. So we recommended that every patient of OP poisoning should be followed up for at least one month after the acute intoxication for development of any neuropsychiatric manifestation.
Keywords: neuropsychiatric manifestation, Organophosphate
Psychiatric Morbidity in Spouses of Alcoholics
Shamiul Akhtar Borbora, Hemendra Ram Phookun
Assam, Guwahati, India
Introduction: Spouses are the principal care givers in alcoholic patient, but it is often seen that due to their intimate nature of their relationship and the constant exposure to the behavior of the alcoholic, they have low martial satisfaction, maladaptive coping skills and poor social support, in addition to economic burden and social stigma which may lead to psychiatric comorbidity and may also affect her home maker and care giver role.
Aims and Objectives: To study the different sociodemographic factors and psychiatric comorbidity in spouses of alcoholics.
Methodology: 80 spouses of diagnosed cases of alcohol dependence patient were studied with a semi-structured proforma and psychiatric morbidity was assessed using Mini International Neuropsychiatric Interview (MINI 5.0).
Results: It was found that 51.20%% had comorbid psychiatric illness mainly mood disorders and anxiety disorders, out of which 18.80% had Major Depressive Disorder followed by another mood disorder Dysthymia which was present in 16.20% cases. Among anxiety disorders Generalized Anxiety Disorder (GAD) was present in 11.20% and Panic Attack was present in 5% of the cases.
Conclusion: Psychiatric comorbidity in the form of mood and anxiety disorders was present in >50% of the spouses of alcoholics and these problems have to be addressed to make the deaddiction programme successful as they are the primary care givers to the alcoholic patients.
Keywords: Psychiatric morbidity, mood disorders, anxiety disorders
Anorexia Nervosa in a Young Adolescent Male- A Case Study
Aditi Garg, Rajat Oswal, Anu Patel.
Department of Psychiatry, Medical College, Baroda.
Anorexia nervosa is a serious eating disorder, characterized by deliberately starving oneself in order to lose weight due to morbid fear of being obese resulting in failure to maintain minimum weight for sustenance. It has two subtypes- the restricting type or the purging type. Only 10-15 % of people with anorexia or bulimia are male. This is a case of an adolescent male with anorexia nervosa.
A 19-year-old male Muslim, educated up to 9 th standard presented with complaints of severe generalized weakness, inability to walk, refused to eat and threatened of suicide repeatedly whenever he was forced to eat.
His complaints started at the age of 14 during the fasts of Ramzan when he barely ate food once a day. He was worried about his weight at that time as his friend told him that he would look ugly on gaining weight. Following this he became obsessed with finding ways to lose weight. He started exercising rigorously and finding the calorific content of various foods. He would drink cold drinks throughout the day to meet his daily calorific requirements and to produce a laxative effect. His scholastic performance started deteriorating & then his parents started consulting psychiatrists and psychologists. Eventually he dropped out of school.
He was admitted six months back when he weighed 43 kgs with BMI of 14. He was started on parenteral fluids with Cap. Fluoxetine 20 mg once daily and multivitamins. His daily nutritional intake was gradually increased to 1100 kcal but he decreased his intake after discharge. Patient is currently on regular follow up.
Anorexia nervosahas a fluctuating course. Patients with multiple relapses are predisposed to a high mortality rate. A definitive treatment method is yet to be devised, but an individualized approach is necessary along with a long-term adherence to the multimodal therapy.
Keywords: Anorexia nervosa, ADOLESCENT MALE
A Rare Case of Priapism Induced by Sodium Valproate in an Adult with Bipolar Affective Disorder
Alok Jyoti Sahoo, Satyakam Mohapatra,
Mental Health Institute, SCB Medical College, Odisha, India
Background: Priapism is defined as a prolonged and persistent, painful erection of the penis without sexual stimulation or arousal. There have been a few case report of priapism resulting from the use of antipsychotics. But Priapism induced by mood stabilizers like Sodium Valproate is rare.
Aim and Objectives: We report a case of a 32-year-old male patient with a bipolar affective disorder, who was experiencing priapism with sodium valproate. The condition was found to resolve on stopping sodium valproate.
Methods: Mr. J, a 32 Yrs male was brought by his family to the psychiatric OPD with an acute onset of elation , thinking high of himself, pressured speech, distractibility, decreased sleep, excessive spending for the past 2 months. Patient had past history suggestive of 3 manic episodes of moderate severity successfully treated with Lithium and Olanzapine and complete inter episodic recovery in last 9 years. There was no past history of any depressive episode or any psychiatric/medical co-morbidity or history of any substance dependence. A diagnosis of Bipolar Affective Disorder , current episode mania was made. He was started with Tab Olanzapine 10 mg HS and Tab Sodium Valproate 500 mg BD and after 48 hours he developed painful , persistent painful erection , despite absence of physical & psychological stimulation. Sodium Valproate was stopped and Tablet Olanzapine was continued as he has prior exposure to Olanzapine. He got relief from Priapism 48 hours after last dose of Sodium Valproate without need of any medical/ surgical intervention.
Conclusion: As Sodium Valproate is a widely used mood stabilizer in bipolar affective disorder among its various uses, monitoring of emergent side effects like Priapism should be done and patient education should be given to report it at the earliest.
Keywords: priapism, Olanzapine, Bipolar Affective Disorder
Hair Fall as a Drug Induced Side Effect in Adolescent Girl After Starting Risperidone Therapy
Rahul Bagle, Vijay Pawar, Anup Bharati, Sushma Sonavane , Nilesh Shah
Gardenia Hsg Society, Phase 2, Somnath Nagar, Wadgao Sheri, Pune, Maharashtra, India
Medication-induced alopecia (usually reversible) is an occasional side effect of many psychotropic drugs. Mood stabiliser's-Lithium & Valproic acid are the mainly implicated culprits of alopecia. Apart from Haloperidol & Carbamazepine, few case reports are available regarding atypical antipsychotics use, particularly Olanzapine & Quetiapine in causation of alopecia.
We came across a 14 years old girl who was brought to psychiatry OPD by her mother with regards to behavioral disturbances for which she was started on Risperidone syrup. Within 2 weeks of therapy, her mother noticed excessive hair loss in the patient. On examination & Dermatological consultation, diffuse non scarring hair loss was observed; no signs of EPR could be elicitated. History was reviewed & trichotillomania was ruled out. All possible medical causes of hair loss (especially, anemia & thyroid) were ruled out &Risperidone was substituted by Atomoxetine to control her hyperactivity symptoms. On next follow up, the hair fall problem was recovered as well as symptomatic improvement was noted.
Psychotropic drugs are considered to cause alopecia specifically by affecting telogenic phase of hair growth and by affecting zinc & selenium chelates, although their routine administration has not been proven yet. Discontinuation of the medication or dose reduction almost always leads to complete hair regrowth. Our case projects towards further scope of advances in pharmacogenomics in view of causation of such rare but cosmetically significant adverse drug events and it also proves efficacy of Atomoxetine in managing hyperactivity symptom of behavioral problems in adolescent age group.
Keywords: Risperidone, pharmacogenomics
Olanzapine Induced Skin Eruptions: A Case Report
Nishtha Chawla1 , Saurabh Kumar 2 , Yatan Pal Singh Balhara 3^
National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi and ^Regional Mentor, International Programme in Addiction Studies, Master of Science in Addiction Studies, King's College London, UK; University of Adelaide, Australia; Virginia Commonwealth University, USA
Introduction: Adverse cutaneous reactions are known to occur with psychotropic medications, which may lead to poor drug compliance. As compared to other groups of psychotropics, antipsychotics are less likely to cause adverse cutaneous reactions. There have been few case reports on Olanzapine induced skin eruptions but none from India.
Case description: A 39 year old gentleman who initially presented to the psychiatric OPD with history of alcohol use for past 20 years meeting the criteria for dependence for past 14 years. He presented with an illness characterised by symptoms suggestive of Mania. He was started on Tab. Valproate and Tab Olanzapine. After 10 days of starting the medicines, patient developed erythematous rashes on upper and lower limbs as well as trunk. Patient had no history of allergic reactions. Necessary investigations were carried out which came out to be within normal limits. Dermatology consultation was taken and a diagnosis of Fixed Drug Erruptions was made, keeping differential diagnosis of erythema nodosum and drug induced panniculitis. As there was improvement in manic features, Olanzapine was tapered and stopped while Valproate was continued. The rashes resolved within a week of stopping Olanzapine leaving hyperpigmentation.
Discussion: Olanzapine is commonly used to control mania. Olanzapine induced cutaneous eruptions is an infrequently reported adverse drug reaction. A high index of suspicion is necessary for its accurate diagnosis. Clinicians should be aware of the potential for cutaneous errptions in association with olanzapine.
Keywords: cutaneous reactions., hyperpigmentation
Prevalence of Specific learning Disabilities in School Going Children
Ayush Sharma, (Brig.)S.Sudarsanan, Sandeep Choudhary .Supriya Agarwal, Vivek Kumar .
Chhatrapati Shivaji Subharti Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh.
Introduction: There is limited data on the prevalence of Specific Learning Disability in our country. Therefore, an epidemiological study to determine the Prevalence of Specific Learning Disabilities was initiated by our department.
Methodology: 50 school going children who would be randomly selected and would be found to be facing academic or behavioral problem will be selected and would then be evaluated using socio demographic data sheet .NIMHANS SLD index and Grade Level Assessment Device will be used to detect prevalence of Specific learning disabilities in these students. Appropriate statistical tools would be applied.
Results and Conclusions: Results and conclusions would be discussed later at the time of presentation.
Keywords: children, Specific learning disabilities
Prevalence and Pattern of Psychiatric Co-morbidity in HIV +ve patients attending ART Centre
SHRUTI, RUCHIR, M. J. SAMANI
Department of Psychiatry,PDUMC, Rajkot, Gujarat, Rajkot, India
Introduction: HIV is a debilitating and life threatening illness with its effect on patient's multiple areas of life and well-being. Various psychiatric co morbidities are associated with HIV infection in patients. Various studies indicate that psychiatric co morbidities are high in HIV positive patients.
AIM: To find Prevalence and Pattern of Psychiatric morbidities in HIV positive patients.
MATERIAL AND METHOD: Study is carried out at ART Centre of PDU Medical College Rajkot. It is a cross sectional study with sample size of 200 patients attending ART Centre with age between 18-65 years and suffering from HIV.Patients were interviewed by using socio-demographic data, clinical data and GHQ. GHQ positive patients are assessed by detailed history and Mental Status Examination. Final diagnosis was established by using DSM IV -TR criteria.Result was tabulated and analysis was done by using chi-square test and t-test.
RESULTS: Out of 200 HIV positive patients, 87(43.5%)was having psychiatric illness.37(18.5% ) had nicotine dependence and rest 50(25%) had other psychiatric illness in form of major depressive Disorder (9.5%),Adjustment Disorder(5.5%), BMD-1(1.5%), Panic Disorder(2.5%), Panic Attack(2%) and Dissociative Disorder(0.5%). .Morbidity was higher in female patients(36.76%) compared to male patients(18.94%) .No any co relation with other variables like CD4 count, WHO Staging and duration of ART taken was found. The main results of our study are consistence with other studies.
CONCLUSION: The Study suggests that prevalence of psychiatric morbidities ishigh in HIV positive patients. Clinicalhistory indicates that majority patients were not being treated for psychiatric illness. This indicatesneed for sensitization of health care providers about this important aspect of overall management of HIV patients.
KEYWORDS: HIV patients, psychiatricco-morbidity, prevalence.
Carbamazepine Induced Steven- Johnson Syndrome- a case report
Jigyansa Ipsita Pattnaik, Sarmistha Priyadarshani
Mental Health Institute, S.C.B.Medical college, Odisha, Cuttack,India
Background: Steven Johnson syndrome(sjs) is a rare life-threatening muco-cutaneous disorder induced by an immune -complex mediated hypersensitivity reaction .Nearly half of the cases are caused by reaction to drugs.It is characterized by widespread blisters arising in macules and flat ,atypical target lesions.Carbamazepine,widely used to treat seizure disorder , bipolar disorder is the most offending agent.
Aims and Objective: To present the case of a patient who developed steven Johnson syndrome on initiation of carbamazepine therapy.
Methods: A 27 yr old patient was referred for psychiatry consultation,from department of dermatology with a diagnosis of steven Johnson syndrome,for complains of his abnormal behavior.He was a diagnosed case of schizophrenia under treatment with risperidone 3mg,trihexiphenidyl 2mg for 7 years.1 month back,he was diagnosed to have affective features for which he was started on carbamazepine as a mood stabilizer in his last visit. On the 7 th day of treatment, he started developing generalized skin lesions associated with myalgia and fever and was admitted to dermatology ward as symptoms worsened gradually.. Carbamazepine was withdrawn and supportive treatment given. After stabilization of general medical condition, valproate was added as a mood stabilizer in addition to previous antipsychotics.Patient improved and skin lesions gradually diminished in further 3 weeks.
Conclusion: In view of the expanding use of carbamazepine in psychiatry patients and the potentially lethal consequences of SJS,we suggest a risk-management approach while initiating carbamazepine therapy.We would caution all users and strongly recommend gradual titration when initiating treatment with carbamazepine.
Keywords: steven Johnson syndrome, carbamazepine
A comparison of efficacy and tolerability of Vilazodone and Escitalopram in the management of depression
Karthik Duraisamy, c. panneer selvan,
sneka mind care, 12, south bye pass road, tamil nadu, tirunelveli, India
Vilazodone is a potent selective serotonin reuptake inhibitor and serotonin 1A partial agonist approved for the treatment of major depressive disorder in adults. Our objective is to compare the efficacy, onset of action and tolerability of the two groups of 15 patients with depressive illness each over a period of 8 weeks. The adult subjects with the clinical diagnosis of depressive disorder according to the ICD -10 were included with the exclusion of organicity, substance induced mood changes and psychotic depression. The efficacy parameters are assessed using the HDRS, MADRS and CGI at 4 different points of time (at 1 st , 2 nd , 4th and 8 th week) of the therapy. The tolerability parameters are assessed based on clinical general physical examination and the UKU scale at 4 different point of time during the course. The correlation and logistic regression analysis has been done using spss v16 to compare both the groups socio demographic and clinical characteristics. The Analysis of variance has been used to compare the efficacy and tolerability of the groups. Results will be analysed and discussed in the poster presentation.
Keywords: Vilazodone and Escitalopram, major depressive disorder
Case Report: Olanzapine Induced Blepharospasm
Rima James Fernandes, Sanjiv Kale , Aparna Ramakrishnan, Paramveer Singh
Ruby mansion,dongri uttan road bhayander(w),Maharashtra,thane, India
Olanzapine is an atypical (second generation) antipsychotic. Its common side effects are weight gain, metabolic disturbances including diabetes mellitus and dyslipidemia.
Blepharospasm is an abnormal involuntary blinking or spasm of the eyelid muscles (orbicularis oculi, procures and corrugated superciliaris). Blepharospasm is an unusual side effect of Olanzapine and is thought to occur due to blockage of D2 dopamine receptor in the basal ganglia.
We describe a case of 16 year old male, a case of seizure disorder since 15 years in remission on antiepileptics. The patient developed psychotic features in the form of auditory hallucinations, persecutory delusions and agitated behavior for which he was started on 2.5 mg olanzapine. Four months after initiation of olanzapine,the patient developed excessive, involuntary blinking movements of both eyelids.
This symptom could have been the result of olanzapine therapy. However, since blepharospasm is an infrequent side effect of olanzapine therapy, hence, the case report.
Keywords: Blepharospasm, olanzapine
Frontotemporal Dementia In A Patient With Bipolar Disorder - A Case Report
Ashitha M L, Roy Abraham Kallivayalil,
Dept of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla , Kerala., INDIA.
Background: Frontotemporal dementias constitute 5% of all irreversible dementias. FTD is the third common major neurocognitive disorder after Alzheimer's Dementia and Vascular Dementia. Early stages of the disease is often characterised by personality and behavioural changes which may lead to misdiagnosis of psychiatric disorders. The condition can mimic psychiatric disorders and often misdiagnosed especially in a patient with previous history of psychiatric disorder.
Objective: To describe the case of a 75yr old woman with previous history of bipolar disorder whose current presentation was consistent with Bipolar disorder. But the duration of illness was prolonged and symptoms remained refractory to medications and was diagnosed as Frontotemporal dementia.
Case Report: 75 year old married female from a upper middle socioeconomic backgroundpresented with inappropriate behaviour, increased irritability and anger, over talkativeness and asking things repeatedly, disinterest in household work since past 2years with past history of T2DM with Peripheral Neuropathy and Hypertension and h/o psychiatric illness s/o Manic episode following 1st delivery 54yrs back, took psychiatric treatment, reached PML and continued medications for 2years.Family history revealed episodic psychiatric illness in elder son and h/o suicide in elder brother .Patient was admitted and started on Sodium Valproate 750mg and Quetiapine 100mg.Even though symptoms were consistent with Bipolar disorder, considering the longer duration and refractory symptoms , we proceeded with brain imaging and neurocognitive testing and Frontotemporal dementia was diagnosed.
Result: This case demonstrates the need to identify differential diagnoses in psychiatric disorders with atypical presentation and thoseresistant to medications
Conclusion: It is difficult to establish a differential diagnosis between Frontotemporal Dementia and Bipolar Disorder especially in patients with history of Bipolar Disorder.Evaluating a patient from a neuropsychiatric perspective is important rather than having psychiatric approach alone.
Keywords: Bipolar Disorder, Frontotemporal Dementia
Catatonia in an adolescent with Bipolar mood disorder: A case report
Harsh Oza Dr. Sunayna Pandey, Nilima Shah ,
Sannidhi Apartment, Bhaikakanagar, Thaltej, Gujarat, Ahmedabad, India
Introduction: Catatonia is a motor dysregulation syndrome in which patients lose the ability to move normally despite having the full physical capacity to do so. Psychiatric conditions, including schizophrenia, bipolar disorder, post-traumatic stress disorder, eating disorders and depressive disorders are associated with catatonia. We report the case of an adolescent with bipolar mood disorder-most recent episode depressed, with catatonia.
