POSTERS

The prevalence, pattern and predictors of psychiatric morbidity in the post flood community in Kerala

Dr. Anoop Vincent

Background: Disaster is a severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the affected community. It has been known that disasters place, the affected people under tremendous pressure to cope and adjust under physically and psychologically hostile conditions.

Aims:

1) To estimate the prevalence of psychiatric morbidity in the flood affected population in Kerala.

2) To determine the variables associated with psychiatric morbidity.

Methods: This is a cross-sectional study conducted in two flood affected panchayats of central Kerala. The sample consisted of 1145 aged between 18 to 65 years who were affected directly by flood. Specially designed profroma was used to collect the sociodemographic data. WHO- SRQ and IES-Revised were used to screen for psychiatric morbidity. Volunteers from within the community were selected and trained to administer the questionnaire.

Results: Majority of the sample N=1063 (93%) screened negative for depression. Depression had a significant relationship with a history of psychiatric illness and physical illness. PTSD was present in N= 283 (25%) and had a significant correlation with history of psychiatric illness, family history of psychiatric illness and physical illness. A major limitation of the study was use of screening tools.

Conclusion: This study gives an insight into the high risk group in the background of a disaster. This will help to plan intervention in areas prone to disasters and ultimately in incorporating Mental Health Services as integral component of Disaster Policy.

Parafalcine meningioma presenting as recurrent migraines and depressive disorder- A case report

Dr Aarti Karahda¹, Dr Shobhit Kumar Prasad²

¹Senior Resident, Department of Psychiatry, Kalpana Chawla Government Medical College and hospital, Karnal, Haryana, ²Consultant Psychiatrist, Sukoon Hospital, Ambala Cant. Haryana, This research has not been published nor is under consideration for publication

Background: Meningiomas are usually benign intracranial tumors, minimally symptomatic or asymptomatic in their early onset and thereby can often result in delayed diagnosis. Meningiomas can present as mental disorders rather than with neurologic signs or symptoms Although seizures and focal neurologic deficits are pevalent symptoms, migraines and depression also may be an important and significant sign. Early diagnosis of meningioma can maximize treatment options and improve outcomes.

Methods: We performed a comprehensive literature review that analyzed similar case reports on this topic. We discussed patient’s neuropsychological and psychiatric profiles to identify symptoms and other clues that could expedite identification of meningiomas in patients with psychiatric disorders.

Results: findings showed evidence to suggest that recurrent migrainous headaches and depression may be correlated with meningioma presentation. Its prevalence is possibly increased with an anterior location of the tumor.

Conclusion: For patients who exhibit nuances of depression without a history of psychiatric illness, an index of suspicion for meningioma may be warranted. in middle-aged and older patients with new-onset psychiatric symptoms, brain imaging to rule out organic brain lesions should be advised.

keywords: Recurrent migraine, Meningioma, Depression

Lessons from the Siri festival: ethnocultural perspectives of a spirit possession cult.

Abhiram N Purohith*, Praveen A, Rashmi A, Rajeshkrishna Bhandary, PSVN Sharma

Department of Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India – 576104.

Introduction: The phenomenon of spirit possession is complex, multifaceted and nearly ubiquitous across various traditional cultures. Spirit possession’s societal and cultural evaluations form its fundamental relation with mental health. There is a stark ambiguity in how this phenomenon is categorized in our current nosological systems. The limitations of current diagnostic definitions arise from failure incorporate sociocultural contexts of these experiences. In this report we aim to describe the Siri festival, unique mass, ritual possession cult that is practiced in the Dakshina Kannada and Udupi districts of Karnataka.

Methodology: We use a ethnocultural approach to describe the ritual. We will present our interpretations of the observations from a psycho-anthropological context.

Discussion: During the annual Siri festival, hundreds of women and men gather to sing the legend of Siri to allow themselves to be possessed by spirits. The Siri cult transcends from individual to group dynamics level in the society as a symbolic form of a power struggle against gender oppression, conflict and suffering of women in the matrilineal system. The myth and the ritual thus allow young women to vent their emotional reactions to personal adversity in a socially acceptable way. Possession as a source of suffering parallels the psychiatric phenomenon of dissociative states. In contrast, possession as a source of healing and a complex symbolic platform raises above the medical perspective as a complex ethnographic phenomenon highlighting the significance of local cultural context.

Spirit possession, Dissociative trance, Mass possession, Dissociative disorders, Culture.

Therapeutic role of Omega-3 fatty acids in children with ADHD

Dr Abhishek Gupta¹, Dr Priti Arun¹, Dr Sushmita Bhattacharya¹

¹Department of Psychiatry, Government Medical College and Hospital, Chandigarh, Mobile no: +91-8770745534. Email: abhishekgupta.ip80@gmail.com

Background: Conventional treatments for ADHD include stimulants like methylphenidate and other medications such as atomoxetine. But these medications have potential serious side effects. Omega-3 fatty acids have been researched as an alternative to drugs owing to side effects and hesitation of parents in giving the child medications. Past studies have shown mixed results, whether given in combination with drugs or alone, in improvement of symptoms.

Aim: To evaluate improvement in ADHD symptoms after 3 months of Omega-3 fatty acids administration.

Method: 27 children in the age group of 6-12 years diagnosed with ADHD as per DSM-5 who were either treatment naïve or not on any medications including for ADHD for the last 3 months were given only Omega-3 fatty acids with Eicosapentaenoic acid (EPA) 180 mg and Docosahexaenoic acid (DHA) 120 mg daily for a duration of 3 months.. Symptom severity was measured using Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) at the time of recruitment (baseline) and then after the end of first, second and third month. Side effects were measured using a checklist developed for the study at the end of each month.

Results: Improvement in symptoms along with improved academic and classroom behavior was observed at the end of 3 months which were significant (p<0.01). Mild side effects occurred in 5 patients which resolved after first month itself.

Conclusion: Besides the pharmacological treatment, alternatives such as Omega-3 fatty acids can also be used to manage the disorder without serious side effects which can also alleviate concerns of parents about side effects of conventional treatment.

Cognitive Remediation Therapy for Schizophrenia – A Case Study

Dr Aditi Sharma

MD Psychiatry 3rd year(JR IIl), Institute-Saraswathi Institute Of Medical Sciences,Anwarpur,Pilkhuwa, Hapur,U.P

Background: The Cognitive Remediation Therapy aims at targeting cognitive deficits using scientific principles of learning with the goal of improving the functional outcomes.

Aim: The aim of this study is to see the effectiveness of Cognitive Remediation Therapy (CRT) using computerised program in helping client with diagnosis of Schizophrenia develop a more systematic approach to activities and overall improvement of their cognitive functions. The focus is on strategy training through repeated practice of various cognitive tasks.

Method: The study was conducted on an individual client with a diagnosis of paranoid schizophrenia using Computerised Interactive Remediation of Cognition-Training for Schizophrenia (CIRCuiTS) program. The assessment of cognitive functions and executive functions were conducted before and after the intervention. The intervention involved formulating a treatment plan with an emphasis on setting cognitive focused, specific, measurable, achievable, realistic and time-framed (Cog-SMART) goals at the beginning. This followed by targeting metacognition and then integrating the learning into everyday life. The total number of session was 40 and the duration for individual session was for an hour. The intervention took place twice a week in a face to face set-up. The client was familiar with the computer usage as the whole intervention was computer based.

Results: The result of the cognitive assessment both pre and post intervention indicate an improvement of cognitive functioning in the client.

Conclusion: Cognitive Remediation Therapy using computerised tools can improve the cognitive functions, metacognitive regulation and abilities for a better daily life activities of people with Schizophrenia.

Psychiatric Comorbidity in a Selective Sample of Transgender Male

Dr Aditi Sharma

Saraswathi Institute of Medical Sciences, Anwarpur, Pilkhuwa, Hapur, U.P, India

Introduction: Transgender is an individual who identify with a gender different from the one they were born with.In ICD10 ,Gender identity issues appear under disorders of Adult Behaviour and Personality in the category Gender identity disorders and include five diagnosis:Transsexualism,Dual role transvestic,Gender identity disorder of childhood,other gender identity disorders and Gender identity disorder, unspecified.The ICD 11 is considering options that would list these concerns in a separate chapter,as medical diagnosis,or as part of new chapter on sexual health and sexual disorders.

Aims&Objectives:

• To assess psychiatric comorbidity in Transgender Male

• To study sociodemographic data of the sample

Method: NGO working for Transgender Male were approached and requested for permission to conduct this study.Detailed work up was done.M.I.N.I scale applied and screening was done for psychiatric comorbidity.Diagnosis was confirmed as per ICD10 by two psychiatrist in the department of psychiatry at SIMS Hapur.

Result: Substance abuse was the most predominant comorbidity followed by mood disorder(depression)

Conclusion: There are not many studies done on Transgender male to assess their mental status.Still there is lot of research to be done in this area as this part of population is one of the most vulnerable group for psychiatric comorbidity

Case report of 18 year old girl of Obsessive Compulsive disorder with Encopresis.

Ritu Meena¹, Tushar jagawat² , Savita jagawat³, Pankaj Tandon⁴ , Alankrita⁵, Gourav Sanmotra⁶, Alankrita Singh

Department of Psychiatry, NIMSR Jaipur, Rajasthan

Encopresis is defined as passing stool into inappropriate places such as the underwear in children. Common in 4-12 years. ICD 10 and DSM-5 specifies to encopresis with/without constipation and overflow incontinence. Fecal leak between solid fecal mass and rectal wall comes out when sphincter muscles are relaxed.

Aim & Objective: To assess the clinical profile of rare case of 18year girl with OCD with encopresis .

Case: A case of 18 year old girl came to psychiatry department of NIMSR Jaipur with complaints of repeated thoughts, ghabrahat, restlessness, repeated hand washing and counting since 1 year. On interview she revealed she hasn’t passed stool since 7 days and similar episodes of stool withholding for 5-7 days previously. Parents revealed she’s done this for past 4 months for which her mother would get angry and beat/scold her then she would pass stool in her clothes. This reflects anger towards her mother. The patient was diagnosed of OCD with encopresis.

Result: Patient was started on antidepressant, anxiolytic, cognitive behavioral therapy and biofeedback. Psycho education and family therapy was started. Four sessions of deep muscle relaxation therapy and 8 sessions of CBT in which daily homework and thought diary was planned after which repetitive hand washing decreased from 100 to 50 per day. Counting decreased from 55 to 25 per day. At 16^th session hand-washing decreased to 10 and repetitive counting to 6 times per day. 22 session of biofeedback with relaxation technique were given for managing encopresis.

Discussion and Conclusion: To the best of our knowledge no case in literature is reported on a 18year old female with OCD with encopresis.

Psychogenic Sneezing : Rapid Response in a 9 year old female with combination of low dose benzodiazepines and psychotherapy

Dr Aman Singh Jamwal

Abstract: Psychogenic sneeze occurs when sneezing has a non-organic cause. The most common differential diagnosis is cyclical and chronic idiopathic functional sneezing. Physical problems in children and adolescents that cannot be explained by somatic etiopathogenesis are common. Despite being a less common symptom of psychological stress, chronic sneezing has been associated with severe functional impairment as well as high caregiver stress. Here, we present a case of psychogenic sneeze in a 9-year-old girl, as well as the pharmacological and psychotherapy treatments employed to treat the illness.

Aims and Objectives:

1. To rule out organic causes for sneezing.

2. To test the results of pharmacological and psychotherapy on the psychogenic origin of sneezing.

Methods:

1. Pharmacological Treatment - Low dose Benzodiazepines were given continuously for 5-7 days

2. Psychotherapy -Parents were counseled about the secondary gain and were asked to act accordingly.

Results: The 9 year old female patient responded well to a combination of benzodiazepines and psychotherapy and helped in diminishing the symptoms.

Conclusion: When the psychogenic nature of the symptoms, their onset and progression (due to intrinsic stress), and their continuance (due to which secondary gain could be elicited) was explained initially, the mother noticed a decrease followed by a stoppage of the sniffles. In this case, a psychogenic stressor was identified. Low-dose benzodiazepines’ function is to alleviate underlying anxiety and make the patient more amenable to psychotherapy. Behavior therapy and supportive psychotherapy (explanation of the illness’ nature and recommendations for coping with symptoms) are helpful. Most occurrences of recurrent sneezing that have been documented are psychogenic, particularly in patients who are young adults. Therefore, it is important to keep this in mind while dealing with such people in order to stop needless and costly health scans and investigations, unneeded drugs, and worry. Sometimes the symptoms can be alleviated by recognizing the primary stressor of the psychogenic triggering event and avoiding secondary gain (seeking attention behavior).

DELUSION OF PROCREATION SYNDROME- A CASE REPORT

Dr Ambica¹, Dr Manal Shaikh², Dr Vijayalaxmi Purad², Dr Fakirappa B Ganiger³, Dr Jitendra Mugali⁴, Dr Somashekhar Bijjal⁵

¹Post-graduate Resident, ²Senior Resident, ³Assistant Professor, ⁴Associate Professor, ⁵Professor, Gadag Institute of Medical Sciences, Gadag

Background: Schizophrenia is severe mental illness with life time prevalence of 1% and is characterized by delusions and hallucinations. Content of delusion is of special interest and is still expanding. Delusion of procreation as a psychotic symptom is rarely seen among these patients.

Case Report: A 29-year old unmarried belonging to lower socioeconomic status rural background who is known case of psychiatric illness presented with complaints of suspiciousness and muttering to self. Her blood biochemistry and neuroimaging studies were within normal limits. Mental status examination revealed delusion of persecution and delusion of procreation which were secondary and bizarre. Diagnosis od schizophrenia was made as per International Classification of Diseases 10^th revision and PANSS was administered to assess the severity of psychotic symptoms. She was continued on risperidone and dose was titrated accordingly. Over the course of hospital stay she improved symptomatically and was monitored for side effects.

Discussion: Delusion is false, unshakable belief that is out of keeping with patients social and cultural background. A sequence of delusion in cycle of human procreation are emerging in recent times. Manjunath et al described delusional procreation syndrome that consist of sequential delusions in every possible stage of procreation such as having spouse, getting pregnancy, having delivered a child, becoming parents, among delusion of pregnancy is believed to be commonly reported.

Conclusion: Delusion of procreation syndrome is a rare type of delusion seen among schizophrenia patients it could be elicited very well in this patient and each stage of procreation syndrome could be seen.

Succubus that are out of ordinary: ‘The night monster’

Dr. Anjali Negi, Dr. VM Rajamani

Central Institute of Psychiatry, Ranchi

Introduction: Succubus is also known as demon female lover who approaches males in their dreams to have sex. This is the phenomenon which is rarely described in psychiatric literature. It is more identified as a cultural belief in different religions.

Case Report: A 30 years old male presented with complaints of aloofness, suspiciousness, violent and wandering behaviour for last 14 years, intake of cannabis for last 10 years in addition to severe socio-occupational dysfunction with family history of schizophrenia in mother and maternal grandmother. On MSE, patient didn’t maintain eye contact, had cheerful, non-communicable affect with tactile hallucinations. Patient expressed his distress by reporting how, at nights, when he would go to bed he would feel as if he was being touched by women especially over genitalia and his clothes were being taken off one by one. After this, he would develop an erection and ejaculate. Routine investigations, CT/MRI-WNL with positive urine- cannabis screening. A diagnosis of paranoid schizophrenia with succubus syndrome was made. Patient was given tablet clozapine and hiked till 175mg considering poor response to previous two antipsychotics. MET and psychoeducation was provided and the patient got improved within a month of the hospital stay & was therefore discharged with patient maintaining well on follow-ups.

Discussion with Conclusion: Our case illustrates a rare case of succubus syndrome in the context of a known case of schizophrenia. The current report could add to the literature on this rarely reported phenomenon.

Keywords: Succubus syndrome, Schizophrenia, Phenomenology

“Compulsive self-mutilation in a case of OCD”

Dr Ankit Gupta, Guide: Dr F. A. Sattar, Dr Kiran Kumar K

Dept. of Psychiatry, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, ankitgupta.bmch@bmch.com, fiazahmedsattar@gmail.com, drkiran.psychiatry@gmail.com,

Background: Self-mutilation is a unique clinical entity which has generated curiosity recently in psychiatry community. This is evident from numerous research articles, case reports and case series published in the recent past. On phenomenological ground, there occur idiosyncrasy between OCD & self-mutilation behavior. Patient included in this report presented with unusual compulsive self-destructive behavior as principal way to relief tension.

Case Presentation: A 32-year-old married from rural background has presented with 1 month h/o self-mutilation behavior of extracting her teeth. Patient reported to have repeated thoughts of ‘TIC-TAC’ sensation in teeth which patient feels would be relieved once she removes it, hence extracts it by long stone piece (quern/ lodhi stone); feels relaxed of TIC-TAC sensation, remains asymptomatic for some time, later develops the same, resulted in removal of almost all lower teeth & 1^st left upper incisor. Patient reports of guilt of the same and changes in her facial appearance d/t same but not able to control her thoughts and acts. Patient also reported of ideas that people outside talk about her and her appearance, but doesn’t react to it.

Conclusion: This case report contributes to important but neglected discussion concerning self-mutilation behaviors in OCD. Although OCD does-not lead to physical health problem, some patient may present with self-mutilation compulsion with serious & irreversible consequences, resulting in additional negative impact on their quality of life. Cases like this demand consultation liaison psychiatry to achieve a better prognosis for both mental & physical symptoms, which also affect family members.

Further details and discussion will be presented at the time of presentation.

Rapid Acting Antidepressant Effects with Ketamine during Pandemic: A case series

Dr. Ankit Sinha, Dr. Chinu Patra, Dr. Bandita Abhijita, Dr. Shree Mishra, Dr. Susanta Kumar Padhy

Background: The efficacy of intravenous ketamine in the rapid alleviation of depressive symptoms and suicidality has been observed across the world by researchers. In India, very few studies have corroborated the findings. Exploration of rapid antisuicidal efficacy of ketamine in Indian subpopulation can be a good treatment strategy for unprecedented rise in suicides during the pandemic.

Aim: To assess efficacy of ketamine infusions on patients with severe depression.

Methods: This is a case series of four patients, of age group 18-58 years, with a diagnosis of depressive episode, having the Hamilton Depression Rating Scale (HDRS) score >20 with exclusion of severe medical or surgical illness. Patients were considered for ketamine therapy either as an adjunct to Electroconvulsive therapy (ECT) or as an alternate in case of active denial or side effects of ECT. A total of 6 sessions of intravenous Ketamine infusions were given on alternate days at a dose range of 0.5-0.7 mg/kg body weight. Assessments using HDRS were repeated at 6 h after first infusion and then every day for 2 weeks.

Results: There were significant and sustained improvement in HDRS (<15) till 2 weeks. None of the patients reported any side effects.

Conclusion: Rapid relief of symptoms and favorable side effect profile makes ketamine a suitable potential candidate for various clinical situations.

Department of Psychiatry Index Medical College, Indore A Case Report of Whatsapp Paranoia

Dr Ram Ghulam Razdan¹, Dr Ankita Shahi², Dr Suvaran Sagar Bajpai³, Dr Surya Pratap Singh Chauhan⁴

Abstract: Whatsapp paranoia is gaining hype in today’s app dependent world. It is a thought process associated with high levels of anxiety and fear, often leading to the point of irritability and delusions. Classically, paranoia is characterised by persistent, persecutory delusions.

So here I am presenting an interesting case of Whatsapp paranoia about a 45 year old female who was brought to the psychiatry OPD of Index Medical College and hospital by her husband with complaints of extreme feeling of guilt, overthinking thoughts of being judged by others due to her behaviour and WhatsApp app status along with disturbed sleep associated with frequent and mid sleep awakening by the thought that she will be killed by the lady about whom she had uploaded the WhatsApp status without the consent, since last 3 months and the symptoms deteriorated with time. After MSE, we found that patient was conscious and oriented, speech was goal directed and comprehensible, mood was anxious and irritable, and affect was congruent to mood. Delusion of reference and persecution was present and insight was absent. She was started on antipsychotics and anxiolytic tablet risperidone 2 mg at bedtime for one month and tablet clonazepam 0.5 mg at bedtime for one month and SOS. After medication, patient improved with treatment and was kept in follow up in OPD. So here I am presenting the case of WhatsApp paranoia diagnosed on the basis of DSM-5.

Paediatric catatonia: Rekindling awareness

Anshu Prasad¹, Priyaranjan Avinash², Robin Victor³, Rohit Gondwal⁴

¹Junior Resident, Department of Psychiatry, Himalayan Institute of Medical sciences, Swami Rama Himalayan University, ²Associate Professor, Department of Psychiatry, Himalayan Institute of Medical sciences, Swami Rama Himalayan University, ³Assistant Professor, Department of Psychiatry, Himalayan Institute of Medical sciences, Swami Rama Himalayan University, ⁴Medical officer, State Mental Health Institute, Selaqui

Introduction: Catatonia in children and adolescents in most literature is described as clinically rare; however, some argue it to be an underdiagnosed neuro-behavioural syndrome. The DSM 5 diagnostic criteria attribute diagnoses to the presence of symptoms such as, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia and echopraxia. We report two cases of catatonia, their evaluation and management.

Summary: We report catatonic manifestations in two young adolescent males with no previous underlying medical condition. First case report highlights intermittent brief periods of catatonic excitement beginning with acute anxiety and followed by fainting spells. The symptoms resolved with adequate pharmacological intervention. The second case report narrates an acute onset psychotic episode followed by stuporous catatonia. The patient did not respond to pharmacotherapy following which neuromodulation in form of mECT (modified Electroconvulsive Therapy) was used.

Conclusion: The two cases give a purview of catatonic manifestations in paediatric population. The treatment of catatonia bears challenges owing to lack of awareness and differential response to available pharmacotherapy. mECT is underutilised in paediatric population due to systemic and stigma-based barriers. If left untreated, catatonia can be lethal.

KEYWORDS: catatonia, paediatric catatonia

Psychiatric manifestation in a patient with positive Anti MOG Antibody

Dr Arunima Krishanan

Background: Neuropsychiatric manifestations of demyelinating disorders are well studied, most common among which are depressive symptoms in Multiple Sclerosis. Anti-MOG (Myelin Oligodendrocyte glycoprotein) syndrome is a relatively rare demyelinating disease frequently associated with neuropsychiatric manifestations along with various sensory and motor dysfunctions.

Case report: A 23y old male patient presented to Ophthalmology OPD with c/o sudden onset pain right eye and decreased vision 2 months back, was referred to Neurology for further evaluation and on imaging was found to have bilateral Optic neuritis. Autoimmune causes were evaluated and Anti MOG antibody was found to be positive. Patient’s symptoms resolved with steroids and monoclonal antibody. A month later, patient complained of decreased sleep, staying inside his house all day, hearing voices, fearfulness, suicidal ideations for which psychiatric evaluation was done and was found to have persecutory delusions and auditory hallucinations. Patient was started on atypical antipsychotics in view of past h/o episodic behavioural illness of TD 10 years prior to the current presentation and steroids were slowly tapered off in 5 days. By day 10 of admission symptoms resolved and patient was discharged now maintaining well under follow up.

Discussion: The above case points to the importance of considering neuropsychiatric syndromes in new onset as well as in already established psychiatric diagnoses. Atypical symptoms even in an already diagnosed major psychiatric disorder should prompt the clinician to look into organic causes.

Conclusion: This case report aims to shed light on the psychiatric manifestations on patients with positive Anti MOG antibodies which may help in early detection and specific interventions.

Response to Armodafinil in a case of Schizophrenia with predominant negative symptoms

Dr Arup Basak,

Final Year Junior Resident, Institute of Psychiatry, Kolkata

Schizophrenia is frequently a chronic and disabling disorder, characterized by heterogeneous positive and negative symptom constellations. Negative symptoms are a core component of schizophrenia that account for a large part of the long-term disability and poor functional outcomes in patients with the disorder.

