The etiology of schizophrenia has been the focus of intensive research for a long time. Perspectives have changed drastically with the development of new investigative techniques. Clinical observations made by Kraepelin, Clouston, Bender, and Watt are now being complemented by neuroimaging and genetic studies to prove the neurodevelopmental hypothesis. At the same time, neuropathological and longitudinal studies of schizophrenia often support a neurodegenerative hypothesis. To provide a theoretical basis to the available evidence, another hypothesis called the progressive neurodevelopmental model has also emerged. This review presents some key evidence supporting each of these theories followed by a critical analysis of each.

Background: Previous Magnetic Resonance Imaging (MRI) studies using manual techniques reporting significant relationship between psychopathology and gray matter volume in schizophrenia are limited by various confounding factors. None used automated image analysis to examine gray matter volume correlates of psychopathology in antipsychotic-naïve schizophrenia patients. Aim: This study aimed at examining the relationship between psychopathology and gray matter volume abnormalities in antipsychotic-naïve schizophrenia patients. Patients and Methods: MRI of 30 antipsychotic-naïve schizophrenia (DSM-IV) patients and 27 age-, sex- education- and handedness-matched healthy controls were compared for gray matter volume differences using Optimized Voxel-based Morphometry (VBM)-an automated, rapid and unbiased technique. Psychopathology was measured using Positive and Negative Syndrome Scale (PANSS) with good inter-rater reliability. The correlations between PANSS scores and gray matter volume were examined using VBM. Results: Schizophrenia patients had significant gray matter volume deficits in frontal, cingulate, temporal, insula and precuneus cortices; thalamus, caudate and cerebellum. Positive syndrome score had significant negative correlation with left superior temporal gyrus volume. Negative syndrome score had significant inverse correlation with frontal, cingulate and cerebellar gray matter volumes. Conclusions: Cortical and cerebellar gray matter volume deficits and their significant negative correlations with psychopathology scores are supportive of 'Cognitive Dysmetria' in schizophrenia.

Background: Though antipsychotics are effective against symptoms of schizophrenia and prevent relapses, their effect on disability has not been studied in a comparative design. Aim: To compare disability of schizophrenia patients receiving continuous antipsychotic treatment with that of those not receiving or receiving irregular treatment in a rural community setting using a naturalistic comparative study design. Patients and Methods: Disability was assessed in 182 schizophrenia patients living in Thirthahalli Taluk of Shimoga District, Karnataka, using Indian Disability Evaluation and Assessment Scale (IDEAS). Fifty patients (27.5%) were receiving regular treatment in the previous 2 years and their disability was assessed for the period when they were on antipsychotics. The remaining 132 patients (72.5%) had off-antipsychotics periods in the previous 2 years and their disability was assessed for the period when they were off-antipsychotics. Results: Patients on antipsychotics had significantly less disability across all domains of disability and in total IDEAS scores. Multivariate regression analysis showed that treatment status predicted disability scores after controlling for the effects of the confounding factors. Different levels of exposure to antipsychotic treatment were associated with different levels of disability. Conclusions: Treatment with antipsychotics is associated with significantly less disability. There is an urgent need to bring schizophrenia patients under the umbrella of treatment.

Background: Decreased cardiac vagal function is linked with increased cardiac mortality and depression is associated with decreased heart rate variability. We have previously shown that the Mood Induction Procedure (MIP) in healthy subjects alters pain perception and thalamic activity during pain perception. Aim: To study the effect of negative emotion on heart rate variability and complexity measures as well as on baroreceptor sensitivity, as these parameters reflect cardiac autonomic function. Patients and Methods: We studied 20 healthy female controls before and after neutral MIP and 20 healthy female subjects before and after negative MIP. We investigated measures of valence of mood, heart rate variability and complexity and the baroreceptor sensitivity index. Results: While there was a significant difference in the valence of mood between the neutral and the negative effect condition, there were no significant differences in any of the heart rate or baroreceptor sensitivity measures between the two groups. Conclusions: Our findings did not show any significant influence of acute negative MIP on heart rate variability and complexity measures and baroreceptor sensitivity, even though depressive disorder and stress are associated with decreased heart rate variability. These findings are discussed in the context of clinical depression and anxiety and the increased risk for cardiac mortality. In contrast to the presented results here, we have previously shown that MIP in healthy subjects alters pain perception and thalamic activity.