Case: A 15 year old male patient, with the past history of a single manic episode, presented with complaints of depressed mood, remaining withdrawn, decreased communication and delusion of reference. He was given Olanzapine 10 mg and Sertraline 50 mg. 2 days later, he developed echolalia, echopraxia, mutism, negativism, posturing, waxy flexibility and extrapyramidal symptoms like hand tremors, excessive salivation, slowness of movements, pinrolling movements, blunt affect. On admission, after ruling out any underlying medical condition, Lithium 600 mg, trihexyphenidyl 6 mg and lorazepam 8 mg were given; and Olanzapine was omitted. There was partial improvement and the patient was discharged. The patient discontinued medicines on his own resulting in a relapse within one month. This time he did not improve with same medications. So, 6 ECTs were given along with medications and the patient improved significantly.
Discussion: 20-30% of patients with bipolar mood disorder may experience catatonic symptoms at some point of time during the course of their illness, usually in adulthood. Catatonia due to bipolar mood disorder in adolescence is unusual. Very sparse data is available for the same. Our patient developed catatonia twice within 2 months, and the second time complete response was obtained with ECT.
Conclusion: It is recommended that in an adolescent with bipolar mood disorder, if and when medicines are ineffective, despite the risk of a reversible cognitive impairment, ECT must be considered as a useful treatment option.
Keywords: Bipolar mood disorder, Catatonia
Rare Neuropsychiatric Manifestation of Wilson's Disease: A Case Report
Sunayna Pandey, Harsh Oza , Nilima Shah
T.R.L Township, Belpahar, Orrissa, Jharsuguda
Introduction: Wilson's disease is a rare metabolic disorder involving copper metabolism; associated with abnormal liver functions and neuropsychiatric manifestations. We report a patient who presented with seizures and pseudoseizures and was later diagnosed to have Wilson's disease.
Case: A 14 years old boy presented with episodes of tremulousness of the body, agitation, confusion and hyperventilation since last 6 years; associated with irritability, confusion, verbal abusiveness, partial amnesia and rarely, urinary incontinence. Medical investigation had revealed marginally low serum ionic calcium (4.25 mg/dl) and parathyroid hormone (7 pg/ml), which was corrected by calcium supplementation. The episodes continued; EEG was suggestive of non-epileptic events. Considering the possibility of seizures with pseudoseizures, anti-epileptics (valproate 1500 mg, carbamazepine 800 mg, oxcarbazepine 600 mg, clobazam 15 mg, levetiracetam 500 mg) and antidepressants (sertraline 25mg, escitalopram 10mg) were given. Non-response to these and the presence of asymmetrical tremor, made us consider Wilson's disease. Liver function tests were normal. Slit lamp examination revealed the presence of Kayser-Fleischer ring. Serum ceruloplasmin and copper levels were 16.35 mg/dl and 174.81 microgram/dl respectively. USG abdomen showed coarse echo texture of the liver.
The symptoms remitted completely with Penicillamine 20 microgram/kg. Anti-epileptics and antidepressants could be gradually tapered off.
Discussion: In Wilson's disease, 40% patients first show hepatic dysfunction, 40% neurological symptoms and 20% with psychiatric manifestations. In this case, the diagnosis was probably not suspected earlier due to normal liver function tests. Seizures may be present in Wilson's disease, however another possibility in our case could be hypocalcemia due to parathyroid dysfunction secondary to copper deposits.
Conclusion: Wilson's disease must be considered as a differential diagnosis in patients who present with involuntary movements, especially tremors, even when the liver functions are normal. Slit lamp examination must be done, followed by confirmatory tests if needed.
Keywords: Wilson's disease, copper metabolism
"A Study Of Dual Diagnosis In Alcohol Dependence"
Vinita Gurjar, JagdishGindodia, Shubhangi R. Parkar, AmeyYeshwantAngane
Department of Psychiatry, K.E.M. Hospital, Mumbai
Background: Dual diagnosis is a common, broad term indicating simultaneous presence of two independent clinical disorders.Recently, it has been used to describe the coexistence of a mental illness and substance use disorder. The etiology of the high prevalence of substance use in patients with psychiatric disorder is unclear. The comorbid or dual diagnosis can be categorized, on the basis of drug of abuse, the purpose that the drug serves, psychiatric symptomatology and etiological significance. There are clinical difficulties in identifying the patients with dual diagnosis due to ascribing a particular behavior, recognizing whether psychosocial deterioration is either due to alcohol dependence or associated psychiatric disorder and also clinically differentiating the symptom profile related to dependence or abuse from the symptoms of psychiatric disorder. Thus diagnosis, treatment and management of dual diagnosis always poses serious clinical dilemma.
Aims and Objectives: 1. To study sociodemographic profile of patients with dual diagnosis. 2. To study clinical profile of the patients with dual diagnosis.
Methodology: This is an open study on a cross section of a population of patients with dual diagnosis. Male patients (18y-65y)coming to de-addiction center of a general hospital in Mumbai were interviewed over a period of 6 months. Those patients fulfilling the exclusion and inclusion criteria were included in the study. DSM-IV criteria for alcohol use disorder and comorbid psychiatric disorder was used.
Results and Conclusion: 70% patients were in the range of 26-45 years of age.Mean age of alcohol consumption was 20years with dual diagnosis, with longer duration of alcohol consumption.47.5% of the patients had schizophrenia, 42.5% had depression and 7.5% had anxiety disorders. Among personality disorders 37.5% had Antisocial Personality Disorder, 20% had other cluster B traits while 7.5% had avoidant dependent personality disorder.
Keywords: Antisocial Personality Disorder, ALCOHOL DEPENDENCE
A Case Series of Diagnosis and Management of 10 Individuals with Asperger's Syndrome
Varsha Karanth, Shankar Kumar, Chandrashekar Hongally
Dept of Psychiatry, Bangalore Medical College and Research Institute, Bangalore
Introduction: Asperger's syndrome ,though an uncommon condition is frequently misdiagnosed leading to unnecessary prescribing of psychotropics and risk of adverse effects .
Aims and Objectives: Hereby describing modes of presentation, clinical approach to diagnosis and assessment schedule used for management of 10 individuals with Aspergers disorder.
Methodology: 10 individual who were clinically suspected with Pervasive developement disorders were further evaluated using the following assessment schedules
- Gilberg's criteria
- Ritvo Asperger s and Autism diagnostic scale (RAADS)
- Autism spectrum screening questionnare(ASSQ)
- IQ assessments
Results: Hypersexuality and inappropriate sexual behavior was a predominant mode of presentation (50%).None of these individuals could be diagnosed with Asperger's syndrome using DSM IV TR or ICD 10 whereas use of Gilberg's criteria helped in establishing the diagnosis which was corroborated with the use of RAADS & ASSQ. 7 out of 10 had distinct pedantic quality with 2 individuals having savant abilities . comorbidity with psychiatry disorders was observed only in 1 individual out of 10.
Keywords: Asperger's syndrome
Prevalence of Depression Among Residents of An Industrial Township Attending The Psychiatry Clinic
Manasa Kaja, Sreejayan.K , PSVN.Sharma , Shripathy.M.Bhat
department of psychiatry,kasturba medical college, manipal, Karnataka, India
Background: The Kudremukh Iron Ore Company ( now defunct) is situated in south Karnataka. It operated for operated for 30 years and closed its mining activities in 2006 due to environmental issues, as per court orders. People from different states of India worked there and stayed in the township with their families. They belonged to a different cultures. Migration and cultural incongruence has been shown to cause stress and emotional disturbances.
Objective: To study the prevalence of depression among residents of an industrial township attending the psychiatry clinic.
Type of study: Retrospective Chart review
Methodology: Retrospective review of the files from the psychiatric clinic that was functioning at the township would be reviewed. The diagnosis was made by consultant psychiatrists providing services at the clinic. Descriptive statistics would be used to arrive at the results.
Results: The results would be presented at the conference.
Sildenafil Induced Mania - A Case Report
Background: Manic episode after Sildenafil Ingestion has been rarely reported.
Aim: To present a rare case of mania that developed after the ingestion of sildenafil, and review the literature on Sildenafil induced manic episode.
Case Report: A 25 years old male came to OPD of Tertiary neuro psychiatric center with the complaints of acute onset of behaviour change withno significant past, family, personal history and premorbid personality. On exploration, history revealed that he took Sildenafil one night after which he started to have behaviour changes characterised by irritability, increased talkativeness, grandiose talks, increased psychomotor activity, increased libido and decreased need for sleep for next 5 days, whenhe was brought to OPD because of unmanageability at home. There is no history suggestive of any decreased sleep or any other substance use or any drug use in patient prior to the onset of behaviour change. He was diagnosed asmanic episode and started with anti-manic agents. The patient gradually showed improvement and then recovered. Causality of Drug induced mania was possible. The Sildenafil induced psychiatric disorders are reported in the past also but they are rare.
Conclusion: Sildenafil can rarely lead to manic episode and there is a need for vigilance on abnormal behaviour changes in people receiving Sildenafil.
Keywords: Sildenafil, grandiose talks
Morgellons Disease - A Case Report
Rahul. P*, K. Sarada**, S. Radharani***
Government Hospital for Mental Care,Andhra Medical College, Visakhapatnam. INDIA
Morgellons disease is a rare clinical entity of unknown etiology. Researchers had varied opinions regarding this condition. Some classify this as an autoimmune dermatological infection. Some opined that this condition may be due to infectious agents like Borrelia, Spirochetes or from a rare variant of fungal infections that affect the skin. Half of the researchers opined that this is an uncommon variant of delusional parasitosis.
Despite the variations in etiology, Morgellons is characterised by severe itching of the skin, followed by burning and crawling sensations under the skin. Initially thought to have a Caucasian predominance, this disease is seen in almost all ethnic groups with no significant gender predisposition. Some researchers pointed out that factors such as chronic stress, immunodeficiency, hypothyroidism and past history of mental illness may act as precipitating factors. Usually appears in the middle age, this condition tends to run a long course with uncertain prognosis.
A single case presented with such similar symptoms, its management and other issues were discussed in the form of a poster. Case study was started on August, 2015 and was case being followed up till now. Study was done in Government Hospital for Mental Care, Visakhapatnam.
Keywords: Morgellons disease, hypothyroidism
Assessment of personality in intravenous opioid users attending OST centre of a tertiary care hospital
Angshuman Kalita, Deepanjali Medhi
Gauhati Medical College Hospital, Bhangagarh, Assam, Guwahati,India
Introduction: Opioid use especially intravenous drug use (IDU) has a major impact on individual, families & communities. The effect is cumulative, significantly contributing to costly social, physical, mental and public health problem. Although the etiological significance of personality in genesis of opioid addiction is not established, it can guide us to develop an effective treatment plan.
Aims and Objectives: To observe the sociodemographic factors in IDUs and assess personality and to study their relationship with various sociodemographic factors.
Material and Method: 100 IDUs attending OST centre of a premier healthcare institute of North East India were selected by serial sampling and 16 PF (FORM A) personality assessment tool was administered. To compare mean of different factors unpaired t test was applied. The different sociodemographic factors were also compared with personality factors to find out the association between them.
Results: Mean age of the population is 27.39 years with a male to female ratio of 24:1. Majority of our population was cool, abstract thinking, affected by feelings and dominant. They were more enthusiastic, expedient, bold and tough minded. They were more suspicious, imaginative, shrewd and apprehensive. They were equally experimenting and conservative. They were more self-sufficient and tense, had more undisciplined self-conflict. Majority had high scores on Extraversion, High Anxiety, Tough Poise, high score on Independence and low scores on Superego/ Control. Among second order factors it was found that females have less Superego/ Control.
Conclusion: Personality of IDUs plays an important role in drug abuse behaviour of them. Each patient with opioid dependence should undergo a thorough psychiatric evaluation so that the clinician can develop a multi-model treatment plan.
Keywords: Personality factors, 16 PF, IDUs, North East India
Atomoxetine Induced Hypomania while on Prophylaxis with Mood Stabilizers in an Adult Patient with Bi-Polar Disorder and ADHD
Vijaya Kumar, Shivarama Varambally
New KABINI HOSTEL, Bangalore, Karnataka, India
Background: Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Bi-Polar Affective Disorder (BPAD) carries the risk of manic/hypomanic switch
Objective: To discuss atomoxetine induced switch to hypomania in a subject with BPAD and ADHD
Methods: Mr. A, a 22 years old male, with a diagnosis of BPAD and Borderline Personality Disorder was stable on Sodium Valproate 1000 mg/d and Quetiapine 400 mg/d since a year. He then had an impulsive deliberate self-harm attempt and was admitted for in-patient care. He was adherent with medications and had adequate serum valproate levels (95 micrograms/ml). Careful evaluation during the inpatient care with a score of24 on Connors Adult ADHD rating scalesuggested that hehad adult ADHD. After patient and caregiver education, he was started on tablet atomoxetine 18mg/d and increased to 25 mg/d after five days. After the second day of receiving 25 mg/d of atomoxetine, he was noted to be more talkative than his usual self and irritable over minor issues. Next day he started reporting expansive ideas, appeared overfamiliar with treating team members and co-patients in the ward. He scored 14 on the Young's Mania Rating Scale. These symptoms were consistently noted for about 3 days while he was on atomoxetine 25mg/d. After discussing with patient and his family members, atomoxetine was stopped. His hypomanic symptoms resolved over 4 -5 days and he became euthymic. The score on the Naranjo adverse drug reaction probability was 8, suggesting that atomoxetine induced hypomania was probable.
Conclusion: Atomoxetine carries the risk of inducing hypomaniaeven when used under the coverage of adequate dose of mood stabilizers
Keywords: Bi-Polar Affective Disorder, ADHD, atomoxetine, hypomania
Porencephaly Presenting as Recurrent Psychosis- A Case Report
Sarmistha Priyadarshani, sarada swain
Mental Health Institite, SCB Medical College, odisha
Backround: cortical malformations of the brain are associated with developmental delay and psychotic features. Porencephaly is a disorder of the central nervous system characterized by cysts or cavities filled with cerebrospinal fluid within the brain parenchyma. These cysts cause a wide range of physical, neurological and in rare cases, psychiatric symptoms. Depending on the location, the presentation may vary from mild intellectual impairment to severe disability to death.
Aim and Objective: To present the case of a porencephalic cyst who presented with recurrent psychosis.
Material and Methods: A 35 yr old female was brought to psychiatry opd with presenting complains of irrelevant talk, muttering to self, wandering around at night and inappropriate laughter. Symptoms had a duration of 11 months with episodic worsening. Past history revealed a similar episode 10 yrs back during pregnancy which persisted about 1year.There was flaring up of symptoms after delivery when she had multiple seizure episodes and developed hemiparesis of both right limbs.MRI of brain revealed the presence of a CSF dense lesion on right fronto-temporo-parietal region with possible communication to right lateral ventricle. All the features suggestive of a porencephalic cyst were found. She was started on quetiapine 100mg and valproate 1000mg.Psychotic Symptoms resolved gradually and a neurosurgery consultation was done after which the diagnosis was confirmed.
CONCLUSION- It is unclear if porencephaly and psychosis concur by chance or are causally related.The area where the porencephalic cysts appear seems to be of relevance.This case highlights the need that in patients with similar clinical features as described above, radiological examination should be carried out so as to discover damaged brain lesions.It highlights the need for further research.
Keywords: porencephalic cyst, quetiapine 100mg
Kluver Bucy Syndrome- A sequel to Herpes Simplex Infection (case report)
Background: Herpes Simplex Encephalitis is the most common infection causing KluverBucySyndrome due to predilection of the virus to selectively affect the temporal lobes. In nearly all the cases of Herpes encephalitis beyond the neonatal period, the etiologic agent is Herpes Simplex virus type 1 ( HSV-1). The syndrome is characterized by psychic blindness (inability to recognise familiar objects), hyper metamorphosis (strong tendency to react to visual stimulus), increased oral exploration, placidity, indiscriminate hyper sexuality and change in dietary habits.
Objective: To describe a case of 37 year old male who developed features of KluverBucy Syndrome after Herpes simplex infection
Case Report: 37year old gentleman, from an MSES family, who had fever with chills and rigor along with vomiting and altered sensorium was diagnosed with Herpes Simplex virus encephalitis and treated 3 months back. He then presented with complaints of hyper familiarity, hyperphagia, hyper sexuality and severe memory impairment. On examination, BP- 130/80mmHg, PR- 78/min, SpO2- 100%room air. Conscious, disoriented with delusions, hallucinations and impaired recent memory. MRI brain revealed T2/FLAIR hyper intensity and thickening in bilateral frontotemporal cortex with diffusion restriction in right temporal region. Patient was started on Olanzapine 20mg, Quetiapine 400mg, Oxcarbamazepine 600mg. Patient showed mild improvement in behavioural abnormalities.
Result: This case emphasize the need to follow up patients with Herpes simplex virus encephalitis for the emergence of KluverBucy Syndrome.
Conclusion: This poster describes a patient who developed unique constellation of limbic abnormalities that resulted in KluverBucy like syndrome as a post- HSV encephalitis sequelae. Diagnosis is confirmed by systemic examination and brain imaging studies and the symptoms can be controlled to an extent with antipsychotics and mood stabilisers.
Keywords: KluverBucySyndrome, indiscriminate hyper sexuality
Benzodiazepine Induced Hypomania in Bipolar Depression- A Case Report
Sarmistha Priyadarshani, sarada swain
Mental Health Institite, SCB Medical College,odisha
Background: Benzodiazepines are traditionally being used for their sedative and anxiolytic properties. Literature also supports its role as having antidepressant properties. But exceptional cases of disinhibition and paradoxical reactions are also known to occur.
Aim and Objective: To report a case of bipolar depression who switched to mania with injectable lorazepam.
Method: A 35yr old female presented to outpatient of psychiatry with 4months duration of feeling sad and gloomy, hopelessness, tearfulness, inappropriate crying, suicidal attempts, not interested in doing any work ,sitting silent throughout the day. On MSE, patient appeared very anxious and tearful, having nihilistic ideas. Past history revealed 2 episodes of hypomania, 8 months back and 2 yrs back for which she was never treated. A diagnosis of bipolar depression was made. Patient was admitted, kept under close observation and ect was planned for severe suicidality. Lorazepam injection was started at 4mg given twice a day intramuscularly to allay the anxiety and sedation, as necessary investigations were done to plan Ect 2 days later. No other medications were given as patient was not compliant. Within 2 days ,patient got relief of anxiety and her symptoms started improving tremendously only to be observed on the 3 rd day, to be smiling and socializing with all other patients.She was unusually talkative and wanted to go for shopping as her dresses were old.MSE revealed features of hypomania. Injectables were stopped and Patient was started on olanzapine 10mg, valproate 1000mg,clonazepam 1mg. patient improved gradually and discharged
Conclusion: Lorazepam is known to have anxiolytic properties but this case brings into attention its potential to elevate and cause rapid drift in mood in case of bipolar patients. Further research is needed to confirm its role as an agent to cause switch.