This is a case of a 27 years aged female patient who was apparently well 7 to 8 years ago,with no family history of any or similar psychiatric illness, developed a sense of fearfulness and avoided social interaction with family and friends that was insidious in onset , gradually progressing in severity and had a continuous course. She was poorly compliant to medications whenever she was prescribed by local doctors. She developed suspiciousness towards family and used to mutter to self, with predominantly having apathy with loss of interest in activities, used to be lethargic not wanting to work , and kept to herself in her own room in which she refused anyone to enter. On examination her affect was found to be blunted with reduced psychomotor activity , avolition , reduced tone tempo and monotonous speech , with delusions of persecution against family members , avolition was present . She was initially started on clozapine and later amisulpride was added but her negative symptoms did not improve even on increasing amisulpride to a dose of 500 mg . Armodafinil was added at a initial dose of 50 mg and increased upto 100mg and over 2 weeks, there was an improvement noted in her negative symptoms that were predominant.

Armodafinil appears to inhibit the reuptake of dopamine by binding to the dopamine-reuptake pump, which leads to an increase in extracellular dopamine levels in some brain regions. We are reporting this case to highlight the effect of armodafinil in improving of negative symptoms while used adjunctively with other already receiving antipsychotics .

Schizophrenia in Paget’s disease- A Rarity indeed!

Arushi Singh¹, Poonam M², Shashikala IM³

KVG Medical College and Hospital, Sullia, DK, Karnataka

Background: Paget’s disease, or osteitis deformans, is a rare chronic condition of the bone that typically results in enlarged and deformed bones. Psychiatric symptoms have been rarely reported in patients with Paget’s disease, schizophrenia being the least commonly reported.

Methods: We report a case of 60 year old male, diagnosed with schizophrenia of 40 years of illness, predominantly with delusions of infidelity, 3^rd person commenting type of auditory hallucinations , never treated since he was not amenable to treatment , presented to the orthopaedics OPD with excruciating bone pains on multiple occasions which led to frequent admissions.

Result: MRI Spine showed Paget’s disease of left iliac bone, compressive myelopathy along with cervical and lumbar spondylosis. PANSS Score was 66 (positive score - 24, negative score – 10, General – 32). Patient was treated surreptitiously with depot antipsychotics after taking caregiver’s consent, in the orthopaedics ward during his inpatient stay.

Conclusion: The co-occurrence of Paget’s disease and schizophrenia is a very rare entity and our case report will add on to the literature of psychiatric manifestations predominantly psychotic with bone disease.

Keywords: Schizophrenia, Pagets disease, Osteitis deformans

Wandering Mentally Ill: what should police do?

Dr Ashish Aggarwal,

Assistant Professor, Department of Psychiatry, Kalpana Chawla govt. Medical college, Karnal

This research has not been published nor under consideration for publication

Background: In India, approximately 400,000 wandering mentally ill people are found in deplorable physical condition wandering the streets and stations. This unique patient population raises several issues, beginning with how to present them in court and responsibilities of those who are involved in their care. When a homeless person enters a tertiary care, both police and the medical officer in charge have difficulty rehabilitating such patients. Despite that new Mental Health Care Act of 2017 (MHCA 2017) has provided new and clear instructions for the mental health establishments, police officer in charge, and magistrate, people with severe mental illnesses face delays in treatment and may lose their rights due to the novelty of provisions.

Methods: We performed a comprehensive literature review of MHCA 2017 and similar research on this topic as well as assessed the problems faced while implementing it.

Results: all the facts compiled guide about the whole procedure to be followed when a homeless person enters a tertiary care.

Conclusion: Provisions for caring for society’s most vulnerable members, as well as measures to monitor their implementation, must be put in place. We want to emphasize the responsibilities and processes to be followed in such situations because it is common legal scenario and source of confusion.

Keywords- Severe mental illness, MHCA 2017

Transcranial Direct Current Stimulation (tDCS) for post-stroke rehabilitation

Babli Kumari*, Sujit Kumar Kar**

Junior Resident*, Additional Professor**, Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India

Background: Stroke is one of the leading causes of disability across the world. Occupational therapy and physical therapy are the main stay strategies of rehabilitation. But in the recent years, neurorehabilitation has also emerged as a crucial component of integrated stroke management.

Aims and Objective: We present here a case of an adult female who was treated with Transcranial Direct Current Stimulation (tDCS).

Method: An adult female with history of 3 episodes of Cerebrovascular accidents (CVA) in past 10 years presented to the Neuropsychiatric Clinic with complaints of difficulty in motor coordination, speech, and visual difficulties for last 3 years. She is also a known case of Hypertension, Rheumatic Heart Disease and Hypothyroidism. Previous neuroimaging showed lesions in left fronto-parietal and occipital regions. Thorough neurological examination was conducted and tDCS sessions were planned for motor and cognitive deficits. Cathode was placed over Right Motor Cortex and anode over Left Dorsolateral Prefrontal Cortex. Likeart scale from 0-10 (0: worst and 10: best performance), MMSE and DASS-21 were used to assess the severity of difficulty.

Result: A total of 12 sessions of tDCS were given in a span of 2 weeks. There was improvement in motor difficulties (from 0 to 5), cognition (MMSE 21 to 25) and mood symptoms (DASS-21 score of 44 to 39). No side effects were reported. At 2 weeks follow-up, the patient was improved showed no further worsening of any of the symptoms.

Conclusion: tDCS is a non-invasive and safer brain stimulation technique which can help in facilitating motor and cognitive recovery in stroke patients.

A case report of adolescent male child presented with dermatitis artefacta

Dr. Brajmohan Gurjar, JR1, Dr. Nimisha Mishra, Dr. Sunil K Ahuja, Dr Ambrish Mishra, Dr. Dheerendra K. Mishra, Dr Amrendra K. Singh, Dr Prashant Maravi, Dr Akshat Varma, Dr Jag Mohan Prajapati

Department of Psychiatry, Shyam Shah medical college Rewa

Abstract: Dermatitis artefacta is a psychocutaneous disorder. The main underlying cause for it considered as international conflicts to satisfy psychological needs of patient. The patient is aware of all sort of injuries made by himself or herself but often feigns it.

Introduction: It is a psychocutaneous disorder where a fully aware patient made self-inflicted wound mostly on accessible parts of integumentary system like skin nails hairs mucosa etc. It is seen predominantly among females and very rare in male’s especially young boys. It is seen most commonly associated with personality disorder, depression disorder, dissociative disorder, Anxiety disorder, and some internal conflicts.

Case Reports: A 13 year old male child presented to Psychiatry OPD with of history of multiple rashes on bilateral arms especially on the accessible areas since 7-8 days .There were no sign of infections neither there was a history of any congenital disease, insect bite or autoimmune disease. As per the patients and his attender, these rashes were periodically present since 1 year. They failed to explain their origin and progression and according to them, these are made of some supernatural powers.

Discussion: Dermatitis artefacta is a part of artefactual disorder can affect any part of body. A thorough history and clinical examination are helpful tools to rule out other dermatological conditions.

Conclusion: It is seen most commonly associated with personality, depression, dissociative and anxiety disorder. Hence, proper diagnosis is required to rule out underlying condition.

Catatonia in Alcohol withdrawal

Dr Ravindra Chavhan¹, Dr Sarika Dakshikar¹

¹Grant Government medical College, Mumbai

Background: Catatonia is a complex clinical neuropsychiatric syndrome characterized by altered motor behaviour, thought and mood. Catatonia prevalent in 10% of patients with psychiatric illness and more commonly associated with neuropsychiatric and medical conditions. Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake. It is associated with wide range of neuropsychiatric symptoms.

Case: Hereby we report the case of 47 years old male, Mr A who was brought by his friend and wife to casualty. On examination, he was found to have stupor, waxy flexibility, posturing, mutism, echopraxia, echolalia after he suddenly stopped consuming alcohol 5 days ago. He was a known case of Schizophrenia on regular and compliant to treatment with tab clozapine. He was clinically diagnosed with catatonia in alcohol withdrawal. Symptoms dramatically improved 4 days after treatment with lorazepam and Vitamins like thiamine.

Conclusion: It is very rarely mentioned that catatonia occurring during alcohol withdrawal. We think that this co-occurrence could be underestimated in practice because alcohol withdrawal symptoms may overlap catatonia symptoms.

Keywords: Catatonia, Alcohol withdrawal

Triple Diagnosis in Psychiatry: A Case Report of Forgotten Entity

Dr Darshan Kalal

ABSTRACT

Background: Patients with Bipolar affective disorder (BPAD), have episodes of manic, hypomanic, and depressive symptoms. Episodes can predispose, precipitate and perpetuate due to other psychiatric or organic illnesses such as HIV. Rarely, such patients may receive a triple diagnosis which is HIV with a psychiatric diagnosis along with substance use.

Aim: Data on triple diagnosis in psychiatry is scarce. We present a case of BPAD in an HIV and HCV infected patient with cannabis and opioid dependence syndrome requiring an interdisciplinary approach for diagnosis and management.

Case: A 34-year-old divorced male with cluster B personality traits, known case of HIV and HCV on treatment with past history of intravenous use of opioids in dependence pattern and active cannabis dependence, diagnosed with the bipolar affective disorder since 2015 presented with current 5^th episode since 2 months characterized by over-talkativeness, elated mood, inflated self-esteem, distractability, hypersexuality, decreased sleep, psychomotor agitation, and grandeur delusion. Multiple episodes precipitated in the past due to non-compliance. This also adversely affected his socio-occupational functioning. Findings of physical examination and medical workup were consistent for a patient living with HIV.

Discussion: We discuss the clinical presentation in detail and the difficulty in managing and the special attention required for this vulnerable group.

Conclusion: The presence of a triple diagnosis may cause difficulty in engaging the patient in treatment which lead to poorer health outcomes. There is a need for improvement in the approach with adequate follow-up and care.

To Study Serum Iron levels In Patients With Bipolar Disorder And Major Depressive Disorder

Dr. Deepa Gupta, Dr. Deepa Gupta, P Dr. Bhavuk Garg, Dr. Dinesh Kataria,

Postgraduate Student, Department of Psychiatry and Drug Deaddiction Centre, Lady Hardinge Medical College, New Delhi, India- 110001,ostgraduate Student, Department of Psychiatry and Drug Deaddiction Centre, LHMC,Associate Professor, Department of Psychiatry and Drug Deaddiction Centre, LHMC Director Professor & Head, Department of Psychiatry and Drug Deaddiction Centre, LHMC, Email ID- drdeepa.gupta@gmail.com. Phone No.: 9205021678

Preferred Presentation type: Poster

To Study Serum Iron levels In Patients With Bipolar Disorder And Major Depressive Disorder.

Background and Aim: Bipolar disorder and major depressive disorder are most common ones among all psychiatric disorders and both are multifactorial illnesses with uncertain etiology. Iron plays a crucial role in development of central neurological system so iron abnormality could be one of the risk factors for these illnesses. Knowledge of relationship of serum iron with bipolar disorder and major depressive disorder would help to prevent progression of illness and improve outcomes through earlier treatment

Method: For this purpose, 50 participants each from bipolar disorder and major depressive disorder were recruited. Demographic profile of participants were noted and severity of both disorders were assessed using Hamilton Depression Rating Scale and Young Mania Rating Scale. Serum Iron levels were assessed for both groups.

Results: Serum iron level in bipolar disorder group was found to be low in 64 % of patients, normal in 32%, and raised in only 4% of patients. Serum iron level in depressive disorder group was found to be low in 62 % of patients, normal in 36%, and raised in only 2% of patients. Mean serum iron in patients with bipolar disorder and depressive disorder were 47.7 ± 44.69 microg/dl and 48.51 ± 43.71 microg/dl respectively. On comparing these two groups, difference was found to be statistically not significant (p = 0.873).

Conclusions: No significant relationship was found between serum iron levels in patients with bipolar disorder and major depressive disorder

Unexplained cuts marks over a adolescent’s body: A possible case of Munchausen Syndrome by proxy

Dr Devangi Shukla¹,Dr. Nityanand Singh², Dr. Pooja Sharma³, Dr Nishant Goyal⁴,

Junior Resident, Central Institute of Psychiatry, Ranchi -834006, Jharkhand, India, Junior Resident, Central Institute of Psychiatry, Ranchi -834006, Jharkhand, India. Senior Resident, Central Institute of Psychiatry, Ranchi -834006, Jharkhand, India. Professor of Psychiatry, Central Institute of Psychiatry, Ranchi -834006, Jharkhand, India.

Introduction: Munchausen syndrome by proxy (MSBP) is a term used for a specific behaviour, in which a parent or a guardian deliberately exaggerates, fabricates, or induces physical or psychological symptoms in a child. In literature, MSBP has mostly been reported in very young children; however, approximately 25% of the cases occur in children over the age of 6 years. It remains a poorly understood and controversial diagnosis.

Case Summary: A 13-year-old female presented with complain of appearance of multiple cut marks on whole body in set of 6 for 3 years. Illness had abrupt onset, fluctuating course and deteriorating progress. On examination, linear cut marks were present on both limbs, chest and abdomen regions with fewer lesions on back and very superficial marks on neck and no cuts on face, in different stages of healing. Investigations revealed normal clotting profile. The patient has normal speech productivity, cheerful affect and Ideas of worry regarding her illness. The adolescent and parent, both denied inflicting the cuts. There is past history of pain abdomen and blood-tinged saliva, multiple invasive investigations and procedures, and both symptoms resolved on its own.

Discussion: This is a rare case of MSBP where the victim is an adolescent and emphasizes on the need for early identification of this psychiatric disorder to prevent mortality and for treatment of perpetrators.

KEYWORDS: Munchausen syndrome by proxy.

Prescribing medicines by a teacher: A case report of unusual presentation of OCD

Dhanashri Gohad¹, Surendra Singh², Anish Shouan³, Navratan Suthar^4, Dhanashri Gohad

¹Junior Resident, ²Senior Resident, ³Former Assistant Professor, ⁴Associate Professor, Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan

Background: Obsessive Compulsive Disorder (OCD) can present with unusual symptomatology.

Aim: To discuss a case of OCD with an atypical manifestation in an adult male teacher who has an obsession and compulsion of “prescribing medications” to the villagers and its management.

Case Summary: A 35 years old male teacher presented with complaint of recurrent obsessional thoughts about prescribing medications to patients and compulsion for the same. He started having these thoughts after conducting duty at a community health center as a COVID-19 booth controller. He perceived these thoughts as intrusive, irrational, absurd, anxiety provoking and distressing; would trying to resist them, but won’t be able to do so. He used to sit beside hospitals, squares in villages, and medical shops to find patients and prescribe medications to them to relieve his anxiety. After prescribing medications although his anxiety symptoms would decrease, but he would feel guilty about prescribing medication as he knew that is not an expert. He also faced financial issues as he used to buy medications for villagers, so that they allow him to prescribe medications. He was diagnosed as a case of OCD with good insight and was started on Tab. Escitalopram which was gradually built up to 20 mg over the 3 months along with psychoeducation and supportive sessions. Currently he is in remission and maintaining well since last 2 months.

Conclusion: This case report illustrates that clinician should remain vigilant about the unusual presentations of OCD to avoid the misdiagnosis and timely management.

Comparison of Sexual Dysfunction in Clinically Stable patients of Schizophrenia Receiving Trifluoperazine Risperidone and Olanzapine

Dr Dharmendra Pratap Verma

Background: Sexual Dysfunction (SD) is a common occurrence in Schizophrenia on antipsychotics, both typical and atypical. Indian studies in this regard are not many in number.

Aims and Objectives: The aims of this study were to investigate SD in Schizophrenics on Trifluoperazine, Risperidone and Olanzapine and also to evaluate the incidence of SD in relation to the duration of illness, duration of treatment and dosage of the drugs in each group of subjects.

Materials and Methods: In stable schizophrenic patients, on Trifluoperazine (n=40), Risperidone (n=40), and Olanzapine (n=40), SD was assessed using Arizona Sexual Experience Scale (ASEX). Demographic profile and duration of illness, duration of treatment and drug dosage were evaluated in each group. Comparisons were made between the incidence of SD between patients taking typical and atypical antipsychotics. Also, distribution of SD with duration of illness, duration of treatment and dose of drugs were assessed in each group of subjects (taking Trifluoperazine, Risperidone or Olanzapine).

Results: 1. Majority of the subjects were males (66.67%) and above 30 years (55%). 2. Incidence of SD was higher with typical antipsychotics (statistically insignificant). 3. Increased duration of treatment and dose of drugs were associated with higher incidence of SD. Patients treated with Risperidone for longer duration and with Trifluoperazine with higher dose had higher incidence of SD (p<0.05).

Conclusion: Incidence of SD is higher in older age groups and with typical Antipsychotics. Increased duration of illness, duration of treatment and higher drug doses, all are associated with higher incidence of SD.

Catatonia or Depression - A Diagnostic Dilemma in Stiff Person Syndrome: A rare case report

Dr Dhritiman Das, Dr Harkishan Mamtani, Dr Krishna Prasad

Junior Resident, MD-2, Department of Psychiatry, NIMHANS, PDF in Neuropsychiatry, NIMHANS, Additional Professor, Department of Psychiatry, NIMHANS

Introduction: Stiff person syndrome(SPS) is an autoimmune neurological disorder that presents with severe progressive stiffness of axial muscles and severe spasms. Its incidence and prevalence are around 1-2 per million population. This condition is diagnosed using criteria, clinical presentation, and classical EMG findings and antibody testing. Anti- GAD antibody inhibits Glutamic Acid Decarboxylase which synthesizes GABA from glutamate. Deficiency of GABA in CNS is supposed to result in SPS. Anxiety and depression are two most common psychiatric symptoms reported in SPS. Catatonia and Conversion Disorder are two most common differential diagnoses with SPS due to similar clinical presentation. Benzodiazepines are the first line drug used for symptomatic therapy. Intravenous Immunoglobulin(IVIG) , corticosteroids and Plasma Exchange(PLEX) are modes of immunotherapy to such patients. SSRIs are the first line of treatment for anxiety and depression in such patients.

Case Description: 70 year old woman presents with gradually progressive stiffness and spasms involving both extremities and trunk with difficulty in walking since past 2 years. She was provisionally diagnosed with SPS after classical EMG findings (with IV Diazepam test) and ruled out all other differential diagnoses after thorough investigations and clinical examination. Anti-GAD antibody was negative in this case. Paraneoplastic cause was suspected. Neuropsychiatry referral was sought in view of persistent crying spells and disturbed sleep.

Discussion: Patient was difficult to be interviewed due to dysarthric speech and continuous crying spells. At initial presentation, catatonia was suspected due to presenting features as per BFCRS scale. But this diagnosis was ruled out after the Lorazepam Challenge test. After thorough history taking and MSE, anankastic traits were discovered prior to onset of illness and a provisional diagnosis of moderate depression was kept in view of depressed cognitions and passive death wishes secondary to difficulty in accepting diagnosis and its related disability. Tab Mirtzapine was initiated upto 15 mg for depression and Tab Quetiapine was initiated at 25 mg HS for sleep disturbances and crying spells secondary to spasms in supine which she tolerated well. She was treated with IVIG,PLEX, IVMP, Diazepam, tizanidine and baclofen for stiffness in SPS.

Conclusion: SPS is a rare neurological condition which can mimic presentations of catatonia and conversion disorder resulting in diagnostic dilemma. Neurological and psychiatric features interplay with each other in SPS. SPS, anxiety, depression and substance use disorders are all manifestations of underlying GABA dysfunction.

Dual advantage of Allopurinol in a person with severe mania and gout: A case report

Dr Dhritiman Das

Junior Resident, MD-2, Department of Psychiatry, NIMHANS

Introduction: Kraepelin had described the relation of purine and uric acid with mania emphasizing the relationship between manic symptoms, uric acid excretion, hyperuricemia, and gout. Subsequently, allopurinol has received attention as a repurposed agent in schizophrenia and mania. However, there is lack of evidence from large, double-blinded, placebo-controlled randomized clinical trial for the efficacy of allopurinol in the treatment of mania.

Case description: 21 year old boy presents with past history of mania which responded well to Olanzapine and Valproate combination. He had a relapse of a manic episode after planned cessation of psychotropics after 2 years of remission. Despite adequate trials of Olanzapine and Valproate combination, his symptoms continued worsening. Trials of risperidone and haloperidol also failed to result in remission. Patient was prescribed Febuxostat for gout and thyroxine for hypothyroidism. On examination he was obese and no signs of active gout were noted. Risperidone was continued at 8 mg however haloperidol was stopped in view of risk of EPSE. Febuxostat was cross tapered with Allopurinol to control gout. No other mood stabilizer was added. Gradually his symptoms improved after initiation of allopurinol with continuation of risperidone.

Discussion: This case highlights the treatment of bipolar disorder with current episode mania with hyperuricemia as a co-morbidity where adding allopurinol not only helps in controlling serum uric acid level but also acts as augmentation to anti-psychotic or a mood stabilizer used in acute control of mania and its prophylaxis. Apart from the emerging evidence supporting a role for dysfunctional purinergic neurotransmission in mood disorders, adenosine agonists have properties similar to dopamine antagonists; there is an established interaction between adenosine and dopamine receptors in ventral striatum, and increasing adenosinergic transmission has been demonstrated to reduce binding of dopamine to dopamine receptors in brain. Allopurinol has been found to increase levels of adenosine in the brain which helps to alleviate symptoms of mania.

Conclusion: To conclude this case report from India highlights successful use of allopurinol in mania. Augmentation with allopurinol may have a unique role in comorbid gout, extra-pyramidal sensitivity, aggression or treatment resistance in mania.

Changing trend of glorification of alcohol in Bollywood cinema and songs through past 5 decades:A review article

Dr Dhritiman Das

Junior Resident, MD-2, Department of Psychiatry, NIMHANS

Introduction: This has been an old trend in Bollywood to glorify use of alcohol through cinematic scenes and song lyrics revolving around its glorification and attempting to establish its rationality of use. Its depiction on large screens and multiplex throughout several decades has proven to have unprecedented influence particularly over youths of the nation who are involved in a race to idealize their film superstars and get influenced easily from their blockbusters thus making them more vulnerable to alcohol abuse and dependence as they tend to rationalize its use rather discouraging them.

Over the past 5 decades there has been a change in pattern and trend of depiction and glorification of alcohol in Bollywood movies and songs in line with changing lifestyle and westernization of Indian culture particularly amongst the youth. It would be interesting to study how glorification of alcohol in Bollywood influences the youth’s mentality and how westernization and demands of youth influences depiction of alcohol in Bollywood.

Objective: To study the changing trend of glorification of alcohol use in Bollywood cinema and songs through the past 5 decades.

Methods: This review article is formulated after study of several published literature on the same. Both quantitative and qualitative aspects of alcohol use being depicted in Bollywood movies are analyzed apart from the lyrical analysis of popular Bollywood songs from past 5 decades which glorify alcohol use in context of diagnostic criteria and terminologies used in alcohol dependence.

Results: Analysis of Bollywood movie scenes reveals how westernization and branding has influenced the setting and glamor associated with glorification of alcohol use in such movies and decides box office collection thereafter. The lyrics of songs have significantly drifted from an old generation contemporary vocabulary to a newer generation dramatic vocabulary.

Mephentermine induced psychosis in a young Indian adult.

Dr. Garima Kandpal*, Dr. Harshit Hemant Salian, MD, Dr. Sourav Avi(Senior Resident), Dr. Shiv Prasad, MD, Dr. Dinesh Kataria, MD

Aim: To discuss the rare presentation and management of a case with Mephentermine induced psychosis.

Case Description: A 33 yrs old male chemist, presented with H/o mepehentermine use from 2.5 years with fearfulness, suspiciousness against family members and aggression, hearing voices and insomnia for a week. It was initiated for body building but he developed tolerance, craving, and withdrawal characterised by lethargy, restlessness and cold extremities with use of 2-3 ml/day. H/o sudden onset of symptoms of fearfulness, suspiciousness, reduced sleep with persecutory delusions, auditory hallucinations, increased PMA on MSE, preceded by use upto 3-4ml/day for 2 months. Patient was admitted and BPRS score on day 1 was 68. Tab. Olanzapine 5 mg OD and Tab chlordiazepoxide 30mg in divided doses was started. Improvement in sleep and PMA was noted by day 3 and reduction of psychosis was seen by day 10(BPRS-35). Patient didn’t have craving or withdrawal. Chlordiazepoxide was tapered and stopped; Olanzapine 5 mg HS continued and followed up in OPD.