Context: Periodic systematic profiling of suicidal risk factors in developing countries is an established need. Aims: It was intended to study the risk factors associated with suicide attempts in Orissa, one of the most economically compromised states of India. Settings and Design: Cross-sectional study in a general hospital. Materials and Methods: Consecutive 149 suicide attempters were evaluated for psychosocial, situational, and clinical risk factors using the Risk Rescue Rating scale, Suicide Prevention Center scale, Lethality of Suicide Rating scale, and Presumptive Stressful Life Event scale. They were compared with healthy and psychiatric controls who had never attempted suicide. Statistical analysis: Chi-square for comparison of categorical variables, t-tests for comparison of means. Results: The male-to-female ratio was closer to one in adults and around 1:3 in adolescents. Younger age, lower-middle economic group, rural background, unemployed, school educated were more represented in this study. Compared to the controls, significantly more number of attempters had a family history of psychiatric illness and suicide, childhood trauma, medical consultation within one month, had experienced stressful life events and had expressed suicidal ideas. In a considerable proportion of attempts, risk was high and rescuability least; 59.1% had more than 50% chance of death. Suicide potential was high in almost half the cases. More than 80% of all attempters had psychiatric disorder; however, only 31.5% had had treatment. Factors like middle age, family history of psychiatric disorders, past psychiatric history, current psychiatric illness, communication of suicidal ideas, the use of physical methods, and high potential attempts, differentiated repeaters significantly from the first-timers. Major physical illness, family and marital conflicts, financial problems, and failure in examinations were more frequent life events. Childhood trauma, noted in around 40% of the attempters, was considerably associated with adolescent suicide attempts. Conclusions: Modifiable risk factors identified in this study have preventive implications.

Background: Emotional problems in school children may result in low level of scholastic performance. The recognition of these disorders needs effective screening tools. The choice lies between self assessment tools or observation based tools. Majority of studies use screening tools based on parental or teachers' observation. Aim: This study was designed to compare a self-assessment based screening tool (general health questionnaire; GHQ) with a parental observation based screening tool (CPMS-Childhood Psychopathology Measurement Schedule). Materials and Methods: Two hundred and eighteen school children were selected through multistage random sampling. The study was conducted in three stages. In the first stage, all the students were administered six-item version of GHQ to screen for emotional problems. Raven's Progressive Matrices was administered to evaluate IQ. In the second stage, parents assessed their child's behavior using CPMS. In the third stage, all students were subjected for detailed clinical work-up. Statistical Analysis: Criterion validity of the tools used and their comparison. Result: GHQ had high sensitivity and specificity compared to CPMS in relation to clinical interview. Conclusion: It is found that GHQ is a better screening tool than CPMS in children aged between 13 and 14 years.

With the introduction of many reforms and changes in medical training in the UK, postgraduate training has undergone significant transformation. The establishment of Postgraduate Medical Education and Training Board (PMETB), Modernizing Medical Careers (MMC), new recruitment processes and changes in the curriculum and examination structure are all having a major impact on the future training and teaching programs in psychiatry in the UK. Entry into psychiatry is becoming increasingly competitive and progression in career is now competency based in addition to the examination requirements subject to an annual review and regular appraisal. A structured portfolio is also vital in order to present evidence of competencies and ensure smooth progression through the training grades. This paper gives a general outline of these changes and describes the new training and examination requirements of the new system in place in the Psychiatric training in United Kingdom.

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, once first presentations may be of psychiatric nature. We present the case of a 20-year-old female patient who initially presented with psychiatric symptoms. The neuropsychiatric manifestations and treatment of this patient with electroconvulsive therapy is presented.

Shared psychotic disorder is often read as case report but not studied in length and rarely looked at in common clinical practice in psychiatry. Only a small percentage of cases involve families. Folie a famille is characterized as a shared psychotic disorder within a family in more than two members. The involved patients have an unusually close relationship and are isolated from others. We describe here a case of folie a famille involving a nuclear family consisting of the husband, the wife, and their three children. The primary patient was suffering from paranoid schizophrenia with prominent delusions of persecution that were imposed upon and later shared by his family. Temporary separation decreased the intensity of shared delusions in the other family members.

A 12-year-old female was admitted to hospital with complaints of abnormal behavior. She was on valproic acid 200mg twice daily and clobazam 5mg at night for the past 13 weeks for her complex partial seizures with secondary generalized seizures. On day 60 of the treatment with valproic acid she developed behavioral disturbances and initiated treatment with tablet chlorpromazine, olanzapine and risperidone. During the present hospitalization, as there was no improvement in abnormal behavior, antipsychotics were discontinued and she was on observation for five days. On day 6, valproic acid was replaced with carbamazepine. Patient started recovering gradually from the abnormal behavior three days after the withdrawal of valproic acid and completely recovered after three months. Causality of valproic acid-induced abnormal behavior was 'possible'. Behavioral disturbances associated with valproic acid are rare and is reversible upon discontinuation of the drug. There is a need for vigilance on abnormal behavioral effects in patients receiving valproic acid.

Writing a 'Diagnostic Formulation' is a skill expected of candidates in the post-graduate examinations in psychiatry in most universities in India. However there is ambiguity regarding what the term means and how it should be written. This article is an attempt to provide some guidelines on this topic.