Keywords: Benzodiazepines , injectable lorazepam.
A Case Of "Rapidly Progressive" Progressive Supranuclear Palsy
Shailendra Mohan Tripathi2*, Priti singh2, Ravi soni3 Rakesh Kumar Tripathi2, S.C.Tiwari1
Department Of Geriatric Mental Health, K.g.m.u. Lucknow, Uttar Pradesh
Progressive supranuclear palsy (PSP) is an uncommon brain disorder that affects movement, control of walking (gait) and balance, speech, swallowing, vision, mood and behavior, and thinking. The disease results from damage to nerve cells in the brain. It is grouped under Parkinson-Plus syndrome as the parkisonian symptoms and cognitive impairment present at the same time. PSP has a typical duration of 5 to 7 years, sometimes longer, and a slow course is part of the diagnostic criteria. Although rare cases of PSP with more rapid progression have been described, they are typically over 2 to 3 years. Faster rates of a PSP phenotype suggest an alternative diagnosis, such as prion, infectious or autoimmune disorders. We ruled out all other possible causes of the neurological or medical disorders having such a rapid progression. We describes a patient with clinical and radiological confirmed case of PSP, progressed very rapidly within 6 months.
Keywords: Parkinson-Plus syndrome, autoimmune disorders
Mobile Use Pattern and Mental Health in Medical Students
Prashant Mishra, Sidharth Arya, Sujata Sethi
HARYANA, ROHTAK, INDIA
Use of mobile phone has become very common not only for the purpose of "traditional phoning" but for various other uses. The most common other functions of mobile phone include texting, chatting, internet surfing as well as for entertainment purposes. The time spent with the device varies but is becoming a problem with young generation amounting to compulsion and addiction.
We have tried to study some of the issues related to mobile use and also how the excessive use can affect mental health. For the purpose of this study 100 medical students were randomly selected.After obtaining consent these students were assessed using special performa for mobile use pattern and GHQ-12. Results are discussed in the light of various usage patterns, and its relation with mental health of user(s).
Keywords: traditional phoning, internet surfing, chatting,
Induced Delusional Disorder: A Case Report of Folie a' Deux
Davuluri Triveni, Susanta Padhy,
Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, India
Background: Induced delusional disorder (or shared paranoid disorder), also known as folie a' deux, is a relatively rare disorder typically characterized by the presence of similar psychotic symptoms in two or more individuals. Usually the "primary" case", i.e. the individual who first develops psychotic symptoms, can be distinguished from one or more "secondary" cases, in whom the symptoms are induced Aim: To discuss a case of a folie a' deux, in which two biological sisters of same family shared same delusions. Methodology: A 22 year old female presented to outpatient clinic with. There were four members in the family: father, mother, two sisters. Among them, the two sisters fulfilled modern operational definitions for induced delusional disorder i) the partners were intimately associated, ii) they had identical delusional content, iii) there was an acceptance and support of the delusional ideas by all four members. The case history and extensive clinical examination concluded that the elder sister was the primary case and the younger sister was the secondary case. The elder sister first developed the symptoms of delusion of reference, delusion of persecution, secondary auditory hallucinations and atypical somatic symptoms. After a year, younger sister also developed same delusional symptoms. Although separation of two individuals is ultimate therapeutic intervention, it was not possible in this case. Elder sister was treated with optimal dose of antipsychotic and then she gradually improved. This led to remarkable improvement in younger sister too, even with very minimal dose of antipsychotic. After 8 weeks both were much improved. Conclusion: Shared delusional disorder is not uncommon, it needs to be diagnosed early and treated effectively. Both genetic and environmental factors are important in the causation of such disorders.
Keywords: Induced delusional disorder
Delusional Disorder of Snake Infestation - A Case Report
Priya Nayak K, Safeekh A .T
FATHER MULLER MEDICAL COLLEGE, MANGALORE
Introduction: Delusional infestation is a condition where a person believes that his or her body is infested with living organisms. It is usually the delusion with larger parasitic infestation. It has been observed both in patients with primary psychotic disorders, as well as those with psychotic episodes secondary to schizophrenia, mood disorders and substance use and also secondary to general medical conditions. Here we present a case of atypical presentation of delusional infestation in a patient with delusional disorder.
Case Report: Mrs. KT a 47 year old lady visited the outpatient department with the history of being infested with snakes in the stomach. She was high school educated homemaker. She had two children and had attained menopause. She reported that the snake is moving around in her stomach for 5 years.She reported of decrease in her food intake and also would have difficulty in breathing. She did not have any significant psychiatric or medical illness in the past. Her socio-occupational functioning was intact.
On examination, the patient was well groomed with anxious affect. She did not have any process disorder or perceptual abnormality. Patient believed that she there was a snake in her abdomen with had entered into her body through sexual intercourse.She insisted on surgical intervention as she believed it was the only way to remove the snake. She was investigated and started on antipsychotics. On subsequent follow up the patient's delusions decreased in intensity.
Discussion: This case illustrates anatypical presentation of delusional disorder. Entire history, symptoms and clinical findings are suggestive ofdelusional disorder. Recognition of this syndrome is critical to institute appropriate therapy.
Keywords: DELUSIONAL DISORDER, atypical presentation
Neuropsychiatric Manifestations of an Adolescent Diagnosed with Wilson's Disease-A Case Report
Anil Kumar Nayak, Satyakam Mohapatra
Mental Health Institute, SCB Medical College, Odisha, India
Background: Wilson's disease (WD) is a relatively rare disease of copper metabolism. The diagnosis is often missed initially. The presentation is usually neurologic or hepatic, seen in 40% of patients. Psychiatric presentation of WD is reported in only 15% of patients.
Aim and Objectives: We report a case of a 15 yr old female patient previously diagnosed with WILSON'S disease, reporting to Psychiatry OPD with behavioural and neurological manifestation.
Methods: Ms. J, a 15 year old adolescent female, presented to Psychiatry OPD with behavioural symptoms of irritability, clumsiness, emotional lability, aggressiveness and disinhibition. She also suffered from cognitive impairment as evidenced by deteriorating academic performance & poor decision making. She also had neurological symptoms like Slurred speech, tremor of hands, dystonia of hands & neck, ataxia, features of Parkinsonism for which she was already under treatment by a neurologist. Her diagnosis of Wilson's disease was confirmed by Elevated Serum & Urinary Coppor values, low serum ceruloplasmin value , MRI Brain finding suggestive of Wilson & KF Ring on edge of iris of bilateral eyes, confirmed by an ophthalmologist. She has positive family History of Wilson's disease in his younger brother. After necessary evaluation, she has been put on Tablet Quetiapine (50mg) and Tablet Lorazepam (2mg) along with Penicillamine and other medications as she was taking before. The patient responded partially & is being followed up.
Conclusion:.A range of neuropsychiatric symptoms can be a presentation of WD. A high degree of suspicion and early detection of WD is critical because early initiation of chelation therapy can prevent a catastrophic outcome.
Keywords: NEUROPSYCHIATRIC MANIFESTATIONS, WILSON'S DISEASE
Trichotillomania in A Mentally Retarded Female: A Case Report
G.Swetha 1 , M.Vijay Gopal 2 , R Ramakrishnam Raju 3
Department Of Psychiatry, GSL Medical College, Rajahmundry, Andhra Pradesh.
Trichotillomania is a chronic impulse control disorder characterized by noticeable hair loss due to recurrent failure to resist impulses to pull out hairs ,usually preceded by mounting tension and followed by a sense of relief.
Trichotillomania is also noted in numerous types of psychopathological conditions like anxiety disorders, mood disorders , substance use disorders ,eating disorders and personality disorders.
Among mentally retarded individuals hair pulling is frequently noted as an abnormal behavior but trichotillomania is rarely seen.
Here we report a case of a 19 year old female who presented with chief complaint of frequent pulling out hairs from head since 5 months that resulted in patchy bald areas over scalp. She reports mounting tension for pulling hair and that followed by relief of anxiety.
On detail history she was found to be low in academic performance. IQ assessment was done and found to be below average. She was diagnosed as trichotillomania with mild mental retardation.
She was started on SSRI and after 2 months there was improvement in her symptoms.
This case highlights the importance of detailed evaluation of trichotillomania in a mentally retarded individual presenting with a behavior of hair pulling.
Keywords: Trichotillomania, Mental Retardation.
Successful Management of Clozapine Adverse Effects with Extended (alternate -day) Antipsychotic Therapy in a Patient with Schizophrenia
Vijaya Kumar, Shivarama Varambally
Background: Management of clozapine related adverse effects is a challenging area in Psychiatry
Objective: To discuss extended antipsychotic therapy to manage the adverse effects of clozapine
Methods: A 42 year old male with treatment-resistant schizophrenia was started on clozapine and the dose was gradually increased up to 400 mg/d over a period of 6 weeks. Dose of clozapine could not be increased furtheras he developedadverse effects such as sedation, hypersalivation and constipation. Risperidone was added to clozapine at the dose of 4 mg/d at the end of 12 weeks of clozapine. On regular therapy with clozapine and risperidone combination although his psychotic symptoms improved (40% reduction in BPRS scores), the adverse effects of antipsychotics became disabling (sedation up to 16 hours/day, hypersalivation throughout the day, and constipation).With patient and his caregiver's consenthe was started on extended antipsychotic therapy i.e., he would be taking both the medications on one day and drug free on the next day. With this regimen,the severity of adverse effects decreased minimally.. After 2 months, patient was advised to take clozapine 350 mg on one day and risperidone 4 mg on the other day. A month later, he was free of all adverse effects. He has now been stable on this regimen for the last 6 months, with sustained improvement in psychosis and no adverse effects.
Conclusion: Alternate antipsychotic therapy may be useful in some patients who do not tolerate daily therapy.
Keywords: Extended antipsychotic therapy, clozapine, adverse effects
Olanzapine Induced Priapism- A Case Report
Sarmistha Priyadarshani, Jigyansa Ipsita Pattnaik
Mental Health Institite, SCB Medical College,odisha
Introduction: Priapism is defined as a painful, persistent and prolonged penile erection. It has been associated with long-term devastating consequences such as impotence, gangrene, and urinary retention.Priapism caused by drugs accounts for 25%-40% of all cases, with the most commonly associated categories of drugs being antipsychotics and antihypertensives.To our knowledge, there are infrequent case reports of priapism following administration of risperidone (23), olanzapine (14), and quetiapine (6).
Aim and Objective: To report a case of priapism caused by olanzapine therapy.
METHOD: A 42 yr old male who was a diagnosed case of bipolar disorder of 10 yrs duration under treatment and maintained with valproate 1000mg since last 1 yr, presented to opd with the complain of overtalkativeness, irritability,decreased sleep for 7 days. Patient was prescribed olanzapine 10mg and lorazepam 2mg in addition to valproate.5 days later patient presented to the emergency department with complain of painful erection since 2 days.the consulting psychiatrist was called on.On history taking,patient reported of having the painful erection episodically, 3 days after starting the new drug which progressed to become prolonged and he had to visit the hospital. By the time he reached, it was over 24 hours duration and gangrene had developed. Olanzapine was discontinued and patient was taken up for a shunt surgery. But due to delay, he developed impotence. Aripiprazole was substituted as the antipsychotic and patient was maintained well and had no further episodes.
CONCLUSION: Clinicians should assess the likelihood of developing priapism before starting any medication known to be causing priapism and inform the patient about the potential reactions. As the consequences can be terrible and leave a lifelong scar for the patient.
Keywords: priapism , Aripiprazole, valproate 1000mg
Re-Examining Standard of Care for Electroconvulsive Therapy: Lessons From Retrospective Chart Review of Twenty Thousand Treatments At General Teaching Hospital in Mumbai
Mosam Phirke. Harshal Sathe, Avinash Desousa, Nilesh Shah.
Background: Electroconvulsive therapy is one of the most effective therapies in psychiatry with wide variation in its pattern of use.
Aims: The present study seeks to examine the pattern of use of electro convulsive therapy in an urban centre .
Method: All records of ECT procedure in the past 5 years were reviewed. The observations were recorded on various parameters of clinical details, indications, co-morbid conditions, etc. Data was collected on semi - structured pre-format and statistically analyzed.
Results: The study showed that 1971 patients received 21796 modified ect treatments. ect was used over wide age range and predominantly for psychotic disorder. It was also given to sizable number of patients with medical co-morbidities.
Conclusion: ECT use was found to be feasible, acceptable and effective treatment in various psychiatric illness. We suggest that, the above factors in a given context can assist in setting a better standard care.
Keywords: Electroconvulsive therapy, psychotic disorder.
Catatonia - Initial presentation in Delirium, A case Report
Premchand, Sripathy M Bhat , Vijayalakshmi
It is a brain disturbance manifested by a syndrome of diverse neuropsychiatric symptoms. Defined as disturbance of consciousness or attention and a change in cognition that develops acutely and tends to fluctuate in severity with varied presentation. Catatonia is seldom considered in evaluation of altered mental status (AMS) in medical settings. To date, 16 cases have been identified that met criteria for concurrent delirium and catatonia, which supports the concept of a catatonic subtype of delirium(Francis et al 2009).The most common signs of catatonia associated with hypoactive delirium are immobility, withdrawal, posturing, mutism, and negativism.
Here we discuss a case of 58 year old female with nil comorbidity operated for diverticulosis presented in her post operative day two with signs of catatonia and further evolution of symptom & management .Catatonia can be the initial presenting symptom of delirium which complicates the picture and hence forth the management. Catatonia may co-occur with or be preferentially diagnosed as delirium.
Catatonia respond well to highpotency benzodiazepines, which are generally avoided in the treatment of delirium.catatonia may worsen or progress to neuroleptic malignant syndrome with butyrophenones (such as haloperidol), which are frequently administered for delirium.Accurate clinical judgment to assess and take therapeutic decision plays a crucial role in management.
Keywords: diverticulosis, neuroleptic malignant syndrome
Behavioural And Emotional Manifestations In A Child With Prader-Willi Syndrome
Shashi Kant Khanna
Background: Consistent with our clinical experience, we found low rates of manic episode and bipolar disorder as co morbid in autism. Reported rates of bipolar disorders in published studies of autism have varied.
Case: A 17 yr old male, student of 10 th class, a known case of childhood autism without intellectual impairment was brought to a tertiary care psychiatric hospital with the history of abnormal behaviour since last 2 months with acute onset, characterised by irritable mood, aggression and decreased sleep. Further on admission, pt was found to have increased psychomotor activity,increased talk, delusion of grandiosity, and subjectively "mast " affect though not evident from his face. Also patient did not make eye to eye contact. There was no history of previous depressive episode, substance use, or use of medications like anti depressants, steroids etc. Patient was diagnosed as manic episode with childhood autism and started on anti manic agents. Pt showed significant improvement within one month.
Conclusion: Though rarely reported, and a diagnostic challenge, but the possibility of mania should be considered when witnessing behaviour and affective changes in patients of autism spectrum disorder as well.
Keywords: psychomotor activity,increased talk, Emotional Manifestations
A Case Report of Lewy Body Dementia with Behavioural and Psychological Symptoms of Dementia
Snehanshu Dey, Satyakam Mohapatra
Mental Health Institute, SCB Medical College, Odisha, India
Background: Lewy body dementia is a common but frequently underdiagnosed cause of dementia often mistaken for the more familiar entity of Alzheimer disease. Clinically the distinction is important, because it can have profound implications for management
Aim and Objectives: We report a case of a 60yr old male patient who was previously misdiagnosed as a case of Psychosis & markedly improved after reviewed diagnosis of LBD and initiation of proper therapy.
Methods: Mr. S, a 60 yr old male was admitted to Psychiatry indoor with complaints of irritability, fearfulness, intermittent aggressiveness, wandering away from home at times, memory impairment , vivid visual hallucinations and fluctuating course of cognition and alertness since last one year. The progression of symptoms had been rapid with gross impairment in personal & occupational life of the patient. On examination the patient revealed neurological symptoms of resting tremor, exacerbated by intentional movement, bradykinesia, rigidity and gait disturbance. The patient has been taking Olanzapine 10mg and Trifluoperazine 5mg along with Trihexyphenidyl 2mg per day since last 2months after being misdiagnosed as a case of Psychosis by a physician, which had caused deterioration of the symptoms. After detailed evaluation & diagnostics, the diagnosis was reviewed to be Lewy Body Dementia with DVT of Left lower limb. The patient was put on Tab Donapezil 5mg, increased to 10 mg OD in 10 days, Tab Syndopa(Levodopa+Carbidopa) 110mg BD , Tab Trihexyphenidyl 2mg OD, Tab Lorazepam 2mg HS. Surgery consultation was taken for management of DVT. The patient has improved considerably since then & is under follow up.
Conclusion: The diagnosis of Lewy body dementia has important implications. It is associated with a high incidence of neuroleptic sensitivity, necessitating great caution in the use of these common antipsychotic agents. Early studies indicate cholinesterase inhibitors can be beneficial for treating the hallucinations and behaviour disturbances that afflict these patients and might also improve cognition.
Keywords: Lewy body dementia, Trifluoperazine
Suicide Attempt, A Clinical Presentation of Delirium Tremens: A Case Report
Padma Angmo, Rajesh Rathi , Pankaj Kumar
IHBAS HOSPITAL, DILSAHD GARDEN, DELHI, India
Background: Delirium tremens is the most serious form of alcohol withdrawal with significant mortality. The various causes of death in delirium tremens are heart failure, pneumonia, renal disease and other medical illnesses. Another important cause of death, which needs to be kept in mind is suicide which is not as commonly reported.
