EPOSTERS

Diagnostic dilemma: Systemic Lupus Erythematosus (SLE) induced psychosis vs Steroid-induced psychosis- A case report

Dr.Sarthak Parmar¹ Dr.Pooja Shatadal² Dr.Ritambhara Mehta³

1.First-Year Resident 2.Assistant Professor 3.Professor and Head, Department of Psychiatry Government Medical College Surat

Introduction:

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition that involves connective tissue of multiple organ systems. It can also involve the brain which can lead to psychiatric symptoms. Among one third of SLE patients have neuropsychiatric manifestations which mainly include anxiety and mood disorders and rarely psychosis. Further, SLE treatment includes the use of corticosteroids which may also lead to psychosis. We came across such a case that presented a diagnostic dilemma as it had both history of SLE and the use of oral corticosteroids in a patient presenting with new-onset psychotic symptoms.

Case Report:

A case of 22-year-old female, was brought by her mother to the psychiatry department with complaints of irrelevant talking, suspiciousness that people were talking about her, crying spells, and sleep disturbances for 2 days.

As the patient was acutely agitated, she was admitted and detailed evaluation was done which resulted in diagnosis of Brief psychotic disorder (DSM-V). She was found to be a k/c/o SLE with APLA positive and vasculitis since the age of 11 years. Since then, she was on medication for the same including Tablet Hydro chloroquine (300) 0-0-1 and tablet Prednisolone (50 mg). Patient was not irregular on medication which would result in flaring up of SLE symptoms including vasculitis, ulcers and rash. Due to poor adherence and non-improvement, patient stopped all other medications prescribed and only took oral Prednisolone for 5-6 months without any consultation. During the ward stay, patient had symptoms of psychosis in the form of persecutory delusions towards mother, grandiose delusions, muttering to self, and authoritative behaviour. Patient was started on tablet Aripiprazole 5 mg and a rheumatology opinion was taken after which prednisolone was tapered and stopped. Patient’s condition gradually improved after that and the antipsychotics were tapered on further follow-ups.

Discussion with Conclusion:

In this case, it was very difficult to distinguish between SLE-induced psychosis and steroid-induced psychosis as the patient was on partial treatment for SLE. Also, management in both the cases is similar as it includes antipsychotics and tapering of oral steroids. There are some associated factors that may help us to distinguish between SLE-induced psychosis and steroid-induced psychosis such as female sex, lupus nephritis, and hypoalbuminemia. SLE patients, who are on steroids, with neuropsychiatric features should be assessed adequately, as there are no specific guidelines and biomarkers to distinguish between these two so to further decide the management plan of the patient.

Keywords : SLE-induced psychosis ,steroid induced psychosis, steroid therapy, antipsychotics

Walking Dead Syndrome - Do or Don’t I exist?

Dr.Prasanth.R.T¹, Dr.Vinutha.R, Dr.Subramanyam.M, Dr.Veda.N.Shetageri, Dr.G.P.Gururaj

¹PG Resident, Department of Psychiatry, East Point College of Medical Sciences and Research Centre, Bengaluru.

Background: Cotard’s syndrome is a series of delusions that one has lost their soul, blood, organs, and body parts to the belief that one is dead or deny aspects of their existence. It includes expansive variation in presentations as well as inciting factors which is relatively rare, often associated with other mental illnesses such as depression and schizophrenia.

Aim and Methods: 51 years old Mrs. S, with history of Hypothyroidism and Autoimmune Hepatitis was brought to our outpatient services with symptoms of posturing and mutism for a duration of 3 years, previously treated with inadequate trials of antipsychotics and antidepressants.

Results: Mental Status Examination was consistent with severe psychomotor retardation with Catatonic symptoms like Posturing, Grimacing with Poor verbal output. Thought content consisted of NIHILISTIC DELUSION that she had no head or face, part of her body was burnt, brain and back were melting, change in the consistency of brain matter as per the food taken. Patient was diagnosed as Schizophrenia and started on electroconvulsive therapy (ECTs). On admission the scores were PANSS:61/210, BFCRS:8/69, HAM-D 8/53 which improved to PANSS:42/210, BFCRS:2/69, HAM-D:5/53 at discharge. 6 months post admission, patient had exacerbations with the varying severity of the delusion however catatonic symptoms have been in remission.

Conclusion: The existing medical literature suggests response of this delusion to ECTs. Early recognition of the syndrome and its treatment with ECTs can be one of the factors for improvement in patient’s quality of life.

Incidence of Alcohol Induced Psychosis with concomitant development of Frontal lobe tumour after Consumption of Country Liquor Only Despite Previous Usage of Varieties of Liquor with different Alcohol Concentration

Dr. Ishaan Gautam¹, Dr Swapnil Aloney²

1.Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email-gsvmkanpur39@gmail.com , Mobile:8077269317

2.Assistant Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email-Skaloney@gmail.com, Mobile: 9890419371

Presenting Author- Dr Ishaan Gautam, Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College,

Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra.

Email- gsvmkanpur39@gmail.com

Mobile: 8077269317

Background: Alcohol one of the common substances being abused worldwide has been known to cause dependence as well inducing behavioural abnormalities which needs to be mentioned as psychosis better termed as Alcohol Induced Psychosis having the characteristics of hallucinatory behaviour and delusions.

Case Presentation:

We are reporting a case of a 36 year old male diagnosed as Alcohol Dependence Syndrome with Psychosis presented in Psychiatry OPD with daily drinking, coarse tremors, agitated behaviour due to hearing of voices which were threatening and commanding in nature, sleep disturbances which were accompanied by difficulty in walking (gait disturbances), weakness in right half of body and loss of smell and taste sensations. He has been daily consumer of alcohol for the past 10 years and the duration of alcohol consumption is characterised by consumption of variety of liquor when described in brief , the initial 3 years he consumed Beer, the next 5 years were characterised by consumption of IMFL and the last 2 years he was drinking country liquor. Psychotic features (Delusions and Hallucinations) have appeared in the past 2 years only. The symptom spectrum can be divided into two groups i.e. Alcohol Dependence Syndrome with Psychosis which appeared initially when he had to remain abstinent from consumption of alcohol for 10 days and the other symptom spectrum consisted of neurological outset which had insidious onset, gradually progressive in course and continuously increasing in severity and it started approximately 3 months back and no such neurological presentation has ever developed in the entire duration of illness. He was admitted and was started on Tab. Olanzapine 10 Mg , Tab. Lorazepam 2mg , Tab. Benfomet Plus. On Neurological Examination- he was observed to having scanning speech and ataxic gait. Subsequently neuroimaging i.e. CT-Scan was done and a tumour mass was found localised at frontal lobe On mental status examination he was conscious, not oriented to time, place and person, normal psychomotor activity, fearful mood with auditory hallucinations.

Conclusion:

Alcohol Dependence Syndrome is characterised by neuropsychiatric sequelae and one of it being Alcohol Induced Psychosis. The term Alcoholic Hallucinosis and Alcohol Induced Psychosis can be used interchangeably.

The confluence of Alcohol Induced Psychosis with Neurological Symptoms is a rare incidence and neurological symptoms arising due to brain tumour.

In such cases psychotic symptoms and neurological symptoms underlying aetiology have to be delineated clearly.

¹H-MAGNETIC RESONANCE SPECTROSCOPY (MRS) BASED CHANGES IN BRAIN METABOLITES IN THE PATIENTS OF MAJOR DEPRESSIVE DISORDER.

¹Gagan Hans, ²Uma Sharma, ²Vishwa Rawat, ¹Pratap Sharan

¹Department of psychiatry, AIIMS, New Delhi, ²Department of NMR, AIIMS, New Delhi

Background

Major Depressive Disorder (MDD) is a mental health disorder with a prevalence of 3-4.5 % (worldwide) and 0.5-7.8% (India). Understanding the biological changes associated with these conditions is a major research priority, and a better understanding of their biological basis could lead to improved diagnosis and treatment.

Aims

To study the metabolic changes in brain in patients with MDD and compare these with healthy controls (HC).

Methods

35 MDD patients were recruited from psychiatry OPD, AIIMS, New Delhi and 34 healthy controls were also recruited. All subjects in study underwent MR Imaging. After localisation, T1-weighted images and multislice T2 weighted images in the axial, coronal and sagittal planes of the whole brain were acquired using a standard spin-echo pulse sequence (PRESS). Three regions of interest were selected for voxel positioning i.e hippocampus, amygdala, and anterior cingulate cortex (ACC). MRS raw data was processed and metabolite concentration [(Mean±standard deviation (SD)] of these brain regions volumes were calculated, compared between two groups (MDD and HC) using student t-test (SPSS, Chicago, Illionois). Level of significance was set at p<0.05.

Results

There was a change in the concentration of total choline [GPC (glycerol-phosphocholine) + PCh (phosphor-choline) in hippocampus of the patients of MDD compared to HCs. No significant change in concentration of metabolites was seen in other two regions between the patients of MDD and HC.

Conclusions

The results suggest that there are significant metabolic changes in brain of patients with MDD.

Obsessive-Compulsive Disorder in a patient with Wolfram Syndrome

Samuvel Sekar, Abigail Ruth Gojer

Department of Psychiatry, Christian Medical College, Vellore

Background:

Wolfram syndrome is a rare autosomal recessive disorder caused by mutations in the WFS1 gene. It is characterized by juvenile-onset diabetes mellitus, diabetes insipidus, optic nerve atrophy, hearing loss, and neurodegenerative symptoms. Psychiatric manifestations include panic attacks and obsessive-compulsive (OC) symptoms, as well as depressive symptoms in the context of the associated disability. Psychotic symptoms have been reported less commonly. Despite the neurodegenerative changes, cognitive functions are usually intact in younger patients. This report details a patient with Wolfram syndrome who developed OC symptoms and severe socio-occupational dysfunction requiring psychiatric intervention.