Discussion: There are few cases of mephentermine induced psychosis reported in literature.. A diagnosis of induced psychosis has been made based on increase in drug use prior to onset of symptoms.

Conclusion: This case highlights use of mephentermine as performance enhancer, leading to dependence and its probable effect on induction of psychosis in certain persons.

Fronto-Temporal Dementia Presented As Treatment Resistant Schizophrenia Improved On Escitalopram.

Dr. Garima Kandpal*, Dr. Bhavuk Garg , MD, Dr. Parvaiz Alam MD, Dr. Dinesh Kataria, MD

Aim: To study the unusual presentation and management of a case with fronto temporal dementia.

Case Description: A 65 year old female presented to us with Total duration of illness 30 years,insidious onset fluctuating course with exacerbation from past 1 week with illness characterised by suspiciousness, delusion of persecution, increased psychomotor activity, lability of mood, disinhbited and disruptive aggressive behaviour and difficulty in ADL .The patient was treated as a case of Treatment Resistant Schizophrenia and receiving Tab. Clozapine 450mg and Tab Sodium valporate 1000mg from 15 years from previous treatment settings with pt being compliant to the treatment. Upon evaluation on Day1 of admission Pts . scores on BPRS was 72 ,MOARS score was 21, MMSE was 21.Mri finding i/v/o suspicion of dementia revealed significant fronto-temporal degeneration on the background of mild cerebral atrophy. Tab Escitalopram 5mg was added to the previous regimen along with tranquilisers .By 2 weeks significant decrease in agitation was noted after 2-3 days with MOARS score decreasing from 21 to 0 , MMSE score improving from 21to 27 with BPRS decreasing to 40.

Discussion: The Food and Drug Administration (FDA) do not currently have any approved drugs for the treatment of FTD. Serotonin reuptake inhibitors (SSRIs) may be useful for reducing the severity of compulsion, agitation, aggressiveness, impulsivity, irritability, eating behavior disruptions, and disinhibition. In our findings, a significant improvement in the symptoms were noted after starting escitalopram which showed improvement in irritability, increased psychomotor activity and in affective symptoms

Conclusion: To the best of our knowledge, this is the first case in Indian scenatrio demonstrating the efficacy of a low dose of escitalopram, only 5 mg/day, for behavioral and psychiatric symptoms associated with FTD.Hence, a greater sample size is warranted for greater validity of results.

Efficacy of Deep TMS (dTMS) on mPFC-ACC for Improving Negative Symptoms of Schizophrenia: A Proof-of-Concept Study

Dr Gulesh Kumar

Introduction: Investigators are searching for various modalities to treat negative symptoms of schizophrenia because these symptoms are disabling and do not respond adequately to antipsychotic treatment. Meta-analyses suggested efficacy of repetitive transcranial magnetic stimulation (rTMS) for the treatment of negative symptoms. dTMS includes all the benefits of rTMS with the advantage of stimulating deeper brain targets. Hypo-functioning in ACC & mPFC has been reported to be important in the development of the negative symptoms of schizophrenia. Recent studies demonstrated the beneficial effects of excitatory dTMS in OCD symptoms via stimulating mPFC and ACC using Hessel 7 (H7) coil. As these areas postulated to be hypo-functioning in schizophrenia patients with negative symptoms, beneficial effects can be expected in these patients with H7 coil.

Objectives: To explore the efficacy of Deep TMS (dTMS) on mPFC-ACC for improving negative symptoms of schizophrenia.

Methods: This was a proof of concept, sham-controlled, rater and subject blinded study. Investigators randomly assigned patients of schizophrenia with predominant negative symptoms into two treatment (Verum & Sham) groups. Treatment consisting of 10 sessions of high frequency dTMS at 10 Hz given at 100% of RMT using H7 coil over 2 weeks in verum group and sham group, respectively. The patients were rated with PANSS, SANS & CGI at baseline, after completion of dTMS (02 weeks) and 4 weeks after completion of dTMS.

Result: A total of 20 patients completed the study. Although both verum and sham groups shown improvement over the time, verum dTMS group showed significant improvement in negative symptoms of Schizophrenia as indicated by significant improvement in SANS score as compared to sham dTMS group (p=0.049, η²=0.300).

Discussion: Findings from our study suggest that adjunctive high frequency dTMS significantly improves negative symptoms and severity of illness among patients with Schizophrenia. Future studies with larger sample sizes will add our knowledge in the beneficial effects of this newer modality of non-invasive brain stimulation (NIBS).

dTMS, Deep transcranial magnetic stimulation, Negative symptoms, H7 Coil, Schizophrenia.

Result

Table: Change in Symptom Severity (PANSS, SANS, CGI) Over Time Between Verum and Sham Groups (N=20)

* p is significant at <0.05 level

Neuropsychiatric manifestations in a case of toxic leukoencephalopathy - A case report

Dr Harshitha V Handral, Dr Madhusudhan S

Department of Psychiatry, Bangalore Medical College and Research Institute, Bangalore.

Background: Toxic leukoencephalopathy is a disorder of brain white matter caused due to exposure to leukotoxic agents. Its neurobehavioral manifestations are diverse, ranging from transient cognitive impairment to dementia, coma and death, rarely catatonia.

Case description: A 77 year old male, with history of nicotine and alcohol use in dependence pattern for more than 30 years was broughtto casualty in a state of altered consciousness after accidentalovernight LPG gas exposure. Following IP care for 3 days, patient had residual fatigability, otherwise asymptomatic over the course of next 2 weeks. In the 3^rd week started to develop confusion, disorientation, irritability, urinary incontinence, decreased self care. Negativism, posturing, rigidity, immobility and brisk deep tendon reflexeswere notedon examination. Cognitive functions were impaired. Bush-Francis Catatonia Rating scale revealed a score of 18. RFT, LFT, serum electrolytes, CBC, B12, CPK were found normal. HCV, HIV, HBsAg, VDRL were Non-reactive.MRI-Brainrevealed features suggestive of toxic leukoencephalopathy. Minimal improvement in catatonic symptoms was noted with Lorazepam.Nootropics, Steroids, Antioxidants, Multivitamins were added along with supportive care. Family members were psychoeducated about the guarded prognosis.The patient succumbed to death in the 5^th week at his residence following discharge on request.

Conclusion: A delayed neuropsychiatric effects of toxic exposure is rarely reported. Hence this case-report adds to the limited literature available.

Kempf disease – a case of homosexual paranoia

Dr Himshikha Srivastava, Dr Kirti Anurag, Prof (Dr) Surjeet Sahoo, Dr Rajkumari Lorinda

Background: Kempf disease, proposed by psychiatrist Edward Kempf in 1921, is a dissociative disorder defined by the patient harboring an unconscious fear of attracting attention from the same gender.

Case report: 38 Year old unmarried male, engineer, non smoker, non alcoholic, no history of chronic illnesses, lacking social skills presented to OPD with symptoms of decreased sleep, restlessness, suspecting three boys in his neighborhood of being gay and making sexual advances towards him. The situation was triggered by the patient travelling to Kolkata by train with the same boys.

MSE: Thought – delusion of persecution “they’re plotting against me”. Perception- Auditory hallucination: “they are talking about me” Insight – Grade I. For acute tranquilization, Inj Lorazepam 4 mg was given stat. Patient was then stabilized with Risperidone 3 mg BD for 21 days.

Discussion: Diagnosis was made after excluding other likely causes. The case was a distinctive pathology of schizophrenia. Patient was evaluated in detail, it was established that he isn’t homophobic and psychotherapy was given. Delusions diminished. Preoccupation with idea of those boys being attracted to him was unshakable.

Conclusion: This is a rare finding hence has fallen out of the clinical spotlight. Such cases are should be identified with caution as it would be worthwhile to explore the concept of homosexual panic in greater detail and develop a management approach catered specifically to it.

Escitalopram-induced liver injury: A Case Report

Dr. Jeevan YM, Post graduate; Dr. Madhusudhan S,

Associate professor, Department of Psychiatry, Bangalore Medical College & Research Institute, Bengaluru

Background: Depression is a growing public health problem that affects over 350 million people globally. Escitalopram, is a selective serotonin reuptake inhibitor and one of the first-line medications for the treatment of depression. Although thought to be generally safe and with minimal drug-drug interactions, we herein present an unusual case of drug induced liver injury, likely secondary to Escitalopram initiation.

Case Summary:A 50-year-old female presented with fever, itching hands, foot and face with early morning puffiness of face; two weeks after initiation of Escitalopram for the treatment of moderate depression. Physical examination was unremarkable. Investigations, including LFT showed increased serum Alkaline phophatase, Aspartate aminotransferase and Alanine aminotransferase which was normal before initiating treatment, serology of hepatitis A, B and C were unyielding. Hence, a diagnosis of escitalopram-induced liver injury was made. Upon stopping escitalopram, repeat liver function tests showed downtrending liver enzymes which eventually normalized after one month.

Discussion:

• Drug-induced liver injury (DILI) is one of the leading causes of hepatic failure.

• Escitalopram is metabolized by the liver, mainly via the cytochrome P450 system (CYP3A4, CYP2C19) and hepatotoxicity may be due to toxic intermediates.

• Multicenter drug surveillance program showed 0.08% of DILI with antidepressants.

Conclusion: Psychiatrists should be aware of the possibility of Escitalopram-induced liver injury when initiating on antidepressant treatment. Measurement of liver function tests could be considered after initiation of antidepressant treatment; especially in patients with pre-existing liver disease and elderly population.

Revisiting vascular Depression- A case study

Dr Karthik J

Introduction: Vascular depression is late-onset depression occurring after clinically apparent silent cerebral infraction or lacunar infracts. Prevalence of vascular depression is 3.4% .

Case description: 36 yr old married male patient, from West Bengal pre-morbidly well-adjusted came with c/o decreased social interaction, low mood, sleep disturbance, decreased interest in activities, fatiguability, decreased sleep & appetite since 6 months. H/o seizure episodes 2 yrs ago.

On MSE: patient maintained good eye contact, had psychomotor retardation, decreased speech output, increased reaction time of speech, had logical linear thinking and no evidence of any delusions, stated he felt depressed & had depressed affect, restricted range, non-reactive mood. On assessing cognitive functions, attention was arousable but not-sustained, able to think abstractly and had intact memory, good insight and judgment.

Psychological assessment was done

MRI: chronic lacunar infracts in bilateral striato-capsular location

Discussion: Patient with vascular depression have relative poorer response to antidepressants. In our case patient was diagnosed early and treatment was started with anti-depressants. Patient showed improvement in cognitive and mood symptoms. Patient was followed up for cognitive decline, dementia and occurrence of cardiovascular and cerebrovascular events.

Conclusion: Psychiatric disorders should always be one to look out in case of cerebrovascular accident. Liaison psychiatry has important role here. Any behavioral disturbance to be managed adequately for reduction in mortality and repetitive transcranial magnetic stimulation could be possible treatment option.

Trichotillomania along with Trichotemnomania secondary to post varicella basal ganglia infarction in an adolescent girl- A case report

Dr Kaushik Pal

Background: Trichotillomania is characterized by recurrent pulling out of one’s own hair leading to variable hair loss. Trichotemnomania is a related disorder where the patient cuts or shaves his/her own body hair compulsively. CNS vasculitis and related stroke are well known after varicella infection in children. Basal ganglia lesions are also noted.

Case: An 11 years old adolescent girl was referred from dermatology OPD with history of loss of scalp hair. The patient said she experienced an irresistible urge to pull and cut her hair and the rising tension is relieved only after the act of pulling or cutting for last 1 year. She had a history of varicella infection 1.5 years ago. She was diagnosed having Post varicella CNS vasculopathy. MRI Brain reveals chronic left capsule-ganglionic infarct (globus pallidus, putamen, external capsule). Tab Fluoxetine 10mg OD for 4 days then 20mg OD was advised along with Habit Reversal Training. Improvement of symptoms was found after 2 months.

Discussion: This case was of interest because of the compulsive symptoms associated with basal ganglia infarction. The pathophysiology of OCD after basal ganglia lesions is probably due to a dysfunction of the fronto cortico striato thalamic loops, which are responsible for a lack of inhibition of automatic behaviour.

Conclusion: Trichotillomania and Trichotemnomania together is a very rare condition. Early detection and management can prevent life threatening condition like trichobezoars and other psychological implications.

A case study of ADHD in patient with Rasmussen’s Encephalitis.

Dr Lavish Chayal ¹, Dr Tejaswini Miskin¹, Dr Ramchandra V¹

¹Grant Government Medical College

Background: Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by pervasive and persistent behavioural symptoms of inattention, hyperactivity and or impulsivity that are extreme for age and interfere with social or academic functioning. The etiology is complex with multiple genetic and environmental factors contributing to risk and ADHD is a common comorbidity in children with neurological disorder. Rasmussen’s encephalitis is a rare chronic neurological disorder, characterised by unilateral inflammation of the cerebral cortex, drug-resistant epilepsy and progressive neurological and cognitive deterioration. It affects mostly children or young adults. In some patients, a prodromal period of mild hemiparesis or infrequent seizures might precede the onset of the acute stage by up to several years.

Case: Hereby presenting a case of a 10 year old boy, Master R, who presented to psychiatry OPD with complaints of irritability, temper tantrums, hyperactivity, decreased sleep, impulsivity, hitting and biting self and others since last 6 years which followed by episodes of fever, hemiparesis, unconsciousness, recurrent seizures. Patient was referred to neurologist where he was assessed and diagnosed with Rasmussen’s encephalitis for which he was treated with Tab Clobazam for seizures and he responded well to Tab Atomoxetine.

Conclusion: This case highlights the importance of understanding the complex etiology of ADHD.

Keywords: Autoimmune, ADHD, Encephalitis, Rasmussen Encephalitis

Drug assisted interview in a case of dissociative fugue

Dr Lopamudra Pradhan, Dr Seema Parija

Background: Dissociative fugue has features of dissociative amnesia plus an apparently purposeful journey away from home or place of work during which self care is maintained. In some cases,a new identity may be assumed,usually only for a few days but occasionally for long periods of time. Although there is amnesia for the period of fugue,the individual’s behaviour during this time may appear completely normal to independent observers.

Case Report: A 26 year old male was brought with complaints of multiple episodes of wandering away from home with no memory of the incidents. Detailed history revealed low mood, feeling sad, decreased social interaction and suicidal thoughts. After detailed workup and serial MSE he could not recall the incidents of travel away from home. Drug assisted interview was done which was diagnostic as well as therapeutic.

Aims-to discuss the usefulness of drug assisted interview in cases of dissociative fugue.

Methods: Detailed case as how drug assisted interview was diagnostic and therapeutic in this index case

Results: The patient could recall the episodes of travel and amnesia. He was able to acknowledge and resolve his conflict.

Conclusion: Drug assisted interview can be beneficial in cases of dissociative amnesia and fugue where other interventions fail.

ALCOHOL AMNESTIC DISORDER - A CASE REPORT

Dr.M.Tirumala Babu¹, Dr.A.Pavani², Dr.M.Haritha Devi³, Dr.G.Hemanth Madhav⁴, Dr.S.Nagaraju⁵, Dr.K.Narasimha Reddi⁶

Junior Resident¹, Senior Resident², Assistant Professor³,

Associate Professor⁴, Professor⁵, HOD & Professor⁶

Department of Psychiatry, Maharajah’s Institute of Medical Sciences, Vizianagaram.

Background: Alcohol amnestic Syndrome or Korsakoff’s psychosis, a mental disorder with a prevalence of 12-14% in the alcoholic population, is associated with chronic use of alcohol and nutritional deficiencies and characterized by prominent impairment of recent memory and sometimes remote memory, while immediate recall is preserved. Disturbances of time sense and difficulties in learning new material are usually evident. Confabulation may be marked but is not invariably present.

Aims: To report and discuss a rare case of Alcohol amnesic syndrome in a middle-aged male patient.

Methods: Diagnosis was made by using ICD 10 criteria. Memory was tested by using the PGI Memory scale. Neurological examination, MMSE, Routine Laboratory and radiological investigations were done.

Results: The patient was treated with T. CITICOLINE 500MG+PIRACETAM 800MG, T. THIAMINE100MG, T. QUETIAPINE 100MG and Cognitive Stimulation and Reminiscence therapy was advised. Follow-up visits showed improvement in his symptoms.

Conclusion: Alcohol amnestic disorder is associated with chronic ethanol abuse and nutritional deficiencies characterized by short-term memory loss, confabulations and disturbances of attention. Because of its significant impact on quality of life, early diagnosis will be of great help.

Dr Manchikalapudi Tirumala Babu, Dr Md. Shahnwaz, Dr Vikash Chandra Mishra

Flat G4, 1^ST Floor, Sai Amrutha Apartment, Phool Bhag, Vizianagaram, Email id: tirumal.babu1994@gmail.com, Phone no: + 919491148079, Assessment of QoL and Depression in Vitiligo patients

Assessment of QoL and Depression in Vitiligo patients

Author: Dr Md. Shahnwaz, Dr Vikash Chandra Mishra

Background: Vitiligo is acquired, chronic, depigmenting disorder of the skin, in which melanocytes, that determine the colour of skin, hair, and eyes are progressively lost. It affect a person’s emotional and psychosocial well being, thus having profound psycho social impact on patient’s life.

Aims:

• To assess Quality of life in vitiligo patients.

• To determine prevalence of depression in patients with Vitiligo and association with severity.

Methods: 30 newly diagnosed patients of vitiligo of age more >18 years, coming to outpatient department during period of 6 months were included in study. Patients with depigmented patches due to causes other than vitiligo or with known history of psychiatric conditions were excluded. History was taken and data was recorded in pre-tested questionnaire after taking informed consent. Pre-validated Vitiligo area severity index(VASI) was used to assess the disease severity,Quality of Life was measured using Dermatology Life Quality Index Questionnaire(DLQI) and diagnosis of depression was made as per ICD10 and was rated on Hamilton rating scale of depression(HAM-D).

Results: Mean age of patients was 30+12.33years. 83.3% patients were having VASI score <5 with mean DLQI of 7.4 while patients with VASI >5 had mean DLQI of 9.3. 80% of patients with VASI >5 had moderate to severe depression as per HAM-D scale while 72% of the patients with VASI <5 had mild depression.

Conclusion: Depression is quite common in patients with vitiligo and severity is associated with impairment in QOL.Patients with vitiligo need to receive comprehensive counselling, regular screening for depression and psychiatric consultation along with disease specific treatment for better QoL.

Psychogenic Purpura: A rare case report

Dr. Mridul Deepanshu¹, Dr. Rakesh Mohanty²

¹Post Graduate Resident, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, ²Assistant Professor, Institute of Medical Sciences and SUM Hospital, Bhubaneswar

Background: Psychogenic purpura, also known as Gardner-Diamond syndrome, is a rare condition that is characterized by spontaneous development of painful, ecchymotic, purpuric lesions that typically is always preceded by severe psychic stress or emotional trauma. The condition is most commonly seen in women, but isolated cases have been reported in adolescents and in males. Psycho-dermatologic evaluation and dermatology and psychiatry liaison have been successful in the treatment of these patients.

Case Report: Mrs. A, a 43-year-old female housewife presented to Dermatology OPD with a 5-month history of bilateral aching pain over lower limbs along with pruritic, reddish, edematous rash in right leg and intermittent reddish black patches in left leg. Numerous dermatology consults and investigations failed to establish any etiology for the condition. After ruling out all the probable diagnoses, the patient was referred to the Psychiatry department. Detailed psychiatric evaluation revealed symptoms suggestive of mixed anxiety depression disorder and temporal changes in mood and functioning and appearance of the lesions were correlated. After detailed psychiatric evaluation, multiple psychic stressors were found and temporal relationship was established. The diagnosis was confirmed with an Autoerythrocyte sensitization test which turned out to be positive. She was then started with SSRIs. After a 6-week follow-up, the patient reported improvement in symptoms.

Conclusion: Although Gardner-Diamond Syndrome is a rare disease; it should be considered in the differential diagnosis of recurrent painful purpura. Prompt diagnosis helps to avoid exhaustive investigations and aggressive treatment.

A case study of pathological gambling disorder

Nimish Savaliya¹, Gyanendra Kumar², Dinesh Singh Rathore³, Anil Kumar Sisodia⁴, Sheetal Tripathi⁵

¹Junior Resident, Department Of Psychiatry, IMHH, Agra, ²Professor Psychiatry, IMHH, Agra, ³Professor Psychiatry, IMHH, Agra, ⁴Professor Psychiatry, Department Of Psychiatry, IMHH, Agra, ⁵Senior Resident, Department Of Psychiatry, IMHH, Agra

Background: Gambling has been an ubiquitous activity in Indian culture, with literature, including ancient scriptures, alluding to its nature and impact. Nearly three quarters of western and Asian culture are engage in gambling but 2-4 % develops pathological gambling. Since it is increasingly acknowledged as a major public health concern, still around 0.23% of pathological gamblers seeks medical help.

Case Report: We report a case of 28 year old male with family history of problem gambling in father , who himself seek psychiatric help with anxiety symptoms of around 7 month duration , with background of progressively increasing engagement in offline gambling followed by online gambling with consequent heavy financial losses since past 8 years. The diagnosis was made as per DSM V (312.31), and patient was started on tab naltrexon 50 mg, sertraline 50 mg and cognitive behavioral therapy.

Conclusion: Our case report adds knowledge to our existing literature regarding the types of help sought by people with gambling disorder so that such type of help can be promoted and adapted to meet the demand of those seeking help more effectively.

A rare case of Cibophobia associated with Obsessive-Compulsive Disorder in a young female

Dr.Nukapeyya Santhosmitha¹,Dr.E.Navya Sree², Dr.Siva Anoop Yella³, Dr.Naveen Kumar Dhagudu⁴

^1,2Junior Resident,MD Psychiatry(ESIC Medical College & Hospital),³Assistant Professor(ESIC MCH), ⁴Professor and HOD(ESIC MCH). Presenting Author’s Email:moony0106@gmail.com, Mobile Number:8897848550

Background: Cibophobia is a very rare type of specific phobia in which people often avoid food and drinks because they are afraid of food itself.

Case presentation: A 25year old female patient,who is currently unemployed, staying with her parents came to the psychiatry OPD with chief complaints of fearfulness to eat food or drink water, palpitations, negative thoughts that she might die if she eats or drinks water,avoiding black colour things thinking something bad might happen, repeated thoughts of dirt contamination, repeated hand washing since 2 months and got admitted in female psychiatry ward in ESIC Hospital.On evaluation, there was no history suggestive of neither depression nor schizophrenia.On Mental Status Examination, she was found to have obsessional thoughts of dirt contamination along with compulsive behaviour of repeated hand washing and she has grade 4 insight.

All the routine investigations are normal.Patient was diagnosed with Cibophobia with Obsessive compulsive disorder.She was treated with Tab.Fluvoxamine 50mg H/S, Tab.Clonazepam 0.25mg BD, Tab.Escitalopram 10mg OD with 2 sessions of Cognitive Behavioural Therapy and discharged after 4 days.Patient came for follow-up after 2 weeks and 1 month, reported 60% improvement.

Conclusion: Cibophobia is very rare among specific phobias and rarely associated with OCD.In this case report, the patient has reported improvement with pharmacotherapy and psychotherapy.

School of medical sciences & research, sharda university, greater noida, department of psychiatry, poster presentation, “secondary mania in elderly” after stroke - A Case Report

Dr Parika Kochhar¹, Dr Kunal Kumar², Dr Abhinit Kumar³, Dr Shruti Sharma⁴, Dr Nikhil Nayar⁵, Dr Swaleha Mujawar⁶, Dr Siddharth Bhargava⁷, Dr Chaitanya Sheoran⁸, Dr Nikita Mann⁹

Junior Resident¹, Professor & Head², Professor³, Assistant Professor^4,5, Senior Resident⁶, Junior Resident^7-9

Mania is characterized by affective disturbances, elevated or irritable mood, increased rate or amount of speech, flight of ideas, grandiose ideation, lack of insight, behavioral disturbances characterized by overactivity and social disinhibition. In 1978, Krauthammer and Klerman introduced the concept of secondary mania where mania is caused by neurological, metabolic or toxic disorders. Mania seems to be more frequent after right-sided lesions, but there are also reports of mania following left lesions.