Case: A 30 yr old, separated, 7th std. educated, working in a printing press, with no significant past history was referred to a tertiary care hospital with the history of suicide attempt by slashing his own throat with a kitchen knife. On exploration, it was found that patient had been using alcohol in dependent pattern for 8 years, with the last intake three days before presentation, followed by symptoms of tremors, anxiety, decreased sleep, picking behaviour, fearfulness, seeing images, confusion. The night before he was brought to the hospital, with the above symptoms, he also started getting aggressive, started muttering to self and picked up a knife and slashed his neck. As family members intervened, he could not inflict deep wounds and he could be saved with timely surgical intervention. He was admitted in psychiatric ICU and treated for delirium tremens, also taking precautions for the high risk behaviours. Patient subsequently could recollect that he had carried out the act in response to visual hallucinations.
Conclusion: In cases of delirium tremens, suicide and self harm risk management should also be carried out, keeping in mind the unpredictability of the behaviour. Also, in cases of suicide attempts, history of substance use should be explored for.
Keywords: Delirium Tremens, symptoms of tremors
A Study of Presence of Depression in Diabetic Patients: Prevalence, Sociodemographic Profile and Correlation of Depression Severity with Diabetes Severity
Rahul Mathur, Dipesh Bhagabati
Madhya Pradesh, Indore
Background: High prevalence of co-existing depression in diabetic patients has been seen in many previous studies and bidirectional relation between these two has already been established.
Objectives: (1) Assessment of prevalence of depression in a diabetic population. (2)Correlation between severity of depression (assessed through HAM-D scores) and severity of diabetes (assessed through HbA1c levels). (3) Correlation between duration of diabetes and depression.
Materials and Methods: The study included 200 patients with diagnosed type 2 diabetes between ages 25-60 years. Glycosylated haemoglobin levels were recorded for all patients. Depression in all patients was evaluated clinically as per the ICD-10 diagnostic criterion of depression. Those who were diagnosed with depression, severity levels were quantified based on the Hamilton Depression Rating Scale. Study sample was divided into 3 groups based on age for better analysis - young adulthood (25-35 years), middle adulthood (36-45 years) and late adulthood (46-60 years). Data were recorded in a structured performa and analysed.
Results: The mean age of the sample is 35.17 years. The prevalence of depression was found out to be 31.5%. No statistical difference of depression prevalence between males and females. Mean HAM-D scores were significantly lower in the middle adulthood. Duration of diabetes was significantly correlated with presence of depression (p=0.010). Severity of depression was significantly correlated with the HbA1c levels (p=0.011).
Conclusion: We have made an effort to understand the various factors affecting the presence of depression in diabetes- age, gender, religion, education, background, duration of diabetes and glycemic control. We found a high prevalence of depression in diabetes and that severity of depression increases with severity of diabetes. We would recommend routine screening of depression in diabetic patients and especially in those with high glycosylated haemoglobin levels.
Keywords: co-existing depression, diabetes and depression.
A Case of Post-Traumatic Stress Disorder; who suffered stampede at Godavari Mahapushkaralu - Successfully Managed
T.Santhi1, M.Vijaya Gopal2, R.Rama Krishnam Raju3
GSL Medical College and General Hospital, Andhra Pradesh
PTSD is defined as the human response to overwhelming life experience as an anxiety disorder and an illness of the mind. It is characterized by prolonged trauma, difficulties with memory, learning and regulating impulses and emotions. Lifetime prevalence ranges from about 10 - 12% among women and 5-6% among men. Here we report a case of 35 year old female, housewife who suffered stampede at Godavari Mahapushkaralu in July 2015. Though she was not critically injured in the incident, it had an impact on her mental health. She was normal for initial 2 days and then developed feelings of fear and anxiety which over days progressed to nightmares, flash backs of traumatic event,emotional detachment, and day time imagery. A provisional diagnosis of post-traumatic stress disorder is made and she was successfully managed with SSRI and CBT. Case history and psychological interventions in detail will be presented at the time of poster presentation.
Keywords: Post traumatic stress disorder, flash blacks, emotional detachment, night mares, SSRI, CBT.
Neuroleptic Malignant Syndrome (NMS) without Raised Creatinine Phosphokinase (CPK) Levels - A Rare Presentation
Kalpana N Raval, Surya , Nischol K Raval,
HYDE PARK, GULTEKDI Sahyadri Hospitals, Pune.
Neuroleptic malignant syndrome (NMS) is one of the few psychiatric emergencies that needs a high level of clinical suspicion and immediate medical attention to prevent further serious medical complications, including mortality. As there are no specific diagnostic tests, diagnosis is mainly dependent on a combination of clinical signs and symptoms along with supportive laboratory investigations. Amongst these investigations, a lot of emphasis is placed on elevated Creatinine Phosphokinase (CPK) levels, which are present in about 90 percent of patients suffering from NMS. We present here a case of Mr. B D, 53 year old, gentleman, admitted for treatment of Acute psychotic episode, who developed NMS during the course of his treatment. Though he satisfied most of the clinical criteria for diagnosis of NMS, his CPK levels remained normal through the course of his treatment. He recovered completely on stopping antipsychotic medication and was eventually stabilized and discharged on Sodium valproate. It is important to note such a presentation, as too much reliance on elevated CPK levels in the diagnosis of NMS might lead to missing the diagnosis completely.
Keywords: Neuroleptic malignant syndrome, Creatinine Phosphokinase
Suicide Attempt Following Escitalopram Treatment- A Case Report
Jigyansa Ipsita Pattnaik, Sarmistha Priyadarshani,
SCB Medical college, cuttack,odisha
Background: Suicidal thoughts and behaviour during antidepressant treatment, especially during the first weeks of treatment, have prompted warnings by regulatory bodies. The aim of the present case report is to highlight the course of emergence and worsening of suicidal ideation during serotonin reuptake inhibitor treatment.
Aim and Objective: to present the case of a suicide attempt after initiating escitalopram.
Method: A 54 yr old female presented with the complain of repeated brooding of past events, feeling sad, decreased sleep, loss of appetite of duration 7-8 days. Past history revealed no psychiatric illness. On MSE, mood was depressed, but no thought or perceptual disturbances present. No thoughts of death or suicidal ideas could be found. A diagnosis of mild depressive episode was made as per ICD-10 and patient was prescribed escitalopram 10mg and lorazepam 2mg. 15 days later, patient presented to the emergency department in a critical condition with a suicidal attempt by hanging during which she was caught by her family members and rescued. After stabilization of her medical condition, patient was interviewed, and she explained it to be a wrong decision. She explained it to be due to repeated thoughts of death coming to her mind which were intensive and compelling. Finally unable to tolerate, she decided to end up her life. She was admitted and escitalopram was discontinued. She was started on sertraline 50mg and lorazepam2mg. a close watch to the patient was advised to the family.2 months later, patient had significant improvement.
Conclusion: In a minority of depressed patients, treatment with an antidepressant drug appears to initiate intense suicidal thoughts and actions. So, this case highlights the need for necessary precaution while initiating any antidepressant therapy and adequate information to the family members about the possible risks and ways to prevent it.
Keywords: suicide attempt, escitalopram. sertraline
Psychiatric Manifestations in Hyper IgE Syndrome: A Case Report and Review of Literature
Swapnajeet Sahoo, Susanta Kumar Padhy
Background: Hyper-IgE syndromes (HIES) are primary immunodeficiency disorders characterized by recurrent skin infections, recurrent pneumonia and increased serum IgE levels. Autosomal recessive form of HIES usually has less severe multisystem involvement as compared to autosomal dominant variants. Association with autism and mental retardation via chromosome 4 has been proposed. However, no other psychiatric disorders have been linked yet with HIES.
Objective: To present a case of a 13 years old male child with Hyper IgE syndrome who presented with dissociative convulsions.
Methodology (Case Report): A 13 year old male child, diagnosed as Hyper IgE syndrome since the 3 years of age following repeated episodes of furuncles and serum IgE levels >=2000. He had a history of repeated hospital admissions and witnessing of death of sick children of his age at hospital. Since Oct 2013, episodes of unresponsiveness for 10-15 mins with increasing frequency and duration without any h/o of frothing, tongue bite, tonic-clonic movements of limbs and urinary/faecal incontinence or disorientation. Following which has parents became overprotective and he stopped going to school. EEG, MRI and other necessary investigations were normal. Symptoms further worsened following father's diagnosis of myocardial infarction. He was admitted and managed with supportive psychotherapy, play therapy, art therapy, and activity scheduling along with environmental manipulation. Hyper IgE syndrome was graded as mild possibly autosomal recessive. The child improved after a period of 20 days and has been maintaining well since last one year.
Conclusion: Stress being main contributor to majority of psychiatric disorders is well known. Childhood onset chronic illness is associated with high levels of stress and dissociation can be regarded as a means to escape from unavoidable stress in this scenario. There is lacuna in search of psychiatric manifestations in childhood onset immunodeficiency disorders.
Keywords: Hyper IgE, dissociative disorders, stress
Opioid Substitution Therapy for Heroin Dependent Pregnant Female
Vaibhav Patil*, Nishanth KN, Ravindra Rao , Atul Ambekar
Department of Psychiatry & National Drug Dependence Treatment Centre, All India Institute of Medical Sciences New Delhi. India
Background: Substance use disorder among female is a global public health concern because of its rising trend and serious impact on both physical and psychological health. Presence of pregnancy further complicated situation. The treatment of opioid dependence during pregnancy is major challenge for doctors as it can lead to variety of complication in mother and fetus. Buprenorphine is opioid substitution therapy which can effectively manage such condition.
Case: A 30 year old married female presented to our de addiction centre with history of 13 years of smack use. It was characterized by tolerance, withdrawal, craving and use despite harm. Patient was in second trimester of pregnancy with 0.5 gm of smack use daily without any abstinence during entire period. She was hospitalized and started on 4mg of buprenorphine which was increased to 8mg during third trimester. Patient did not report any withdrawals and craving on medication. She was registered in antenatal clinic of our hospital. Delivery was uneventful. After delivery she was maintained on buprenorphine considering psychosocial profile and long duration of opioid use.
Conclusion: Buprenorphine has been established as treatment alternative to methadone in pregnant opioid dependent women over last few years. Not only its safer substitute but it also prevents complicating withdrawals during pregnancy. Thus it forms important part of comprehensive treatment approach to opioid dependent female.
Keywords: opioid use, Buprenorphine
Pathways to Care in Elderly Persons with Dementia
Sk Altaf Hossien, Sk Altaf Hossien , Santosh Loganathan
NEW DOCTORS HOSTEL, CIP KANKE, RANCHI, JHARKHAND, RANCHI, INDIA.
Introduction: Because of rising life-expectancy and/or declining death rate, world's population is aging. With longer life this has also resulted in high number of people living with dementia with a current estimate of 35.6 million worldwide. Research shows that most people currently living with dementia have not received a formal diagnosis. There is a significant treatment gap because of lack of awareness and understanding of dementia.
Aims and objectives: Our aim is exploring the various pathways taken by the caregivers of the persons with dementia before they come to a specialized centre.
Methodology: 35 caregivers of persons with dementia were enrolled for the study from NIMHANS Geriatric clinic service. Caregivers were interviewed about the pathways they have taken to reach the specialized centre using Short Explanatory Model interview (SEMI). Qualitative data analysis was done using ATLAS.ti. Contents of interviews examined thoroughly, read and re-read several times. Multiple themes were identified and coded for each item.
Results: After close and in-depth observation, we have found three major types of pathways taken by the caregivers of persons with dementia. Pathway I (The Neuro-psychiatrist Pathway): Where people go to a psychiatrist or a neurologist as first contact when symptoms of dementia become apparent and from there they were referred to a tertiary care speciality clinic like NIMHANS. Pathway II (The General Practitioner Pathway): In the second type of pathway, caregiver identifies dementia symptoms in their relatives. They consult a private practitioner or general hospital because of convention, proximity or earlier experiences. Then they were referred to either a psychiatrist or a neurologist. And finally from there they are referred to tertiary speciality clinic. Pathway III (The Non-Cohesive Pathway): In third type of pathway found in our study, people moved from one place to another as they, they were hardly aware and informed about nature and course of illness, they were not satisfied with the care. And finally ends up at a tertiary care.
Conclusion: Awareness and understanding is significantly less in public leading to a treatment gap and delay in help seeking in dementia. Primary care physician could be trained and sensitize to identify dementia early in the course. At the same time primary care service should be implemented with facilities of screening and initial management.
Keywords: understanding of dementia.
Perceived Stress and Burden in Primary Caretaker of Substance use Disorder
ganeshnagar lawyers colony, Uttar Pradesh, Agra
Aims & Hypothesis: To assess perceived stress and family burden among the primary caretaker of substance use disorder.A substance dependent person in the family affects almost all aspects of family life. This leads to problems, difficulties or adverse events which impact the lives of family members and causes enormous burden on family caregivers. The present study aimed to assess the pattern of burden and stress borne by the primary caretaker of substance use disorder.
Background: Substance use disorder has taken epidemic proportion within part of India which borders Pakistan.It has deleterious consequences not only on the patient with substance use disorder but also on the members of his family.Their mental health is very crucial for the rest of the family.
Method: This study was done in a tertriary care hospital of North India on primary caretakers of subjects diagnosed with substance use disorder.All primary caretaker underwent detailed assessment using Family Burden Interview Schedule and Perceived Stress Scale.
Results: Atotal 100 consecutive patients were taken Majority were in age group of 18-40 years.Their caretaker were assessed as a part of the study.45%caretakers were spouses,30% being father ,20% being mothere.Majority of the primary caretakers had moderate to severe financial burden,moderate to severe disruption in family routine,moderate to severe disruption in family leisure and interaction.There was mild disruption in physical and mental health of the caretaker.Majority had moderate subjective burden and moderate to severe total family burden.Total Perceived Stress as perceived was moderate to severe in severity as perceived by primary caretaker.
Categorising caretakers as spouses vs non spouses it was found that family routine, familyleisure, familyinteraction, total family burden was significantly lower in spouses than non spouses. Total Perceived Stress was found to be significantly lower in spouses.
CONCLUSION: In conclusion we found moderate to severe stress in all spheres assessed on FBIS & Perceived Stress Testin caretakers of majority of them.Effect of physical health and mental health was mild -moderate in all the primary caretakers.The burden and Perceived Stress was less in spouses as compared to non spouses.
Keywords: Stress , burden , Substance use disorder.
An overview of Wernicke's Encephalopathy
Ravindra Munoli, Mahima Acharya
Department of Psychiatry, Kasturba Medical College, Manipal University, Manipal, , karnataka
Wernicke's encephalopathy (WE; Wernicke's disease) refers to neuropsychiatric manifestationsdue to thiamine (Vitamin B1) deficiency. In addition, Vitamin B1 deficiency results in all forms of Beriberi and Korsakoff syndrome.Classically, when fully developed,it manifests with triad of confusion,ophthalmoplegia and ataxia. However, all three features may be seen inonly 10% of patients (Cook, 2000). Thiamine deficiency is invariably seen in malnourished chronic alcohol users. Wernicke's encephalopathy is characterized by delirium and Korsakoff's syndrome (occurring as a sequela to Wernicke'sencephalopathy) is an amnestic disorder in which there isno confusion state.Wernicke΄s lesions were observed in 0.8 to 2.8% of the general population autopsies, and 12.5% of alcoholics. This figure increases to 35% of alcoholics if including cerebellar damage due to lack of thiamine (Torvik et al., 1982).WE was first identified in 1881 by the German neurologist Carl Wernicke, although the link with thiamine was not identified until the 1930s. A similar presentation of this disease was described by the Russian Psychiatrist Sergei Korsakoff in a series of articles published 1887-1891. Present poster focuses on Wernicke's encephalopathy clinical features and management.
Keywords: encephalopathy, Thiamine deficiency, delirium
Knowledge, Attitude, Practices of Disulfiram Amongst Relatives of Patient with Alcohol use Disorder
Manish Tale, Riteeka Dikshit, AvinashDesouza, Nilesh Shah.
GHANTI ROAD,PARSI COLONY,DADAR, MAHARASHTRA, MUMBAI, India
KAP (Knowledge, Attitude and Practice) studies are highly focused evaluations that measure changes in human knowledge, attitudes and practices in response to a specific intervention, usually outreach, demonstration or education. KAP surveys reveal misconceptions or misunderstandings that may represent obstacles to the activities that we would like to implement and potential barriers to behavior change. The objective of this study is to assess the knowledge, attitude and practice of theDisulfiram amongstrelatives of patients with alcohol use disorder. Survey was performed at a tertiary care hospital in Mumbai about the drug usage and awareness.Relatives of 400 patients diagnosed as alcohol use disorder was interviewed. Apart from their basic personal information and history, various questionnaires were asked to respondents with respect to management, drug experience and its impact on quality of life. The results and conclusion are awaited.These results canserve as the baseline (reference value) for use in future assessments and treatment plans.It can suggest an intervention strategy that reflects specific local circumstances and the cultural factors that influence them; plan activities that are suited to the respective population involved.
Keywords: Knowledge , attitude , practice , Disulfiram
Monitoring Lithium level- Current Understanding
Ravindra Munoli, Mahima Acharya
Department of Psychiatry, Kasturba Medical College, Manipal University,Manipal,Udupi, Karnataka
Lithium is gold standard mood stabilizer, often used as first line drug in Bipolar patients. One issue with lithium is narrow therapeutic index. One of the earlier studies to examine the optimal dose of lithium in the treatment of symptoms of acute mania advocated a serum lithium concentration between 0.9 mEq/L and 1.4 mEq/L. Later studies, like that of Stokes and colleagues, illustrated that effective mania response could generally be achieved with doses between 0.5 mEq/kg/day and 0.72 mEq/kg/day, corresponding to serum lithium levels close to 1.0 mEq/L. Numerous controlled, double-blind studies over several decades have now shown a 70% to 80% response rate of lithium monotherapy in acute manic episodes with doses of lithium between 900-1,200 mg a day, corresponding to serum lithium levels of 0.6-1.2 mEq/L.The optimal dose of lithium for the treatment of acute mania is different than the optimal dose for maintenance therapy. Coppen and colleagues showed that effective maintenance doses correspond to serum lithium levels as low as 0.4-0.6 mEq/L, with far fewer side effects. By contrast, Gelenberg and colleagues reported relapse rates three times higher (38% vs. 13%) with lithium levels 0.4-0.6 mEq/L versus 0.8-1.0 mEq/L. Most clinicians adhere to the package insert, and maintain lithium serum lithium levels to between 0.6 and 1.2 mEq/L. Current presentation tries to address these issues.