Case Report:

A 23-year-old woman presented to the endocrinology outpatient clinic with early onset diabetes mellitus, diabetes insipidus, visual impairment and hearing loss. A diagnosis of Wolfram syndrome was confirmed by genetic testing. She was referred to the psychiatry department with six months history of excessive hand washing, increased time spent in personal care, irritability and aggressiveness. On examination, she reported obsessive thoughts regarding dirt and contamination and compulsive cleaning rituals, with good insight into her symptoms. A diagnosis of obsessive-compulsive disorder (OCD) was made and she was commenced on Fluoxetine. She has since shown gradual improvement during the period of follow up.

Conclusion:

Patients with Wolfram syndrome have poor quality of life and a guarded prognosis. Though context related anxiety and depressive symptoms are well documented, OCD has not been commonly reported. This report adds to the limited knowledge on the psychiatric manifestations of this rare disorder. Future studies need to explore the neurobiological basis of OCD in this disorder.

Author for correspondence:

Dr. S. Samuvel

Department of Psychiatry

Christian Medical College, Vellore

Email: drsaminvincible@gmail.com

Contact number: 9047850917

A case of 19 years old female presenting with Landau Kleffner Syndrome (LKS) .

AUTHORS

DR SAWARN¹ DR ANKIT CHAUDHARY²

¹Second year Resident, Department of Psychiatry, Chirayu Medical College, Bhopal

²Assistant Professor, Department of Psychiatry, Chirayu Medical College, Bhopal

BACKGROUND

Landau Kleffner Syndrome (LKS) is a rare childhood neurological disorder characterized by the sudden onset of language regression following epileptic seizures. This case study focuses on a 19-years-old female with regression of intellectual faculties following onset of seizures.

OBJECTIVE

In this poster, the objective of this case study is to explore the clinical presentation, diagnostic process, and management strategies for a 19-years-old female with LKS.

METHODOLOGY

A detailed analysis of the patient’s medical records, including history, physical examination findings, neuroimaging results, and electroencephalogram (EEG) recordings, was conducted. Additionally, interviews with the patient’s family and healthcare providers were conducted to gather further information about the patient’s condition and management.

CONCLUSION

This case study highlights the challenges faced in diagnosing and managing Landau Kleffner Syndrome in a 19-years-old female. The findings emphasize the importance of early identification and intervention to optimize language and cognitive development in individuals with LKS. Further research is needed to explore effective treatment strategies for this specific population.

KEYWORDS

Landau Kleffner Syndrome (LKS), electroencephalogram (EEG)

A case of cerebellar degenaration in a patient with alcohol dependence syndrome

Dr Ateeba Ahmed, Dr Parul Gupta

Department of Psychiatry, Jawaharlal Nehru Medical College, Wardha

Background : Chronic alcohol use induces silent changes in the structure and function of central and peripheral nervous system that eventually results in irreversible repercussions.Alcohol induced cerebellar degenaration is one of the commonest acquired forms of cerebellar ataxia.Hereby we report a case of cerebellar degenaration in a chronic alcoholic patient.

Case description: A 51 year old gentleman,presented with complaints of alcohol consumption since 30 years and difficulty in maintaining balance while walking since 3 years.Previously he had history of alcohol withdrawal seizures and delirium tremens.On examination he had an ataxic gait with abnormal tandem walking,dysmetria and dysdiadochokinesia.His MRI revealed cerebral atrophic changes and NCV showed axonal motor polyneuropathy.He was managed on benzodiazepines,thiamine supplementation.

Conclusion: This case highlights that chronic alcohol consumption can lead to cerebellar atrophy and the defects persist even with abstinence from alcohol.

A case of Hair-pulling : Trichotillomania or Adjustment Disorder?

Dr Ipsita Basu, Dr Ankit Singal, Dr Ritwik Mishra

Background:

Trichotillomania is characterized by recurrent pulling of hair leading to significant hair loss, accompanied by unsuccessful attempts to decrease or stop the behaviour. Adjustment disorder is a maladaptive reaction to identifiable psychosocial stressor(s) within a month of occurrence of the stressor.

Aim:

This case report presents the case of a 13-year-old child with hair-pulling to understand the psychopathology and diagnosis.

Methods:

13-year-old girl, with no past or family history of psychiatric illness, presented with 8 days history of pain upper abdomen, vomiting and loss of appetite. CT Abdomen and UGI endoscopy revealed trichobezoar, which was removed by laparotomy. Patient gave history that she reached late to school one day owing to her mother plaiting her hair. Feeling humiliated by her teacher’s scolding, she started feeling that she should not have hair, as it was the cause of her humiliation. She convinced her mother to get her a haircut, but later had irresistible urge to pull out her hair and throw it away, and later, to eat the pulled out hair. Gradually, also developed loss of interest in previously pleasurable activities.

Result:

MSE revealed depressed affect with decreased range and reactivity. She responded well to CBT and supportive psychotherapy. She was observed drug-free, and has been stable even after 4 months of the same, on regular follow-up.

Conclusion:

The above case caused a diagnostic and therapeutic dilemma, albeit with excellent prognosis.

A Case of Meige Syndrome Mistaken for Conversion Disorder

Yatika Chadha, Pawan Arun Khadse

Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (DMIHER), Wardha

Background:

In this case study, we explore a compelling instance where Meige Syndrome, characterized by involuntary facial and neck movements, was initially mistaken for conversion disorder. We investigate the diagnostic hurdles and delve into potential factors that contributed to the misdiagnosis.

Case Description:

A neurologist referred a 50-year-old married woman for psychiatric evaluation due to a four-year history of speech difficulties, involuntary facial muscle twitches, blepharospasm, and neck muscle spasms. She also had difficulty swallowing, which made her primarily consume a semi-solid diet. Since the above symptoms aggravated during stress, the neurologist’s referral was to rule out conversion disorder.

After an initial evaluation by a psychiatrist, the patient received a provisional diagnosis of conversion disorder and was prescribed antidepressants. However, a more comprehensive history and examination by the other two psychiatrists revealed pronounced, involuntary, and forceful dystonic movements in oromandibular, pharyngeal, lingual, and neck muscles. Meige syndrome was considered a diagnosis in addition to identifying a mild depressive episode. The referring neurologist later confirmed this diagnosis, and the patient was prescribed a combination of Syndopa, Trihexyphenidyl, and an antidepressant. This treatment considerably reduced both mood-related symptoms and dystonic movements over the next four weeks.

Conclusion:

This case highlights the intricacies involved in the misdiagnosis of Meige syndrome and underscores the significance of comprehensive clinical evaluations and awareness of atypical presentations. An accurate diagnosis facilitated effective treatment, offering invaluable insights to healthcare professionals and illuminating the multifaceted nature of neuropsychiatric disorders.

A CASE OF OPIOID I.V DRUG ABUSE WITH CO-MORBID HEPATITIS C VIRAL INFECTION

PRESENTER : Dr. F. MOHAMED RAFI 2^nd YR PG

Dr. MAIKANDAAN, PROF AND HOD

Dr. PRADEEP. R , PROFESSOR

Dr. VAISHALI.S, SENIOR RESIDENT

DEPARTMENT OF PSYCHIATRY,

MADHA MEDICAL COLLEGE & RESEARCH INSTITUTE, KOVUR.

INTRODUCTION :

Opioid dependence is a significant clinical and public health issue in India. The prevalence of opioid use was 2.06% of the general population and 8.5 lakh people used injectable opioids with pharmaceutical opioids form 0.96%.The prevalence of hepatitis C was 30% in persons with injectable drug use. Injectable drug users share needles and syringes due to non-availability and non-affordability. It can cause abscesses, venous thrombosis and viral infections like hepatitis B, C and HIV.

CASE REPORT :

A 18 year old school dropout male from semi-urban background in Chennai who is a known case of opioid dependence syndrome presented to psychiatry OPD with abdominal pain, i.v drug abuse, anger outburst, sleep disturbance for 4 months. At presentation, he had confusion, disorientation and tremors. Blood investigations were done. It revealed elevated total bili rubin, direct bilirubin, SGOT, SGPT, Hepatitis C viral titre. He was treated with benzodiazepines, antipsychotics and antiviral drug. Clinical opioid withdrawal scale (COWS) was done – 5 (mild withdrawal). After 1 week of treatment his hepatitis C viral titre decreased. He had good appetite and sleep was adequate.

DISCUSSION :

Opioid dependence syndrome with co-morbid viral infections are common in North India. But it is a rare phenomenon in South India. It has a high mortality rate. So early recognition and immediate treatment is important.