Here is a case of 60-year-old male from Meerut, retired army professional, married who came with the chief complaints of aggressive, violent behavior, increased talk, decreased sleep and increased activity since past 2 months, insidious in onset and continuously progressive in nature. On MSE he was unkempt, untidy, overfamiliar, irritable affect, increased volume of speech, grandiose delusion with impaired judgement and insight grade 1 showing past h/o hypertension, non compliance with medication, h/o stroke 2 months back after which he had these symptoms. On MRI right sided old frontal lobe infarct present. Patient was admitted and started on Olanzapine and Quetiapine and showed improvement in behavioral symptoms. Hospital stay was 1.5 weeks after which he was discharged on the same medication and is currently maintaining well.

This case highlights the importance of ruling out organic causes in patients who present with behavioral changes and have psychiatric symptoms. A high index of suspicion is required in elderly people with comorbidities for early detection and prompt intervention of such disorders.

Rivastigmine for Parkinsonian Motor Symptoms in Dementia with Lewy Bodies: A Case Series

Dr. Porimita Chutia¹, Dr. Shailendra Mohan Tripathi²

¹2nd year DM trainee, Department of Geriatric Mental Health, King George’s Medical University, Lucknow, Uttar Pradesh. Phone- 9957730765, Email- porimitachutia@gmail.com, ²Associate Professor, Department of Geriatric Mental Health, King George’s Medical University, Lucknow, Uttar Pradesh., Phone-9864501214, Email- dr_smtripathi@rediffmail.com, Phone- 9415531178, Place of study: Department of Geriatric Mental Health, King George’s Medical University, Lucknow, Uttar Pradesh, Preferred presentation type- Poster for “Professor K.C. Dube Poster Session 1 award”

Rivastigmine for Parkinsonian Motor Symptoms in Dementia with Lewy Bodies: A Case Series

Introduction: Dementia with Lewy bodies (DLB) is characterized by progressive cognitive decline along with visual hallucinations, fluctuating cognition, and spontaneous features of Parkinsonism. The prevalence of parkinsonian motor symptoms is around 75-80% in DLB patients. Profound cholinergic deficit and the efficacy of cholinergic drugs in improving the cognition and neuropsychiatric symptoms is well established in DLB. Rivastigmine, a dual inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) is extensively studied in DLB but there is dearth of literature on its effect of parkinsonian motor symptoms in DLB.

Clinical Case Series: Here, we present case series of 3 in-patients with a diagnosis of DLB treated with oral Rivastigmine. The patients presented with diverse extrapyramidal symptoms along with other features of DLB. Bradykinesia and masked facies were common in all 3 patients, asymmetrical upper limb rigidity in 2 patients and axial rigidity in 1 patient. On oral Rivastigmine 1.5mg twice daily the response was first noticeable in facial expression within 48hour. A noticeable improvement in bradykinesia and rigidity was noted after a week of commencement of Rivastigmine, which was validated using objective change in MDS-UPDRS scale scores.

Discussion: The major neurochemical pathology of DLB is cholinergic and dopaminergic deficit. Rivastigmine as a cholinergic drug is predicted to exacerbate parkinsonism according to cholinergic-dopaminergic antagonism theory. The reduced binding of nicotinic and muscarinic receptors in the striatum along-with complex interaction of neurotransmitter pathways in striatum might explain the improvement in parkinsonian motor symptoms in DLB patients with Rivastigmine. This report highlights Rivastigmine as a single drug therapy for treating diverse symptomatology of DLB patients and also paves the way for future research in other parkinsonian syndromes.

KEYWORDS: Cholinesterase inhibitors, lewy body parkinson’s disease

Pyridoxine as a useful agent in treating tardive dyskinesia

Surabhi Sharma ¹, Preeti², Dinesh Kataria³

¹Senior Resident, Department of Psychiatry, Lady Hardinge Medical College and SK Hospital, New Delhi, ²Junior Resident, Department of Psychiatry, Lady Hardinge Medical College and SK Hospital, New Delhi, 3Director Professor and Head, Lady Hardinge Medical College and SK Hospital, New Delhi, Mail- preetidalal200@gmail.com, Number-7065503575

Background: Tardive dyskinesia (TD) is an iatrogenic disorder of drugs mainly antipsychotics leading to debilitating and functional problem in patients. Common risk factors include elderly female, Diabetes, Substance use and mood disorders. Various agents like Clozapine, Amantadine, Tetrabenazine, Quetiapine have their clinical roles in treating TD disorder and anticholinergic agents too like trihexyphenidyl. Rare molecules like Pramipexole, Pyridoxine, neurochemical supplements like Gingko Biloba have proved to improve TD symptoms.

Objective: To describe a case of Tardive Dyskinesia showing improvement on Pyridoxine.

Case Report: This is a case of 59-year female having severe depressive disorder with psychotic symptoms developed Tardive dyskinesia on tablet Olanzapine. She did not improve on Tetrabenazine, Clozapine, Vitamin E and Clonazepam. Patient showed improvement on Abnormal involuntary movement scale (AIMS) and lip mouth movements started to disappear after adding Pyridoxine dose 100 mg per day in divided doses.

Conclusion: The role of Pyridoxine can be considered in treatment of tardive dyskinesia though exact mechanism of Pyridoxine is not clear and further research is indicated.

Keywords: Pyridoxine, Tardive dyskinesia, AIMS

A rare case of alcohol withdrawal manifesting as REM sleep behaviour disorder

Radhika Chakraborty, Tathagata Biswas, Biswa Ranjan Mishra, Arpit Parmar

Introduction: Alcohol withdrawal is an emergency condition with varied presentations ranging from anxiety and insomnia to delirium tremens. Rapid eye movement (REM) sleep behaviour disorder (RBD) is characterized by violent enactment of dreams during REM phase of sleep. This report presents an interesting case reflecting a rare association of alcohol withdrawal with RBD.

Case Summary: The index patient is a 40-year-old male consuming alcohol in dependence pattern for the past 25 years. Two years back, following the diagnosis of diabetes, he reduced the frequency and amount of alcohol intake. He started having symptoms like tremors, sleep disturbances and irritability suggestive of alcohol withdrawal. During this time his roommates would complain that he would be kicking, punching and shouting in his sleep. Interestingly, his symptoms would occur about two hours following onset of sleep and he would not have any recall regarding this the next morning. This hinted towards an association of the parasomnias with the alcohol withdrawal state. Based on clinical suspicion of RBD a polysomnography was suggested which corroborated with the clinical findings. Management was therefore started in view of alcohol withdrawal with 50 mg chlordiazepoxide which was gradually tapered. Along with the resolution of the physical symptoms of alcohol withdrawal, his parasomnias also resolved.

Discussion: This case underlines the fact that though the patient had presented with complaints suggestive of parasomnias; a detailed history and clinical findings (time of onset and pattern of the symptoms, and co-presence of physical signs of withdrawal) hinted towards a rare alcohol withdrawal complication.

Conclusion: More awareness of the existence of acute forms of RBD and greater familiarity with the various potential clinical pictures (especially in the context of alcohol withdrawal state) may help to avoid misdiagnoses and mistreatments.

Treatment Satisfaction among Persons with Psychiatric Disorders & their Caregivers Receiving Telepsychiatry Services: A Qualitative Study

Dr Ravindra Munoli

Background: Telepsychiatry is shown to be effective in reaching rural population in terms of people accessing treatment. Various studies report benefits of telepsychiatry in getting quality services for persons with psychiatric disorders over the years. However, fewer studies related to treatment satisfaction among persons with psychiatric disorders and their caregiver‟s receiving telepsychiatry services in Indian context.

Aims: To study the treatment satisfaction among persons with psychiatric disorders and their caregivers receiving telepsychiatry services in Manipal Model of Telepsychiatry.

Methods: Cross sectional descriptive research design used. Semi structured interview schedule and focused group discussions carried out to assess the treatment satisfaction. Total 45 persons with psychiatric disorders and 28 Caregivers receiving Telepsychiatry services at Community Health Centre, Hebri, Primary Health Centres of Kandloor and Shiroor of Udupi District were recruited into the current study.

Results: Qualitative results of this study revealed high satisfaction among patients and caregivers with telepsychiatry services on different domains such as time, cost of treatment, convenience, doctor-patient communication, and health-care quality.

Conclusion: The present study witnessed that, patients, and caregivers highly satisfied with telepsychiatry services provided to them. These findings clearly may pave way to comparative exploration of satisfaction with mental health care delivery in person and in telepsychiatry mode.

Neuroleptic Malignant Like Syndrome in a patient with Autism Spectrum Disorder with Catatonia and Psoriasis

Dr Shivangi Mehta , Dr Reema Bana

Background: ASD shows florid medical and psychiatric comorbidities, catatonia being one. Patients receive antipsychotics for behavioural management which might lead to development of NMS. Symptoms of NMS and catatonia are quite similar bewildering the clinician. Also, often comorbidities compound the rocky terrain further adding to the dismay of the clinician in the management in ASD. We present a clinical case report highlighting this conundrum.

Case Report: 19 years old male, diagnosed with ASD with history of 1 episode of seizure and psoriasis presented with decreased interaction, maintenance of mundane postures, decreased sleep, poor oral intake, urinary incontinence, non-passage of stools for 15 days. At the time of admission BFCRS was 15. Patient was started on Inj. Lorazepam gradually uptitrated to 10 mg/day without improvement. Aripiprazole 2.5 mg was added and patient developed fever (99^oC) within a day. Consultation-liasion with department of medicine was sought where a possibility of NMS was kept. Total CK was 971.2 IU/l and serum potassium was low (2.8 mEq/L). Patient did not fulfil Levenson’s criteria for diagnosis of NMS. Aripiprazole was continued, hydration was maintained; potassium supplements and ECTs were started. Total CK levels decreased within a week and gradual improvement was seen in the clinical condition.

Discussion: Index patient is a known case of psoriasis and presented with hypokalemia both of the entities are known to increase total CK individually; giving catatonia a NMLS presentation. After maintenance of hydration and providing potassium supplements, aripiprazole and ECTs were planned. Patient showed gradual improvement. It is therefore necessary to broaden the clinical knowledge with emphasises on medical comorbidities in ASD altering the clinical picture.

Autism Spectrum Disorder, catatonia, Neuroleptic Malignant Like Syndrome, hypokalemia

Dynamic Emotion Laden Inventory of Videos for Emotion Recognition (DELIVER): development and validation

Rohit Verma¹, Navkiran Kalsi², Anita Sheerha³, Neha Priya Shrivastava⁴, Neha Behal⁵, Shubham Narnoli⁶, Dr Rohit Verma

¹MD Psychiatry, Additional Professor of Psychiatry, ²M. Tech Cognitive Neurosciences, Post-doctoral Fellow, ³PhD Psychology, Research Assistant, ⁴BDS, PGDPHM, Research Officer, ⁵Dip Medical Lab Technician, ⁶MD Psychiatry, Senior Resident, Brain Mapping Lab, Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, Room No. 4096, 4^th Floor, Teaching Block, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi – 110029, E mail: rohit.aiims@gmail.com

Financial Disclosure: The study is sponsored through the Cognitive Science Research Initiative (CSRI) grant of Department of Science and Technology (DST), Government of India (D.O. No. DST/CSRI/2017/186 dated April 12, 2018).

Conflict of interest: All authors declare that they have no conflicts of interest and that the manuscript, to the best of the author’s knowledge, does not infringe upon any copyright or property right of any third party.

Abstract

Background: Literature on emotion recognition is majorly based on facial expression datasets and that too limited to static images mainly. There is scarcity of Indian literature on evaluation of emotion recognition capabilities using dynamic videos due to lack of availability of such instrument. This pilot study presents the development and validation of a culturally relevant database with emotion laden videos as a toolbox for research in the subcontinent.

Methods: Short videos were collected for each of the basic emotions (neutral, happy, angry, sad, disgust, fear, contempt and surprise) after search over internet for videos available free for use independently by three researchers. A thorough discussion in a committee comprising of psychiatrists, psychologists (clinical and cognitive), lay individuals and professional artists was conducted to select 40 videos (5 videos of each emotion) limited to 5 second of display duration.

Each video was validated by 15 Psychiatrists or Psychologists. Apart from recognition of emotional quality of the basic emotions, a free choice was provided for mentioning emotion other than asked. Results were discussed in terms of inter-rater reliability using kappa agreement.

Results: The percentage hit rate of all the emotions after exclusion of contempt was 86.38 ±18.75% with a mean kappa for emotional expression as 0.76. Individual hit rates were high for all emotions (>0.7).

Conclusion: The Dynamic Emotion Laden Inventory of Videos for Emotion Recognition (DELIVER) database is a useful tool in the Indian context for conducting research in the field of the emotion recognition. It has been validated in an Indian population and is found to have good internal consistency and reliability.

Keywords: Emotion, emotion recognition, video, emotional intelligence, social perception.

An observational study on smartphone usage and cognition in undergraduate students of Homoeopathic medical college

Dr Roma Dilip Shahani, Dr Devavrat Harshe,

D Y Patil Medical College, Kolhapur

Introduction: Pervasive smartphone use causing interruptions in our work life, may take a toll on our focus, work quality and productivity, and our personal relationships. Previous studies conducted for effect of smartphone on cognition were based largely on subjective questionnaires, which is prone to recall and raters’ bias. This study utilizes a novel telemetric method to evaluate quantum of smartphone use and it’s effect on cognitive performance in students.

Methodology: 100 Undergraduate students of III^rd B.H.M.S. using android smartphone were included. Participants installed two free applications, i.e. THINC-it® (containing various tests for attention, working memory, response time and executive functions) and My phone time©Smarter Time 2018 on their phones. They were advised to continue using their smartphone in regular manner and follow up at every 7^th day upto five consecutive weeks, on which readings were recorded. Repeated measures ANOVA was used.

Results: Smartphone use increased for first week, then showed gradual decline over weeks 2, 3 and 4 but again a small rise in week 5. THINCit scores got better over five weeks. The cognitive performance increased in last week but the growth is very minimal. With the exception of CRT (Choice Reaction Time Test) at week 2 [r=0.43, P=0.03], 3 [r=0.47, P=0.02] and 5 [r=0.50, P=0.001], no other statistically significant correlation emerged.

Conclusion: Cognitive functions and smartphone use in minutes have an inverse relationship when studied for short time span. However, this study offers mixed findings on the exact nature of relationship between smartphone use and cognition. Social and environmental stressors play a significant role in mediating this complex relationship.

Dancing Delirium Due To Scorpion Sting – A Rare Neuropsychiatric Sequelae

Saikrishna Yadav Anna, Sravanthi Penubarthi, Srinivas Kandrakonda, Vishwak Reddy Vatte

Department of Psychiatry, Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Telangana State.

Abstract: Scorpions have adapted to diverse environments and are found mainly in tropical and sub-tropical countries. Scorpion stings are primarily due to accidental contact with a scorpion. Scorpions can inflict fatal stings on humans. Delirium is a nonspecific syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behavior, emotion, and the sleep-wake cycle.

We report a case of a 70-year-old female who presented to casualty one day after getting stung by a scorpion. She presented with altered sensorium, acute severe psychomotor agitation, persecutory ideas, not recognizing family members, and visual hallucinations. CNS examination showed no focal neurological deficits. No history of any physical or psychiatric comorbidities were present. Blood investigations and neuroimaging were done to rule out metabolic causes /organicity. All the test results revealed to be within normal limits. Based on history, examination, and investigative findings, the case was diagnosed with delirium and was assessed periodically with Delirium Rating Scale (DRS), which at the time of admission was 25. The patient was under observation, Inj.Olanzapine 2.5mg IM and Inj. Lorazepam 2mg IM were administered 8^th hourly on day one and 12^th hourly on day 2. On day three, she was discharged as there was no altered sensorium, psychomotor agitation completely reduced, DRS was 3, and no psychiatric symptoms were observed. For efficient management of such cases, there is a definite need to enlighten about this rare presentation, especially in tropical rural medical centers.

Delirium, scorpion sting, DRS

Comparison of psychiatric co-morbidities and quality of life in patients with epilepsy and psychogenic non-epileptic seizures

Dr Sandeepta Ghosh

Background: Epileptic Seizure is intermittent disturbance of consciousness, behavior, emotion and motor function resulting from cortical neuronal discharge. Psychogenic non-epileptic seizures (PNES) are episodes that superficially resemble epileptic seizures, but lack abnormal neuronal activity in EEG. Significant correlation noted between clinical symptoms & psychiatric co-morbidities and quality of life (QoL) in both group of patients.

Aims: To compare the prevalence of psychiatric co-morbidities and QoL in patient with epilepsy (PWE) and PNES, and to assess the relation of sociodemographic factors affecting psychiatric co-morbidities and QoL.

Methodology: In this hospital-based descriptive cross-sectional study, 38 and 22 patients of epilepsy and PNES have been included.

Results:Higher prevalence of PNES was seen in women (77.3% vs 28.9%) and with recent adverse life events (27.3% vs 2.6% in PWE). Longer duration of illness seen in epilepsy (p <0.001). Major Depressive Disorder was higher among person with PNES (PWPNES) (Chi = 9.468, p = 0.024), whereas Trait Anxiety was higher among PWE (Chi= 3.951, p = 0.047). SOFSE score found no significant difference in Social and Occupational function (p = 0.654) but QOLIE-31 scale shows better QoL in PWE in comparison to PWPNES (p = 0.038).

Conclusion: It is pertinent to look for psychiatric co-morbidities and QoL in these patients and implement proper management protocols to improve their functionality as the psychiatric co-morbidities are found to impact their occurrence.

E-Poster Presentation

Dr Sanjana K, Dr Bhagyavathi H D

Institute: Mandya Institute of Medical Sciences, Mandya-571401.

Intravenous Ketamine Infusion for Treatment-Resistant Major Depressive Disorder with Generalized Anxiety Disorder with High Suicidal Risk In Elderly Patient- Case Report

Background: Several clinical studies suggest that ketamine is not only effective in treatment-resistant patients but also has significant anxiolytic properties.

Aim:

• To study the efficacy of Ketamine in Treatment-Resistant Depression with comorbid Anxiety

Case Description:

• A 65-year elderly female patient, presented with long-standing Major Depressive Disorder and Generalized Anxiety disorder for more than 20 years with Diabetes Mellitus and Hypothyroidism.

• On objective assessment, her Hamilton Depression score (HAM-D) was 28 and Hamilton Anxiety (HAM-A) score was 15.

• Even after 3 cycles of ECT, she continued to have depressive and anxiety symptoms with persisting suicidal thoughts.

• In view of high suicidal risk, Ketamine infusion was started.

Method:

• Ketamine infusion treatment (0.5 mg/kg) was given at the rate of 2.5 ml/min over 45 minutes.

• Total 6 infusions given every alternate day.

Results:

• A positive improvement was noted in the patient within 24 hours of 2^nd infusion.

• HAM- A:1, HAM-D:2 at discharge.

• The patient was followed up in OPD once a month(HAM- A:0, HAM-D:0 consistently for 6 months)

Conclusion:

• Ketamine leads to increased production of brain-derived neurotrophic factor (BDNF) and mammalian target of rapamycin complex 1 (mTORC1), both of which are decreased in patients with major depression.

• We have shown ketamine infusion successfully replaced ECT with no cognitive impairment observed and lower health expenses.

A Case of Amilsulpride-induced Mania in a patient of Schizophrenia - A Rare presentation

Dr Shivani Hatgaonkar

Introduction: Amisulpride is an atypical antipsychotic used for the management of schizophrenia and other psychotic disorders. Though there have been previous reports of atypical antipsychotic induced mania or hypomania, amisulpride induced mania has been rarely reported. Here is a case of schizophrenia who developed a manic episode while on amisulpride treatment. This case suggests that use of amisulpride should be judicious as it poses a risk of drug induced mania in susceptible individuals.

Case presentation: A 21 year old Hindu unmarried male, from rural background, presented with complaints of decreased sleep, withdrawn behaviour, hearing of unreal voices, fearfulness & suspiciousness since last 2 months following stressor. Patient had recently been admitted at a private hospital for 8 days and given medication (however details of treatment were unavailable), patient perceived around 50% improvement in symptoms, however the medication was discontinued since last 10 days and patient again became symptomatic and brought to us. He was admitted in the psychiatry ward and all routine investigations (CBC, LFT, RFT, ECG) were done. Patient was started on T. Olanzapine (7.5 mg increased to 10 mg) in view of psychotic features and T. Lorazepam (2 mg) HS in view of sleep disturbances. However as patient showed persistent negative symptoms of withdrawn behaviour, affective blunting, avolition etc. he was started on T.Amisulpride (50 mg) on day 12 of admission. After three days of giving T. Amisulpride (50 mg), patient developed sudden onset manic symptoms in the form of increased sense of well-being, irritable mood, overtalkativeness, aggressive behaviour, increased activity, distractibility and patient’s Youngs Mania Rating Scale (YMRS) score came to 28/60 on day 15 of admission, following which T. Amisulpride was stopped and T. Olanzapine was gradually uptitrated to 20 mg and patient was posted for a series of 6 modified ECTs in view of aggression and risk of harm to others. On above treatment, patient’s manic and psychotic symptoms resolved gradually and he showed good response. The YMRS score came down to 2/60 on day 25 of admission. However, as patient again started showing negative symptoms, T.Aripiprazole (5 mg) OD was started with caution along with the ECTs, on which his affect was improved and he started interacting well with relatives. Patient showed significant improvement on the above treatment and was discharged after a duration of 30 days.

Discussion: The benzamide derivative amisulpride shows a unique therapeutic profile being antipsychotic, at high doses, and disinhibitory, at low doses, while giving rise to only a low incidence of extrapyramidal side effects[¹]. It is a second-generation antipsychotic that preferentially binds to dopamine D2/D3 receptors in limbic rather than striatal structures. High dosages preferentially antagonise postsynaptic D2/D3 receptors, resulting in reduced dopamine transmission, and low dosages preferentially block presynaptic D2/D3 receptors, resulting in enhanced dopamine transmission[²]. So, at low doses, amisulpride leads to an increase in dopaminergic activity, which could explain the onset of manic symptoms [³]. Literature from 2004 to 2010 disclosed 16 reports of atypical antipsychotic-induced mania/hypomania. These reports included a total of 28 cases of induced manic or hypomanic symptoms following treatment with olanzapine (seven cases), quetiapine (five cases), ziprasidone (five cases), aripiprazole (four cases), amisulpride (two cases), zotiapine (two cases), perospirone (two cases) and paliperidone (one case). The search has not revealed any cases of manic/hypomanic symptoms associated with the prototypical atypical antipsychotic clozapine. Twenty-four patients suffered from schizophrenia and four had schizoaffective disorder (bipolar type in three of them and atypical depression in one). About 68% of the cases presented a manic episode and the others, hypomanic episode. The time of onset was very variable from 1 day to 3 months (in several cases the dose of atypical antipsychotic was increased just prior to such period). In the majority of cases, improvement or remission was observed following atypical antipsychotic withdrawal; in others, dose reductions were sufficient [⁴]. The sudden development of mood symptoms in this Schizophrenia patient following initiation of Amisulpride, and its gradual resolution on stopping Amisulpride and initiating ECTs led us to think of the causal relationship between the two.

However, more literature is required in this field.

Perinatal Catatonia: A Case Report

Dr.Shruti Zunzunwala, Dr. Shruti Zunzunwala, Dr. Surabhi Sharma, Dr. Prerna Kukreti,

Postgraduate Student, Department of Psychiatry and Drug Deaddiction Centre, Lady Hardinge Medical College, New Delhi, India- 110001, Email ID- shrutiii.zun@gmail.com, Phone No.: 7972427846,Postgraduate Student, Department of Psychiatry and Drug Deaddiction Centre, LHMC, Senior Resident, Department of Psychiatry and Drug Deaddiction Centre, LHMC, Associate professor, Department of Psychiatry and Drug Deaddiction Centre LHMC,

Introduction: Catatonia is a psychomotor syndrome typically characterized by mutism, stupor, catalepsy, stereotypies, and mannerisms. Catatonia is less described in the context of pregnancy or the postpartum period. Indian case series described 13 patients who received ECT for catatonic agitation in a cohort of 78 patients psychiatrically hospitalized for postpartum psychosis, yielding a prevalence of 16.7% in that population.