Keywords: Lithium, acute mania,
Musical Hallucinations in an Alcohol Withdrawl State
Manish Tale, Avinash Desousa, Nilesh Shah, Sushma Sonovane, Anup Bharti.
Department of Psychiatry , Lokmanya Tilak Muncipal Medical College and General Hospital, Sion ,Mumbai. Maharashtra India.
Objective: We are reporting a rare case of musical hallucination in a male who had a history of alcohol consumption for 22 years. Methods: We present a 44-year-male with a history of alcohol consumption since 22 years presented with fearfulness, hearing voices and decreased sleep for 7 days. The last drink was 11 days prior to presentation. Results: The patient was diagnosed to have alcohol withdrawal syndrome and had musical hallucination whereby he heard voices reading a poem in a rhyming manner. These voices threatened him in these musical rhyming ways that they would make him go mad, would not allow him to sleep and would kill him and his family members. Conclusion: Musical hallucination has heterogeneous clinical and pathophysiological etiology, and has been reported in the elderly and in those with hearing impairment, central nervous system disorders and psychiatric disorders. Musical hallucination is very rare in alcohol withdrawal syndrome. The treatment of musical hallucination includes carbamazepine, clomipramine and Electroconvulsive therapy (ECT).
Keywords: Musical Hallucination, Alcohol Withdrawal, Auditory Hallucination
Neuropsychiatry of Folic Acid Deficiency
RavindraMunoli, Mahima Acharya
Department of Psychiatry, Kasturba Medical College, Manipal, Manipal University,
Introduction: Folic acid (Vitamin B9) is a water-soluble vitamin required for various bodily functions. It is part of vitamin B group and is also referred as folate and pteroylmonoglutamate (PteGlu).Folate is required for synthesis, repair and methylation of DNA, and it is a cofactor in certain biological reactions (Weinstein et al., 2003). During pregnancy and infancy,it aids in rapid cell division and growth. Other significant role is in production of RBCs. Usually,folate deficiency is because of lack of dietary folates.Folate deficiency usually presents with macrocytic anemia, diarrhea, and pregnancy complications; rarely with neuropsychiatric manifestations.Current presentation focuses on aetiology, clinical features, investigations and management of Neuropsychiatric manifestations of folic acid deficiency.
Keywords: Folic acid, macrocytic anemia
Neuropsychiatry of Niacin Deficiency
Ravindra Munoli, Mahima Acharya
Department of Psychiatry, Kasturba Medical College, Manipal, Manipal University, Udupi, karnataka
Niacin (Vitamin B3 or Nicotinic acid) is one of the water soluble vitamins and its dietary sources are animal products, fruits, seeds; in addition, it is synthesized endogenously from tryptophan. It is required as coenzyme for various reactions in body and for both DNA repair and steroid hormones synthesis in adrenal glands. Niacin deficiency is following lack of niacin in diet and chronic malnutrition. Mild deficiencies will present with tiredness, headache, whereas severed deficiencies will present with encephalopathy features (with delirium) or pellagra- diarrhea, dermatitis, dementia. Mild cases recover with treatment however, chronic deficiencies may recover incompletely. Current presentation tries to look at the aetiology, neurobiology, clinical manifestations and management of Neuropsychiatric manifestations of Niacin Deficiency.
Keywords: tryptophan. Neuropsychiatric manifestations
Olanzapine Induced Thrombocytopenia: A Case Report
Swapnajeet Sahoo, HimanshuSingla Sandeep Grover,
Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, India
Background: There is limited literature on olanzapine associated thrombocytopenia.
Aim: To present a case of persistent delusional disorder who developed thrombocytopenia while on olanzapine, which improved shifting to clozapine.
Methodology (Case Report): A 32yearold,female, presented to the outpatient clinic with delusion of erotomania with significant socio-occupational dysfunction. Exploration of history revealed that she was suffering from a psychotic illness of a single delusion since last 12 years, for which she was treated with various antipsychotics like trifluperazine, amisulpiride and risperidone with poor treatment response. She was started on olanzapine, gradually increased to 25 mg/day over the period of 6 weeks, withno improvement and was considered for clozapine. During the pre-clozapine work-up her haemogram revealed low platelet count (46,000/ cumm) from baseline (3.5 lakhs/cumm) without any clinical manifestations of thrombocytopenia. Detail hematology work up to rule out any autoimmune etiology came out to be negative. Repeated evaluation over the period of 2 months showed persistent thrombocytopenia with platelet counts varying between 46,000 to 80,000. In view of persistent thrombocytopenia, clozapine could not be started and was admitted to inpatient unit. Olanzapine was graduallytapered and platelet counts were monitored.To our surprise, serial reports revealed an increase in total platelet count while olanzapine was being tapered and complete normalization of platelet count after 4 days of complete stoppage of olanzapine. Possibility of olanzapine induced thrombocytopenia was considered. Later on, clozapine was started which was gradually increased to 200 mg/day with biweekly monitoring of total platelet count before each increment in dose of clozapine. No further decline in platelet count was noted.With clozapine, her psychosis improvedby nearly 60% at the time of discharge and she has been maintaining well for the last 3 months with clozapine with no evidence of any blood dyscarsias.
Conclusion: Olanzapine can rarely cause thrombocytopenia.
Keywords: thrombocytopenia, clozapine,
Prevalence, Correlates and Disease Burden of Migraine in an Urban Population of Kolkata, India
Neelanjana Paul*, Biman Kanti Ray, Malay Kumar Ghosal, Avijit Hazra, Sujata Das, Shyamal Kumar Das
Department of Psychiatry, ICARE Institute of Medical Sciences & Research, Haldia, West Bengal, India
Objective: Community studies on headache are lacking from developing countries, though its epidemiology and economic burden has regional variations, with strong influences of social, financial and cultural factors. This comprehensive study assessed prevalence, clinical correlates and disability burden of migraine in an urban community, and underlying risk factors through case-control analysis.
Methods: This two-stage, cross-sectional study used validated, globally-accepted diagnostic criteria to study migraine in a representative sample aged 20 to 50 years, residing in an urban area of India. Sex- and age-matched controls without any history of headache were evaluated for putative risk factors. Subjective reactions to various situations were measured by Stress-Arousal Checklist. Disease burden was measured using WHO approved disability weights, as disability adjusted life year (DALY), which was formed exclusively by years of life lived with disability.
Results: Screening of 2421 individuals (52.17% females) revealed one-year prevalence of episodic headache of 18.01% (95% CI 16.48-19.54%), of whom migraine without (73%), and with (19%) aura were diagnosed in 374 individuals. Lower educational status, adverse environmental exposures, long-distance travel and oral contraceptive drugs emerged as significant risk factors for developing migraine in our cohort. DALY projected to per 100,000 population showed maximum burden in subjects aged 25 to 39 years and a higher burden in females.
Conclusion: Migraine is influenced by external factors and the individual's perception of stress and negative emotions. Public health measures are essential for their proper management, as they entail significant burden, especially in the most productive age-groups.
Keywords: migraine in an urban community, prevalence, clinical correlates
Prevalence, Risk Behaviours, Attitudes and Knowledge about HIV, HBV and HCV Infections Among IDU's Inmates of Central Jail, Amritsar
Rahul S P, P.D. Garg , Manjit Singh, Rajiv Arora, Neeru Bala, Rajinder Maago
Govt. Medical College,Amritsar,Punjab
Introduction: India has a huge number of substance abusers, with an estimated 1.1 million IDU's.Prisons being associated as facilities liable of high risk of infectious disease, as a result of the possibility of transmission of infections in prisons surroundings. The study was aimed at confirming prevalence of HIV, hepatitis B and hepatitis C among IDU class of prisoners, as well to assess their risk taking behaviours, knowledge and attitudes related to it.
Material and Methods: In this cross-sectional study,1980 IDU prisoners have participated, providing answers to structured questionnaire and in order to analyze blood for HIV,HBV and HCV, rapid blood tests in detecting antibodies has been used.
Result: Prevalence of HCV is 48.33%,HBV 5%,HIV 8.83%.Out of total IDU's,10% were involved in only risky sexual practices(Multiple partners, Money sex, MTM sex),39% had only shared syringes, needles and other paraphernilias (Cooker, vials, ampoules, cotton, rinse water, back loading) 15 % were involved in taking both of the risks together. Among HCV Positive category,90% confirmed the history of sharing .As for the manner of infection with HIV,HBV,HCV viruses, the awareness about correct use of condom and not sharing other means like needles, syringes and other paraphernilias as preventive measures ,only 52%,63% and 20% respectively gave correct answers.40% out of total IDU's inspite knowing about these risks involved, took the risk of sharing while injecting.
Conclusion: These findings indicate that there is high HCV seroprevalence, high risk taking behaviour and less awareness about the necessary preventive measures .It clearly indicates the appreciable magnitude of the problem that may emerge as an epidemic if it goes unheeded.HCV infection seems to be more common in IDU's than HBV and HIV infections, again pointing toward the urgent need to prioritise this area for early screening and relevant targeted interventions in these populations.
Keywords: prevalence of HIV, hepatitis B and hepatitis C among IDU class of prisoners
Psychiatric Co-morbidities in Patients of Domestic Violence Attending Psychiatry OPD
Sandeep Antil, Brig S.Sudarsanan Sandeep Choudhary, Supriya Agarwal, Vivek Kumar
Chhatrapati Shivaji Subharti Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh
Introduction: We are planning for this study as literature regarding psychiatric squaele of domestic violence is less in this part of country which have been listed third according to Times of India survey and underreported.
Methodology: 50 female patients of domestic violence who would be randomly selected and would be found to be facing domestic violence as per HITS(Hurt, insult, threat and scream) criteria will be selected and would then be evaluated using socio demographic data sheet and for psychiatric comorbidities using ICD-10 criteria. Severity of psychiatric disorders would be assessed according to Beck's Depression Inventory (BDI), Hamilton Anxiety Rating Scale, clinician Administered post traumatic stress disorder scale (CAPS), Brief Psychiatric Rating scale (BPRS). Appropriate statistical tools would be applied.
Results and Conclusions: results and conclusions would be discussed later at the time of presentation.
Keywords: co-morbidities , domestic violence
Right to information act, 2005 and privacy in public mental health sector in India
Senior resident, Mental Health Institute , SCB Medical College, Odisha, India
Background: The Right to Information Act (RTI) 2005 entitles citizens of India to request and access information that is publicly available and related to public interest. But disclosure of information is restricted to information provided in a fiduciary relationship, personal information that has no relationship to any public activity or interest, or if it would case unwarranted invasion of privacy of the individual.
Aim and Objectives: To discuss how privacy in public mental health sector is affected by the use of right to information act (RTI) 2005 in India.
Methods: Many psychiatric hospitals in India have been getting requests from patients, their family, relatives or employers for access to records under the RTI Act. Persons with mental disorders have the right of confidentiality of information about themselves and their illness and treatment; such information should not be revealed to third parties without their consent. Confidential information if requested by family members or employers should be provided only after explicit permission is obtained from the patient. Unlike others, records of psychiatric patients were made not only on the basis of physical conditions, but also based on inputs provided by patients and their relatives, who functioned as informants for mental health assessment. The fiduciary relationship in psychiatry cases extends not only to the patient but also to the information shared by others.
Conclusion:Public mental health care facilities are under the purview of the RTI Act, private hospitals are not and hence not obliged to share any information on their patients. So there should be a uniform policy for both sectors. Psychiatric institutions should adopt very cautious approach in revealing information about records of patients under RTI act as sensitive information, if divulged, could be misused.
Sertraline and Skin Reactions: A Review
Ravindra Munoli, Mahima Acharya, Samir Kumar Praharaj
Department of Psychiatry, Kasturba Medical College, Manipal, Manipal University, Udupi, Karnataka
Sertraline is an SSRI antidepressant, which is uncommonly associated with adverse cutaneous drug reactions such as rash, pruritus, dermatitis, purpura, urticaria, rarely, Steven-Johnson syndrome. The product monograph of sertraline shows infrequent association of sertraline with acneiform eruptions.Various side effects of sertraline have mentioned in literature and case reports have been published. However, dermatological reactions are less reported, rather acneiform reactions are rarely reported. The basis for these dermatological manifestations is unclear, however probable mechanism is increased sertraline activity at dermal-epidermal junction leading to these manifestations. In addition, once symptoms appear, it will either be stopped or antidepressant will be changed. But the crux is almost all antidepressants will act by sertraline enhancement, so choosing an antidepressant will be difficult. But recent molecules may provide an alternative option in such conditions.
Keywords: Sertraline, antidepressant, acneiform
An Interesting Case of Obsessive Slowness
Akriti Kamran, Deeksha Elwadhi
MAMC campus, Delhi, INDIA
Background: The obsessive slowness (OS) was first described by Rachman (1974) who documented ten cases of "primary obsessive slowness".The literature on obsessive slowness is limited and primarily deals with the diagnostic criteria, neurobiology, along with some highlights on the management. We report a case of obsessive slowness, which was satisfactorily treated with combined pharmacotherapy and behavioral therapy.
Case report: Mr. P, a 30-year-old malepresented with 5 year history of insidious onset and progressively deteriorating course of symptoms characterized by progressive slowness in self-care behavior (brushing, bathing, changing clothes, walking, and eating)which was not accompanied by anxiety, and avoidance of routine activities,repeated tapping behavior (with no explanation), with significant socio-occupational decline. The mental status examination revealed dishevelled lookand repeated tapping behaviour. He was diagnosed as a case of Obsessive slownessand started on T.Fluoxetine 20 mg, gradually increased to 60mg along with behavior therapy in form of prompting,pacing & shaping. After beginning of the combined therapy, within 3 weeks improvementin time spent in getting out of bed, brushing, going to toilet, answering to questions, changing clothes, and eating was noticed.Afterdischarge from the hospital, he came regularly for follow-ups and maintained the improvement uptill 2 months of discharge
Discussion: In our case, slowness in self-care behavior which was not accompanied by anxiety corresponds to description of primary obsessive slowness by Rachman (1974).In our case, there was considerable improvement in symptoms related to slowness after 3 weeks of intervention (combined therapy of fluoxetine along with behavioral therapy in the form of prompting, pacing, shaping);while most of the studies reported that effect occurs over 6-16 weeks.
Conclusion: His case demonstrates a successful treatment of obsessive slowness with early response on combined therapy.
Keywords: obsessive slowness
To Study Correlation of Insight and Voluntariness of Indoor Patients in Hospital for Mental Health and a General Hospital Psychiatry Unit
Aims & Objectives: 1. To study correlation between patients's Insight about illness and their Voluntariness for getting admitted in Hospital for Mental Health and a General Hospital Psychiatry Unit.
Materials and Methods: All the newly admitted patients during one working month in HMH Vadodara and New Civil Hospital Surat, clinically diagnosed patients suffering from mental illness willing to participate in the study were included in this study. Patients were assessed after 2 nd and before 7 th day of their admission. Consenting participants were administered a proforma which includes
- Demographic data
- Questionnaire, which investigate and provide a quantitative and qualitative measure of understanding, intentionality and voluntariness dimensions for admission.
- Insight was assessed using Birchwood Insight Scale.
Statistical Test: Chi-square test, mean, percentage and qualitative assessment.
Results & Conclusion:
- Involuntary admitted patients had poor insight when compared with voluntary admitted patients.
- None of the patients were aware of their rights for admission.
- Clinical Insight is not enough for determining voluntariness, patient with good to fair insight were also involuntarily admitted.
- Patients with voluntary admission were more aware of the reason for admission and role of medications provided to them.
- Many patients who were involuntarily admitted denied for being forcibly admitted.
- No significant difference was found about thoughts of getting, planning or maintaining their job outside after discharge.
- More patients with voluntary admissions felt need for hospitalization in future.
Keywords: Voluntariness, Insight, Understanding, Intentionality
Use of Opium Containing Herbal Drug and Associated Mania - A Case Report
Jawahar Singh, Rishab Gupta Deepak Charan Prajapati, Ravindra Rao
Department of Psychiatry, AIIMS, New Delhi.
Introduction: In India, non-allopathic medicines have gained popularity as a treatment option in the recent years. Concerns have been raised on the use of these medicines due to their non-uniform quality, purity and misuse/abuse. There are no reports on its use/abuse and the association with psychiatric morbidity.
Case report: A 33 years old, male doctor contacted the outpatient drug dependence treatment clinic. He was using a herbal medicine called 'Kamini Vidrawan Ras' (containing opium 10 mg/tablet) up to 4 tablets/day for last seven months for its pleasurable effects. After 4-5 days of consuming the drug, he developed persistent euphoric mood, as well as increased energy/confidence. He became overtalkative and started making elaborate plans regarding his career. His need for sleep decreased and yet felt fresh and energetic the whole day. He also started donating money to whosoever he deemed needy. These symptoms continued for two months, during which his pill use continued in the same pattern. The psychiatric symptoms subsided over two weeks after discontinuation of the herbal medicine due to its unavailability. As he experienced withdrawal symptoms, he consulted a local psychiatrist, who prescribed tablet Buprenorphine 4 mg/day. He remained well for next 6 weeks on Buprenorphine and was lost to follow up subsequently.
Discussion: Since ages, the use of opium in the non-allopathic medicines is based on the experience of cure of decreased power/energy, sexual dysfunction, and pain perception along with its use as a coughs suppressant. The use of herbal products in India is increasing as they are easy to obtain, socially acceptable, and not well and closely monitored by the law. Use of these herbal products in the west is currently gaining attention because of their easier purchase through internet. Clinicians should be aware of the use of certain herbal medications and their associated psychiatric symptoms.
Keywords: Buprenorphine, Kamini Vidrawan Ras
Teratogenic Effects of Psychotropic Drugs- A Case Report
Malvika Dahuja, Supriya Agarwal, (Brig.). S. Sudarsanan, S. Choudhary , Vivek Kumar,
Chhatrapati Shivaji Subharti Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh.