E- poster: A Case Of Protracted Akathisia

Dr Abhishek Gupta^1, Dr Bikashita Deka²

Akathisia is a common and distressing neuropsychiatric syndrome associated with antipsychotic medication, characterised by subjective and objective psychomotor restlessness. It is commonly caused by anti psychotic drugs. We describe here a 24 year old Indian man having OCD with complaints of uncontrollable, discomforting repetitive thoughts of contamination leading to washing of hands & other body parts multiple times, for prolonged duration to get relief from those thoughts for a brief duration. The patient was prescribed fluvoxamine SR in initial at 50 mg hiked up to 150 mg, later on 2 mg risperidone along with 2 mg trihexyphenidyl added to increase effect but within 3 days of adding risperidone patient developed restlessness leading to pacing in the room continuously, unable to stay seated. A diagnosis of akathisia was made, and risperidone had been stopped and propranolol added at a dose of 20 mg bd which later was hiked to 40 mg bd. But patient response was poor in next 3 days & patient also develop insomnia because of restlessness, so benzodiazepine in form of etizolam along with propranolol at a dose 0.5mg + 40mg bd added & lorazepam 2 mg as prn (pro re nata) for insomnia. Patient improved completely after 7 days and later all benzodiazepine was tapered off. Here we discuss the presentation of akathisia persisting for 10 days even after removal of causing agent.

A Case of Reverse Seasonal Affective Disorder

INTRODUCTION-

Reverse SAD occurs when the change in seasons triggers a depression that starts in summer and subsides by late fall or winter. According to the National Alliance on Mental Illness ,this summertime depression affects less than one-tenth of all SAD cases.

AIM-

To discuss a case of reverse seasonal affective disorder in a middle aged female.

CASE REPORT-

A 50 year old woman presented to the OPD with history of episodic psychiatric illness for last 25 years. The current history was of 2 months of subacute onset of feeling low, accompanied by tearfulness, poor concentration and loss of interest in pleasurable activities. She was irritable and complained of marked fatigue. Her self confidence declined as she was unable to do her routine household work She felt excessive restlessness, apprehension and experienced palpitations when entering warm areas like the kitchen. On the other hand, she reported distinctly feeling more relaxed and cheerful when in the shade, or sitting under a fan. She had difficulty in falling asleep, and her appetite was normal. No weight change was noticed. The patient had multiple simliar episodes over the past 25 years, beginning in April - May and terminating in August. Apart from 1 single episode which occurred during month of November and resolved by March, 2017 all episodes occurred during summers at a frequency of 1 episode per year.She did not seek treatment for the previous episodes. On examination, she was cooperative and had a sad affect. She had depressive ideation of feeling low, lacking confidence in herself, felt her condition was worsening and expressed wish to die. Her physical examination revealed no abnormality and investigiations including a thyroid profile were within normal limits. She was started on fluoxetine, 20 mg daily,and melatonin 5 mg night dose.She showed improvement during next follow up after 2 weeks.

CONCLUSION-

Individuals with reverse SAD are often misdiagnosed with major depression,anxiety,dysthymia as it is fairly esoteric compared to winter SAD.

A 44 year old male presented with 5 months history of Generalised fatiguability, decreased appetite. 2-3 month history of yellowish discoloration of eyes. 1 week history of increased goal directed activities, grooming, delusion of grandiosity and hallucinatory behaviour with 1 day history of physical aggression towards family members. Past history of similar episode associated with yellowish discoloration of eyes.

General physical Examination revealed blackish discolouration of hands, legs, 3x3 cm of black patch on skin and icterus.

Mental status examination revealed increased psychomotor activity, Elated affect, Flight of ideas, delusion of grandiosity with otherwise intact intelligence with an insight of grade 1.

Laboratory evaluation revealed Hemoglobin(Hb) of 5.0g/dl with Macrocytic blood picture with mild leucopenia and mild thrombocytopenia. Liver function test showed Unconjugated hyperbilirubunemia with negative viral markers. Severe deficiency Serum Active-B12 with a value of Serum Active-B12 being 9 pmol/L .

Patient was treated with B12 supplements along with antipsychotics in view of severe physical aggression. During the course, there was reduction in YMRS score with drop in the bilirubin content, also improvement in skin manifestations were seen.

A Case Report of Escitalopram Induced Euprolactinemic Galactorrhea

Background

Certain classes of antidepressants like MAO inhibitors, TCAs and SSRIs, can lead to elevated plasma prolactin level and galactorrhea. Here is a case of 34 year old woman, who was treated with Escitalopram for depression and developed galactorrhea without hyperprolactinemia.

Case Report

A 34 year old female, premorbidly well adjusted, with nil contributory past or family history presented with 2 months history of low mood, decreased interest in activities, decreased sleep following a strained relationship with a friend. General physical examination was insignificant. On Mental status examination, had normal psychomotor activity. Mood subjectively sad and objectively depressed, restricted range, no thought or perceptual abnormalities. Cognitive functions were adequate with intact social judgement and full insight. A diagnosis of single episode depressive disorder, mild (ICD 11) was made.

Course

Patient was prescribed tablets Escitalopram 10 mg and lorazepam 2 mg at night which was tapered off over 2 weeks. Response was present at 3 weeks, but had galactorrhea within 2 weeks of start of treatment, which was reported only after about 5 months. Routine investigations were normal; serum prolactin, FSH, LH and thyroid profile were all normal including the MRI of Brain. Evaluation by endocrinologist, OBG and surgical team were insignificant. Escitalopram was tapered and stopped over next 4 weeks. Galactorrhea stopped within the next 2 weeks and patient is maintaining well without any medications.

Conclusion

Galactorrhea is a rare adverse effect of Escitalopram and more so with normal prolactin levels.

A CASE REPORT OF SHARED DELUSIONS: AN UNUSUAL CONSEQUENCE OF A CLOSE MOTHER-SON BOND

DR PINKY YADAV ¹

DR ANKIT CHAUDHARY²

1-1^st year resident, department of psychiatry, Chirayu Medical College, Bhopal

2-Assistant professor, department of psychiatry, Chirayu Medical College, Bhopal

BACKGROUND :

Jules Baillarger was the first to report this condition in 1860. In DSM –III, it was listed as Shared paranoid disorder. In DSM –IV, the term was changed to shared psychotic disorder (Folie a deux).

In DSM -5, it was removed as separate disease entity. ICD-10 lists it as Induced delusional disorder.

OBJECTIVE:

This case report evaluates the clinical profile of a case of Delusional disorder in a 19 year old boy whose mother was having systematized delusions since her teenage.

METHODOLOGY:

This case report evaluates the clinical profile of a 19 year old male who was brought to psychiatry clinic of a Tertiary care hospital. On the basis of comprehensive clinical and psychological tests, he was diagnosed with Delusional disorder according to ICD-10. On interviewing the patient’s mother, it was found that she was having systematized delusions since her teenage. Patient was treated on inpatient basis.

CONCLUSION :

By this case report we wish to bring in light the milieu of presentation of a case of Delusional Disorder in the patient whose illness was influenced by his mother who herself was having systematized delusions.

KEYWORDS: Systematized delusions, Induced delusional disorder.

A CASE REPORT ON DISSOCIATIVE FUGUE

DR PONMANI (SECOND year Postgraduate, SMVMCH)

DR ARUN S (Head of department, SMVMCH)

DR SOUGANYA DEVI@MAHALAKSHMI (Assistant professor, SMVMCH)

BACKGROUND

Dissociative fugue is a psychiatric disorder characterized by amnesia coupled with sudden unexpected travel away from the individual’s usual surroundings and denial of all memory of his or her whereabouts during the period of wandering.

CASE REPORT

A 55 years old male was brought to psychiatry OPD by his wife with complaints of forgetfulness, sad mood , low energy , reduce interaction for past 1 month . According to wife , patient went missing from home for about 25 days for which the patient did not have any memory. he had financial crisis and worries about his daughter marriage were major stressors. Mental status examination, showed depressed affect. EEG and neuroimaging were taken to rule out organic causes which showed normal finding. SSRI was started and psychotherapy were also given. due to persisting symptoms Lorazepam assisted interview was conducted after getting appropriate consent . patient gradually started regaining his memory of the events during the missing period . patient was started on CBT sessions to address the psychosocial issues. He is on regular follow-up .

DISCUSSION

In this case patient was having forgetfulness for a certain period of time . After lorazepam assisted interview patient started regaining his memory, we also address the ongoing stressor in an empathetic manner . psychological support help the individual to come back to his normal life and prevent future episode of fugue .

A CASE REPORT ON TRICHITILLOMANIA IN A CHILD.

Dr.Tadepalli Apoorva Namrata ¹(First year resident in Psychiatry-Katuri Medical College), Dr.Suresh Kumar Kota²(Professor and HOD Psychiatry-Katuri Medical College),Dr.Boddupalli Harimanasa ³(Assistant Professor in Psychiatry-Katuri Medical College).

Background: A disorder characterized by noticeable hair loss due to a recurrent failure to resist impulses to pull out hairs. The clinical prevalence rate of trichotillomania was 1.24% with the mean age at first presentation was 10.1 years (SD=4.4; range 2-14). The disorder is included under habit and impulse disorder according to ICD-10,but it is discussed under obsessive-compulsive spectrum disorders as it shares certain features of obsessive-compulsive disorder.

Aim: To identify the occurrence of other psychiatric disordres underlying to trichotillomania.

Case: A 13year old boy has been referred from dermatology OPD to psychiatry with his mother as informant, reporting hair loss at specific area over scalp, child has become silent at home since 3 months, occasional ingestion of hair strands noticed by mother since 1month.

Result: Dermatological causes of alopecia were ruled out and a significant stressor was associated with the child’s habit of pulling hair.

Conclusion: Depression in children is difficult to identify. Trichotillomania, though is an isolated psychopathology, it is one of the presentations for underlying depression in children.

Trichotillomania , Depression

A clinical study on Memory dysfunction in patients of Depressive Disorder

Background – Research in the last decades have shown that depression is associated with a significant disturbance in cognitive functioning. Memory dysfunction appear to represent one of the core features of cognitive dysfunction in depressive disorders with an impact on many functional outcomes.