Case Presentation: Mrs. S, a 28-year-old female, P6L6, 15 days postpartum, presenting with social withdrawal, persecutory ideas, hallucinatory behaviour since past 4 years with mutism, staring, poor oral intake, posturing, disturbed biological functions since past 1 month. She had disturbed vitals, pressure sores on buttocks, dehydrated tongue and was underweight. History of spontaneous pre term delivery under unhygienic conditions was revealed. History of similar catatonic symptoms during her previous pregnancy. Patient was admitted in psychiatry inpatient unit. Her Brush Francis Catatonia Rating Score improved by 50 percent on lorazepam challenge test. Investigations revealed Hep C positive status along with hypoalbuminemia. Patient was medically stabilised and treated with benzodiazepines and modified electroconvulsive therapy during the ward stay. Unfortunately, the neonate at patient’s residence at village, had demise on day 20 postpartum.

Conclusion: In this case, there were adverse effect to the health of the fetus and mother due to catatonia in perinatal period. Catatonia can carry significant risks of medical complications for the fetus as well as the mother, especially if symptoms are prolonged.

CAN ARACHANOID CYST CAUSE DISSCOIATIVE MOTOR DISORDER ? A CASE REPORT

Dr Siddharam S

Dr Manoj Shettar, Dr Arun Gadad, Dr Sachin B S, Dr Girish Babu,Dr Abhay Matkar

CASE SUMMARY-

15 year old boy who was a case of communicating retrocerebellar arachnoid cyst presented with insidious onset of headache, sadness, reduced interest in studies, reduced appetite and episodes of fearfulness since 6 months with acute onset of difficulty in walking since 3 days. He had no past history or family history of psychiatric illness. Examination revealed astasia abasia gait, reduced psychomotor activity, reduced speech, depressed affect. A diagnosis of moderate depressive episode with dissociative motor disorder was made. He was treated with Supportive psychotherapy and escitalopram 15mg per day with complete remission of symptoms. Therefore, it is important to differentiate symptoms arising out of organic etiology and psychiatric disorder.

Neuroimaging reveled presence of communicating retrocerebellar arachnoid cyst was detected.

KEYWORDS-Arachanoid cyst,Depression,Dissociative motor disorder

BACKGROUND: Delusional Parasitosis or Delusion of Infestation is characterized by a belief of infestation by small but macroscopic organisms along with tactile hallucination. It is a common disorder in South Asian cultural context.

AIM: To describe psychopathology and management of a case of Delusional Parasitosis.

CASE: A 71 year old married male presented to dermatologist with a one year history of intense scalp itching mostly over parieto-occipital region with sensation of crawling of small insects perceived to be 1-2 inches long, of varied color mostly red headed with black body , which he described by sketching them. The patient believed that the insects had burrowed into his scalp and skull bone and laid multiple white eggs resulting in nodes on his scalp. To exterminate the insects, he used multiple ointments, herbicides, antibiotics, even kerosine oil and shaved his head . Systemic physical examination revealed no remarkable findings except multiple infected scalp wounds measuring 2 cm × 1cm in the parieto-occipital region with no evidence of insect or lice. The patient was referred to Psychiatry OPD. Mental Status Examination revealed irritable affect with restricted range, Delusion of Infestation, Tactile Hallucinations with impaired judgement and absent insight. Montreal Cognitive Assessment Score was 29/30. The patient responded to low dose oral Risperidone with complete remission in 2 months.

DISCUSSION: Clinical presentation and challenges in management due to poor insight and late psychiatric consultation will be discussed.

CONCLUSION: Accurate diagnosis and appropriate management can result in good outcome, even in the elderly.

Marfans with schizophrenia -A case report

Introduction

Marfan Syndrome (MFS) is an autosomal dominant disorder characterized by connective tissue defects in multiple organ systems. The lifetime prevalence of MFS is two to three per 10,000 . Interestingly, cases of patients with MFS and schizophrenia have been reported. The following case illustrates the co-occurrence of schizophrenia in a child with Marfan Syndrome.

Case report

A 15year old boy who presented to psychiatry OPD with symptoms of laughing to self, talking to self and social withdrawal. He was diagnosed as schizophrenia based on history and PANSS scoring. Marfan was confirmed by clinical examination with the following findings wrist sign, thumb sign, pes planus, arm span 165 cm, pectus carinatum, rigidity, upper segement:lower segment ratio was reduced.

Discussion

Schizophrenia is the most common psychiatric illness in marfan. It is possible MFS results from a defective fibrillin or other microfibril protein component with pleiotropic developmental effects on target tissue including the brain with associated TGF-β alterations that ultimately lead to schizophrenia. Mostly it appears in late adulthood but here the rare presentation with early adulthood.

Conclusion

MFS patients should be monitored for psychiatric illness and patient with signs of marfanoid features should be looked in early stages for appropriate medical care. Better understanding with the syndrome and psychotic illness can lead to screening in early ages and treatment can be provided.

C-L Psychiatry in Functional & Inflammatory Bowel Disease

DR SURYA PRATAP SINGH CHAUHAN¹, DR SUVARAN SAGAR BAJPAI² DR RAM GHULAM RAZDAN³

(1,2=PG Resident, 3=Professor & Head)

Background-

Shrinks working in academic settings may have limited interaction with IBD patients and feel less than equipped to deal with the multifaceted issues that arise. IBD affects approximately 17% of the population and a great majority of these patients may benefit from psychiatric intervention. Prescribing for these patients can be complicated and overwhelming, resulting in fewer providers and lower quality care.

AIM- To better edify therapists in plateful these thought-provoking patients and feeling contented working with their gastroenterology colleagues.

METHODS- A literature review was conducted using Pubmed, Psychosomatics, and the Levenson text, searching for current information on treatment of patients with IBD and or IBS symptoms to understand a better consensus of treatment recommendations and to better understand current work on the brain gut axis.

RESULT AND DISCUSSION-In reviewing the current works in psychiatric care of IBD patients, TCA remain the most studied and utilized antidepressants in this population. TCAs and CBT may lessening the activation of the pre frontal cortex and registration of pain in stressful situations. There may also be room to use Bupropion secondary to the effects on Dopamine and Norepinephrine as well as on inflammatory markers. As psychiatrists we can be a part of the treatment and care of these patients with both psychopharmacological intervention as well as psychotherapy.

Sexual Dysfunction Among Alcohol Dependence Disorder Male Patients

DR SUVARAN SAGAR BAJPAI¹, DR SURYA PRATAP SINGH CHAUHAN²,

DR RAM GHULAM RAZDAN³

(1,2=PG Resident, 3=Professor & Head)

Background :

Most persons prefer alcohol before sexual activity due to its disinhibiting property and alcohol is believed to be a powerful sexual facilitator and aphrodisiac. Chronic alcohol abuse is a well-known factor, which induce sexual dysfunction. DSM-V has a separate entity as substance induced sexual dysfunction.

Aim :

Study the prevalence & pattern of sexual dysfunction in Alcohol Dependence Disorder in male patients.

Material & Methods :

Cross-sectional Case-control study of 40 male patients admitted in psychiatry ward at IMCHRC for deaddiction and 40 controls from OPD male patients came for sexual dysfunction consultation. Alcohol Dependence Disorder & sexual dysfunction diagnosis was made on basis of DSM-V. Data collected through Socio-demographic Questionnaire, AUDIT, IIEF & PEDT.

Result :

In both groups around 50% of subjects belong to age less than 35 yrs. All participants belong to rural area and are hindu . Majority (65% )of subjects were illiterate and rest were upto graduate. 60% of subjects were daily wagers. 20 patients [50%] who had alcohol dependence had erectile dysfunction and 12 persons [30%] among control has erectile dysfunction. Majority of cases [55%] and controls [60%] had no premature ejaculation.

Conclusion :

Prevalence of sexual dysfunction is significantly high among persons with alcohol dependence comparing with non-alcoholics. Erectile dysfunction is not significantly higher for persons with alcohol dependence than controls. Premature ejaculation is the most common sexual dysfunction among controls.

CASE REPORT: SCRUB TYPHUS WITH PSYCHOSIS

Swati C¹, Hemendra Singh²

¹Department of Psychiatry, St. John’s National Academy of Health Sciences, Bangalore-560034, Karnataka, India.

²Department of Psychiatry, Ramaiah Medical College and Hospitals, Bangalore-560054, Karnataka, India.

Introduction: Scrub typhus is a vector borne febrile illness caused by Orientia tsutsugamushi. Psychiatric manifestations in the absence of organic pathology associated with scrub typhus are rare.

Case report: Here is a 20-year-old female who had acute febrile illness which was diagnosed as Scrub typhus which was treated with Doxycycline and paracetamol. Within 1 week of onset of illness patient developed visual hallucinations, auditory hallucinations, persecutory delusions, and referential ideation. Lab investigations including CSF analysis and MRI brain ruled out organicity. Diagnosis of acute psychosis was made and treated with risperidone.

Discussion: Similar to previously reported cases patient developed psychotic symptoms within 2 weeks of febrile illness diagnosed to be scrub typhus. Visual hallucinations seem to be a common presentation in Acute psychosis associated with scrub typhus.

Conclusion: Acute psychosis is a rare complication of scrub typhus which may require independent treatment.

OPIOID WITHDRAWAL DELIRIUM : A CASE REPORT

Dr Tanisha Pruthi , Postgraduate student , Department of Psychiatry and Drug Deaddiction Centre , Lady Hardinge Medical College , New Delhi -110001

Email ID- tanishapruthi@gmail.com

Phone No. 9818139133

Dr Tanisha Pruthi , Postgraduate student , Department of Psychiatry and Drug Deaddiction Centre , LHMC

Dr Bushra Zahoor , Senior Resident , Department of Psychiatry and Drug Deaddiction Centre , LHMC

Dr Sajjadur Rehman , Specialist , Department of Psychiatry and Drug Deaddiction Centre , LHMC

OPIOID WITHDRAWAL DELIRIUM : A CASE REPORT

INTRODUCTION: Opioids are one of the commonly abused substances in India. Opioid withdrawal symptoms classically include severe muscle cramps, bone aches, autonomic symptoms, anxiety, restlessness, insomnia, and temperature dysregulation. However, reports of cases with delirium during withdrawal are few. This case illustrates the need for psychiatrists and physicians to be aware of the possibilities of delirium with opioid withdrawal and monitoring for the same is important because of its complications.

CASE REPORT :

A 39 year old male patient presented to the LHMC Psychiatry Department , with symptoms suggestive of delirium , who developed opioid withdrawal symptoms prior to the delirium.

The last use of opioid was 7 days before the onset of the symptoms , which was followed 6 hours later by 2 episodes suggestive of generalised tonic clonic seizures. The patient developed symptoms suggestive of Catalonia . BFCRS scale was applied and the score came out to be 16 following which the patient showed improvement on 2mg Lorazepam . No other past psychiatric , family history or any other comorbidity was found.

DISCUSSION :

Opioid withdrawal is generally thought to be uneventful but there are some reports of opioid withdrawal seizures, delirium5and both seizures and delirium in patients having sudden abstinence after periods of daily use. A remote possibility of using adulterated opium could be a probable risk factor in both cases. A close watch should be kept while managing patients with opioid withdrawal in view of the possibility of withdrawal delirium so that this potentially life threatening complication could be detected and treated in time.

A Case report of Apeirophobia

Dr Ram Ghulam Razdan¹, Dr Tanul Jain²,

Dr Surya Pratap Singh Chauhan³, Dr Suvaran Sagar Bajpai⁴

(1=Professor & Head; 2,3 & 4=PG Resident)

In Apeirophobias one comes to the realization that after death you will live forever. This experience is inherently anxiety provoking. People suffering from apeirophobia struggle to grasp infinity and confess their uncertainty about what happens after death.

So here I am presenting an interesting case of Apeirophobia about a 46-year-old Muslim male postgraduate business-man who was brought to the psychiatry OPD of Index Medical College and hospital by his wife with complaints of extreme feeling of worry about what will happen to him after death as he overheard the conversation of two people in a funeral of neighbour that after ceremonial burial soul lives forever and goes to heaven or hell as per their deeds during their lifetime. Since then, he was continuously thinking about his afterlife and excessively worried about it which interfered with his personal, family and professional life. These complaints were associated with irritable behaviour, motor restlessness, reduced concentration, forgetfulness, disturbed sleep due to nightmares and reduced appetite. These symptoms persisted since last 6 months and worsened over time. After MSE, we found that patient was conscious and oriented with worried look on his face, not able to sit steadily on chair, speech was normal tone, soft voice, raised volume and decreased reaction time, communicable, comprehensible, goal directed. mood was anxious and worried, and affect was congruent to mood. His mind was clouded with worrying thoughts and overvalued ideas about the afterlife and insight was partial. He was started on antidepressants and anxiolytic tablet paroxetine 12.5 mg for 5 days then dose was increased to 25 mg at bed time with tablet clonazepam 0.5 mg at bedtime and SOS for 2 months and non-pharmacological intervention, cognitive behavioural therapy and insight-oriented psychotherapy. With pharmacological and non-pharmacological management, patient improved and was kept in follow up in OPD. So here I am presenting the case of Apeirophobia (Specific Phobia) diagnosed on the basis of DSM-5.

“GAMING DISORDER PREDOMINANTLY ONLINE” ,A case report.

Dr.Tapendra Kumar Satpathy, Dr.Rasmita Behera, Dr. Seema Parija

SCB MEDICAL COLLEGE AND HOSPITAL MHI,CUTTACK,ODISHA.

BACKGROUND-GAMING disorder predominantly online (ICD 11 -6C51.0) is characterised by a pattern of persistent or recurrent gaming behaviour that is primarily conducted over the internet manifested by 1.Impaired control over gaming(eg.onset,frequency,intensity,duration,termination,context)

;2.Increased priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities ; and 3.Continuation or escalation of gaming despite the occurrence of negative consequences with significant impairment in personal ,family,social,educational,occupational,over period of at least 12 months.

CASE REPORT: Index patient JRN , a 17 years old male from middle SES,a +2 2^nd year science student,from Jharkote,Nayagarh with premorbid personality well adjusted and sociable type before ,with no past h/o any psychiatric disorder in self or in family members,came to MHI opd on 21.07.22 with parents ,with complaints of Inattentive and careless attitude,increased interest in online gaming over phone,violent and aggressive behaviour in trivial matters over last 2 years , significant decrease in academic performance over last 1 years .Precipitating factors – increase use of mobile phone and decresed outdoor activities during lockdown period.General and systemic examination found to be normal. On MSE patient is anxious,irritable during interview,ETEC -present but fleeting,attitude cooperative,rapport

established,thought content-preoccupied with thought of how to procure mobile phone and will play online game FREEFIRE.

CONCLUSION ;Diagnosis of Gaming Disorder is made after excluding all other likely disorders.Patient was evaluated in detail , abstinence therapy, motivational

interview,cognitive behavioural therapy administered to patient , positive parenting therapy to parents were given and patient was improved a lot at the time of discharge and also during follow up sessions.

References- 1.The ICD -11 Classification of Mental and Behavioural Disorders.

2. Kaplan and Sadock’s SYNOPSIS of Psychiatry

CASE REPORT OF FEMALE DHAT SYNDROME

INTRODUCTION – Dhat syndrome is common in Indian male patients. There are only few reports of female equivalent of dhat syndrome. In females passage of whitish vaginal discharge is associated with multiple somatic and psychological symptoms.

CASE DISCUSSION – 27 year old female patient came with complaints of passage of watery, nonfoul smelling, scanty vaginal discharge , preceded most of the times by sexual desire and associated with multiple somatic and psychological symptoms. Patient believes her symptoms are mainly due to vaginal discharge. Medical and gynecological examination was normal. Speaking about sex was restricted at her family before marriage. Her family members hold the same belief about vaginal discharge as patient.

MANAGEMENT – Diagnosed as F48.8 (other specified neurotic disorders). Psychoeducated. Tablet sertraline was started with 50mg OD, increased to 100mg after 15 days. Tablet clonazapam 0.25mg at night was given for a week. Patient reported of 5-10% improvement in symptoms after a month.

DISCUSSION – Patient considered her symptoms are mainly due to vaginal discharge. Significant contribution from family member’s attitude towards sex and belief about vaginal discharge is present. SSRI and psychoeducation seems to be helpful.

A RETROSPECTIVE ANALYSIS OF PATIENTS POSTED FOR ECT IN A TERTIARY CARE CENTRE

BACKGROUND; ECT is an important part of therapeutic intervention in contemporary psychiatric practice. ECT has clearly defined indications, demonstrated efficacy and safety, well known side-effects and established standards for optimal practice. With accumulation of greater knowledge, ECT has developed into a complex treatment requiring psychiatrists, anaesthesiologists and frequently other medical specialists.

AIM; to evaluate sociodemographic details and clinical parameters of patients posted for ECT in a Tertiary care centre, Bagalkot.

METHOD; A retrospective review was carried out to identify patients who had received ECT in the period January 2019 to October 2022. During the study period, complete records of 61 patients were available. Details regarding their sociodemographic and clinical parameters were extracted from these records.

RESULTS; the mean age of study sample is 32.38 ± 8.52 years of which 32[52.5%] are male. 23%[n=14] of patients were diagnosed as paranoid schizophrenia using ICD 10 criteria. Most common indications were augmentation[n=16, 26.2%] and acute manic symptoms [n=16, 26.2%]followed by active suicidality[n=13, 21.3%]. 36.1%[n=22] of the study population had previously received ECT. The mean value of Hb is 12.50±1.71, RBS is 111.25±27.30, S. creatinine is 0.91±0.19, S. sodium is 139.48±3.47.

CONCLUSION; this study shows that augmentation and acute manic symptoms are most common indications. Almost one third of patients had previously responded to ECT. A medical history, physical examination and appropriate laboratory investigations are necessary in order to detect any significant medical illness prior to the administration of ECT.

A case of very early onset Trichotillomania

Dr. Vishwa Thakkar¹, Dr. Manish Thakre², Dr. Sudhir Mahajan³, Dr. Pranjalee Bhagat⁴, Dr. Prashant Tiple⁵. Department of Psychiatry, Government Medical College, Nagpur

1. Postgraduate, Department of Psychiatry, Government Medical College and Hospital, Nagpur

2. Professor, Department of Psychiatry, Government Medical College and Hospital, Nagpur 3.Assistant Professor, Department of Psychiatry, Government Medical College and Hospital, Nagpur

4. Assistant Professor, Department of Psychiatry, Government MedicalCollege and Hospital, Nagpur

5. Professor & Head, Department of Psychiatry, Government Medical College and Hospital, Nagpur

BACKGROUND

Hair pulling disorder. (Trichotillomania) is a disabling condition characterized by essential criteria of recurrent hair pulling resulting in noticeable hair loss. Individuals who have symptoms before 6 years of age are uncommon and classified as very early onset “trichotillomania”. The literature on very early onset Trichotillomania is sparse contributing to poor understanding of this variant.

AIM

To present the case of a 4-year-old female child with very early onset Trichotillomania, who improved with pharmacological as well as behavioural intervention.

CASE SUMMARY

This case presents a 4 year old female brought by her mother with complain of hair pulling since 1 year resulting in a bald patch over her right scalp. Patient was admitted in the Psychiatry ward for detailed evaluation.Patient was started on syp.Fluoxetine 1.5 ml OD along with behavioural modification which involved token economy in the form of giving her an apple at the end of each day if she kept the gloves in her hand.

CONCLUSION

The above case highlights the presentation of a very early onset Trichotillomania and how pharmacological and behavioural management together helped in improving the condition.

hair pulling, behavioural modification

Acute Memory loss in a 49 year old Woman with Mixed Anxiety Depression and Post-Menopausal Irritability: A rare case report

Dr Aakash Ponda. Dr. Darpan Kaur, Dr Adarsh Singh, Dr. Dhvani Satija, Dr. Rakesh Ghildiyal

Department of Psychiatry, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai

Background

Memory problems can occur in depression, anxiety, post-menopausal syndrome and on certain medications.

Aims and objectives

We describe a rare case of a 49-year-old woman who had sudden onset of acute memory loss in a known case of mixed anxiety depression.

Method

Mrs. XYZ ,a 49-year-old married female, a known case of mixed anxiety depression, well maintained on Tablet Escitalopram 10 mg hs and Tablet Clonazepam 0.5 mg 1 sos since 2 years and reported some irritability during a recent follow-up for which she was started on Tablet Oxcarbazepine 150 mg HS by a consultant psychiatrist who felt it to be related to the mood disorder. During the next follow-up after 1 month, she reported subjective improvement in her irritability ,however, she had a subjective complaint of acute memory loss since last 1 month .MMSE score was 24 .History was reclarified and her last menstrual period was reported to be 3 months ago. Referral to the gynaecology departments was made where she was diagnosed with post menopausal syndrome and advised lifestyle modifications. Neurological evaluation was normal. Literature was reviewed and a clinical decision to explore reduction in the dosage of Tablet Oxcarbazepine and gradual tapering of the drug was made. Subsequently after 4 weeks she reported an improvement in her subjective symptoms, MMSE score (30) and is doing well.

Conclusion

Multiple factors can link to such symptoms. A systematic stepwise approach, re-looking the history, exploring associations, reviewing literature, trying multidisciplinary approaches and rationalization of medications may be helpful.

Case of Intellectual Disability due to Pantothenate Kinase-associated Neurodegeneration

Pantothenate kinase-associated neurodegeneration is a type of neurodegeneration with brain iron accumulation. Classic PKAN is has early-childhood onset of progressive dystonia, dysarthria, rigidity, Intellectual disabilities. Atypical PKAN is characterized by later onset with speech defects, psychiatric disturbances.

Case Presentation: Mr.J 9yrs male belongs to sikh family resident of Punjab, presented with an illness insidious onset and continuous in nature. The patient was maintaining well in school 2 years back when he started to have a decline in academic performance. The teachers of the school would also complain that the patient would be less attentive in class unlike his usual self. The mother noticed that the patient was not able to recollect his school assignments a day later.In the first semester of class 3 patient scored 81%which dropped to 40% by 2^nd semester and 35 percent in the 1^st semester of 4^th class. He would have frequent falls for which mother would term the patient to be clumsy. For the past 2 years also would pass stool or urine at night, which had increased for the past 6 months to almost twice a week. A private practitioner put the patient on atomoxetine for the complaints of inattentiveness but there was no improvement, after which the patient was referred to GMCH.A neurological examination showed an extensor toe. An MRI was planned which was suggestive of PKAN.

Discussion: This case illustrates the presentation of Classical PKAN at a relatively later age with intellectual disability as presenting complaint.

Schwartz Bartter Syndrome in a patient of Alcohol Dependence Syndrome in Withdrawal delirium.

1)Dr Aastha Mishra, Resident, Department of Psychiatry, GMCH, Guwahati.

Email: aasthamishra11@gmail.com

Phone: 6388093422

2)Dr Deepanjali Medhi, HOD, Department of Psychiatry, GMCH, Guwahati.

1)Dr Aastha Mishra, Resident, Department of Psychiatry, GMCH, Guwahati.

Email: aasthamishra11@gmail.com

Phone: 6388093422

Background: Rising alcohol concentrations in body inhibits the secretion of Anti Diuretic Hormone which causes augmented diuresis whereas in acute withdrawal state inappropriate rebound secretion of ADH occurs causing increased water retention and dilutional hyponatremia.

Aim:

1-To understand neuroendocrinological mechanisms of development of Schwartz Barter syndrome in ADS.

2-To ensure early diagnosis and prompt yet careful management to reduce mortality rate due to overcorrection of hyponatremia.

Case report:

A 46yr old male admitted with symptoms of hand tremors, decreased sleep followed by irrelevant talking, inability to identify family members and confused behaviour for 2 days after stopping alcohol intake 6 days ago. Patient had been consuming alcohol for 20 years. He started consuming alcohol 2-3 times/week initially which increased gradually to 750 ml IMFL/day for last 6yrs with early morning drinking for last 3yrs with a past history of seizure with fall 1yr back.