Introduction: No psychotropic drug is safe in pregnancy. SSRIs (selective serotonin reuptake inhibitors) like fluoxetine and sertraline can cause spontaneous abortions, pulmonary neonatal hypertension and neurobehavioural syndrome.
All second generation antipsychotics, except clozapine are category C drugs, according to US FDA (United States- Food and Drug Administration). Typical antipsychotics have shown to cause increased glucose levels in fetus. <20% of olanzapine crosses placenta. Olanzapine has rarely been seen to cause spontaneous abortions and major malformations.
We hereby present a rare case of 39 years old female with Bipolar Affective Disorder with gravida 4, para 2, 1 abortion, 2 live births with 28+3 weeks pregnancy with chronic hypertension who was taken up for elective Caesarian Section. Previously, patient was on 150mg Sertraline, once daily; olanzapine, 2.5mg night. She was continuing these medicines even during pregnancy. She was then started on 20mg of fluoxetine, once daily for 1 month prior to delivery and quetiapine (sustained release) 200mg at night was started after delivery. In Doppler, umblical artery showed increased resistance with intermittent absence of end diastolic flow, reversal of flow absent. Level 2 scan showed an anomalous fetus followed by Non Stress Test after 20min biweekly till delivery.
After caesarean, baby examination showed micrognathia, limb deformities, calipotalus equinovarus, short neck, single umblical artery, polyhydramnios, choroidal plexus cyst, subcutaneous oedema, right thumb absent, bilateral flexed wrist joint , subglial bleed, cyanosis, Heart Rate was<60/min, gasping, birth cry and reflexes were absent, gross motor activity was very weak.
DISCUSSION: SSRIs (Fluoxetine and sertraline) and SGAs (Olanzapine mainly) in this case are most likely causes of teratogenesis. Rest can be attributed to diabetes and hypertension.
Keywords: fluoxetine, Bipolar Affective Disorder
Major depressive disorder is a heterogeneous condition with a variable response to a wide range of treatments. Treatment resistant depression (TRD) is most commonly defined as when a current episode of depression has not responded to at least 2 adequate trials (i.e. appropriate dose, duration and extent) of different classes of antidepressants. The search for potential biomarkers of psychiatric disorders is a central topic in biological psychiatry. However the mechanisms of response to antidepressant therapy are poorly understood, and few biomarkers are available that can predict response to pharmacotherapy. Here, we will describe putative mechanisms and future potential markers that can be used to predict response to pharmacotherapy, such as markers of drug metabolism or blood-brain barrier (BBB) function ,the activity of specific brain areas or neurotransmitter systems, hormonal dysregulations or plasticity ,and related molecular targets.
To Study Comparison of Quality of Life Among Intravenous Drug users with and Without Psychiatric Morbidity Onopioid Substitution Therapy
PinkySwaroop, B.S. Sidhu, BaldeepKaur
Dept. of Psychiatry, GMCH, Patiala
Introduction: The practice of injecting drug use(IDU) has been spreading to different parts of world as well as in India. Opioid substitution therapy(OST)is oral administration of an opioid drug prescribed as a replacement. In India, methadone and buprenorphine are recognized as effective agonists for maintenance treatment. Quality of Life (QoL) is defined as subjective assessment of impact of disease and treatment across the physical, psychological, social and somatic domains of functioning and well-being. . Psychiatric morbidity generally refers to the incidence of both physical and psychological deterioration as a result of a mental or psychological condition Various studies revealed the psychiatric morbidity with psychoactive substance use.Objective:To study comparison of QoL among IDU with psychiatric morbidity and without psychiatric morbidity on OST.
Material & Method: Subjects aged 18-60 years who come for treatment at OST Centre, Rajindra Hospital, Patiala were included. Purposive sampling method was done.Written informed consent was taken. Identification data including socio-demographic profile was recorded. World Health Organization Quality of Life Bref Hindi version scale (WHOQoLBref) to asses QoL and MINI Plus was used to asses psychiatric morbidity.Theresults and observationswere recorded and data was statistically analysed by using Statistica 7.0.
Results: The results of present study revealed that Qol was poorer in patients with psychiatric morbidity as compared to patient with psychiatric morbidity .Conclusion:Thus it can be concluded that Qol was poorer in patients with psychiatric morbidity as compared to patient with psychiatric morbidity
Keywords: Quality of life, intravenous drug users, opioid substitution therapy, buprenorphine
Assessment of Stress in first year M.B.B.S. Students.
Sajal Ashish Nag Jyoti Shetty, Sajal Ashish Nag
Department of Psychiatry, Bharati Vidyapeeth Medical College and Hospital, Dhankawadi, Pune
Introduction: Stress is the body's automatic response to any physical or mental demand placed on it. The Bachelor of Medicine and Bachelor of Surgery (MBBS) is a tough course as compared to other professional courses. The students entering into the course are very young and most of them are moving out of their house for the first time, they have to deal with various problems and situations like vast syllabus, peer competition for academic performance, adjustment issues, low self-esteem issues, continuous evaluation and long duration of training can be a few precipitating factors for stress in 1 st year medical students.
The Department of Psychiatry, BVDUMC & Bharati Hospital has been having regular stress management workshops in the 1 st semester of MBBS since the past 3 years.We present our study on assessment of stress in 1 st year medical undergraduate students.
Aim: Assessment of Stress in 1 st year Medical undergraduate students
Objectives: 1.To assess different stress factors among the first year MBBS students.
Methodology: This study was done on 150 students joining 1st year MBBS in the academic year 2015-2016 at Bharati Vidyapeeth Deemed University Medical College & Bharati Hospital Pune. Assessment of stress was done applying scales Perceived stress scale and Symptoms of Stress scale .Stress management workshop was conducted to address some of the issues.
Results: Appropriate statistical analysis done to results obtained.
Discussion: Findings will be presented and management strategies including benefits of regular stress management workshops will be discussed.
Keywords: stress management, M.B.B.S. Students
Prevalence and Treatment Coverage for Depression in Adults in Sehore District, Madhya Pradesh
Sandesh Samudre, Tanica Lyngdoh, Vaibhav Murhar, Rahul Shidhaye,
Rishi Nagar, Char Imli, Madhya Pradesh, Bhopal
Background: Globally depression accounts for 40.5% of DALYs caused by mental & substance user disorders and it also significantly contributes to the burden allocated to suicide and ischemic heart disease making it a public health priority. This study through PRIME project aims to assess prevalence of depression among adults in rural communities in India and associate of various socio demographic and economic factors with depression.
Methods: A population based cross sectional survey of adults in rural district of Madhya Pradesh, India. Data was collected for 3220 participants using simple random sampling method based on 2011 census data. Structured interview in Hindi was administered using questionnaire application program on tablet device.
Results: PHQ-9 score was used to assess depression severity. The prevalence of current depression (defined PHQ-9≥9) was 17.9% & severe depression (defined PHQ-9≥15) was 4.3%.
Multivariable analysis showed very strong inverse relationship between higher education, high income and current depression. Among those who reported of being in debt, risk of depression increased by 26% (RR 1.3, 95% CI 1.0-1.8). Education, occupation and indebtness retained significant association with severe depression.
Discussion: Our study clearly indicated that depression in rural community is high and is strongly associated with socio-economic determinates such as education, employment and indebtness which is consistent with other similar studies in India. Community based mental health programmes with focus on improving socio-economic ecosystem in essential to tackle depression.
Keywords: substance user disorders, , risk of depression
Baclofen Induced Skin Rash: A Case Report
Anantprakash Siddharthkumar Saraf, Inamdar Arizwaseem Shahajahan, Santanu Nath
Dept. Of Psychiatry, Lgbrimh Tezpur, Assam,Tezpur-784001, India
ObjectiveS: Adverse cutaneous drug reactions, commonly known as drug induced skin rashes are known to occur with many drugs used in psychiatry with varying frequency and severity. Baclofen is a GABA receptor agonist, specifically for the GABA B receptors. It is a centrally-acting skeletal muscle relaxant, primarily used to treat spasticity and now being increasingly used in the treatment of alcohol dependence as an anti-craving agent. Although it is known to cause various adverse effects, incidence of morbiliform skin rashes have been reported rarely. We report a case of young man with alcohol dependence, who developed morbiliform maculopapular skin rashes after receiving baclofen.
Method: A 35 year old man with history of alcohol dependence was admitted to the drug deaddiction ward of a tertiary care mental hospital in North-east India. After initial management of withdrawal symptoms with benzodiazepines and tapering them off, tablet baclofen 20 mg per day was started as an anti-craving agent. Three days after starting of baclofen, he started complaining of itching over body, along with development oferythematous maculopapular skin rashes; which were managed symptomatically after stopping of baclofen and followed up till resolution by eighth day. All other possible causes were ruled out by relevant laboratory investigations and dermatological opinion; and the Naranjo ADR Probability Scale revealed an ADR score of 7, which indicated a probable adverse reaction due to the drug.
Results: Multiple, erythematous, pruritic, non-scaly, maculopapular skin rasheswithout any mucosal involvement developed after 3 days of starting Baclofen in absenceof any other systemic signs; and diminished gradually after discontinuing the drug.
Conclusion: Baclofen has propensity to cause skin rashes as one of its adverseeffects.
Keywords: baclofen, skin rash, alcohol dependence, adverse reactions
Prevalence of Blood Borne Diseases Among Opioid Injectors Attending Rims Hospital
AndreeciaMnMawiong, N. Heramani Singh, S. Gojendra Singh
Department of Psychiatry, Regional Institute of Medical Sciences,Imphal,Manipur, IMPHAL -INDIA
Background: Blood borne diseases are diseases which are transmitted through blood, in this study we are concentrating mainly on HIV, HBV and HCV.
Objective: The purpose of this study is to find the prevalence of blood borne diseases among opioid injectors who attended De-addiction Center Department of Psychiatry RIMS.
Methods: This is a cross-sectional study, all the consecutive opioid injectors who attended De-addiction Center were screened using the semi-structured proforma to find out the presence of any blood borne diseases and blood investigations were sent to confirm the presence of the diseases. Reports were collected and data was analyzed statistically using spss21.
Results:105 patients were analyzed and the common blood borne diseases are HCV 62.9% (n=66), HIV 56.2% (n=59), HBV 15.2% (n=16). 72.4%(N=76) of the opioid injectors had contact with sex workers, 83.8% (N=88) share needle.All patients were male.
Conclusion: From this study we conclude that many opioid injectors do share needles and has sexual contact with sexual workers which are the main cause for the high prevalence of blood borne diseases among this group of population.
Keywords: opioid injectors, blood borne, diseases
"A Case Report of Lady With Delusion of Entangled Thread Who Responded On Ect"
Delusional disorder is an illness characterized by presence of at least 1 month of delusions but no other psychotic symptoms 1 . Delusions can be referential, grandiose, persecutory, erotomanic, nihilistic, or somatic. The mean age of onset is 40 years. 2 In Somatic type of delusional disorder, the core belief is delusions around bodily functions and sensations. These patients are usually first seen by other medical specialists. 3 Review of case reports on treatment for delusional disorder shows that antipsychotics, antidepressants and cognitive-behavioral therapy show response in most of the cases. 4 There are case reports of benefit of ECT in somatic delusions.
Mrs. X, a 38 year old female presented to Central Institute of Psychiatry, Ranchi with 1 year illness with complaints of sensations of thread in her brain and viscera which could be felt getting melted like a fluid, at times tightening and constricting from within for which she kept moving her mouth, shaking her head to get it distangled; was diagnosed as delusional disorder and all measures including medications and psychological intervations proved futile, later she responded on ECT; interestingly patient herself had been demanding ECT. Details of the case and its interesting psychopathology will be discussed at the time of presentation.
Keywords: Delusions, ECT.
Emerging Trends And Prevalence Of Drug Abuse: A Study Conducted At Swami Vivekananda Drug De-Addiction and Treatment Centre, Amritsar
Gurpreet Singh. PD Garg, manjit singh, dr rajiv arora, neeru bala
Aims & Objectives: The epidemic of substance abuse in the present generation has assumed alarming dimensions in the state of Punjab. The success story of Punjab's economy has seemingly come to an end. District Amritsar being close to border is deeply influenced. Maximum cases were registered under the NDPS Act in year 2012 in Punjab, with the nationally highest drug-related crime rate of 51.6, against the national average of 2.8 .The present study aims to identify the emerging trends and prevalence of drug abuse among the patients.
Methodology: In the year 2014 and 2015, consecutive patients on outdoor basis from the month of January 2014 till august 2015 were considered and their urine was screened for various drugs with rapid immunochromatographic assay kits available in the centre.
Results & Discussion: A total of 10,568 patients were screened for urine toxicology. 9815 patients were found positive for morphine, out of which 5785(54.74%) of patients were abusing heroin in one or other form, which was concluded from the personal interviews of opioid positive patients. Rest include other opioids, alcohol, sedatives, cannabis, cocaine, amphetamines and tobacco. The International Narcotics Control Board in its 2002 report released in Vienna pointed out that in India persons addicted to opiates are shifting their drug of choice from opium to heroin.
Conclusion: High numbers of heroin abusers indicate its high addiction potential. Due to its high cost majority of addicts are not able to procure it and get involved in illegal activities. So immediate steps like demand reduction via proper education of youth and proper treatment of addicts with individual or group counseling are required to curtail the current drug menace in punjab.
Keywords: substance abuse, opioid positive patients
Atypical Presentation of Obssesive Compulsive Disorder in an Adolescent
K. T. Rajasekhar reddy 1 , D. Vijayalakshmi 2 , S. Radha rani 3
Government hospital for mental care Vishakhapatnam.
Background: Obsessive compulsive disorder is common among children and adolescents with a point prevalence of about 0.5% to a life time prevalence of about 2% to 4%.among teens it is 0.6% to 1%. Most commonly reported obsessions include fear of contamination, worries related to harm befalling themselves or family members, fear of harming others due to loss of control over aggressive impulses. We present a case of 13 yr old boy presenting with self injurious behaviour of continuously slapping himself, leading to severe bruises over forehead and around periorbital area, occipital areaanorexia, refusing to sit in a chair, school refusal, associated with familial and financial stresses. The child showed significant improvement with treatment, which highlights the importance of early diagnosis and appropriate treatment.
Keywords: obsessive compulsive disorder, adolescence, atypical presentation
Study of Sleep Pattern and Quality in Post Graduate Residents Working in A Tertiary Care Hospital
Pritam Omprakash Chandak, Abhijeet Faye , Sushil Gawande , Rahul Tadke , Vivek kirpekar , Sudhir Bhave
Vidhyachal Hostel,Nkpsims And Lata Mangeshkar Hospital, Digdoh Hills,Hingna,Nagpur, Maharashtra, Nagpur, India.
Background: Sleep disturbances are key presenting symptoms of many psychiatric disorders. Resident doctors working in a tertiary hospital setup is one such population domain which has irregular sleep schedule. They are likely to have poor sleep quality which can affect their overall functioning. Present study was carried out with the aims to study sleep pattern, quality of sleep and its correlation with various demographic and work related factors in them.
Methodology: 85 post-graduate residents were given proforma containing demographic profile, work details, sleep questionnaire and Pittsburgh sleep quality index(PSQI)scale. After a specific period 50(59%)returned the completed proforma.The data thus collected was analysed statistically.
Results and Discussion: Demographic profile suggest that mean age of the participants was 27 years (SD=1.07) with 64% were males and 36% were females. 34% were in surgery and allied branches, 34% medicine and allied branches,20% para clinical and 12% pre-clinical branches.46% were in 2 nd year,30% in 3 rd year and 24% in 1 st year of post-graduation.74% of them reported having sleep problem. Hours wise 26% of them was sleeping for more than 8 hours,38% less than 6 hours and 36% 6-8 hours. In majority of them total duration of sleep disturbance was less than 2 days/week. A few of them taking medications but majority of them would take help of reading book or listening music. Many of them reported emergency duties and academic stress as a major factor for insomnia. Residents working in clinical branches had significantly high Global score of PSQI as compared to pre and para clinical. Factors of gender and year of post-graduation didnot affect sleep quality.
CONCLUSION: The resident doctors working in a tertiary hospital are vulnerable to sleep disturbances. Reduced total average sleep hours lead to reduced concentration and cognitive functioning. Residents in clinical branches have significant poor quality of sleep.
Keywords: Sleep disturbances, post-graduate residents.
Psychiatric Disorders in Wives of Patients with Alcohol Dependence Syndrome
Sumit Rana, R.C. Jiloha
Dept. Of Psychiatry, PGIMS Rohtak,, Hamdard Institute of Medical Sciences and Research, New Delhi.
Aims: Alcohol use in patients is known to cause psychological problems in their wives, but the severity of those psychological symptoms is less well documented. We studied the psychiatric disorders in the wives of patients with Alcohol Dependence Syndrome.
Method: Severity of alcohol dependence was assessed in patients diagnosed with Alcohol Dependence Syndrome. Their wives were assessed for psychiatric disorders using SCID- I (Structured Clinical Interview for DSM-IV Axis I Disorders).
Results: Around 1/3rd of subjects had Axis I psychiatric disorder. Adjustment disorder was most common diagnosis present in 29.4%. Mild depressive episode and Anxiety disorder NOS came close second each present in 23.5%.
Conclusion: Significant number of wives of patients with Alcohol Dependence Syndrome was suffering from Axis I Psychiatric Disorders. So there is urgent need to focus on the treatment of wives of such patients and enhanced use of harm-reduction model in the treatment of patients with Alcohol Dependence Syndrome.
Keywords: alcohol, wife, psychiatric, disorders
Organic Impulse Control Disorder Treated with Sodium Valproate: Case Report
Penchilaiya Venkatalakshmi*, Balaji Bharadwaj, Shivanand Kattimani, Ravi Philip Rajkumar
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education, Pondicherry.
Impulse control disorder can present in a variety of forms and degrees of severity. One among them is compulsive sexual behaviour where individual engage in compulsive and persistent socially inappropriate continued sexual activities despite the negative consequences created by these activities. Such behaviours have been reported in patients with frontal lobe lesions or tumours, seizure disorder and in Parkinson patients on dopamine agonists. Though there are previous case reports and series for impulse control disorder, specific treatment guidelines for compulsive sexual behaviour are not available as it is a heterogeneous group of patients.