Objective – This study aimed at assessing the memory deficits in patients suffering from depression and to study the corelation between memory dysfunction and severity of depression.

Method – A Total of 40 patients with Depression diagnosed according to ICD – 10 Criteria and 40 healthy controls were included. PGI Memory scale and Hamilton Depression Rating scale (HAM – D) was adminstered and analysis was done using Chi – square test and Pearson’s correlation.

Results – The study revealed significant differences in the Dysfunction scores between the study and control population. In the study group majority of patients had memory dysfunction and a positive correlation was found between mamory dysfunction and HAM – D scores.

Conclusion – Depression is associated with significant disturbance in memory and the memory dysfunction increses with increase in the severity of depression.

A comparative study of student burnout and perceived stress among medical and engineering students.

Harshith Mahadev¹, Pavitra K S²,Deepak R S³, Ananthkalyan D⁴Aruna B Rao⁵

Background:

Students undergoing Medical and Engineering training are said to experience high levels of academic pressure leading to burnout, characterized by emotional exhaustion, depersonalization, reduced personal accomplishment in academic life. Literature comparing burnout and stress experiences in these students is limited underscoring the need for targeted support.

Aims:

• To compare prevalence of student burnout and perceived stress among engineering and medical students.

• To study various factors associated increased burnout and stress.

Methods:

We conducted a cross-sectional study using a self-administered online questionnaire. Burnout and stress were measured using Copenhagen Burnout Inventory Student Survey (CBI-SS), Perceived Stress Scale (PSS-10) respectively. A total of 438 responses were collected, comprising 292 engineering and 146 medical students.

Results:

Medical students overall exhibited a higher burnout rate 92.41%compared to engineering students 84.8%.

High stress levels seen in 26.89% medical students versus 19.93% engineering students.

Burnout increased as students advanced through their academic years in both courses. It steadily rose from 72% in 1st year engineering to 95% in 4th year. All Medical students had highest burnout in 4th year (100%) and 96.42 % during internship.

Conclusions:

Medical and engineering students grapple with substantial levels of burnout and stress throughout their academic journeys. Medical students consistently reported higher burnout rates and stress levels. This highlights the imperative need for effective support and coping mechanisms to enhance student well-being and mental health during their educational training.

A Cross-Sectional Study Of Psychiatric Morbidity In Patients Of End Stage Renal Disease

Background : The impact of psychological factors on the outcome of patients with End stage renal disease (ESRD) has been receiving more attention lately.

Aims : To study the prevalence of psychiatric comorbidities in patients of ESRD undergoing dialysis and post-transplant surgery.

Methods : 80 diagnosed patients of ESRD taking treatment from Nephrology Unit were included. Karnofsky score for each patient was calucated. All patients were assessed with Hindi version of General Health Questionnaire- 12 (GHQ- 12), Hospital Anxiety and Depression Scale and BDI. Cognitive functioning was assessed using the Mini- Mental State Examination (MMSE). Simple rating for quality of life will be performed by asking the patients how they rate their quality of life along a five-category Likert scale from poor to excellent.

Results : The mean Karnofsky score was found to be 63. A significant number of patients were having psychological distress with mean GHQ-12 scores of 6.5. Anxiety symptoms were more common than depressive symptoms. 07 patients scored below cut off in MMSE signifying cognitive impairment. Most of the patients rerated their QoL to be poor to average.

Conclusion : This study shows high prevalence of psychiatric comorbidities in ESRD. It is crucial to recognize these psychiatric comorbidities in dialysis patients because they can significantly impact the overall well-being and treatment outcomes of these individuals. Comprehensive care for dialysis patients should address both their physical and mental health needs.

A Diagnostically Challenging Case: Epilepsy Presenting with Acute Psychosis and Prolonged Catatonia.

Introduction - 10-15% of adult catatonia cases, not linked to mood disorders, coincide with epilepsy. epileptic catatonia is often brief. We present a case of a patient with seizures and psychosis who experienced catatonia showed poor response to standard medications but improved with electroconvulsive therapy.

Background - A 17-year-old female, known to have focal impaired awareness seizure disorder, presented with recurrent seizures over the past year followed by postictal psychotic symptoms like disorientation and hallucinations, which initially resolved within hours. Her condition worsened, resulting in agitated behaviour, impulsive actions including hair-pulling, auditory hallucinations, heightened fearfulness, neglect of personal hygiene, and disrupted sleep patterns. She was prescribed oxcarbamazepine, clonazepam, flupenthixol with melitracen, which effectively controlled her seizures. On admission, she was alert but disoriented, mute, immobile, with a blank stare, posturing, grimacing, non-compliant with commands, and refused food, tachycardia. Initial investigations were unremarkable. Treatment involved lorazepam, levetiracetam, aripiprazole reducing her catatonia by 75%. Due to worsening psychosis, she received two sessions of electroconvulsive therapy (ECT).

Discussion : Seizures and catatonic symptoms resolved completely with a 55% improvement in psychosis through anti-epileptic meds, antipsychotics, benzodiazepines, and ECT, highlighting the importance of careful medication management in catatonia.

A rare case of accidental mercury poisoning manifestating with neuropsychiatric symptoms in an adult male

DR ADITYA VOHRA - JUNIOR RESIDENT

DR FIONA MAHAPATRO ( PROFESSOR AND HOD )

DR SS KALE (PROFESSOR )

DEPARTMENT OF PSYCHIATRY

DR DY PATIL SCHOOL OF MEDICINE , NERUL, NAVI MUMBAI

BACKGROUND -

Mercury is the 2^nd most common form of heavy metal poisoning in the world. Exposure to mercury is wide ranging, according to its three forms:elemental mercury (e.g.,thermometers,dental amalgams); inorganic mercury (e.g., minerals used as medicinal ad.additives and skin whitening creams); and organic mercury (e.g., pollution-related methylmercury found in fish.

Neuropsychiatric symptoms of mercury poisoning are initially insomnia, memory loss and irritability, later on progressing to anxiety, depression, personality changes, delirium, hallucinations, and seizures.

CASE REPORT -

A 47 year old BAMS doctor was brought to the casualty in Oct 2022 with complaints of irritability, angry abusive outbursts, wandering spells and sleep disturbances since April 2022 with H/o disorientation in time, place & person since 10 days. On enquiry H/o accidental mercury poisoning in April 2022 . H/o depressive features present since 4 years

On MSE pateint was conscious, minimally cooperative, disoriented to time, place & person, attention was ill sustained,affect was perplexed & judgement was impaired.

DISCUSSION -

Impression - Delirium due to unknown or unspecified aetiological factors ( mercury) Emergency treatment was administered under Medicine department : oral penicillamine:250mg and then transferred to Psychiatry. For behaviour control psychotropics were given . Serum Mercury - Normal Range - 0.21-1.3 μg/L

April 2022 - 102.4 μg/L

May 2022 - 48.95 μg /L

Aug 2022 - 5.6 μg /L

Nov 2022 - 4.3 μg/L

Dec 2022 - 4.17 μg/L

Delirium rating scale scores was 30 (on admission) declined to 14 (on discharge).

DISCUSSION & CONCLUSION-

Mercury poisoning can have varied presentation.Though rare it is not uncommon. Only 8 case shave been reported in literature till date. Diagnosis can be established from a comprehensive history and confirmatory laboratory values.

A RARE CASE OF ACUTE AND TRANSIENT PSYCHOTIC DISORDER WITH PSYCHOGENIC FEVER INDUCED BY MEDITATION

DR INDULEKHA V M¹

CO-AUTHOR: ²DR DIVYAKUMARI SHERIGAR

INSTITUTION: SAPTHAGIRI INSTITUTE OF MEDICAL SCIENCES AND RESEARCH CENTER,BENGALURU.

DESIGNATION: ¹POST GRADUATE , ²ASSISTANT PROFESSOR OF PSYCHIATRY,DEPARTMENT OF PSYCHIATRY.

INTRODUCTION AND BACKGROUND:

Meditation is a method to engage in mental or physical exercises to reach a heightened level of consciousness. Some meditation techniques might cause rise in body temperatures according to studies .An Acute and transient psychotic disorder is characterised by sudden emergence of symptoms reaching their severity within 2 weeks according to ICD-11 .This is a rare presentation .

AIMS AND OBJECTIVES:

To study a rare case of Meditation- Psychogenic fever induced acute and transient psychotic disorder .

METHODS:

A 32 year old unmarried male patient, living alone, employed as an engineer with prior history of OCD 2 years ago ,treated and relieved of complaints since 1 year and 1 episode of loss of consciousness following prolonged meditation and breath modulation 8 months ago being brought by his brother with fever and abnormal behaviour was studied.

Relevant investigations done .

RESULTS:

This is a rare type of ATPD presenting with meditation induced psychogenic fever and raised lactate levels with mild respiratory alkalosis .

CONCLUSION:

There has only been limited number of cases reported of this kind either because of lack of awareness among masses or due to lack of extensive studies. The patient was started on Tab.Olanzapine 15 mg with improvement .

A rare case of behaviour changes due to Brivaracetam

Presenting author - Dr. Akanksha

Co-author - Dr. Ritu Meena, Dr. Tushar Jagawat

Brivaracetam is structurally related to levetiracetam and has a similar mechanism of action through binding to SV2A but with approximately 20-fold higher affinity and greater selectivity. Treatment emergent psychiatric adverse effects of the drug have been said to range from mild to moderate and very less compared to other antiepileptics. Behaviour changes from Brivaracetam have rarely been reported in literature.