On MSE, patient was disoriented to time, place, person and found to have low Serum Sodium levels (lowest value-118mg/dl) and treated with salt capsules, 3% hypertonic saline infusion and fluid restriction but hyponatremia persisted.

Patient was suspected to have SIADH and endocrinology opinion was sought and patient was then started on Tab Tolvaptan (ADH antagonist).

Result- Significant improvement was seen in him clinically and the patient attained normal values of Sodium (138 mg/dl) within 7 days of starting Tolvaptan.

Conclusion- Hyponatremia is a common manifestation in patients of alcohol withdrawal syndrome due to excessive diaphoresis but this hyponatremia when fails to get corrected by usual modes of treatment, should raise the suspicion of atypical causes of hyponatremia such as SIADH which can help clinicians to take judicious measures in time.

Ketamine use disorder, a case report

Background: Ketamine is a dissociative anesthetic derived from phencyclidine primarily used for the induction and maintenance of anesthesia, recent studies have shown it to be useful in multiple other roles such as an antidepressant and as an adjunct in substance use disorders. With its use gaining a foothold, it has also been found to be increasingly used as a recreational drug due to its psychotomimetic and hallucinatory action.

Aim: To highlight an unusual perceptual phenomenon in a case of ketamine use disorder.

Methods: A 38-year-old male presented to the OPD with complaints of insomnia, irritability, anxiety, fearfulness, and a ‘feeling of being slapped’, on trying to consume ketamine after abstaining for 5 days. The patient had been using Ketamine for the past 1 year. Further history revealed the use of alprazolam and a past history of multiple substances such as pentazocine and diazepam. The BPRS scale was utilized to quantify the psychotic symptoms.

Results: The case study revealed the psychotomimetic symptoms in a patient with ketamine use disorder that persisted after withdrawing consumption and possibly inhibited further use as well.

Conclusion: Ketamine hydrochloride gaining prominence as a substance of abuse among the population but can induce schizophrenia-like or psychotomimetic symptoms. The consistency and magnitude of such symptoms induced by ketamine use and withdrawal should be further studied.

Keywords: ketamine, psychosis, perceptual phenomenon, BPRS, SUD

Randomized controlled trial of Transcranial Direct Current Stimulation (tDCS) as an early augmentation in adolescents with Obsessive Compulsive Disorder

Dr. Aditya Agrawal*, Dr. Vivek Agarwal**, Dr. Amit Arya***, Dr. Sujit Kumar Kar***,

Junior Resident*, Professor and Head**, Additional Professor***

Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India

Background: OCD is a common mental illness with a quarter of patients presenting before 10 years of age. Current treatment strategies takes weeks to show response and augmentation with antipsychotics adds to the side effects. tDCS is safe in children and has shown promising results in OCD. Early augmentation with tDCS can improve outcomes in adolescent OCD patients.

Objectives: Study the safety and efficacy of tDCS as an early augmentation strategy in adolescents with OCD.

Methods: Drug naïve adolescents patients aged 10-18 years were screened. Written informed consent was taken. Baseline CY-BOCS scale was applied. Fluoxetine 20mg increased to 40mg was given to all patients and then randomized into active and sham groups. Protocol chosen: cathode – Supplementary Motor Area, anode – right deltoid, 2mA, 20mins, ramp – 20s, 10 sessions were given. Side effects were assessed. CY-BOCS was applied at 2, 6 and 12 weeks again and results were analyzed.

Results: Total 16 patients completed the study (9-active, 7-sham). Both groups showed significant reduction in CY-BOCS score from baseline to 12 weeks but change at baseline vs 2 weeks was significant in active but not in sham group. Mean change at 2 weeks was significantly more in active group (12.89±7.89 v/s 5.28±2.56, p=0.026) but not at 6 weeks or 12 weeks. Remission rates were higher in active group at 2 weeks. Adverse effect between the groups was comparable.

Conclusion: tDCS is a safe and effective as an early augmentation strategy in adolescents with OCD. However, its effects seem to wean off after termination of treatment.

Drug emergent metabolic syndrome in patients on antipsychotic medication

DR ADITYA SHRIVASTAVA¹, DR SURYA PRATAP SINGH CHAUHAN², DR RAM GHULAM RAZDAN³

(1,2=PG Resident, 3=Professor & Head)

Background :

Metabolic syndrome is the term used to define a group of risk factors, which when clustered in an individual, increases the risk for subsequent development of coronary artery disease, type 2 diabetes mellitus and stroke. The metabolic syndrome comprises of central obesity, elevated cholesterol and triglycerides, impaired glucose tolerance and increased blood pressure. Studies have also shown that there is a higher risk of metabolic syndrome in psychiatric populations on antipsychotic medications.

Aim :

Estimate the prevalence and incidence of metabolic syndrome in antipsychotic naive psychiatric population followed up over 3 months.

Methods:

A prospective cohort study was conducted where the prevalence of metabolic syndrome in antipsychotic naive patients coming to IMCHRC OPD was measured at the time of starting antipsychotics and follow up done for 3 months. SDQ, anthropometric measurements, Blood pressure & Blood investigations data were collected for 50 patients.

Results:

The prevalence of metabolic syndrome in antipsychotic naive patients with mental illness was 32%(16). The prevalence of sub threshold metabolic syndrome was 30% when only 2 criteria and 14% when any one of the NCEP ATP III criteria were fulfilled. After 3 months, only 11 patients maintained follow-up till 3 months, and the prevalence was 22%.

Conclusion:

The prevalence of metabolic syndrome in drug naïve patients was found to be comparable to other Indian studies. The prevalence of sub-threshold metabolic syndrome was much higher than previously reported.

Role of Transcranial Direct Current Stimulation (tDCS) in Moderate Depressive Episode after failed Ketamine therapy: A case study

Akanksha Shankar*, Pawan Kumar Gupta**, Sujita Kumar Kar**

Junior Resident*, Additional Professor**

Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India

Background: tDCS is a non- invasive neuromodulation technique which has gained recent attention in management of treatment refractory depressive symptoms.

Method: Miss W, 16-year-old, accompanied by her parents presented in the Psychiatry OPD with complaints of feeling of emptiness for 5 years, acts of self-harm for 3 years, persistent pervasive low mood and loss of interest in previously pleasurable activities for 2 years. There was history of child sexual abuse. The patient had hospitalization twice. In her 2^nd hospitalization, the patient was on Tab. Lithium 600mg/day, Tab. Escitalopram 30 mg/day and Tab. Mirtazapine 30 mg/day. There was static response observed on rating scale (HAM-D 15) and the patient continued to express suicidal ideations and low mood. Following this, the patient was given 6 sessions of Ketamine (4 I.V. & 2 oral) at dose of 30 mg and good response was observed on first 3 sessions only. The patient was then planned for tDCS for the augmenting role.

Result: The patient was given 20 sessions of tDCS in 10 days. Significant improvement was observed. HAM-D score before the start of tDCS was 15 which to reduced 8 after 20 sessions.

Conclusion: In treatment resistant cases of depression, tDCS can be a beneficial augmenting modality

ANGIOEDEMA IN A PATIENT ON SERTRALINE: A CASE REPORT

Dr. Akanksha Shukla, Postgraduate Student, Department of Psychiatry and Drug Deaddiction Centre, Lady Hardinge Medical College, New Delhi, India- 110001

Email ID- akankshashukla950@gmail.com

Phone No.: 9873778749

Dr. Akanksha Shukla, Postgraduate Student, Department of Psychiatry and Drug Deaddiction Centre, LHMC

Dr. Bushra Zhr, Senior Resident, Department of Psychiatry and Drug Deaddiction Centre, LHMC

Dr. Dinesh Kataria, Director Professor & Head, Department of Psychiatry and Drug Deaddiction Centre, LHMC

ANGIOEDEMA IN A PATIENT ON SERTRALINE: A CASE REPORT

Background:

Sertraline is a Selective Serotonin Reuptake Inhibitor, it is generally considered a safe drug and is FDA approved for the management of major depressive disorder. Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. It is mediated by bradykinin, presenting with face and oropharyngeal involvement. There are only few case reports on Sertraline-induced angioedema in the literature.

Objective: To describe a case of angioedema associated with sertraline

Case Report:

Mr. S, a 46-year-old male presented with low mood, decreased interest, easy fatiguability, difficulty concentrating, decreased sleep, episodes of ghabrahat since three months impression of depressive episode was made and patent was started on Tab. Sertraline 50 mg followed by acute onset of swelling of lips after 3-4 hours of first dose. Liason was done with dermatological department and diagnosis of angioedema (Quincke’s edema) was made. No other cause could be found. Sertraline was suspected to be the causative agent and was stopped. Patient was treated with antihistamines and the edema subsided over the next week. Patient was then switched to Cap. Fluoxetine 20mg with subsequent improvement in depressive symptoms.

Conclusion:

According to the Naranjo Adverse Drug Reaction Scale, the probability of association of this adverse reaction with Sertraline was 6 suggestive of probable adverse drug reaction. In this case, the temporal relationship suggests Sertraline as the causative molecule. Our patient had angioedema involving the lips and tongue, which indicates is seriousness. Thus the recognition of such adverse effect requires a high index of suspicion, early recognition, and prompt management. Patients and their caretakers should be warned of symptoms of such adverse reactions when started on Sertaline.

Key Words:

• Angioedema

• Sertraline

• Adverse drug reaction

Post Injection Syndrome with Olanzapine Long Acting Injectable in a patient with Schizophrenia

Dr. Surjeet Sahoo¹ Dr. Sayari Kamilya¹ Dr. Alok Gupta¹

Institute of Medical Sciences and SUM Hospital¹

Key words: olanzapine , long acting injections, post injection syndrome

Background - Long-Acting Injectable Antipsychotics (LAIs) are first-line treatments in non-compliant patients suffering from psychosis. Adverse effects of LAI Olanzapine Pamoate include Post Injection Delirium/Sedation Syndrome. It occurs in less than 0.1% of injections with the said drug.

Aims - To discuss the rare side effect of Long-Acting Injectable Antipsychotic Olanzapine Pamoate, ie, Post Injection Syndrome.

Description - A 29 year old male with a diagnosis of paranoid schizophrenia for 5 years and a history of uneventful intake of oral olanzapine was given long-acting olanzapine (300mg) injection for the first time due to non-compliance to oral medications. The patient became drowsy and disoriented to time, place, and person within 20 minutes of administration. He started hyperventilating and became restless. He was hemodynamically stable but was unarousable for multiple hours (GCS - 6). He had 3 episodes of vomiting and developed hyponatremia (serum Na⁺-123meq/l and Cl^-- 88meq/L). Lorazepam was used to manage agitation. The patient improved after 36 hours and was discharged one day later. He was restarted on risperidone 2mg + trihexyphenidyl 2mg after 15 days on the next visit.

Conclusion - This case is a reminder of the potential risk associated with Olanzapine long-acting formulation. Injections should only be given in a hospital with emergency services, and after injection, 3-5 hours of observation is a must. Patients usually recover within a period of 72 hours.

Organic Delusional (Schizophrenia like) Disorder following Craniopharyngioma

Dr. Anjana.A , Dr. Jai Indiadevi D , Dr Neelakandan.S, Dr Saravana Jothi , Dr. Poornachandrika P

Background:

Craniopharyngioma is a rare, virtually benign tumour of the central nervous system which is an embryonic malformation that can occur in the sellar/parasellar region. It can cause symptoms like headaches, visual disturbances , endocrine disturbances and rarely psychiatric manifestations.

Case report:

A 32 year old male reported to outpatient department with complaints of frequent headaches, sleep disturbances, hearing voices, suspiciousness, talking to self and irritability for the past one year with similar complaints which occurred 8 years ago. Patient had history of craniopharyngioma which was excised in 2015 with secondary hypothyroidism and hypogonadism. Mental status examination revealed persecutory delusions, delusion of control , auditory and visual hallucinations. MRI brain revealed cystic lesion in sella with suprasellar extension suggestive of recurrence of craniopharyngioma. Hormonal assay revealed mild elevation of prolactin levels and Hypothyroidism. A diagnosis of Organic delusional (schizophrenia like) disorder was made and patient treated with T. Haloperidol 10mg, T. Aripiprazole 5 mg, T. Sodium Valproate 400 mg with significant improvement after 1 month of treatment. Endocrinologist and neurosurgery opinion were also sought and patient was started on T. Thyroxine 50 microgram and T. Bromocriptine 7.5 mg.

Discussion:

Psychosis has been rarely reported in craniopharyngioma patients. Temporal association between reemergence of psychosis with recurrence of the tumour points towards organic psychosis. It maybe owing to close relation of craniopharyngioma and frontal-subcortical structures.

References:

1)Ortiz Torres M, Shafiq I, Mesfin FB. Craniopharyngioma. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan

2) Bowers, A.R. and Hughes, L. (2021), Craniopharyngioma presenting with psychiatric symptoms: a case report. Prog. Neurol. Psychiatry, 25: 18-20. https://doi.org/10.1002/pnp.715

Psychiatric presentation of Colpocephaly: A Case Report

Ankit Sinha, Bandita Abhijita

Background

Colpocephaly is an anatomic finding manifested by disproportionately enlarged occipital horns in comparison with other parts of lateral ventricles. Postulated aetiologies include perinatal injuries, genetic disorders, and morphogenesis error. Typically diagnosed in infancy, due to associated intellectual disability, seizures, motor and visual abnormalities, discovery in adulthood is uncommon and has only been reported in nine cases previously. To the best of our knowledge, there is no mention of neuropsychiatric manifestations of colpocephaly in literature till date.

Aim

To report a case of colpocephaly in an adult presenting with depressive disorder.

Methods

A 38-year-old male had symptoms of on and off headache, low mood, pessimistic ideas, anhedonia, disturbed biological functions and passive death wishes since last 6 years and worsening since last 4 months. With no apparent psychosocial stressors, he visited multiple physicians, but had no relief. Magnetic resonance Imaging (MRI) showed an incidental finding of colpocephaly. He visited to our Emergency Department, where detailed neurological evaluation revealed no abnormality. Subsequently, he was referred for psychiatric evaluation. He fulfilled criteria for moderate depressive episode on assessment and was started on Escitalopram 10 mg.

Results

After 4 weeks of treatment initiation, patient showed significant improvement in depressive symptoms and continued follow up under Psychiatry. He remained treatment adherent.

Conclusion

Although patients with colpocephaly often present with neurological manifestations, a small proportion may remain asymptomatic. Colpocephaly with associated callosal abnormalities presenting with psychiatric symptoms have earlier been reported. Knowledge of such clinical presentation is needed to avoid unnecessary investigations and treatment delay.

CLINICAL STUDY OF SLEEP DISTURBANCE AND SLEEP HYGIENE IN CHILDREN AND ADOLESCENTS WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER

Dr.Ankita Devrani¹, Dr Vivek Agarwal² , Dr Pawan Kumar Gupta³, Dr Pooja Mahour³

¹Junior Resident; ²Professor and Head; ³Additional Professor

Department of Psychiatry, King George’s Medical University, Lucknow, U.P

Background: Attention-deficit hyperactivity disorder (ADHD), affects 5% to 7% of school-age children and adolescents. A high prevalence of sleep disturbances have been found in children with ADHD and these impact daytime behavior and cognitive functioning.

Objectives: To study sleep disturbances and sleep hygiene in children and adolescents with ADHD as compared to healthy controls.

Methods: 66 children with ADHD and 50 age and gender matched healthy controls between 6-16 years were recruited. Patients with co-morbidties and mental retardation were excluded. They were assessed on Attention Deficit Hyperactivity Rating Scale (ADHD RS) for severity of ADHD, Child Behaviour Checklist (CBCL) for behavioral and emotional problems, Children’s Sleep Habit Questionnaire to assess sleep problems, Brown ADD scales for executive function, Children’s Sleep Hygiene Scale and Adolescent Sleep Hygiene Scale(ASHS) for sleep hygiene and Children Global Assessment Scale for functioning.

Results: 83% of ADHD children had at least one sleep problem as compared to 38% of controls. Significant differences were seen on bedtime resistance, night wakings, parasomnias, day time sleepiness. sleep onset delay, sleep duration and sleep anxiety. On CSHS significant differences were seen on cognitive, environmental, bedtime routine and sleep stability. On ASHS significant differences were seen on cognitive, bedtime routine and behavioural arousal. Significant correlation was found between total CSHQ and ADHD RS ((ρ=0.4, p=0.001). No significant correlation was found between CSHQ and Brown ADD total T scores.

Conclusion: Among ADHD children, sleep disturbances are common and sleep hygiene is poor . Sleep disturbance is also related to ADHD severity.Further studies using larger sample size and other objective measures like polysomnography can be used in future Indian studies

Obsessive compulsive symptoms in patient with Craniopharyngioma: A case study

Authors: Ankita Saroj*, Sujita Kumar Kar**

Junior Resident*, Additional Professor**

Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India

Background: Craniopharyngioma is a rare, benign, and slow-growing brain tumor. It makes up 1%–5% of primary brain tumours, usually over the sellar and suprasellar region. Headache, increased intracranial pressure, and hydrocephalus are all common symptoms of mass effect. Here we like to discuss a case of post operative craniopharyngioma with obsessive compulsive symptoms.

Method: A adult male presented to outpatient services of department of psychiatry with chief complaints of increased irritability, recurrent repetitive thoughts of contamination and repeated acts of cleaning for one year. His irritability was provoked and would occur whenever he was stopped from his cleaning acts. The patient was a known case of Craniopharyngioma which was diagnosed 2 years back when patient developed symptoms of forgetfulness and blurring of vision for 1 year. Patient was operated and was on medication. Recent neuroimaging showed reoccurrence of tumour growth in intraventricular region compressing the striatal and thalamic region. The patient was started on Tab Sertraline 50mg HS which was increased to Tab Sertraline 100mg Hs after 2 weeks and Tab Risperidone 1mg HS.

Result: The patient was followed after 6 weeks and 10 weeks. The family members reported slight improvement in symptoms.

Conclusion: Brain tumours like Craniopharyngioma may have symptoms of psychiatric disease.

The prevalence, pattern and predictors of psychiatric morbidity in the post flood community in Kerala

Background: Disaster is a severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the affected community. It has been known that disasters place, the affected people under tremendous pressure to cope and adjust under physically and psychologically hostile conditions.

Aims:

1) To estimate the prevalence of psychiatric morbidity in the flood affected population in Kerala.

2) To determine the variables associated with psychiatric morbidity.

Methods: This is a cross-sectional study conducted in two flood affected panchayats of central Kerala. The sample consisted of 1145 aged between 18 to 65 years who were affected directly by flood. Specially designed profroma was used to collect the sociodemographic data. WHO- SRQ and IES-Revised were used to screen for psychiatric morbidity. Volunteers from within the community were selected and trained to administer the questionnaire.

Results : Majority of the sample N=1063 (93%) screened negative for depression. Depression had a significant relationship with a history of psychiatric illness and physical illness. PTSD was present in N= 283 (25%) and had a significant correlation with history of psychiatric illness, family history of psychiatric illness and physical illness. A major limitation of the study was use of screening tools.

Conclusion: This study gives an insight into the high risk group in the background of a disaster. This will help to plan intervention in areas prone to disasters and ultimately in incorporating Mental Health Services as integral component of Disaster Policy.

Partial Empty Sella in patients of Schizophrenia- Case series

Background Empty Sella is a radiological finding suggestive of a flattened pituitary in Sella turcica, filled with cerebrospinal fluid (CSF). It may be primary or secondary due to processes causing injury or shrinkage of gland. It is called partial if less than 50% of Sellar space is filled with CSF. Risk factors for finding and presentation include Female sex, Multiple pregnancies, obesity, hypertension. It could be incidental or may present as symptoms of hypopituitarism. There are case reports from various regions of the world including India on mentioned finding in mental illness including psychosis, mood affective disorders, however association or correlation could not be found in the literature.

Cases We discuss 3 cases, a 38 years old man presented with cannabis use psychotic disorder, schizophrenia- like with duration of psychotic symptoms being 1 month, a 70 years old female with paranoid schizophrenia for 25 years with florid positive symptoms, and a 50 years old female with paranoid Schizophrenia with total duration of illness 15 years, admitted in psychiatry ward where an MRI was done revealing Partial Empty Sella in all 3 cases, with no other abnormal finding

Conclusion Partial empty Sella has been noted in various mental illness as case reports, and we report 3 case studies with the mentioned finding. However, it needs to be studied whether the finding is coincidental or associated with the primary illness, especially Schizophrenia where such non- specific neurological findings are often seen

BACKGROUND: Seasonal affective disorder(SAD) is a subtype of recurrent depressive disorder. Most of patients report variations in mood during both winter and rainy seasons however we report a case where low mood occured every year exclusively during monsoon season.

AIM: To highlight an uncommon presentation of seasonal affective disorder.

METHODS: A 49 year old male presented with history of low mood, decreased appetite, anhedonia and somatic complaints which he experienced at same time of year (during monsoon months of June and July) every year for last 3 years with relief during sunny days and remission at end of season. A formal diagnosis of seasonal affective disorder was made. Seasonal pattern assessment questionnaire (SPAQ) was applied to assess mood along with behaviour changes which showed significant result.

RESULTS: Patient reported to have not taken any treatment in past except symptomatic treatment from a local physician. We started patient on a tricyclic antidepressant (Dosulepin), to which patient responded well although no specific pharmacotherapy has been approved for SAD till date. Recent researches show benefit from light therapy however efficacy has not been proven.

CONCLUSION: We came across an unusual presentation where symptoms appeared only during monsoon season with full remission at end of season. This highlights a possible variant of this disorder which psychiatrists should anticipate especially during monsoon seasons. This also emphasizes need to understand that SAD can occur not necessarily in winters but also almost exclusively in monsoon season in a region where there is high rainfall and mild winters.

ACUTE AND TRANSIENT PSYCHOTIC DISORDER IN A CASE OF PORENCEPHALIC CYST

Dr. Arnab Deb¹, Dr. Munmun Debbarma², Dr. Priyajyoti Chakma³

1= post graduate trainee, 2= senior resident, 3= assistant professor

Department of psychiatry, Agartala government medical college

INTRODUCTION: Porencephaly is a rare disorder of the central nervous system and involves a cyst or a cavity filled with cerebrospinal fluid in the brain’s parenchyma. These cysts may be due to a number of causes including birth injuries to brain causing haemorrhage , local damage from ischemia etc. Clinical manifestations such as paresis, seizures, mental retardation, learning disability and psychiatric symptoms from porencephalic cysts may differ according to localisation. There are only a few case reports of porencephaly and psychosis associations in the literature.

CASE: A 24 years old female with no past and family history of psychiatric illness and no past history of neurological problems started suspecting her family members for causing harm to her and was talking irrelevant things for last 5 days. Her sleep was severely disturbed, she was behaving abnormally and was muttering. She was being abusive and aggressive to the family members. She was found to have paranoid delusions and auditory hallucination. Neurological examination finding was normal. A diagnosis of acute and transient psychotic disorder without acute stress was made as per ICD 10. Her NCCT brain showed ill defined hypodense area in left periventricular white matter and MRI Brain showed porencephalic cyst in left periventricular white matter. EEG showed abnormal electrical brain activity. She was prescribed tablet olanzapine 5 mg and over next 2 follow ups it was increased to 10 mg. within 20 days her symptoms resolved.

CONCLUSION: I could not find any reported case of porencephalic cyst manifesting as psychosis in India from thorough literature search. Porencephalic cyst is a rare CNS finding and majority of the time is asymptomatic. It becomes symptomatic if there is increase in size and mass effect in brain parenchyma, and symptoms are usually based on the location of the cyst. As per literature there is higher chances of psychosis, if located in the prefrontal and medial temporal lobe of the brain. In our case the lesion was in left temporal lobe which may correlate with the development of psychosis. Hence all ATPD cases may require detailed neurological examination and neuroimaging.

A study on patients of Internet addiction disorder- A Case Series

1) Dr. Arun Prasanth. M, Resident, Department of Psychiatry, GMCH, Guwahati. E-mail: marunprasanth95@gmail.com

2) Dr. Bishnu Bashyal, Assistant Professor, Department of Psychiatry, GMCH, Guwahati.

3) Dr. Deepanjali Medhi, HOD, Department of Psychiatry, GMCH, Guwahati.