We present here a case of organic impulse control disorder in the form of urge to inappropriately touch women leading to social embarrassment and being beaten by public. These symptoms had begun after an episode of head injury. His investigations did not reveal any major abnormalities. In absence of past or family history of psychiatric illness and absence of symptoms of mood disorder this was considered to be organic impulse control disorder. He was treated with sodium valproate to which he responded and remained symptom free for five years under follow up.
Keywords: Impulse control disorder, Parkinson patients
A Study of 8-hydroxy-2'-deoxyguanosine an Oxidative DNA Damage Biomarker Among Adolescent Inhalant Users
A. Verma, R. Jain, A. Dhawan, R. Lakshmy
National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
Background: Inhalants are known to induce oxidative stress. Literature suggests that toluene inhalation causes a decrease in antioxidants and formation of oxidation products of proteins, lipids and DNA. The modified base 8-hydroxydeoxyguanosine (8-OHdG) is a sensitive marker of the DNA damage which contributes to mutagenicity and cancer promotion. The present study examined the association between 8-OHdG and inhalant users seeking treatment at a tertiary care centre of India.
Methods: The study included individuals exposed to toluene (Group I) and healthy individuals with no history of drug use (Group II). Five ml of blood and thirty ml of urine was collected from each patient, meeting the inclusion criteria. Urinary Hippuric acid and serum concentrations of 8-OHdG were determined by using Gas liquid chromatography and ELISA respectively.
Results: A total of 40 male subjects (toluene exposed, n = 27 and unexposed, n = 13) were included. Mean Age for Group I and Group II were 12±2.08 and 15.69±2.68 years respectively. Mean hippuric acid concentration (mg/ml) in group I and II was found to be 0.23±2.07 and 0.09±0.05 respectively. Toluene exposed subjects showed significant increase in 8-OHDG levels (ng/ml) when compared with the controls (26.47±19.31 versus 0.88±0.29, p < 0.01).
Conclusion: The findings suggested that toluene abuse is linked to genotoxicity and oxidative DNA damage. Further studies with larger sample size are needed to understand the biological significance of 8-OHdG among inhalant users. Supported by National Drug Dependence Treatment Centre and University Grants Commission, Government of India.
Keywords: toluene, genotoxicity, hippuric acid
Opioid Withdrawal Delirium V/S Organicity: A Case Report.
Arti Tyagi, Vivek Kumar, (Brig)S. Sudarsanan, Sandeep Choudhary.
Department of Psychiatry, Subharti Medical College, Meerut.
Opioids are one of the commonly used substances of abuse in India. Its withdrawal symptoms classically include craving for an opioid drug; rhinorrhoea or sneezing; lacrimation; muscle cramps; nausea or vomiting; diarrhoea; pupillary dilatation; piloerection, tachycardia or hypertension; yawning; and restless sleep. Opiates are not commonly known to cause withdrawal delirium but case reports are emerging which depicts the direct correlation of delirium during withdrawal of opioids. Similarly, delirium is also observed in rapid opioid detoxification using a combination of the long acting opioid antagonist, Naltrexone and the alpha 2 agonist Clonidine. In the current scenario, when the cases are repeatedly reported to be emerging with opioid withdrawal delirium we came across with the case of opioid withdrawal who present with delirium on 10 th day of abstinent. The close vicinity of emergence of delirium after remittance of uncomplicated opioid withdrawal in this case raised the suspicion of both complicated opioid withdrawal and organic pathology. Further CSF examination had revealed the infectious pathology and ruled out the possibility of complicated opioid withdrawal.
Impact of pictorial warnings on tobacco users
Jasmin Arneja, BS Chavan, Ajeet Sidana and Jasvir Singh
Dept of Psychiatry, Govt Medical College Chandiagrh.
Introduction: Research from other countries has shown that large and clear pictorial warnings on tobacco products leads to increased quit rates in tobacco users and curbs nontobacco users from starting its use. Few earlier studies from India had reported that pictorial warnings failed to any much impact on quitting as the pictures were innocuous and unclear. The current warnings on tobacco products occupy 40% of the packed space in India and it is not known whether they motivate the active users for quitting and prevent initiation of tobacco use in non users.
Methodology: This study was conducted in the department of psychiatry, Govt. Medical College and Hospital, Sec-32, Chandigarh. Male and females above 15 years age which were both active users, occasional users and those who had never used tobacco products were recruited. The sample was drawn from the family members of patients visiting psychiatry OPD and those patients who were asymptomatic at the time of intake. They were recruited from the psychiatry OPD and psychiatry community outreach clinics. They were administered a questionnaire developed for the study assessing the knowledge about pictorial warnings of smokers, tobacco chewers and those who did not use any tobacco product ever.
Results: Majority of the tobacco users/smokers reported that the pictorial warnings were clear and they could understand that the images represented cancer or lung damage. However majority of the users who were dependent on nicotine reported that they overlook the pictures and it had very little impact on using tobacco products. Majority of the non dependent users reported that the pictorial warnings had significant impact on their tobacco use.
Conclusion: The pictorial warnings have significant impact of curbing the non dependent users from using the tobacco products.
Keywords: tobacco products, pictorial warnings
Do People Differentially Seek Care for Depression, Alcohol use Disorders and Psychosis? Results from a Cross-sectional Community Survey from Sehore District, Madhya Pradesh
Kimberly Lacroix, Mahesh Somani, Rahul Shidhaye, SujitRathod
Background: The treatment gap for mental, neurological and substance use (MNS)disorders in Low and Middle Income Countries (LAMIC's) has pointed to the need for scaling up mental health services in these countries.Research on help seeking behaviors has pointed to the need to understand the local conceptualization of mental distress to facilitate scaling up mental health services. This study aims to understand the intension to seek care for three priority mental disorders: depression, alcohol use disorders and psychosis, in the Sehore district of Madhya Pradesh.
Method: A cross-sectional community survey was conducted in 2014 inSehore district of Madhya Pradesh. A structured questionnaire was randomly administered to 3220 participants. Participants were presented with three vignettes describing people experiencing symptoms of mental disorders (depression, alcohol use and psychosis); they were asked about their knowledge and beliefs about the problems and their attitudes towards people with these problems.
Results: Amongst the community surveyed, 51.06% intend to visit the public health sector, 28.04% mental health facilities, 23.14% private medical sector, 18.39% traditional healers and 5.96% would not seek help at all for mental health problems.Among those who mentioned intention to seek help at the public health sector 54.65% would go for problems related to depression, 54.44% for alcohol, however only 44.64% would seek help at the public sector for psychosis. 42.21% would visit mental health facilities for problems presenting as psychosis as opposed to 22.58% for depression and 18.58% for alcohol. Of those mentioning they would seek help from traditional healers 25.47% would go for problems of psychosis, 13.09% for problems presenting as depressionand 16.21% for alcohol related problems.
Outcomes: There seems to be a difference in people's intention to seek help between the three disorders. There is a preference to visit mental health facilities and traditional healers for problems identified as psychosis. For depression and alcohol help is most likely to be sought from public health sector, and from the private sector.
Keywords: depression, alcohol use disorders psychosis
Persistent Delusional Disorder- Somatic Type with Severe Depressive Episode, Patient Presenting with Self Inflicted Neck-A Case Report
KrishnaMahadevan, Sumesh Balachandran, Druhin
Pariyaram medical college,Kannur
Background: Somatic-type delusional disorder is characterized by development of a single delusion in which affected individuals complain of infestation, deformity, personal ugliness, exaggerated sizes of body parts, foul body odor , are thus more likely to consult other specialists than a psychiatrist.
Aim and objective: To present the case of a 70 years old lady who presented to emergency department with multiple self inflicted neck wounds in whom a diagnosis of persistent delusional disorder was made and patient improved on treatment.
Case: Mrs. D., 70 year old lady with a past history of hypertension was referred after surgical closure of alleged h/o self-inflicted neck wounds. Patient had persistent throat pain, discomfort and sleep disturbance for past 6 years with anergia, anhedonia and sadness for past few weeks with history of multiple ENT examinations, endoscopies and MRI with nil abnormality. On MSE the patient was depressed, had well-systematized somatic delusion with tactile hallucinations with no insight and normal Higher Mental Function. After the surgeons didn't heed to her repeated requests for operation, the patient had tried to "operate" on her neck with a knife to remove a piece of coconut shell which she believed was stuck in her throat. Her BPRS - 32, HAMD- 28, and VAS for pain- 4. A diagnosis of persistent delusional disorder, somatic type with severe depressive episode was made, managed with risperidone 2 mg/day and sertraline 50 mg/day coupled with insight-oriented psychotherapy.
Discussion: In Persistent delusional disorder, patient lacks insight into the disease with minimal dysfunction. But patients with well systematized delusions can act out on their delusions. This patient who tried toperate on her neck reminds us the importance of an early psychiatric referral which could have avoided such a catastrophe.
Keywords: persistent delusional disorder,somatic,self inflicted neck wound
Study of Marital Adjustment in Depression and Somatoform Patients in a Tertiary Care Rural Institute
Dr. Nikhil Goel
Bhagat Phool Singh Government Medical College, Village Khanpur Kalan, Sonepat, Haryana
Background: Marital adjustment has been described as 'the state in which there is an overall feeling in husband and wife of happiness and satisfaction with their marriage and with each other. Marital circumstances have been indicated to be a salient risk factor for disproportionately high prevalence of depression. Researchers have reported a strong association between marital problems and depression. Studies have reported that patients with chronic physical symptoms of obscure etiology who are referred to a psychiatric consultation service demonstrated characteristic differences in their marital adjustment and family structure. Literature research yielded few studies which examined association of marital adjustment with depression and somatoform cases in a rural tertiary care centre.
Aim: To assess marital adjustment in depression and somatoform disorder.
Settings and design: A case control study conducted in the Department of Psychiatry at BPS GMC (W), Khanpur kalan, Sonepat.
Material and Method: 30 married cases of each depression and somatoform were taken. Control group included 30 patients of epilepsy. Brief details of psychiatric illness and socio-demographic background were recorded. Locke-Wallace Marital Adjustment Test (1959) was administered.
Results and conclusion: 67% and 43% cases of depression and somatoform disorder respectively had poor marital adjustment. The mean score for marital adjustment in somatoform cases (97) was just below cut-off limit (100 out of 158), the depressive cases performed much worse with a mean score of 80. There was significant difference in marital adjustment score between depression and epilepsy patients. This suggests that there is a significant association between marital adjustment and psychiatric illness.
Keywords: somatoform disorders , marital adjustment,
Treatment Resistant Depression: Mechanisms and Biomakers
Parth Mehta, Dr Manushree Gupta
SUKH VIHAR, DELHI, INDIA
Major depressive disorder is a heterogeneous condition with a variable response to a wide range of treatments. Treatment resistant depression(TRD)is most commonly defined as when a current episode of depression has not responded to at least 2 adequate trials (i.e. appropriate dose, duration and extent)of different classes of antidepressants. The search for potential biomarkers of psychiatric disorders is a central topic in biological psychiatry. However the mechanisms of response to antidepressant therapy are poorly understood, and few biomarkers are available that can predict response to pharmacotherapy. Here, we will describe putative mechanisms and future potential markers that can be used to predict response to pharmacotherapy, such as markers of drug metabolism or blood-brain barrier (BBB) function, the activity of specific brain are asor neurotransmitter systems, hormonaldys regulations or plasticity,and related molecular targets.
Keywords: Treatment resistant depression , biomarkers
Burnout and Quality of Life Among School Teachers of Jammu Division (J&K)
Dr Piyali Arora , Dr Manu Arora, Piyali Arora,
Deptt. of Psychology, Govt. of Jammu and Kashmir, Higher Education Deptt. J&K, India
Background: Large number of literatures emphasized on burnout and health consequences on professionals. Teaching job is equally stressful, where major environmental factors include poor working conditions, scarcity of resources and heavy workloads leading to absenteeism, depression and anxiety, requesting a transfer, and leaving the profession among the teachers. However, impact of burnout due to prolonged job stress on quality of life (QoL) is understudied. Jammu & Kashmir, though frontier state of Indian union, but threatened by prevailing conditions like extreme weather and cross-border sponsored terrorism contributing to the educational backwardness in the state. Teachers here are under high pressure relating to management of these social issues and as well as to do justice with their teaching role. Aim: To study the effect of burnout and quality of life among teachers of Jammu Division (J&K). Methodology: Participants were 150 teachers comprising of 75 male and 75 female teachers teaching in various govt. schools of Jammu Division. They were assessed by the Maslach Burnout Inventory - Educator Survey (MBI-ES) and Quality of life scale revised version designed by B.L Dubey, P. Dwivedi, and S.K Verma. Result: Analysis revealed male teachers experience significant burnout in terms of emotional exhaustion and personal accomplishment compared to female teachers. There was significant correlation found between personal accomplishment and quality of life among male teachers. Conclusion: Study has implication that managing burnout condition will improve QoL of teachers.
Keyword: Teacher, Burnout, Quality of Life
An Epiphanic Diagnosis of Schizophrenia
Rahul Savalgi1 Praveen Arathil2 Kesavan Kutty Nayar3
Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, Kerala.
Several aetiological theories have been proposed for schizophrenia, including developmental or neurodegenerative processes, neurotransmitter abnormalities, viral infection and immune dysfunction or autoimmune mechanisms. Patients are diagnosed based on the presence of several distinct symptoms and the absence of any detectable organic cause for these features. Five autoimmune disorders appeared more frequently in patients with schizophrenia prior to the onset of schizophrenia as well as in the patients' parents: Hashimoto's Thyroiditis, intestinal malabsorption syndromes, acquired haemolytic anaemia, interstitial cystitis, and Sjögren's syndrome. Autoimmune thyroid disease was more commonly seen in patients with schizophrenia-spectrum disorders. Psychosis, stroke like signs, seizures, abnormal EEG findings and high CSF protein concentration were found in patients with encephalopathy and high serum antithyroid antibody concentrations. This is a case report of a 30 year old male patient, who initially presented with clinical findings suggestive of Hashimoto's encephalopathy and subsequently based on non responsiveness to encephalopathy treatment, and complete response with antipsychotics the diagnosis was revised to Paranoid Schizophrenia.
Keywords: neurodegenerative processes, neurotransmitter abnormalities, autoimmune mechanisms
Hemi Facial Emotion Recognition in Schizophrenia Versus Bipolar Disorder
Rishikesh V Behere, UmeshTonse, Samir Kumar Praharaj, PSVN Sharma
Department of Psychiatry, Kasturba Medical College, Manipal, INDIA
Background: Facial emotion recognition deficits are one among the important deficits in major mental disorders. Laterality differences have been described in schizophrenia versus bipolar disorder and also in emotion processing. However using hemi facial emotion stimuli as neurobehavioral probes in assessing these differences in schizophrenia versus bipolar disorder have not been well studied.
Aim: To study patterns of hemi facial emotion recognition in schizophrenia versus bipolar disorder as compared to health controls.
Methods: 31 patients of remitted schizophrenia, 21 patients of bipolar disorder in remission and 88 healthy controls were recruited. Hemi facial emotion stimuli were derived from the Tool for recognition of emotions in neuropsychiatric disorders (TRENDS) using standard protocol. The performance of recruited subjects was assessed on the hemi facial stimuli paradigms and responses recorded using a forced choice response method.
Results: Between groups it was observed that all groups better identified the right-right composite images as compared to the left-left composite images(Schizophrenia t=2.8, p<0.008, Bipolar disorder t=3.3, p=0.003, Controls t=4.6, p<0.001). The left-left composite images were significantly over-identified as compared to right-right composite images in schizophrenia (t=2.24, p=0.03) group. On ANOVA there was no statistically significant difference across the groups.
Conclusion: Assessment on hemi facial stimuli demonstrated a laterality difference in emotion processing in schizophrenia versus bipolar disorder.
Clinical Study of Impairment in Executive Functions in Children and Adolescents with ADHD
Saurabh Kumar, Amit Arya, Pawan Kumar Gupta, Vivek Agarwal, PoojaMahour
Department of psychiatry,K.G.M.U.Lucknow, U.P., India
BACKGROUND: In recent past executive functions impairment have been implicated as a core deficit in ADHDindividual. Behavior rating scales are claimed to better assess the Executive Functions impairment in ADHD as they tell about impairment caused in real life situation. There is limited research on this area in India.
AIMS: To clinically assess the impairment in executive functions in children & adolescent with ADHD. And to compare the impairments (if any) in executive functions of ADHD with healthy controls.
METHOD: A total of 60 children and adolescents of 6-16 years, 30 ADHD and 30 normal controls were recruited from out-patient services of the department of psychiatry of a medical college in north India. Diagnosis was confirmed by DSM IV-TR. ADHD group is further divided on the basis of subtypes and presence or absence of comorbidities. Both the groups were assessed onMalin's Intelligence Scale for Indian Children (MISIC) and Brown Add scales for children and adolescents (BADDS). Data is statistically analyzed on SPSS.
RESULTS: Among the children with ADHD, 77.27% of children showed impairment in 4/6 domains of executive functions of BADDS. Among the adolescents with ADHD, 62.5% of adolescents showed impairment in 3/5 domains of executive functions of BADDS. The children and adolescent with ADHD did not show any significant difference in executive functions on the basis of subtype of ADHD and presence or absence of comorbidity. None of controls showed impairment in any domains of executive functions on BADSS. Both the study group and control group did not show any difference in IQ on the basis of MISIC.
CONCLUSION: Executive functions impairments are present in ADHD individuals. These impairments are core feature of ADHD and are not affected by subtypes of ADHD or either presence of absence of ADHD.
Keywords: ADHD, Executive functions, BADSS
"Headache" Need for Psychological Evaluation
Zeeshan Mujawar, Swaleha Mujawar, Nilofer Mujawar Pankaj Singh
MUSEUM ROAD,CIVIL LINES, NAGPUR, MAHARASHTRA
Aim: To study the psychological stressor causing headache in school going children.
Study design: Retrospective study
Inclusion criteria: School going children(Age 8-16 years) attending Tertiary Care Hospital for headache. Physical examination and neurological examination normal. CT, MRI normal and who does not fit into migraine.
Exclusion criteria: Headache triggered by food and beverages. Physical and neurological examination abnormal. CT,MRI abnormal. Family history compatible with diagnosis of migraine.