AIM & OBJECTIVE To assess the clinical profile of a rare case of 22-year-old male with behaviour problem due to Brivaracetam use CASE A 22-year-old male with a history of epilepsy since the past six months was referred from neurology department with history of irritability, aggression and fearfulness. There was no history of psychiatric illness, drug use or recent head trauma. The symptoms were not related to seizure episode and surfaced one month after initiation of Brivaracetam.

RESULT Patient was started on antipsychotis and benzodiazepines. There after his symptoms improved and behaviour became normal within few days.

DISCUSSION & CONCLUSION No case has been reported in literature about behaviour problem due to Brivaracetam to the best of our knowledge

Adult ADHD Masquerading As Multiple Addictions: Addressing Diagnostic And Treatment Needs

Dr. Jeffi Vijayakumar*, Dr. Christina George**,Dr. Haritha Babu. C***

Junior resident, Dept. of Psychiatry

**Professor, Dept. of Psychiatry, Dr. SMCSI Medical College, Karakonam

***Senior Resident, Dept. of Psychiatry, Dr. SMCSI Medical College, Karakonam

BACKGROUND

ADHD is a disorder that begins in childhood and continues into adulthood. Adults who are diagnosed with ADHD experienced several symptoms of ADHD before the age of 12, which are often missed. Most of the untreated ADHD in childhood or adulthood can lead to behavioural, emotional, social and vocational problems. Adolescents and young adults with substance use disorders (SUD) and attention deficit/hyperactivity disorder (ADHD) are increasingly presenting in clinical practice.

CASE REPORT

Mr. X, is an18 year-old boy, who presented to the Psychiatry OPD, with complaints of excessive use of multiple substances, including nicotine, alcohol and cannabis, along with clinical features suggestive of gaming disorder. Intervention was sought in view of his substance use pattern as well severe behavioural issues such as impulsivity and anger outbursts. On detailed evaluation, it was identified that he had symptoms of hyperactivity and inattention, which were not addressed in childhood by the parents and continued to manifest now. Adult ADHD self-report scale and Wender Utah Rating scale were administered and a diagnosis of Adult ADHD was made. There was no clear evidence of significant personality disorders or medical disorders. He was started on treatment with Behavioural therapy and Atomoxetine.

CONCLUSION:

Individuals with ADHD can get caught in a jumble of thoughts and emotions which can often lead to agitation and impulsivity with co-occurring SUD. Initially substance use ameliorates the symptoms and related problems of ADHD. Without identifying and treating the underlying ADHD, the cooccurring SUD which is due to impulsivity becomes a vicious cycle, which will be broken off only by effective treatment of ADHD.

Aetiology & Clinical features of Delirium: An Observational Cross-sectional Study in A Tertiary Care Rural Hospital

Background:

Delirium is acute change in mental status characterized by disorganized thinking and/or altered level of consciousness. The aetiologies of delirium are diverse and multi-factorial, and they often reflect the pathophysiological consequences of an acute medical illness. Even though delirium is a common clinical entity, diagnosing and managing those who are affected can be very challenging due to its broad-based phenomenology. Since delirium is associated with high mortality, better understanding of clinical features and etiology can help in understanding high risk and preventable conditions.

Objectives:

To describe & compare the aetiology and clinical features in patients of Delirium admitted to Hospital.

Methods:

It is a descriptive observational cross-sectional study, every patient in the hospital who develops altered sensorium and referred to department of psychiatry was evaluated for presence of delirium according to the operational definition and DRS-R-98 diagnostic criteria over a period of 9 months.

Results:

It was found that there was significant correlation between sleep wake cycle disturbances and short-term memory with CNS Pathology & long-term memory with Hyponatremia and Reanl derangements.

Conclusions:

The current research findings concludes that impairment in sleep and short-term memory may suggest CNS Pathology, on the other hand impairment in long-term memory can be suggestive of Hyponatremia or Renal derangement leading to Delirium.

Affective Disorder and Hereditary Spherocytosis- A Case Report

Dr.RamyaDeepika.Y.R¹, Dr.Vinutha.R, Dr.Geethanjali.P, Dr.Veda.N.Shetageri, Dr.G.P.Gururaj

¹PG Resident, Department of Psychiatry, East Point College of Medical Sciences and Research Centre, Bengaluru.

Background: Hereditary Spherocytosis is the most prevalent cause of hemolytic anemia due to an abnormal red cell membrane. Deficient or abnormal proteins may include Spectrin, Ankyrin, Band 3, and Band 4.2. Bipolar disorder is a multi-factorial disorder caused by genetic and environmental influences. The most significant and replicated genes is Ankyrin 3.

Aim: To assess the clinical and hematological profile of a 39-year-old female with affective disorder.

Methods: 39 years old married female, mother of one 14 years old girl child, presented with symptoms suggestive of a manic episode of 2 months duration on first admission. On examination she had pallor, icterus, and splenomegaly. After 1 month of discharge, off medications, she presented with symptoms suggestive of a depressive episode of 2 weeks.

Results: The case was managed in liaison with the Departments of General Medicine and Pathology. During the hospitalization, patient was noted to have declining hemoglobin levels and increasing total bilirubin levels and reticulocyte counts. Peripheral smear showed microcytic hypochromic anemia with spherocytes, Flow cytometry analysis using Eosin 5 Maleimide showed reduction of Mechanical Fragility Index (MFI) of 27.9% suggestive of HEREDITARY SPHEROCYTOSIS. Genetic counselling was done. Affective symptoms were managed with low dose antipsychotics.

Conclusion: Affective disorders are known to be associated with medical comorbidities. Studies suggest genetic association of Ankyrin gene in bipolar disorders and hereditary spherocytosis. A thorough assessment of medical comorbidities helps us in holistic management of affective disorders.

An interplay of psychotropic medications in HIV patient with mental illness in a long stay home for destitute- A case report

Dr. Shivangi Mehta¹, Dr. Geeta Galgat², Dr. Karan³

^1,2,3Department of psychiatry, Government medical college and hospital-32, Chandigarh

Aims:A case to see any drug interaction between psychotropics and ART in HIV patient with psychiatric illness.

Background:As per literature, patients with HIV or on treatment for AIDS are at higher risk for mental illness than the general population or vice-versa. Psychotropic medications are frequently co-prescribed with antiretroviral therapy (ART), both of which are metabolised in liver, potentially leading to a drug-drug interactions (DDI) and adverse side effects, the consequences of which can range from sub-therapeutic drug concentrations resulting in treatment failure or toxicities due to both. However, with the close monitoring and appropriate dosing of psychotropic agents, the benefit of increased adherence and quality of life outweighs the risks.

Case Summary:A 40 years old female resident of Ashreya home, a permanent home for Orphaned/Destitute/Abandoned mentally challenged persons by the government, complaints of irritability, suspiciousness, self-muttering, self-smiling, aggressive behaviour, self-harm thoughts for unknown duration. She was started on Haloperidol tablet but to ensure compliance had to be started on injectable Haloperidol long acting 75 mg fortnightly which had to be stopped due to dystonia, and subsequently stabilised on Olanzapine 15 mg, Risperidone 8 mg and Fluoxetine 20 mg. She was also receiving ART (Tenofovir, Lamivudine, Efavirenz) for HIV. The medications were co-prescribed since 12 years, patient followed up regularly, no DDI reported and maintained well with the compliance to the treatment.

Conclusion:Psychotropics and antiretrovirals may be used safely with appropriate dose and blood count monitoring even in a long stay home.

Psychotopics, HIV, ART , Ashreya home, Mental illness.

ANOREXIA NERVOSA IN RURAL INDIA

Dr. Shivani Gusain (Senior Resident), Dr. Nishant Goyal (Professor),

Central Institute of Psychiatry

Background: Anorexia Nervosa (AN), an eating disorder having first been identified in the 17^th Century Europe has been considered a western syndrome with emphasis on slimness as a measure of beauty. Global development and rapid changes in South-East Asian countries in economy, mindsets, and adoption of Western attitude has occurred, there have been sporadic reports of AN in the past few years in India mostly in cities. Our case report digresses from the familiar theory of AN being a westernized concept in presenting a case from Rural India.

Aims: To demonstrate a case of anorexia nervosa in a 16 year old female, hailing from rural Bihar

Methods: Presented with complains of- decreased and restrictive intake of meals, increased concern over her appearance for 4 years, anger outbursts for last 3 years, BMI of 18kg/m² and menstrual irregularities. Clinical interviewing, hormonal profiling and psychological assessments were done.

Results: Showed improvement with Cap Fluoxetine 20mg, Tab Olanzapine 10 mg, schema-based therapy, family therapy and dietary counselling.

Conclusion: The past decades have seen a rise in the cases of AN in the Indian subcontinent. Our case emphasizes the need to keep an open mind as to the possibilities of an eating disorder in children and adolescents irrespective of geographical or racial distribution; as well as to understand the correlation between social media usage and self-esteem in relation to eating disorders.

Assessment of Anxiety Levels in patients scheduled to undergo MRI (Magnetic Resonance Imaging).

Introduction

MRI has been known to induce elevated levels of anxiety in patients due to multiple factors such as fear of closed spaces when they are scanned in the confined tube for a long duration, loud noise during scans, etc. This study aims to objectively assess anxiety levels in patients scheduled to undergo MRI, using HADS (Hospital Anxiety & Depression Scale).