Dr. Arun Prasanth. M, Resident, Department of Psychiatry, GMCH, Guwahati.

Background: Internet addiction refers to excessive or poorly controlled urge or behaviour to access the internet. According to Young, internet addiction comprises of compulsive behaviours related to any online activity that disturbs normal daily life and induces stress on social relationships. Treatment involves pharmacotherapy and psychotherapy.

Aim: To study three cases of Internet addiction treated in Psychiatry department of Gauhati Medical College and Hospital and in various psychiatric inhouse centres in Guwahati

Case 1: A 15-year old female with complaints of increased time spent in mobile usage, decreased interest in studies, frequent lying, stealing money from home, irritability, frequent altercations with parents, breaking household items, was admitted in Psychiatry ward of Gauhati Medical College and Hospital

Case 2: An 18-year old Male with complains of increased time spent in online gaming, decreased performance in academics, decreased role functions, admitted in a Psychiatric inhouse centre in Guwahati

Case 3: An 18-year old male with complaints of increased time spent in online gaming, decreased role functions, not attending school properly, irritability, demanding behaviour. He was admitted for the same in a rehabilitation centre in 2020, but no improvement in symptoms. His demanding behavior and irritability increased and was physically abusive towards mother, admitted in a rehabilitation centre in Guwahati.

Conclusion: Patients with internet addiction disorder have temperament difficulties. Lack of adequate evidence based data makes it difficult in treating such cases. Hence, research is required to understand various treatment modalities in internet addiction disorder.

Safety of transcranial direct current stimulation (tDCS) in the management of craving in patients of Alcohol Use Disorder: findings from a Randomised Controlled Trial

Arundhati Gairola*, Anil Nischal **, Amit Arya***, Sujit Kumar Kar***

Junior Resident*, Professor**, Additional Professor***

Department of Psychiatry, King George’s Medical University, Lucknow, U.P, India

*Corresponding author: Arundhati.gairola94@gmail.com

Background: Alcohol Use Disorder is one of the most common substance use disorders leading to mental health problems. Among the approved pharmacological interventions, due to limited efficacy and side effect profile, many patients discontinue treatment leading to relapse. Thus, there is a need to explore newer modalities such as neuromodulation that target specific brain areas and also explore their safety and tolerability.

Aims :To study the safety of tDCS in the management of craving in Alcohol use disorder.

Method: Patients of Alcohol Use Disorder aged between 18 and 60 years were recruited in the RCT following management of alcohol withdrawal symptoms and taking informed consent. Patients were randomized into active and sham groups each containing 16 patients. 5 sessions of tDCS with the following protocol: Anode placement at Right DLPFC, Cathode placement at Left DLPFC, 2 mA of current, for a duration of 20 minutes/session, RAMP time: 10 seconds were delivered over a period of 1 week. tDCS side effects checklist was applied after each session.

Result: Out of the 80 sessions administered in each group, adverse effects were reported in 27 sessions (33.75 %) in active group and 10 sessions (12.5%) in sham group. The number needed to harm is 5 (with a confidence interval of 95%),i.e, about 1 in every 5 sessions will harm. However, the effects are only mild to moderate in intensity as measured in the tDCS side effects checklist and are short-lived. No side effect required any active intervention or caused any dropout.

Conclusion: tDCS is a safe and well-tolerated treatment modality for craving in Alcohol Use Disorder.

When an Imaginary Friend Gets out of Control! – A case report of ATPD with evolving BPD in a 15 year old harbinged by a Childhood Imaginary Companion.

Dr. Arvind Rengarajan M.D., Dr. C. Panneer Selvan M.D., Dr. Noorul Hasan M.D., Dr. Aswath Babu Srinivasan M.D.,DNB.,

Background: Childhood Imaginary Companion (CIC) is a normal experience in many children which helps with coping. There have been reports of CIC being an early indicator of psychotic disorders in adulthood. This particular case is unique where the normal CIC experience turned into a hallucinatory phenomenon, in the presence of an evolving Borderline-Personality Disorder.

Case Report: A 15-year-old girl, presented with acute onset of talking to self, sleep disturbances, anger outbursts and an act of self-injurious behaviour over past 2 weeks. Detailed history revealed that since the preschool years she had an imaginary friend (CIC) whom she conversed when in private with total voluntary control and insight regarding imaginary nature. This practice continued over her adolescence. When faced with a stressor (inter-personal conflicts with new schoolmates) over the past two weeks, the CIC had started turning hallucinatory with loss of voluntary control, content becoming derogatory and commanding, causing significant distress. Mental status examination showed an increased psychomotor activity, anxious affect, with 2^nd person auditory hallucinations. Detailed assessment also showed features of Evolving Borderline Personality (identity problems, affective instability, dichotomous-perspective of relationships). She was evaluated with BPRS, Borderline-Personality Scale Features for Children-11, Imaginary Friends Questionnaire-2.0. The results showed clearcut presence of psychotic features, evolving Borderline-Personality disorder, and a clearcut differentiation between the previous ‘normal’ CIC experience and a current ‘pathological’ hallucination. She was treated as an inpatient with T. Amisulpride gradually titrated up-to 200mg/day and was started on DBT-C (Dialectical behavioural-therapy for children). She showed significant response by the end of one week after which she was discharged and followed up further as out-patient.

Conclusion: The presence of CIC persisting beyond early adolescence can be a possible indicator of not only psychotic or dissociative disorders in adulthood, but also warrants a thorough assessment of presence of any evolving personality disorders.

Endoxifen in Mania episode in patient with primary renal disease: A case report

Astut Kurariya ¹, Rashmi Vishwanath ¹, Avinash Kamath ¹, Anil Kumar M N ¹, Savitha Soman ¹

¹Department of Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India - 576104

Background - Mood stabilisers have been shown to alter the PKC pathway. Deranged PKC activity has been found both in postmortem brains and platelet from patients with bipolar disorder. Accumulating evidence suggests an imbalance of the PKC signalling system in mood disorders. Endoxifen, 4-OH-N-des-methyl-tamoxifen, is an active metabolite of tamoxifen and has shown a four-fold inhibitory activity of PKC compared to tamoxifen. Short term studies comparing Endoxifen to valproate and lithium have shown favourable results in terms of side effects profile and efficacy. Case overview - A 53 year old gentleman diagnosed with bipolar disorder, Diabetes Mellitus, Hypertension, Dyslipidemia secondary to Primary Renal disease requiring Immunosuppressant for control and worsening of renal profile, presenting in manic episode while on dual oral mood stabiliser, second generation antipsychotic and Benzodiazepine. Patient was started on Endoxifen and significant clinical improvement was noted within 7 days with minimal adverse effects. Patient was followed up for 3 months with good response in both mood symptoms and renal parameters. Conclusion - Endoxifen can be a choice in patients with Bipolar disorder with concurrent renal comorbidities , as augmentation (or mono therapy) in whom conventional mood stabilisers cannot be tried due to safety, tolerability and efficacy concerns. Long term studies regarding safety of Endoxifen in patients with renal diseases are needed to substantiate the role.

Obsessive-Compulsive Disorder in an Adolescent with Intellectual Disability – A Case Report

BACKGROUND: Individuals with Intellectual Disability (ID) have a higher risk of psychiatric comorbidities including Depression, Anxiety and Obsessive-Compulsive Disorder (OCD) and other psychoses. However, due to lack of proper communication and various reasons, these disorders are often under-diagnosed among these population.

CASE REPORT: A 15-year-old male presented with complaints of an insidious onset illness characterized by repetitive acts of washing hands, excessive cleaning, bathing, and refusing to touch anything when he gets out of house. When stopped from doing these acts, he became very agitated and aggressive towards family members. The Individual had no significant past or family history of psychiatric illness and had no history of substance use. A structured assessment was conducted, and Intelligence Quotient (IQ) by Wechsler Intelligence Scale for Children (Indian adaptation) was found to be 48 (Moderate ID). Mental status examination was done, and Yale-Brown Obsessive compulsive scale symptom checklist was administered. He was found to be very anxious, had difficulty in explaining why he does these acts. He had obsessions of contamination and had compulsive cleaning and washing rituals. He was started on capsule Fluoxetine 20mg daily. At 4 weeks follow up, he had significant improvement.

CONCLUSION: Diagnosing OCD in patients with Intellectual Disability is difficult because of presence of much repetitive behavior, inability to express anxiety and ego dystonicity of thoughts and behavior. Further research with large sample sizes is recommended to understand the key characteristics of this population in more depth.

Erotomania (De Clerambault’s syndrome) in a male with Triple Diagnosis: A case report

Dr. Auroshreeta Das

Department of Addiction Medicine, Department of Psychiatry, LGB Regional Institute of Mental Health, Tezpur, India

Background: A delusion is a false, unshakeable belief that is out of keeping with the patient’s social and cultural background. De Clerambault (1942) described a variant of Delusion of Love/ Erotomania in which typically, a woman (subject) believes a man (object), who is older and of higher social status than her, is in love with her. Male erotomania is a rare and probably underdiagnosed condition, mostly cited in forensic samples in lieu of their violent behavior in this disorder. The disorder falls under the Persistent Delusional Disorder in the ICD-10 and is described as a subtype of Delusional Disorder in DSM V.

Objectives: Our objectives are to elucidate the typical features of Delusion of love and to discuss diagnostic/management challenges of the same when associated with comorbid substance use disorder and HIV infection (I.e., triple diagnosis).

Case: A middle-aged Indian male developed sudden onset erotic delusions with repeated mental imageries of the lady of interest and significant acting out for 2 years. Owing to the distress, the patient yielded to regular drinking, ultimately developed alcohol dependence syndrome for last one year. He also sustained multiple head injuries under intoxication. History revealed HIV-positive status on Anti-retroviral therapy. NCCT and MRI was normal. Medications given were diazepam tapering dose, risperidone 6 mg.

Discussion/Conclusion: De Clerambault described the stage of evolution of erotomania as hope-resentment-grudge, in which the last phase is most important. Ellis and Mellsop (1985) adopted the criteria for pure Erotomania, which can be classically highlighted in this case. The diagnosis of erotomania has implications in case management, treatment and prognosis and if missed, it may culminate in violent situations with legal repercussions.

Pregabalin addiction: A case report

Background: Pregabalin is a GABA analog that is used for neuropathic pain and an antiepileptic for partial-onset seizures. It decreases the influx of calcium and thus reduces the release of excitatory neurotransmitters. As pregabalin is being studied as a treatment for other drug addictions, it itself has upcoming abuse potential.

Aim: To highlight the addictive potential of pregabalin primarily prescribed for neuropathic pain management.

Material and Methods: A 25year old young male presented with complaints of use of pregabalin capsules for the last 4 years. The patient was started on pregabalin for complaints of back pain following a road traffic accident. He experienced euphoria and increased energy after consumption, he developed tolerance and it increased gradually to 15 capsules per day. He started experiencing problems in his socio-occupational life and had severe withdrawal symptoms like headache, irritability, palpitations, trembling, and numbness in his limbs. The patient was admitted and managed. He was discharged on improvement. The patient has been following up regularly.

Result: Pregabalin is likely to be abused for its euphoric effects. The patient reported severe withdrawal symptoms and craving, thus showing gabapentinoid effect on brain’s drug reward system.

Conclusion: Our case highlights the abuse potential of pregabalin and the need for prescribing pregabalin cautiously. Further literature is required to manage these patients. The problem is more significant as pregabalin is used as a treatment for another drug addiction.

Keywords: Pregabalin dependence, abuse, withdrawal

Alcoholic Hallucinosis: - A Rare Presentation

Dr B Meher[¹], Dr G Hemanth Madhav[²], Dr S Nagaraju[³], Dr K Narasimha Reddi[⁴]

1.Post Graduate, 2. Associate Professor, 3. Professor, 4. Professor & HOD

Department of Psychiatry, MIMS, VIZIANAGARAM

BACKGROUND: Alcoholic hallucinosis is a complication of chronic alcohol abuse characterized predominantly by auditory hallucinations that occur either during or after a period of heavy alcohol consumption. In International Classification of Diseases-10 (ICD-10), it was classified under Mental and Behavioural disorder due to Alcohol use, Psychotic Disorder - predominantly hallucinatory type. In ICD-11, it is relabelled as Alcohol induced Psychotic Disorder with hallucinations (6C40.60). It sometimes may progress to a chronic form mimicking schizophrenia.

AIMS: To report and discuss a rare case of Alcoholic hallucinosis in a 50-year-old male patient.

METHODS: Diagnosis was made by using ICD 10 criteria. Neurological examination, routine laboratory, hematological and radiological investigations were done.

RESULTS: Patient had 3^rd person auditory hallucinations and tactile hallucinations with depressive symptoms and diagnosed as Mental and behavioral disorder due to alcohol use, Psychotic disorder - Predominantly hallucinatory type. He was started on Tab. QUETIAPINE 25mg and Tab. AMISULPRIDE 50mg, gradually increased to Tab. QUETIAPINE 200mg and Tab AMISULPRIDE 400 mg. Patient was regularly visiting for follow up. Despite high doses, symptoms persisted.

CONCLUSION: Alcoholic hallucinosis is a rare complication of chronic alcohol abuse with a prevalence of 4% in alcoholism. Because of its significant medical and psychiatric implications early intervention will be of great help.

Dapsone induced psychiatric manifestations – A case report

Dr. Bandita Abhijita, Dr. Nishtha Chawala, Dr. Koushik S Deb, Dr. Rakesh Chadda

INTRODUCTION

Leprosy is successfully treated with multi-drug therapy (MDT). ENL (Erythema Nodosum Leprosum) commonly seen in Lepromatous leprosy (LL) is treated with corticosteroids, thalidomide or clofazimine. Psychiatric comorbidities seen with leprosy are depression, anxiety, and rarely psychosis. Apart from disease itself, behavioral associations can also be seen with MDT, which are relatively rare. This case study briefly presents clinically relevant evidence on behavioral symptoms resulting from MDT in a case of LL with ENL, and how different specialities liaisoned for management.

CASE DESCRIPTION

A 20-year-old male diagnosed with LL presented in Dermatology with symptoms of ENL. He was initiated on MDT (daily Dapsone and Clofazimine with monthly Rifampicin, Clofazimine, Dapsone). On third day, he was found perplexed and disoriented to time, place. After one day of such delirious state, he developed mutism, staring, posturing, poor oral intake, and self-care for which psychiatry consultation was sought. Routine blood investigations were normal. Lorazepam challenge test turned positive. With low dose oral lorazepam, catatonia resolved subsequently but euphoria, pressured speech, grandiosity, overfamiliarity, and decreased need for sleep became apparent. With diagnosis of Organic bipolar affective disorder, it was decided to stop the possible offending drug in liaison with dermatology and endocrinology. Due to persisting symptoms of adrenal insufficiency, Prednisolone 15mg was continued. Thalidomide was stopped for a month but no changes in symptomatology were noted. Meanwhile patient started improving with Risperidone up to 6mg. He was then discharged expecting further improvement after MDT completion.

RESULTS

On monthly follow up, family members revealed patient had stopped MDT due to logistics and had shown drastic improvement in mood soon after. Without any altercation in Prednisolone dose, the remission of symptoms after stopping MDT established a cause-effect relationship. Patient continued to maintain well on monthly follow-ups with no further episodes.

DISCUSSION

There are reports of various behavioral symptoms induced by Dapsone. Dapsone can induce mania by enhancing oxidative stress. Proposed to be a dose-independent side effect, it occurs rapidly on rechallenges. There are no definitive treatment guidelines for such cases. Researchers have tried stopping the drug and use of antipsychotics. Cessation of MDT along with simultaneous antipsychotics helped in successful remission in our patient.

CONCLUSION

In summary, symptoms possibly associated with Dapsone, varied from delirium to catatonia and mania. In addition, comorbidities further complicated the picture. Such cases require proper liaison between different specialties. Prevention, timely diagnosis and treatment are the key steps for improvement. Further studies are needed focused on the possible mechanisms that will direct rational drug use.

Schema Therapy Augmented Exposure and Response Prevention in Obsessive Compulsive Disorder: A Case Study

Bandita Abhijita, Sujata Satapathy, Koushik Sinha Deb

Background

Early maladaptive schemas (EMS) are often present in patients with obsessive-compulsive disorder (OCD) according to Jeffrey Young. Schema therapy (ST) may be an additional therapeutic approach to Exposure and Response Prevention (ERP) in OCD. Although ST is a promising treatment, yet no such case has been reported till date in India, with only a handful case reports in Western literature.

Aim

To illustrate a case of long standing OCD treated with ST augmented ERP

Methods:

A 25-year-old unmarried male presented with 4 years of continuous illness of obsessions of symmetry, magical obsessions, obsessive doubts with predominant mental compulsions. Cognitive distortions and maladaptive schema modes were assessed using Inventory of Cognitive Distortions and Young Schema Questionnaire. Six major schemas named as emotional deprivation, social isolation, subjugation, self-sacrifice, unrelenting standards, approval seeking and entitlement were identified and targeted in the weekly therapy sessions. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) were measured weekly.

Results

The patient benefitted significantly with our approach of ST augmented ERP. YBOCS was 9 at the end of 6 weeks of therapy. He also received Sertraline 100 mg. The improvement was sustained over a six-months follow up period.

Conclusion

Over the last years, interest in ST has increased as an intervention for patients with chronic psychological disorders with an unsatisfactory response to traditional CBT. ST is supposed to addresses EMS that are thought to maintain their disorder. In our case, we demonstrate the alleviation of obsessions using schema therapeutic elements. Further such studies are needed in Indian settings.

OPIOID WITHDRAWAL SEIZURE: A RARE CLINICAL ENTITY

DR. BIJAY KUMAR PRUSTY, DR. KIRTI ANURAG,

DR. (PROF.)SURJEET SAHOO, DR.RIYA NAGESH SHETTY.

INTRODUCTION:

• Common opioid withdrawal symptoms are severe muscle cramps, profuse diarrhea, rhinorrhea, lacrimation, fever, hypertension, pupillary dilatation and tachycardia.

• Seizures are rare in opioid withdrawal with a prevalence of 12.5%. Few reports are available on complicated opioid withdrawal where a patient presents with seizure on abstinence.

CASE PRESENTATION:

• A 35yr male with chronic opioid abuse for 8yrs on a daily basis in the form of brown sugar with no history of high grade fever, head injury or prior seizure episodes presented with multiple episodes of generalized tonic clonic seizures following abstinence for 4 days.

• No other commonly found withdrawal symptoms were present.

• There was no other substance use, except nicotine in dependence pattern.

• All related investigations were within normal limits.

• A diagnosis of mental and behavioral disorders due to use of opioids and dependence syndrome withdrawal state complicated with seizure.

DISCUSSION:

• Chronic opioid use causes changes in homeostatic adaptations in neurons of the brain which increases the neuronal excitability.

CONCLUSION:

• Seizure as sole presentation of opioid withdrawal is rare. When complicated by other medical comorbidities it becomes further difficult to diagnose and treat.

• Increased clinical suspicion and strict vigilance will help in timely management of this life threatening complication and provides a better neurological outcome.

Depression amongst Rheumatoid Arthritis patients and barriers to seeking professional help - an Observational study.

Background: Rheumatoid Arthritis (RA)is an inflammatory autoimmune disease affecting synovial joints with multiple systemic, including neuropsychiatric manifestations. However, there are only a few studies of depression in RA patients. Also, there are no major studies assessing the correlation between the severity of RA with the severity of depression and assessment of barriers to accessing mental healthcare in these patients. Hence, this study was conducted.

Aim: To study the prevalence of depression in RA patients attending a general hospital setting with the objectives of identification of correlation of depression in RA with Socio-demographic, clinical factors and to identify barriers which prevent them from seeking psychiatric help.

Methods:70 RA patients who fulfilled the inclusion criteria participated in the study. Socio demographic details were taken,Clinical Disease Activity Index,Numerical Pain Rating Scale,Beck Depression Inventory and Barriers to Access Care Evaluation were administered.Data was tabulated and analysed.

Results: Prevalence of depression in our study population was 44.2% with significant positive correlation between the severity of RA and severity of depression(p-0.46). Attitudinal barriers contributed more towards a lack of help-seeking behavior than stigma-related or instrumental barriers.

Conclusions: Prevalence of depression among RA patients was 44.2% with nearly equal distribution of severity of mild, moderate, severe depression.Clinical disease activity was found to be higher in patients of depression.The pain index was found to be higher in depressed RA patients.Attitudnal barriers prevented the patients from taking help for their illness.Its imperative to screen RA patients for early diagnosis and treatment.

Psychodynamic Psychotherapy in Complex PTSD: An Indian Case Study

Chinu Patra, Ankit Sinha, Bandita Abhijita, Shree Mishra, Susanta Kumar Padhy

Background: Post Traumatic Stress Disorder (PTSD) is a distressing condition often seen after major traumatic event in around 10% of women . Complex PTSD encompasses classic symptoms of PTSD, along with symptoms of disturbances in self-organization. Psychodynamic psychotherapy has been advocated as an effective treatment. However, psychiatric training in the form of adequate exposure and carrying out psychotherapy is observed to be inadequate/low in India.

Aims: We present a case of a woman with complex PTSD after accidental death of her son who benefitted from combination of pharmacotherapy and structured psychodynamic psychotherapy.

Method: Structured psychotherapy was used as a treatment strategy by identifying intrapsychic conflicts, negative affect, and defense mechanisms related to PTSD. She also received Sertraline simultaneously.

Results: Over 3 months of treatment there were improvements in all aspects of her symptoms including dissociation, flashbacks, mood and nightmares. Improvement was sustained over 1 year of follow-up.

Conclusion:

Most recent evidence is use of Cognitive Processing Therapy, Eye Movement Desensitization and Restructuring (EMDR), and others with significant trauma focus in PTSD. Psychodynamic Psychotherapy is another promising treatment protocol. This case demonstrates how therapist can help link memory traces, affects, and behaviours related to traumatic experiences that help in the process of healing. More research needs to be conducted in this area and address the reasons underlying lack of manualized psychodynamic psychotherapy by therapists in Indian settings.

Gender dysphoria as a part of delusional system in Schizophrenia

Introduction

“Gender dysphoria” is a sense of inappropriateness with one’s natal sex. There is marked incongruence between expressed gender and natal gender causing significant distress or impairment. Schizophrenia patients may experience gender dysphoria because of delusionally changed gender identity.

Case summary

A 24yr old unmarried, male presented with complaints of headache, aloofness and muttering to self for 4years, feminine behaviour for 1.5years, 1 episode of applying vermilion on forehead 10 days prior to admission. Illness had insidious onset, continuous course, and deteriorating progress. The patient had female voice pitch, delusion of being married to a male actor, and acting out on auditory hallucination of the actor asking him to elope. He had delusion of giving birth to 21 children in 4years and ideas of persecution against a man who he believed was his first married partner. He felt having both sexes in his body and being wooed by men because of his beauty. His account of thought being withdrawn by looking at his eyes explained his reduced interaction. There was no childhood history of distress with the male gender or identifying himself as female. The psychotic symptoms showed improvement on Tab. Olanzapine 30mg as noted objectively and subjectively.

Discussion

The case highlights the instance of onset of gender dysphoria exclusively during the course of schizophrenia. The gender identity and associated distress often enmesh with prevailing psychopathology in patients, negatively affecting their quality of life.

Key word: gender dysphoria, schizophrenia

1. Dr. Deboki Chattopadhyay, Junior resident, Central Institute of Psychiatry, Ranchi-834006, Jharkhand, India

2. Dr. Chandramouli Roy, Senior resident, Central Institute of Psychiatry, Ranchi-834006, Jharkhand, India

3. Dr. Pooja Sharma, Senior resident, Central Institute of Psychiatry, Ranchi-834006, Jharkhand, India

4. Dr. Suhas Ganesh, Assistant Professor of Psychiatry, Central Institute of Psychiatry, Ranchi-834006, Jharkhand, India

5. Dr. Basudeb Das, Director and Professor of Psychiatry Central Institute of Psychiatry, Ranchi-834006, Jharkhand, India

Prevalence of depression in adolescents and young adults in rural part of Haryana

Background:

Depression is one of major raging problems which contributes to overall burden of disease. Depression is equally prevalent amongst children, adolescents and adults. Recent Indian studies has shown 3%–68% prevalence of depression among children and adolescents and 54% among college students.