Method: School going children (Age 8-16 years) who came to Tertiary Care Hospital for headache which interfered with play and school work were evaluated and investigated. Those students whose physical examination and neurological examination normal , whose CT, MRI normal and who did not fit into migraine were assessed with the help of
"Developmental Psychopathology Checklist for Children (DPCL)" DPCL scale. This scale is divided into four major parts and then further subdivided into a final total of 124 points. The participants were interviewed and they were scored according to the scale. Two important divisions were psychosocial stressors and rest of the stressors. The scores were evaluated and the scores of boys and girls compared.
Statistics- Using t-test to Compare Two Sample Means, with the help of QI Macros 2014 Microsoft Excel Software.
Results and conclusion: The Study conducted on children between the age group 8 -16 years at a Tertiary Care hospital in (Maharashtra) revealed that varying psychological factors are a cause of headache in children both Boys and Girls.
Every child with headache which interferes with play and school work should have psychological evaluation for stressors. These should then be addressed to prevent further deterioration.
Keywords: Headache, Children (DPCL)" DPCL scale
A Comparison of Job Stress and Quality of Life of Health Care Employees
Harshal Thadasare, Rucha Sule, Nilesh Shah, Avinash Desousa, Sushma Sonavane
Department Of Psychiatry, Lokmanya Tilak Medical College, Sion hospital Sion Maharashtra Mumbai, India
Background: Stress has been defined as a nonspecific response of the body to any demand made upon it. Several studies have found high level of job stress experienced by health care employees and also the phenomenon of burnout & depression.
Aims: This study endeavours to compare job stress&quality of life of health care employees from various departments in a public hospital.
Setting & Design: Cross sectional study conducted in a tertiary health care centre.
Methods: After informed consent, health care employees from various departments (emergency medicine, surgery, orthopaedics, paediatrics etc.) were interviewed & data was collected. They were screened using Workplace Stress Scale & WHO QOL-BREF to identify job stress & quality of life.
Statistical Analysis: Done using SPSS 20 Software
Result: Quality Of Life mean score of the study population on Physical Domain was 69.88 (SD= 15.23), Psychological Domain was 63.73 (SD=14.90), Social Domain was 68. 58 (SD= 16.52) and Environmental Domain was 58.79 (SD= 18.62)-56.4% of the auxiliary health workers reported moderate to dangerous levels of stress.
Conclusion: Significant association was found between Quality of life and job stress. Job stress was independent of the various work variables including job profile and nature of work.
Lokmanya Tilak Medical College
Sion, Mumbai 400022
Free Paper On Valproate Induced Hyperammonemic Encephalopathy
Valproate Induced Hyperammonemic Encephalopathy (VHE) is a serious disease that can lead to death. It can, however, be reversed if a precocious diagnosis is made. It is therefore extremely important to recognize it and discontinue VPA treatment. It is characterized by decreasing level of consciousness, focal neurological deficits, cognitive slowing, vomiting, drowsiness, and lethargy. Although VHE is rare, VPA frequently causes a rise in serum ammonia levels, usually resulting in asymptomatic hyperammonemia. In one study, ammonia levels were measured in 55 patients taking VPA and 12 patients taking other anticonvulsants.29 of the 55 patients receiving VPA had elevated ammonia levels, but none of the patients receiving other anticonvulsants had elevated levels. Hyperammonemia can present from 04 days to 04 yrs after valproic acid therapy initiation. Hyperammonemia stimulates increased glutamine synthetase activity, causing increased production of glutamine in astrocytes. Cerebrospinal fluid and blood levels of glutamine may be elevated in conjunction with hyperammonemia. Glutamine in astrocytes causes an osmotic shift of fluid into the astrocytes, producing astrocyte swelling and cerebral edema. Urea cycle enzyme deficiencies (OTC) & Carnitine deficiency (congenital or acquired, e.g., from hepatic failure, strict vegetarian diet), concomitant to treatment with VPA, favour hyperammonemia and the development of VHE. Patients with VHE should be screened for OTC deficiency. OTC deficiency is an X-linked disorder-most common inherited cause -diagnosis is by DNA analysis or biopsy. Most men with OTC deficiency die in the neonatal period. Heterozygote females, however, may be either asymptomatic or have an aversion to protein until the development of VHE. Principles of management are to correct the biochemical abnormalities, ensure adequate nutritional intake and compounds that increase the removal of nitrogen waste. Treatment involves withdrawl of Valproate, cessation of protein and/or nitrogen intake, hemodialysis and supportive care with parenteral intake of calories.
Keywords: Valproate, . Hyperammonemia
SSRI Induced Manic Switch in Patient of Schizophrenia With Co Morbid OCD
*Aditya Patil ** Krishna Kadam *** SwaroopBhatankar **** Netto.
B.J. Medical College And Sasoon Hospital,Pune
Background: OCD in a patient with schizophrenia has been reported to be a frequent co-morbid disorder. OCD is also common comorbidity in bipolar affective disorder patient. Patient in our indoor facility had developed constellation of these three conditions.
Case: Mr. A, 30 yr old unmarried male patient who is a known case of Schizophrenia paranoid since 2013,had history of suspiciousness, withdrawn behaviourover last 8 months. He hadrepetitive intrusive sexual thoughts and images and compulsive behaviour in the form ofrepetitive touching of his genitalia and forehead and avoidance of looking at females .Along with it, patient had delusion of persecution against neighboursPatient was started on Tab. Olanzapine 10mg/day, up titrated gradually to 20 mg/day. In addition patient was given Tb. Fluoxamine 100mg/day which was gradually uptitrated to 200mg/day over 4 weeks. After that patient developed elated affect, inflated self esteem, grandiose plans. Though over the period of 4 weeks his psychotic and obsessive symptoms were reduced, these new group of symptoms emerged. So patient was started on Tb. Sodium Valproate 600mg/day in divided dosage to overcome manic features.
Discussion: In patient with Schizophrenia, OC features can be seen in about 23% of patients and SSRI are quite often used. However it may lead to emergence of manic symptoms.As reduction of SSRI could again lead to increase in OC symptoms, adding mood stabilizer is one of the best option, which could be tapered off gradually if required .
Conclusion. Caution should be taken for detecting SSRI induced manic features in patient of Schizophrenia with co morbid OCD.
Keywords: OCD, Schizophrenia, Sodium Valproate
Hyperthyroidism Presenting As Psychosis: A Diagnostic Dilemma
* Khushboo Chauhan ** Nitin Abhivant*** SwaroopBhatankar **** AlkaPawar
B.J.G. Medical College & Sassoon General Hospital, Pune
Background: Anincreased prevalence of psychiatric disorders with endocrine disorders have been described in literature, with special reference to the thyroid disorders. However, psychosis has been described as a rare complication in hyperthyroidism. These cases may present with diagnostic dilemmas as the psychopathology may arise due to the thyroid dysfunction per se or independent to it, which is important to differentiate as it affects the long term management decisions in such cases.
Case report: A 48 years old female was brought by family members with gradually progressive suspiciousness since past 2 years. The patient had 20 years history of multinodular goiter. She was started on haloperidol 10 mg/day. Her thyroid function test results were TSH< 0.05 mIU/mL (normal range 0.4-4.0 mIU/mL), free T3 9.20 pg/mL (1.8-4.2 pg/mL) and free T4 70.15 ng/dL (0.7-1.9 ng/dL).The diagnosis of psychosis secondary to general medical condition (hyperthyroidism) was made. Endocrine reference was done and the patient was started on carbimazole 20mg/day and propranolol 40mg/day. She showed gradual improvement in the symptoms and thyroid profile. By the end of fourth week, free T3 and free T4 levels reached normal values and TSH levels showed an increasing trend. She was discharged on 10 mg/day haloperidol and 20 mg/day methimazole. On follow up haloperidol was gradually reduced and later stopped. The patient till date over a period of 8 months follow up is maintained well.
Conclusion: Adequate and prompt treatment of the endocrine abnormality is essential to achieve remission of psychopathology and long term anti-psychotic treatment may not be essential.
Keywords: endocrine disorders, haloperidol
Depression in A Rare Case Of Wilson's Disease
Umar Mushir, M.s. Bhadoria., Pankaj Kumar, Parth Pandya ,Meenakshi Jain , Viral Patel , Umar Mushir
Index Medical College Hospital And Research Centre, Indore
Wilson's disease is a rare genetic disorder involving the liver and brain, with onset frequently in adolescence. Psychiatric symptoms are often the first manifestation of the disease and can obscure the diagnosis. Although such patients are more commonly seen in neurological and hepatological settings. Mental health professionals must keep in mind a high level of suspicion. We present the case of a 17-year-old male patient who initially presented with neurological symptoms like slurred speech, impaired writing, involuntary movement and signs like choreoathetoid movements, dystonia ,altered power. On general examination he was found to have K-F ring in the cornea. Later he developed symptoms and signs of major depressive disorder. He responded well to Zinc 150 mg per day and Tablet Escitalopram 20 mg per day.
We conclude that: It is recommended that Serum Ceruloplasmin should be measured in all psychiatric patients who show personality change, specially towards disinhibited, bizarre or reckless behaviour, in those who show neurological signs not accounted for by medications and in patients with unexplained liver disease.
Keywords: genetic disorder, choreoathetoid movements.
Prevalence Of Depression In Copd
Prabhat Sharma, M.s.bhadoria, Sudhir Maurya, Bhajan Lal, Rishab Pratab Singh
Index Medical College Hospital & Research Centre,Indore.
Aim& Objective: The aim of study to know the prevalence of depression in copd patients attending tertiary care centre ( index medical hospital, indore).
Materials & Methods: 40 copd patients were enrolled in study according to copd gold criteria - 2015. They were screened for depression as per hamilton- d rating scale.
Conclusion: Depressive symptoms are common in all stages of copd and increases with increase in severity of restricion. The prevalence of depression in rural patients with copd is high. Patients with copd should be screened for depression and those with higher depression score should undergo further evaluation and treatment.
Keywords: copd, depression
Electroconvulsive Therapy- A Promising Panacea For Resistant Obsessive Compulsive Disorder.
Krishnagiri, Behind Sct Quarters, Medical College, Trivandrum, Kerala, India
Obsessive compulsive disorder(OCD) is a common clinical scenario that poses therapeutic challenge. We report a case of 23 year old female, college student, presenting with continuous mental illness for more than 10 years duration, characterised by repeated hand washing, taking more than 3 hours to bath and clean herself with severe impairment in social, occupational and interpersonal domains of functioning. Her mental status examination revealed obsessions of contamination and compulsion to clean herself repeatedly. She had poor insight into the nature of obsessions and it had a delusional quality. CT Brain was done and was normal. She was having hypothyroidism, which was corrected with 125 μg daily. She was treated with sertraline 200mg and fluvoxamine 300 mg was added in view of poor response. Aripiprazole 15mg was tried as an augmentation to the regime. During the course of hospital stay, patient became increasingly irritable, distressed by the obsessions and started showing suicidal tendencies.In view of the inadequate response to the OCD and suicidal tendencies, electro convulsive therapy(ECT) was considered as a therapeutic modality. She was taken up for ECT with informed consent. Eight cycles of modified ECT was given with adequate duration of seizures. Patients suicidal tendencies resolved and she was symptomatically better over the course of ECT, as evidenced by a significant reduction in the score of Yale Brown Obsessive Compulsive Scale(YBOCS) from baseline score of 34 (extreme severity) to 12 (mild severity ). So, this case hightlights the importance of considering Electroconvulsive therapy as a safe and effective therapeutic option in treatment resistant cases of Obsessive compulsive disorder.
Keywords: Obsessive compulsive disorder, Aripiprazole, Electroconvulsive therapy
Management of Gambling Addiction: a case report
Shivangi Mehta, AjeetSidana, . KrunaliUkey
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
Objective: Gambling is defined as staking something on a contingency. Many traders are gambling without even knowing it - trading in a way or for a reason that is completely dichotomous with success in the markets. There is also the growing influence of popular computer games, video terminals (video poker, slots machines) and online casinos. Health professionals need to consider the harmful effects of gambling considering that gambling can destroy families and has medical consequences.
Participant and Method: A 40-year old bank manager diagnosedinitially with mood disorder and two attempts ofself harm in past three years, was eventually diagnosedas a case of gambling addiction using both the DSM-V criteria and Problem Gambling Severity Index.
Results: The participant's gambling urges were not caused by any 'trigger' incidents, were independent of mood disorder and were so severe to lead him to deliberate self harm. Even after adequate trial of two mood stabilizers from different classes including Lithium, patient neither showed improvement in mood symptoms nor his gambling behaviour, however patient's gambling behaviour and mood symptoms both showed marked improvement following start of Naltrexone upto a dose of 100mg/d and were maintained at 4 month follow-up with gradual decline in craving for gambling as monitored on Problem Gambling Severity Index.
Conxclusions: Gambling addiction appears to be a very serious problem and can cause significant distress in the lives of people it affects and their family members.
Keywords: Gambling, Lithium,
A case of Pellagra in an Alcohol Dependent Syndrome
Vivek pratap Singh, Ekram Goyal, Saurav Kumar, Adnan Kadiani, Saldanha D
Department of Psychiatry, Dr D Y Patil Medical College Pimpri, Pune
Background: Alcohol has been used and abused since ancient times. Continuous use of alcohol affects the individual, the family and the society in different ways. The pattern of alcohol intake around the world is constantly evolving and alcohol is omnipresent today ]. It's said that liquor industry is worth rupees 7,500 Crores a year, rice consumption is worth only 2,880 Crores notwithstanding the annual hooch tragedies. Highest per capita consumption of alcohol in India is mind-blowing consumption rate of 8.3 liters per person. Alcohol abuse comes with a heavy price on those who do not take care of their nutrition. A case of Pellagra is presented here.
The case: A 40yrs old male was brought to the psychiatric OPD with chief complaints of Alcohol consumption of 15 yrs duration and hyper-pigmented skin lesions of 3 months, loose stools and generalized weakness, dizziness, Irritability and tremulousness, Tingling sensation of limbs, decreased Sleep and appetite of 7 days duration. On general and Systemic examination he was pale and was having multiple hyper pigmented patches on upper limbs, nape of neck and on face, he was anxious and perplexed, poor concentration, impaired memory, peripheral neuritis and lack of authentic insight into his drinking problems.
On investigation showed deranged liver function tests and low hemoglobin count of 9.6 gm% .A diagnosis of Alcohol dependence syndrome with pellagra was made and was treated with Vitamins, protein diet and anxiolyitcs in low doses to control withdrawal symptoms. He made an eventful recovery.
Discussion: The case will be discussed in the light of available literature.
Keywords: Alcohol, Tingling sensation,
A case of Dissociative Amnesia or is it Malingering?
Shivang Aggarwal, Saldanha D
Department of Psychiatry, Dr D Y Patil Medical College Pimpri, Pune
Backgroud: Dissociative Amnesia is defined as a sudden inability to recall important personal information, an inability not due to an Organic Mental Disorder. It is most often observed in adolescent & young females. Amnesia often begins suddenly usually in the context of severe psychological stress.e.g. War, disaster or acute trauma.
Malingering is defined by intentional production of physical & psychological symptoms motivated by external incentives (e.g. avoiding work or military obligation, obtaining financial compensation, evading criminal prosecution etc.)
The case: A 24 year female was brought to casualty by her friends with complaints of unable to recall events of two years back, inability to recognize her friend and roommate, headache and giddiness for last six hours. Patient had a break up with her boyfriend one month back. There was no h/o epilepsy, substance abuse or blackouts in the past. Her immediate memory was impaired as she could not tell the physician recent events. Her judgment and insight was also impaired. She was admitted and investigated. All routine investigations including C T Scan were done and were normal. Patient was given Tab.Clonazepam 0.5 mg stat and was watched. Few days later she claimed that her memory was back but yet she could not recall as to how she was admitted in the first place and who brought her to the hospital. Except for the irritation while questioned about her boy friend she had no memory lapses after days of admission. She continued to maintain her inability to recall the events leading to her admission
Discussion: To identify and treat a patient with Dissociative Amnesia is a challenge that a psychiatrist should be aware of. Every case of Dissociative Amnesia should be screened for other psychiatric morbidity like Malingering and treat accordingly.
Keywords: Dissociative Amnesia, Clonazepam
Clozapine-induced acute Hypertriglyceridemia: A Case Report
Mitesh Kumar, Ajeet Sidana
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
Objective: To highlight the association between the use of clozapine and the early development of hypertriglyceridemia, a condition that substantially increases the risk of cardiovascular events and other medical complications.
Method: Clinical information and data from investigations in a single patient were collected and reviewed in light of the literature.
Results: A 34-year-old female with a background history of schizophrenia presented with acute elevation of serum triglycerides and cholesterol within 2 weeks of starting clozapine. Her metabolic parameters normalized following discontinuation of clozapine.
Conclusion: Possible hypotheses for lipid dysregulation with atypical antipsychotics include weight gain, dietary changes and the development of glucose intolerance, however some other factors may be responsible for this rapid escalation of lipid levels. Lipid and metabolic profiles should be closely monitored in patients receiving clozapine in order to facilitate early detection and intervention to prevent further health complications.
Keywords: clozapine, schizophrenia
Obesity Hypoventilation Syndrome
Ramjan Ali, Ravi Gupta, Sanjeev Kumar, Rakhi Khanduri
The prevalence of Obesity Hypoventilation Syndrome in the general adult population is estimated to be 0.15% to 0.3%. In patients undergoing bariatric surgery, approximately 8% present with OHS.We are presenting a case of 55 yr ,male who presented with history of Snoring,Poor quality sleep,Recurrent awakening ,Dry mouth during night ,Non refreshing sleep in the morning ,Feel sleepy during day time ,multiple nape during the daytime which are irresitable ,No cataplexy ,history of bilateral nasal bleed. His BMI was 32.4 kg per m2. Polysomnography examination depicted severe Obstructive Sleep Apnoea with Apnoea-Hypopnoea index of 78.8. Awake Acid Base Gas Analysis disclose hypercapnia (PaCO2= 56 mmHg) and hypoxemia (PaO2=52mmHg). Based upon the history, examination and investigation Diagnosis of Obesity Hypoventilation Syndrome was made.
Keywords: Obesity Hypoventilation, Apnoea-Hypopnoea
Source of Support: None, Conflict of Interest: None