Methods

The study was conducted involving 2413 patients who presented to the MRI Centre of a tertiary care hospital over a period of One year. All patients scheduled to undergo MRI were explained the objective of the study and those willing to participate were given a self-administered set of questionnaires of HADS-A (Hospital Anxiety and depression score – Anxiety subset). Out of 2413 eligible patients, 2027 completed the questionnaires and were included in the study.

Results

The prevalence of anxiety amongst the pre-scan sample group was detected to be 52.5% & in the post-scan group 66.5%. There was a greater proportion of females detected with anxiety at 60.3%. The most common age group involved was in the range of 41-50 years (37.7%). The fear of confinement in closed space and apprehension of high noise levels was detected to be the most common cause of anxiety at 44%.

Association between Alcohol use and Cognitive impairment- A case control study

Aim:To look for correlation between patients with alcohol dependence syndrome and cognitive decline

Background: Alcohol consumption has escalated rapidly in many countries over the past decade. Evidence suggests a correlation between alcohol use and cognitive impairment. [¹] Cognitive impairment is characterized by a decline in memory, language, and other cognitive function, which is not severe enough to interfere with daily activities. [²] This study is in search to find the correlation between long term alcohol use and cognitive impairment in patients.

Methods:

The study was done in in-patient set up in the hospital. Consenting participants between the age group of 18-60 years, who fulfilled the ICD -10 criteria of Alcohol dependence syndrome were taken up consecutively for the study as cases . After matching the socio-demographic variables, controls were added.

Detailed clinical assessment was done and the Montreal cognitive assessment Scale (MOCA) was administered to assess the cognitive impairment.

Results:

In our study, we found positive correlation between the duration of alcohol use and cognitive impairment through the MOCA scores, hence signifying the cognitive decline in patients with alcohol dependence syndrome.

Discussion:

This study concludes significant correlation between cognitive decline and alcohol dependence syndrome. Apart from the physical comorbidities, cognitive impairment associated with patients with alcohol dependence syndrome also plays a role in prognosis and long term management.

References:

1. Sachdeva, A., Chandra, M., Choudhary, M., Dayal, P., &amp; Anand, K. S. (2016). Alcohol-Related Dementia and Neurocognitive Impairment: A Review Study. International journal of high risk behaviors &amp; addiction, 5(3), e27976. https://doi.org/10.5812/ijhrba.27976

2. Yen, F. S., Wang, S. I., Lin, S. Y., Chao, Y. H., &amp; Wei, J. C. (2022). The impact of heavy alcohol consumption on cognitive impairment in young old and middle old persons. Journal of translational medicine, 20(1), 155. https://doi.org/10.1186/s12967-022-03353-3

Bioequivalence of paliperidone long acting injection in patients with schizophrenia: results from a randomized, cross-over, open-label study

Arthik Shetty, Amaresh Chakra, Chirayu Shah, Prashant Devkare, Shruti Dharmadhikari, Amey Mane and Suyog Mehta

Background and Aims

Paliperidone palmitate once-monthly long-acting injection (PP-LAI), an atypical antipsychotic is approved in India for acute and maintenance treatment of schizophrenia in adults. The purpose of this study was to assess relative bioequivalence of Paliperidone LAI from Sun Pharma in patients with schizophrenia with respect to the innovator Paliperidone injection.

Methods

This was an open label, multi-center, randomized, two-treatment, two-period, two-sequence, multiple dose, steady state cross-over study in patients diagnosed with schizophrenia (DSM-V). Primary objective was to assess relative bioavailability of test product (T) of Paliperidone LAI 156 mg in comparison with reference product (R) - Paliperidone injection 156 mg. Secondary objective was to monitor the adverse events of the investigational product.

Results

Sample size was 94 patients with schizophrenia. The 90% confidence interval (CI) for the ratio of the test (Ta) and reference (R) for Cmax ss was 91.47% (85-99) and for AUC0-t was 95.64% (90-101). Both values were within the 80%-125% range. Adverse effect profile of the investigational product was favorable.

Conclusions

Based on these results, Paliperidone LAI from Sun Pharma is bioequivalent to the innovator product in patients with schizophrenia and have a favorable safety profile. The availability of long acting injection of Paliperidone would definitely improve the patient compliance and adherence to the treatment

UNUSUAL CASE OF ENTERIC FEVER PRESENTING AS ACUTE PSYCHOSIS: A CASE REPORT

BY-

DR. RACHNA SINGLA (1ST YEAR RESIDENT, DEPT OF PSYCHIATRY, D.Y. PATIL HOSPITAL)

DR. SANJIV KALE (PROFESSOR, DEPT OF PSYCHIATRY, D.Y.

PATIL HOSPITAL)

BACKGROUND

• Enteric fever is a food borne bacterial infection, caused by Salmonella Typhi and Paratyphi, commonly manifesting as stepladder fever, rose spots and gastrointestinal symptoms lasting for 3-21 days.

• Neuropsychiatric manifestations commonly include Delirium, Aggression, Parkinsonism, Meningitis, Encephalitis, or Polyneuropathy.

• Acute psychosis is a rare manifestation of Enteric fever with a prevalence of 0.63%, developing within the first 3 days of illness.

• Appropriate antimicrobial therapy is the mainstay of treatment of both intestinal and neuropsychiatric manifestations.

• Here we present an unusual case of enteric fever presenting as Acute psychosis.

METHODS

• 15y/o female was brought by relatives to OPD with complaints of altered behavior in the form of fearfulness that someone will harm her, hearing of voices, irritability with angry and violent outbursts, irrelevant talk, sleep disturbances and decreased selfcare since 3 days.

• On Mental status examination patient was minimally cooperative, Eye-contact was not maintained, Mood was Fearful with Persecutory Delusions and Auditory Hallucinations.

• Patient also had a history of fever spikes since 3 days. Routine Investigations were normal except SGOT/ SGPT - 229/137(raised) and Widal Test was positive with raised ‘O’ and ‘H’ titres - 1:320

RESULT

• Patient was started on Oral Antibiotic (Cefixime). Olanzapine and Clonazepam were also given orally for behavioral control.

• Patients symptoms improved in 5 days treatment and psychotropics could be tapered.

DISCUSSION

Enteric psychosis is due to the effects of toxin on the CNS rather than direct bacterial invasion. Patients usually respond well to Antimicrobial therapy although psychotropics help in management of psychiatric symptoms.

CASE REPORT OF GERIATRIC BIPOLAR PATIENT WITH MANAGEMENT DIFFICULTY

Introduction:

Managing bipolar disorder in geriatric patients presents a unique set of challenges due to the complex interplay between ageing-related factors and the condition itself. Geriatric bipolar patients may present with atypical symptoms, such as cognitive decline, which can be mistaken for other age-related conditions like dementia. Here, we discuss a case of a geriatric bipolar patient with management difficulty.

Case Report

A 70 year old Hindu female from urban UP with a bipolar illness came for admission with chief complaints of increased talkativeness, increased psychomotor activity, suspiciousness, death wishes, forgetfulness, weakness and disturbed biological functions; episode frequency being every 2-3 years for 2-3 months duration. The patient had multiple medical comorbidities (cholecystectomy, ophthalmic surgery, hypertension, fractured left forearm, electric shock by live wire in the past, occasional hand tremors). The patient had sinus bradycardia with sinus arrhythmia on admission and increased heart size. The patient had multiple side effects on psychotropics and MECT and had to be sent to GHPU setting due to cardiovascular comorbidity and dyselectrolytemia.

Discussion:

Bipolar disorder is a frequent reason for psychiatric hospitalization in later life. Studies have shown early lithium neurotoxicity reported within the therapeutic range in older individuals. ECT is an effective and safe treatment option for elderly patients. In conclusion, managing bipolar disorder in geriatric patients is a complex endeavour that demands a holistic approach, careful consideration of age-related factors, and collaboration among healthcare providers, patients, and their families.

Clinicians- Watch out for NMS

Department of psychiatry (MMCRI), Chennai

Dr. Nirmal Kumar Seenan 2nd year PG,

Dr. Maikandaan CJ (Professor &HOD),

Dr. Pradeep R, Professor,

Dr. Vaishali. S, Senior Resident

INTRODUCTION : Neuroleptic Malignant Syndrome (NMS) is an uncommon life-threatening Psychiatric emergency that has been observed to occur in some patients following the administration of anti-dopaminergic agents or the rapid withdrawal.This involves high fever, altered mental status (AMS), severe muscle rigidity, and signs of autonomic dysfunction. Leukocytosis and elevated serum CPK are also seen.

Case Report: 50years old female, housewife, diagnosed with schizophrenia for 10 years, during her recent review with her psychiatrist antipsychotic change was done (Olanzapine) was added and dose increased. Few days later she developed fever, confusion, vomiting, slowness of movement. She was brought here and admitted in medical ICU in drowsy state with low bp and Spo2, blood investigations including fever panel was normal except Leucocytosis. Despite adequate Antibiotics coverage, fever persisted. After 1week psychiatrist opinion was obtained, history was noted & in view of Fever, rigidity, leucocytosis, elevated CPK level, she was suspected to have NMS and advised to start on T. Bromocriptine and stop Olanzapine, but this diagnosis was not considered seriously by the clinicians, only after repeated discussion with them they realized it and started bromocriptine only on day 10, then she recovered well and discharged.

Conclusion: NMS is a potentially fatal complication of neuroleptic therapy regardless of the duration or dose of the drug. So in view of high-mortality rate, early recognition and immediate referral is important. So awareness of NMS among clinicians is mandatory for differential diagnosis especially for patients receiving a neuroleptic medication who develops high fever or rigidity.