Aims and objective:

To check the prevalence of depressive disorders in school going adolescents and College students in rural part of Haryana

Method:

This is a cross sectional study that included school and college students attending science exhibition. Students who visited psychiatry zone were asked to fill PHQ-9 questionnaire. Descriptive statistics and chi-square test was used in data analysis.

Results

A total of around 500 students visited the psychiatry zone and 342 students participated in the study. Among those participated 177(51.8%) were male and 165(48.2%) were females. The mean age of the sample was 17.52 (11-22) years. The prevalence of depression was 170 (49.7%). Based on the severity scores 50 (29.5%), 63 (37.1%), 57 (33.4%) had mild, moderate, and severe depression, respectively. The prevalence of depression among male and female students was 78(47.3%) and 92 (52.0%) respectively (P=0.38). The prevalence among the school students (<=17 years) and college students (>=18 years) was 117(54.90%) and 53(41.1%) respectively (P= 0.01).

Conclusion:

This study shows that prevalence of depression among children and young adults is higher in the rural part of India. There is need for increased focus on mental health of school and college students.

A case of Obsessive Compulsive Disorder with Auditory Hallucination

BACKGROUND :

Obsessive-compulsive disorder (OCD) and psychotic disorders exhibit both biological and phenomenological overlap . Furthermore, there is no clear distinction in between hallucinations of psychosis and obsessive hallucinations of OCD. This may be due to, these patients describe varying degrees of overvalued ideas.

CASE PRESENTATION :

Index patient Mr. A.S ,30 years old male was admitted with chief complaints of hearing divine voices for last 25 years. It was also associated with two episodes of ending his own life 10 years back and repetitive checking behaviour for last 3 years. The illness was insidious in onset, continuous in course and gradually deteriorating. Mental Status Examination reveals normal psychomotor activity with anxious affect, obsessive thoughts & compulsive checking behaviour, second person auditory hallucination with intact judgement and grade 3 insight. Patient was on antipsychotic medications only prior to admission. After thorough history taking and serial MSE, it was confirmed that the voices were his own thoughts & he was shifted to high doses of SSRI along with tapering of antipsychotics. Patient improved significantly. The voices were also reduced and patient was discharged in stable condition.

Conclusion :

In the aforementioned case, diagnosis was thought to be a psychotic disorder at first place and patient was prescribed antipsychotic for years but his symptoms were not relieved . After starting of SSRI along with tapering of antipsychotics, patient was relieved of symptoms including hallucinations. So, it is important to evaluate hallucinations properly in a case of OCD patient before terming it as a part of psychosis.

A CASE OF PSEUDOCYESIS

INTRODUCTION: Pseudocyesis is a rare but debilitating somatic disorder in which a woman presents with outward signs of pregnancy, although she is not truly gravid. It is a psychopathological clinical syndrome in which the non-pregnant woman firmly believes herself to be pregnant and manifests many signs and symptoms of pregnancy.

Neuroendocrine/endocrine mechanisms proposed may lead to the development of psuedocyetic traits including hypomenorrhea, amenorrhoea, galactorrhoea, diurnal or nocturnal hyperprolactinemia, abdominal distension, and apparent movements and fetal pains at the expected date of delivery.

CASE DETAILS: A 30-year-old female referred by the Obstetrics and Gynecology department to the psychiatric ward for complaints of false labor pains and amenorrhoea since 9 months after her Urine pregnancy test came out to be negative and Transvaginalsonography showed the absence of a fetus but the presence of bulky ovaries. Her blood investigations like Serum FSH/LH/testosterone and Serum Prolactin and Serum HCG were done to rule out any endocrinal cause which came out to be within normal limits. She was treated with Tablet Duloxetine for her somatic complaints. A thiopentone interview was done which revealed her desire for conceiving a male child and neglect in her family. Supportive counseling along with psychotherapy was done for the same after which the patient reported improvement.

CONCLUSIONS: Pseudocyesis results from a multidimensional group of factors and a holistic and comprehensive approach should be taken to its treatment. Cooperation between gynecologists and psychiatrists would likely be useful in addressing the condition.

Psycho-social Factors Among Psychiatric In-patients with Alcohol Dependence Syndrome In BPKIHS

Shakya DR, Nepali S, Kumar R, Deo BK, Mishra S

Prof. Dr. Dhana Ratna Shakya, Department of Psychiatry, BPKIHS

Background:

Alcohol Dependence Syndrome (ADS) is associated with various psychosocial factors which influence the initiation, progression to dependence and also affect the treatment outcome.

Objectives:

The objective of the study was to assess the psycho-social factors in patients admitted with Alcohol Dependence Syndrome in psychiatric ward of BPKIHS.

Materials and Method:

A hospital based cross-sectional study was conducted among 54 patients of ADS admitted in psychiatry ward of BPKIHS, Dharan. Respondents were interviewed using COPE Inventory Scale, Personality Trait Inventory and International Personality Disorder Examination.

Result:

Majority of ADS patients use Rationalization as a defense mechanism. Perceived Stress Scale showed more (64.8%) were exposed to moderate stress. Most coping strategy used was denial and Cyclothymia trait was present in the highest number of patients. Personality Disorder was present in52% of ADS patients in which more had Anankastic Personality Disorder.

Conclusion:

Various psychosocial factors need to be assessed for comprehensive understanding of individuals with ADS.

Alcohol Dependence Syndrome, Psychosocial factors

Clinico-psycho-social profile of patients referred under consultation-liaison psychiatry in a tertiary care hospital

Dr. Dimple Ojha¹ (Resident doctor), Dr. Harful Singh² (Professor) Department of Psychiatry, Sardar Patel Medical College, Bikaner, Rajasthan

Introduction: Consultation-liaison (CL) psychiatry has 2 main domains- first being providing expert advice on a referred patient and second of liaison.

Aim: To study the socio-demographic, clinical and psychiatric profile of patients referred under consultation-liaison psychiatry in a tertiary care hospital.

Materials and Methods: This observational study was done over a period of 2 months from October 2022 to November 2022 after taking approval from ethical committee of the college. Data collection of all in-patients who were referred for CL psychiatry was done by a proforma including socio-demographic details of the patient, primary department and diagnosis at the time admission, reason for referral, past history of psychiatric illness and the psychiatric diagnosis (as per ICD-11).

Results: Out of 140 patients, 39.28% were in the age group of 40-60 years and 73.57% were male. 43.75% referrals were from general medicine department and 32.14% were with history of substance use (withdrawal or overdose). Most common reason for referral was for cases of abnormal behavior with altered sensorium (21.42%) followed by anxiety symptoms (17.14%). Most common psychiatric diagnosis made after evaluation was disorders due to substance use (31.42%) followed by mixed depressive and anxiety disorder (17.85%).

Conclusion: The study has revealed higher representation of disorders due to substance use followed by mixed depressive and anxiety disorder among patients referred under CL psychiatry.

Keywords: Consultation-liaison psychiatry, disorders due to substance use, mixed depressive and anxiety disorder.

Creating awareness and promoting mental health through a cycling rally

Dimple Shah¹, Shilpa Aggarwal¹

Manotsav Foundation, Mumbai, Maharashtra

Background

India has faced many challenges in building awareness about mental health programs. The National Mental Health program was introduced to promote mental health and make services accessible to people. Extensive research has shown us the physical and mental health benefits of cycling. Cycling rallies for mental health promotional community activity have been organized by many global organizations and educational institutions. We attempt to study the impact of such community activities.

Objective

This study examines the impact of cycling rallies as a community activity in creating awareness and promoting mental health, and different factors that result in increased community participation.

Method

This is a qualitative study. Cycling Rally was organized by Manotsav Foundation at Sanjay Gandhi National Park to Kanheri Caves. A total of 97 participants between the age group of 12 to 52 years old participated in the rally. Responses from the participants were collected with semi-structured questionnaires and videotapes. Responses were analyzed using Thematic analysis.

Results

Analysis of questionnaires and videotapes identified two major themes. These were: 1. Reason for participation: outdoor activity and to be physically active. 2. Perceived Benefits of Participation: reduced stress and felt close to nature after the pandemic.

Conclusion

Cycling rallies as a community activity can improve health outcomes, lead to more responsive care, facilitate people’s involvement in treatment decisions and improve quality and safety. Organizations and trained mental health professionals can organize similar community activities for promoting mental health.

H1-MR Spectroscopy based evaluation of metabolic abnormalities in anterior cingulate cortex, hippocampus, and amygdala in treatment naïve patients with unipolar and bipolar depression

Gagan Hans1*, Uma Sharma2, Hem Chandra Pandey3, Vishwa Rawat2 and Pratap Sharan1

Departments of Psychiatry1, All India Institute of Medical Sciences, New Delhi, India-110029.

Department of Nuclear Magnetic Resonance and MRI Facility2, All India Institute of Medical Sciences, New Delhi, India-110029.

Department of Transfusion Medicine3, All India Institute of Medical Sciences, New Delhi, India-110029

Background

Major Depressive Disorder (MDD) and Bipolar Depression (BPAD) share an overlapping symptomatic spectrum between them. Understanding the biological changes associated with these disorders is research priority.

Aims:

To perform MRS of brain regions namely (hippocampus, amygdala, and ACC) in patients of MDD and BPAD to ascertain the metabolic abnormalities in these brain regions in Indian patient population.

Materials and methods:

25 MDD patients, 20 BPAD and 15 Healthy controls were recruited from the Outpatient Department (OPD), Department of Psychiatry, AIIMS, New Delhi. All subjects underwent MR Imaging on a 3T whole body MR system (Ingenia, Philips) with 32 channel head coils. A preliminary analysis of data of 20 MDD, 10 BPAD and 10 controls was done as other data has not been analyzed yet.

Results:

Preliminary results showed that the concentration of glutamine and glutamate (glx) was significantly increased in the hippocampus of the patients of MDD (p<0.05) compared to HCs while no significant change in the metabolite concentration was seen between BPAD and HC. No significant changes in the metabolite concentrations were seen between any of the groups in ACC.

Conclusions:

These results suggest that there may be alterations in glutamate metabolism in the patients of MDD.

Psychiatric Morbidities of Deliberate Self-Harm & Its Association with Mean Platelet Volume

Dr.Gaurav Pawar, Dr. Kshirod Kumar Mishra, Dr. Harshal Sathe, Dr. Ahmed Reshamvala

Introduction

The prevalence of Deliberate self-harm (DSH) in India has increased in recent years. The tendency of self-harm is positively associated with stressful life events and depression. Increase in the mean platelet volume (MPV) has been consistently associated with depression. The changes in MPV in people doing self-harm has not been adequately researched in Indian population.

Objectives:

To describe the demographic, psychological factors, estimate mean platelet volume & its association with patients of self-harm.

Methods:

This was a hospital based descriptive, observational, cross sectional study. The data was collected from 150 consecutive referrals DSH to the psychiatry ward in our hospital. Severity of depression, anxiety & suicide intent was quantified by corresponding validated psychometric scales.

Results:

Majority of the study participants belonged to 18-39 years age group and most of them were males (N=105, 70%). Poisoning was the most common mode of DSH (N=125, 83.33%). Diagnosable psychiatric illnesses were found in 77 (51.33%) patients, most common being adjustment disorder (N=32, 21.3%). MPV showed positive association with stressful life-event but did not vary significantly with depression & suicidal intent.

Conclusions:

Our study highlights the sociodemographic, psychosocial & clinical factors present in individuals attempting self-harm. The positive association of MPV with stressful life-events adds to the existing evidence supporting neuroinflammatory hypothesis of psychological distress.

Contact details: Dr. Gaurav Pawar

Email ID- dr.gauravpawar7@gmail.com

Mob no- 9326138063

A Rare Case on Trichotillomania with Conduct Disorder – A Case Report Form

Dr.Saikiran Pasupula 1, Dr.Akhilendra Srinivas Oggu2 , Dr.Kiran Vaddedi3 , Dr.Neeli Uma Jyothi4

1. Assistant Professor, 2. Post graduate, 3. Associate Professor, 4. Professor & HOD, Department of Psychiatry, Guntur medical college, Guntur.

Background:

Trichotillomania is the compulsive urge to pull out one’s own hair leading to noticeable hair loss, distress and social or functional impairment. Excoriation (skin-picking) disorder is characterized by recurrent picking of skin, leading to skin lesions and significant distress or functional impairment. It is classified under Obsessive–compulsive and related disorders (OCRD); Body-focused repetitive behavior disorders in ICD-11 and Obsessive-compulsive related disorders in DSM 5.

Case Description:

A 19-year-old female came with gross developmental delay, poor scholastic performance, poor social interaction, repetitive impulses to pull hair & itch over arms since ~1 year. Patient has developmental delay in all the domains- language, motor, cognitive & social domains. Self-care is maintained with recurrent urges to pluck hair, has patchy hair loss, would pluck her hair 3-4 times/day. On questioning patient says she plucks hair when she feels itchy and irritable and throws away the hair, and is unable to control the impulses even though it’s painful and has recurrent itching of arms, with multiple hyper-pigmented plaques with crusting. Upon plucking hair and itching patient feels relief.

Conclusion:

The objective was to demonstrate a patient with moderate intellectual disability with late adolescent onset of trichotillomania. OCRD is known to affect patients with intellectual disabilities at rates that are lower than those in the general population. Due to developmental disabilities and poor communication in these patients, the disorder is difficult to diagnose, goes unnoticed and untreated, having negative impact on their quality of life.

Key Words: Trichotillomania, OCRD, Intellectual Disability.

Olfactory Reference Syndrome- A Case Report

¹Dr. Harman Singh Bhatia, Senior Resident

Department of Psychiatry, Central Institute of Psychiatry, Ranchi

Introduction-

Olfactory reference syndrome is characterized by persistent preoccupation with the belief that one is emitting a perceived foul body odour/breath that is unnoticeable to others. Individuals experience excessive self consciousness about the perceived odour and are involved in activities which lead to impairment in various important areas of functioning.

Case history-

A 47 year old male patient presented with complaints of feeling that a bad odour is coming from him and other people are having problems due to this bad odour because of which patient started taking baths at regular intervals, remaining aloof, feeling sad, stopped going to work, started believing that he has some serious illness such as cancer, sleep disturbance and ideas of self harm. Patient has history of alcohol and cigarette smoking. Patient’s mother had Oesophageal cancer. Patient’s routine investigations were within normal limits and EEG was done to rule out Temporal Lobe Epilepsy. Patient was started on 20mg FLUOXETINE, 10 mg OLANZAPINE and 0.5 mg CLONAZEPAM, following which patients symptoms reduced significantly.

Discussion-

Olfactory reference syndrome is a rare disorder and this is a rare case of Olfactory Reference Syndrome with features of Depressive disorder. Although symptoms were first described in 1971, there is very limited published literature, limited to only case reports and case series. It appears in DSM 5 under Other Specified Obsessive Compulsive Disorders and has been recently included in ICD 11 as Olfactory Reference Disorder. The clinical course of this disorder is chronic and debilitating for the patient and family and has been treated with both SSRIs and Antipsychotics in the literature.

Episodic Occurrence of Obsessive Compulsive Disorder during Pregnancy: A Case Report

Harmanpreet Kaur¹, Tushar Kanta Panda^2, Preethy K³

Harmanpreet Kaur

¹Junior Resident, ²Ex-Senior Resident, ³Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan

Introduction:

Pregnancy and postpartum period has been associated with increased risk of onset and exacerbation of Obsessive-Compulsive Disorder (OCD). Also, females in post-partum period have been found to have more OC symptoms than during the pregnancy. In this case report, we are presenting a unique case in which patient had an episodic illness with onset of obsessive symptoms during 2^nd trimester and remitted completely one month before pregnancy.

Case summary:

A 28-year-old pregnant woman presented at 20 weeks of gestation with history of repeated intrusive thoughts and images of sexual nature, along with mental compulsions for 2 weeks. This was associated with depressive symptoms of severe intensity secondary to the OC symptoms. She had one similar episode in the past during her first pregnancy. In both these episodes, she predominantly had sexual obsessions, Both the episodes were self-limiting and resolved within 6 months – first episode remitted without treatment and in the second episode, patient was treated with sertraline up to 200 mg, which she stopped at 28 weeks of pregnancy and is off medications and maintaining well till now.

Discussion: A meta-analysis found obsessions related to contamination and cleaning compulsions to be the most common OC symptoms during pregnancy. However, Index case predominantly had sexual obsessions. Also, while studies report OCD to be more common in post-partum period than in pregnancy, symptoms of index case did not recur during post-partum period. More studies are needed to understand the biological basis for this increased risk of OC symptoms during pregnancy.

Simultaneous presentation of Neuroleptic induced Catatonia and Neuroleptic induced Parkinsonism: an unusual case report

Dr. Harshitha G S ¹, Dr. P. Swathi ²

1. Post Graduate

2. Assistant Professor

Department of Psychiatry, Andhra Medical College, Visakhapatnam.

Background: Catatonia is a rare clinical syndrome characterized by severe behavioural abnormalities including motoric immobility or excitement, negativism or echolalia or echopraxia. Neuroleptic induced Parkinsonism is an extrapyramidal side effect of antipsychotics characterized by rigidity, shuffling gait, tremors and stooped posture. Existence of neuroleptic induced catatonia and parkinsonism together poses a great challenge for the treating psychiatrist.

Aim: To study a rare presentation of neuroleptic induced catatonia and parkinsonism

Methods: A young male, 28 years old with history of Schizophrenia and past history of Epilepsy and occasional tobacco use on T. Risperidone and T. Trihexyphenidyl 2mg presented in stuporous state with reduced personal care and food intake, fearful, maintaining uncomfortable position for hours, not interacting with anyone since 3 days. He was noticed to have tremors of both hands and pill-rolling tremor in the right hand, rigidity, mutism, posturing, negativism and staring looks with reduced blinking. Antipsychotic was stopped and Inj. Lorazepam 4mg and Inj. Promethazine 50mg IM was given. Blood investigations and MRI Brain did not reveal any abnormality.

Result: Diagnosis of neuroleptic induced catatonia and parkinsonism was made. Symptoms improved and patient was discharged with T. Lorazepam 6mg, T. Trihexyphenidyl 2mg.

Conclusion: Prompt recognition and management is needed to prevent further progression of these symptoms to Neuroleptic Malignant Syndrome and Malignant Catatonia.

Key words: catatonia, parkinsonism, neuroleptic,

Tuberculos (TB) Meningitis with Tuberculoma in a child masquerading/presenting with conversion disorder- A case report.

Background: Central nervous system tuberculosis (TB) & tuberculoma though uncommon can turn dangerous and fatal. Accounting for 5-30% of all intracranial lesions in developing nation’s intracranial tuberculoma can manifest clinically in a variety of ways, depending on the location, size, and number of lesions. Patients presenting with psychological symptoms can add difficulties in the diagnosis and treatment of such rare medical illnesses. In the present report we discuss a rare case of a child with TB meningitis with tuberculoma presenting with conversion disorder.

Case presentation: A 15 year old male child was brought to psychiatric OPD with one month history of episodes of behavioural changes starting after the death of his uncle. Based on history & observation he had episodes of unresponsiveness accompanied by tremors of hands & falling in a hesitant manner. Patient remained responsive to surrounding environment and the episode resolved dramatically on isolation. Physical & neurological examination was normal. On account of past history of mild fever before initiation of the symptoms paediatrician opinion was sought to rule out organic cause. Patient was hence admitted, Computed tomography (CT) & CSF analysis was done which revealed suspected TB meningitis with intracranial tuberculoma.

Conclusion: Medical conditions can have both physical as well as psychological symptoms. Normal physical examination and casual relationship with any stressful event shouldn’t be perceived as precursor to make psychiatric diagnosis. Patient presenting with suspected conversion symptoms should be thoroughly examined for any unusual symptom to prevent any delay in management.

Keywords: TB Meningitis, Tuberculoma, Conversion, Child

Different responses to common treatment modalities in young Obsessive Compulsive Disorder patients: A case series

Background: Obsessive-Compulsive Disorder (OCD) is a chronic and disabling disorder marked by obsessions and/or compulsions that are ego-dystonic and cause significant distress to the patients and their families. Lifetime prevalence of OCD is 2-3%. Treatment includes mostly pharmacotherapy (SSRIs, clomipramine) and psychotherapy. Aggregate statistics for SRIs suggest 70% treatment-naïve patients improve moderately.

Aims: To study the treatment responses in three young cases of OCD in the Psychiatry department of Gauhati Medical College and Hospital.

Case 1: 18-year old female developed fear of contamination and excessive cleaning following death of her uncle, for 1 year. She improved with adequate dose of single SSRI within 3 months.

Case 2: 26-year old married female, with anankastic personality-trait, was admitted with repeated doubts and fear of contamination, compulsive checkings and handwashing for 4 months, which followed after an argument with her in-laws. She earlier stopped SSRI 30 days after initiation due to non-improvement. Patient started showing improvement with adequate SSRI and TCA, with ERP therapy.

Case 3: 30-year old unemployed male presented with feeling of impurity on seeing black colour, thus avoiding seeing his own face, fear of contamination, and repeated cleaning. He was treated with combination of adequate pharmacotherapy (TCA + SSRI) and psychotherapy over 10 years, without much response. After flooding was done, his anxiety increased and symptom of contamination increased involving hospital environment, following which he stopped visiting earlier place of treatment. Patient showed response to combination of SSRI and SGA, with ECT and Behavioural therapy.

Result: Fear of contamination is common symptom and response to different modalities of treatment is varied in the 3 patients.

Conclusion: Treatment response varies patient-to-patient, which may be independent of common phenomenology. Early treatment and associated stressor can be predictors of good response. Non-compliance and long duration of untreated illness may need combination of treatment modalities. Behavioural therapy like flooding should be done cautiously with management of associated anxiety for fruitful outcome.

1. Dr. Himasree Thakuria, 1^st year Post Graduate Trainee, Dept of Psychiatry, Gauhati Medical College and Hospital, Guwahati , Email: himasreethakuria@gmail.com , Ph: 7896976396

2. Dr. Prayashi Kashyap, 1^st year Post Graduate Trainee, Dept of Psychiatry, Gauhati Medical College and Hospital, Guwahati , Email: prayashikashyap4@gmail.com , Ph: 9365286052

3. Dr. Utpal Bora, Assistant Professor, Dept of Psychiatry, Gauhati Medical College and Hospital, Guwahati

4. Dr. Deepanjali Medhi, Professor and HOD, Dept of Psychiatry, Gauhati Medical College and Hospital, Guwahati

Assessment of Depression and Anxiety among caregivers of Psychiatric patients

Dr. Isha Choudhary¹ (Resident Doctor), Dr. Harful Singh² (Professor), Dr. Aditi³ (Resident Doctor), Department of Psychiatry, Sardar Patel Medical College, Bikaner, Rajasthan.

Background-Successful management of patients with psychiatric illness mainly relies on care-givers and family acts as a major support system. Caregiving being an emotionally draining experience, exposes the caregivers to increased risk of developing symptoms suggestive of depression and anxiety.

Aim – To assess depression and anxiety among caregivers of patients admitted at Psychiatry department of tertiary care centre in Rajasthan.

Materials and Methods- This cross sectional observational study was conducted after taking ethical clearance from ethical committee of the college and written informed consent from 50 caregivers of patients-25 of patients with disorders due to substance use and 25 of patients with other psychiatric diagnosis. A proforma with socio-demographic details was filled, HAM-D and HAM-A scales were administered and scored.

Results- Caregivers of patients with disorders due to substance use comprised more of females (64%) in contrast to patients with other psychiatric diagnosis where it comprised more of males i.e. 56%. HAM-D score analysis showed that depression was present in more number of caregivers of disorders due to substance use 13 (52%) as compared to patients with other psychiatric diagnosis 10 (40%). HAM-A analysis of score showed anxiety in 17 (34%) caregivers and was more among caregivers of patients with disorders due to substance use and female caregivers.

Conclusions- The results of the study can be used to plan for early interventions to reduce stress among caregivers of patients with psychiatric illness.

Keywords- Caregivers, Depression, Anxiety