Comparison of thyroid function and c-reactive protein (CRP) levels in unipolar and bipolar depression

Background:

Major depressive episodes can occur in both depressive disorder and bipolar and related disorders. Multiple neurobiological theories have been put forward to explain depressive psychopathology. One of the prominent theories is alterations in hypothalamic-pituitary-thyroid axis functioning & another theory is the role of immune dysregulation.

Objectives:

1. To compare thyroid function and CRP levels in patients suffering from a major depressive episode associated with Depressive disorders versus a major depressive episode associated with Bipolar and related disorders.

2. To identify the thyroid function and CRP level as biochemical markers for differentiating unipolar and bipolar depression.

Methods:

This is a cross-sectional study that included patients with Major Depressive episodes attending Psychiatry OPD of SNMC, Agra. Currently, 27 patients are enrolled. All patients were assessed using a sociodemographic proforma, The Hamilton Depression Rating Scale (HAM-D) & Hamilton Anxiety Rating Scale (HAM-A) were administered to those who were diagnosed as having Major Depressive Episodes.

Results: Currently 27 patient is enrolled of which 9 has a diagnosis of bipolar depression & 18 have unipolar depression. Out of these total patients, 25.92% patient have dysfunctional thyroid function, and 40.74% have CRP levels more than normal. When compared between unipolar & bipolar depression thyroid dysfunction is found more in unipolar depression 27.77% & 22.22% in bipolar depression.

Conclusion: This study supports the neuroendocrine theory of depression & possible role of the immune dysregulation hypothesis.

Abstract for E-Poster Presentation: Complex PTSD and Regressive behavior : A Case Report

Harsh Khandelwal¹, Mukesh Kumar Swami²

¹Senior Resident (Psychiatry), NIMHANS, Bengaluru ²Additional Professor (Psychiatry) All India Institute of Medical Sciences, Jodhpur, Rajasthan

Background: Regression as a defense mechanism has been hypothesized to serve as a means to return to a developmental stage when people feel more secure. The association with complex PTSD is sparingly documented.

Aim: To highlight association of regression as a marker for presence of history of childhood trauma in adults

Case Summary: A 41 year old, married female with multiple medical co-morbidities & alleged history of repeated childhood sexual abuse at 8 years of age presented with illness of 33 years with sub-acute onset & episodic course with 1 episode lasting for 1 year following incident, characterized by low mood, reduced interest, nightmares and anxiety symptoms associated with recall of trauma, hypervigilance & avoidance of related stimuli and academic decline. A similar episode in 2007 occurred with dissociative episodes, regressive behavior & self harm attempt of high intent and lethality. Incomplete remission was achieved with treatment and in 2017, 2020 & 2022 exacerbations of symptoms occurred precipitated by stressors. There was significant self blame, low self esteem and emotional dysregulation with marital conflicts, financial instability and poor social support. She was treated with Tab Sertraline 250mg & Tf-CBT and 80-90% improvement was achieved.

Clinical Implications: The case illustrates repercussions of CSA permeating all facets of existence and importance to view cases with regressive behavior with extreme caution.

Convergence Spasm Masquerading as Abducens Palsy: A Diagnostic Challenge

Nayan Sinha¹, Kamaldeep Sadh¹, Pawan Arun Khadse¹, Sourya Acharya²

1Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (DMIHER), Wardha.

2Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research (DMIHER), Wardha.

Background:

This case report discusses an unusual presentation of convergence spasm, a rare eye disorder that can be mistaken for abducent palsy. We examine the diagnostic challenges, distinctive features, and the importance of accurate diagnosis and proper management.

Case presentation:

A 29-year-old homemaker from a low-income family was hospitalized after a fall that injured her right temporal region. This resulted in vomiting, transient right eye vision loss, right ear tinnitus, and facial tingling. Her vision improved, but she experienced double vision and an inability to move her right eye outward. She underwent thorough medical evaluation as an inpatient in the medicine ward, which revealed impaired right eye abduction and external rotation, along with normal fundus examination results. Hematological investigations and a brain MRI were unremarkable. VEP recordings showed prolonged p100 latencies in both eyes. Initially, multiple sclerosis was considered, and a prednisolone regimen improved her symptoms temporarily. However, her ocular issues resurfaced during arguments with her husband, leading to a transfer to the psychiatry ward. Psychiatric evaluations diagnosed convergence spasm and moderate depressive episodes linked to a borderline personality disorder. Treatment with antidepressants, dialectical behavioral therapy, and couple interventions significantly improved her ocular and mood symptoms.

Conclusion:

This case underscores the intricacies of diagnosing convergence spasm, particularly when it closely resembles abducent palsy. The accurate differentiation of these conditions is essential to provide targeted treatment and prevent unnecessary interventions. Our findings emphasize the significance of careful clinical evaluation and highlight a unique diagnostic conundrum in neuropsychiatry.

Cutaneous adverse reactions and treatment challenges in a case of Treatment Resistant Schizophrenia

Dr. Purbasha Mitra, Dr. Shree Mishra, Dr. Tathagata Biswas

Introduction: A third of schizophrenia cases are treatment resistant (TRS) needing clozapine therapy. A third of TRS are either clozapine resistant or can’t tolerate side effects. Here we report a case of TRS developing clozapine-induced seizures and agranulocytosis and rashes on another psychotropic, highlighting the treatment challenges.

Case Summary: 39 year old male with 22 years of illness suggestive of TRS presented active auditory hallucinations and was on clozapine, amisulpride and lithium with history of GTCS and agranulocytosis on clozapine higher dose. Though planned for clozapine augmentation with ECT, , clozapine was stopped because of tardive seizures. After failure of MECTs, Clozapine was reintroduced and hiked till 150 mg. In view of decreasing trend in granulocyte count, Lithium 150 mg was started and within 4 hours, he developed erythematous rashes, that the dermatology team opined was probably lithium induced and prescribed topical steroids. Lithium was stopped and he was discharged on clozapine 175 mg and haloperidol 7.5 mg with close follow up.

Discussion:

There are no clear guideline for TRS patients with clozapine intolerance. Options include ECT augmentation, high dose of antipsychotic and combination. Here, ECT failure led to difficulty. Clozapine could not be hiked because of seizures and agranulocytosis and lithium led to rashes. Finally, Clozapine and Haloperidol combination tried though literature has conflicting evidence. Future studies are needed in this area for further evidence

CYPROHEPTADINE AND DEXAMETHASONE INDUCED SUICIDALITY AND OBSESSIONS PRESENTING TO LIASON PSYCHIATRY- A CASE REPORT

Aaliya Khanam¹, Zaid Ahmad Wani^1, Shabir Ahmad¹ Nigah Nazir¹

¹Institute of Mental Health and Neurosciences, Kashmir.

Background: The concomitant occurrence of Cyproheptadine and dexamethasone-induced obsessive-compulsive disorder in a single individual, followed by attempts of suicide, is an extremely uncommon event. This prompted us to report this case.

Methods: This is a case report in which consent was obtained from the patient.

Case: Mr. B, a 20-year-old unmarried male, an army aspirant, pre-morbidly well adjusted, with no significant family history of any psychiatric illness was referred to the liaison psychiatry from the medical side, following suicidal attempt through organophosphate poisoning. A detailed exploration revealed a history of distressing blasphemous, antireligious, and sexual thoughts for 1 month and two attempts of suicide in the last week. He described these thoughts as senseless, involuntary, and disturbing. To overcome these thoughts, he would now frequently go for ablutions, cleanse himself repeatedly, and recite Holy Scriptures which was quite contrary to his usual routine. However, these thoughts would not give in. His Yale-Brown Obsessive-Compulsive Symptom Score (YBOCS) was 29. These symptoms had begun just 1 week after he started taking CH (8 mg in two divided doses) and dexamethasone (0.5 mg twice daily) on the advice of a friend for bodybuilding. Mr. B was a young lean male who always aspired for a fit and muscular body to join the Indian army.

Results: Both offending agents were stopped. He was given a trial of 20 mg/day of fluoxetine for therapeutic improvement. After 2 weeks, his YBOCS dropped down to 16, and after 4 weeks, his obsessive symptoms resolved completely.

Conclusion: Consistent reports, on the tonic inhibition of serotonin (5HT1A) receptor expression in certain brain regions exerted by corticosteroids, and anti-serotonergic properties (5HT2A and 5HT2C) of Cyproheptadine hint toward the possible mechanism in our case. The psychiatric side effects such as OCD and suicidal attempts of even low doses of oral corticosteroids, in combination with Cyproheptadine might be potentiated. Clinicians need to execute caution while prescribing combinations of such drugs.

cyproheptadine, dexamethasone, OCD, suicide.

Daridorexant: A Game-Changer Hypnotic?

Abhishek Kalra¹, Prof. (Dr.) Sudhir Kumar², Prof. (Dr.) Haseeb Khan³, Major (Dr.) Rakesh Saxena⁴

¹Junior Resident, ²Professor & Principal, ³Professor & Head, ⁴Assistant Professor Department of Psychiatry Hind Institute of Medical Sciences Safedabad, Barabanki, Uttar Pradesh

PRESENTING AUTHOR

Dr. Abhishek Kalra

Junior Resident

Department of Psychiatry

Hind Institute of Medical Sciences

Safedabad, Barabanki, Uttar Pradesh

Email-abhishekkalra.ak1@gmail.com

Mob No- +91 9910003362

BACKGROUND: Insomnia is a complex sleep disorder that affects millions of people around the globe. Insomnia is frequently accompanied by coexisting comorbidities, making it a complex disorder requiring a multimodal approach to treatment. The present study is aimed at highlighting the recently approved novel DORA drug - “Daridorexant” for the treatment of Insomnia.

AIM: To review the novel hypnotic drug “Daridorexant”

MATERIALS AND METHODS: A comprehensive search across reputable medical and scientific databases, including PubMed, Embase, Web of Science, and the Cochrane Library, to find relevant studies published to date. The search included keywords and Medical Subject Headings (MeSH) related to “Daridorexant,” “Insomnia,” and related terms. The studies found were analysed and summarised in the present poster.

RESULTS: Daridorexant is a compound exhibiting dual antagonistic activity towards orexin type 1 and type 2 receptors (OX1 and OX2) and has recently obtained approval from the US FDA for the therapeutic management of insomnia in adult patients. The efficacy of this intervention in mitigating symptoms of insomnia, enhancing daytime functionality, and enhancing overall sleep quality has been demonstrated. Daridorexant is an effective molecule in treating insomnia symptoms, additionally, the adverse effects and potential dependency were found to be lesser when compared with benzodiazepines and other sedatives.

CONCLUSION: Available studies document that Daridorexant effectively reduces insomnia symptoms with few adverse events. Future prospects for Daridorexant in the field of insomnia disorders are promising.

Delayed Psychosis following Snakebite Envenomation

India suffers one of the highest incidence of snakebite envenomation (SBE) in the world. Hypopituitarism is an uncommon but well-recognized complication of viperid envenomings , particularly of Russell’s viper species (both Daboia russelii and Daboia siamensis). RV venoms can cause neurotoxicity, myotoxicity, hemolysis, coagulopathy and other haemostatic disturbances, and thereby leading to delayed behavioural disturbances.

Case Vignette : 64 years old male, H/o Viper Bite in 1985, underwent dialysis. In 2018 he had complaints of increased tiredness, decreased drive for activity, evaluated and found to have Pan hypopituitarism , MRI brain showed Empty Sella syndrome , Probable pituitary apoplexy, treated with hormone replacement. H/o CAD, Hypothyroidism, S/P Covid -19 , with no significant family history of mental illness being reported. Since 4 months family members noticed to have Suspiciousness, abusiveness, visited the Psychiatry OPD . On examination : conscious, oriented.L/E: Loss of axillary & pubic hair. Mental status Examination : Delusion of Infidelity with Grade I insight. Diagnosed as Psychosis NOS - Secondary to brain damage / Covid infection/ Steroid Induced. He was started on oral antipsychotic (Tab. Olanzapine ). Thereafter he complained of bilateral pedal edema .Endocrinology consultation was sought, found to have low cortisol level, low TSH and Free T 4 . Medicine Optimisation with thyroid supplement, oral Steroid along with oral antipsychotic . His Psychotic symptoms improved within 2 weeks .Presently he is continuing the treatment and doing well.

Only few such cases has been diagnosed and reported. Due to the scarcity of sufficient case studies it’s highly suggestive of the need for citations and research on such clinical scenarios

Key words : Hypopituitarism, Russell’s viper, Psychosis NOS

Introduction- Valproate is commonly used as a mood stabilizer in patients with mania and BPAD. Valproate induced delirium is a very rare adverse effect seen in patients on valproate therapy.

Case- My patient 65 year old male presented in psychiatry opd with complains of overtalktiveness, increased self esteem increased appetite, decreased need for sleep, over familiarity, increased psychomotor activity from last 15 days. Patient was admitted in psychiatry ward and well evaluated clinically and detailed mental state examination was done.

Patient was started on Sodium Valproate 500 mg twice daily dose.After 2 days patient was found disoriented to time place and person but was hemodynamically stable and CT and MRI suggestive of only age related brain atrophy. Patients laboratory investigations were not suggestive of any significant changes and patient was not improving with current management which made us to think whether is it a case of valproate induced delirium not common in clinical entity but also important and rare complication to consider. After discussion patient’s current management was changed and valproate was put on hold to see any changes or betterment in symptoms and was started on another mood stabilizer. After which patient’s condition improved and started to recognize people from his family and orientation improved.

Conclusion- Valproate induced delirium here presented with normal ammonia levels, commonly thought to be associated with hyperammonemia made it difficult to diagnose and also to rule out other possibilities.

Keywords- BPAD, Valproate, Delirium

Case Report: Charcot-Marie-Tooth Disease Type 2 with Psychosis: ABSTRACT SUBMISSION FOR E-POSTER, ANCIPS 2024

Presenting author- Dr.Sanjeev Padmanabhan 2nd year MD psychiatry Saveetha Medical College Hospital chennai

Co-Authors:

Dr.Lavanya, SR, Psychiatry department, SMCH, Chennai Dr.Shanthi Nambi, HOD Psychiatry, SMCH Chennai.

Background:

Charcot-Marie-Tooth disease (CMT) is a group of inherited neuropathies characterized by progressive muscle weakness and sensory loss. CMT type 2 (CMT2) is a subset of CMT characterized by axonal degeneration. Psychiatric symptoms, such as psychosis, have been reported in CMT2 patients, although the exact link remains unclear.

Aim and Objectives:

This case report aims to highlight the co-occurrence of CMT2 and psychosis in a 39-year-old male and to discuss the potential contributing factors and management considerations.

Case Report:

Mr.R, a 39-year-old male, a known case of CMT2, presented with a one-year history of auditory hallucinations, followed by self-talk, gesturing, and smiling to himself for one month. He also exhibited increased speech, tall claims, and irritability.

Mental Status Examination:

Conscious, oriented, appropriate mood and affect, normal psychomotor activity, good eye contact, coherent speech, and relevant thoughts. However, the patient demonstrated inflated self-esteem and auditory hallucinations of a female voice from outer space.

Psychological Intervention:

Psychoeducation about the illness was provided to the patient and his family. A detailed evaluation and IQ test were planned for further assessment.

Patient and family were educated about CMT2 and psychosis.

Pharmacotherapy:

Ativan 2mg nightly and Sizodon 2mg nightly were prescribed and patient asked to follow up in 7 days.

Discussion:

The development of psychosis in patients with CMT2 is a complex phenomenon with potential contributing factors including genetic predisposition, axonal degeneration, and psychosocial stressors. The shared genetic pathways between CMT2 and neuropsychiatric disorders, as well as the potential neurodegenerative processes in CMT2, might contribute to the development of psychosis. Additionally, the chronic nature and physical limitations associated with CMT2 can lead to psychological distress, which might further increase the risk of psychosis.

Conclusion:

This case report emphasizes the importance of recognizing and managing psychosis in CMT2 patients. A comprehensive approach that addresses both the neurological and psychiatric aspects is essential for improving the patient’s quality of life. Further research is needed to elucidate the underlying mechanisms and develop effective treatment strategies for co-occurring CMT2 and psychosis.

Early-Onset Fahr Syndrome with Psychiatric Manifestations - A Rare Case

Dr Soram Nganbaren (JR-1), CMCH, Bhopal

Dr Chirag Patel (Asst Prof), CMCH, Bhopal

Background

Fahr Syndrome is a rare neurological disorder characterized by the calcification of specific brain regions, leading to various neurological and psychiatric symptoms, presenting in the 4^th or 5^th decade. However, the correlation between Fahr Syndrome and psychiatric manifestations remains poorly understood. We present a rare case of early-onset Fahr Syndrome with prominent psychiatric symptoms.

Aims/Objective

This case report aims to present a young patient presenting with psychiatric symptoms, being incidentally diagnosed with early onset Fahr syndrome, and highlight the importance of considering rare syndromes in patients presenting with psychiatric symptoms.

Methodology/ case report

We present a case of a 22year old male who presented in a psychiatry OPD of a tertiary care hospital with a 2year history of untreated progressively worsening depressive symptoms. Detailed clinical assessments, laboratory investigations and neuroimaging studies were conducted and analysed.

Discussion/Results

Investigations reveal reduced parathyroid and calcium levels. Neuroimaging revealed extensive calcification in parts of basal ganglia. The psychiatric symptoms exhibited were managed with a combination of psychotropic medications and psychotherapy along with consultation with neurologist and endocrinologist on reference basis.

Conclusion

This case highlights the rare occurrence of early-onset Fahr Syndrome with prominent psychiatric manifestations. Recognizing and understanding the psychiatric symptoms associated with Fahr Syndrome is crucial for proper diagnosis and management. Further research is needed to elucidate the underlying mechanisms linking calcification with psychiatric symptoms in Fahr Syndrome.

Effect of Endoxifen on functional connectivity at intrinsic large brain activity and task-based activation of brain in patients with bipolar I disorder

Basudeb Das, Nishant Goyal*, Pooja Sharma, Chandramouli Roy

Central Institute of Psychiatry, Ranchi, India

*presenting author

Aim:

To compare task-based activation of brain and resting state fMRI at baseline and after 6 weeks of endoxifen therapy with focus on changes in functional connectivity at intrinsic large brain networks in patients of bipolar disorders.

Methods:

In this single centre, prospective study, bipolar I disorder patients prescribed endoxifen were recruited. MRI images were acquired at the fMRI centre, Central Institute of Psychiatry, on a Philips Ingenia 3.0 T whole body system equipped with a 16-channel head coil. Both resting and activation scan with specific task (Stroop task) were obtained. In the 1^st level analysis for each participant, bivariate correlation analysis was computed between each pair of region-of-interest (ROI) (ROI-to-ROI analysis). General linear model was used for all second-level analyses of functional connectivity data. For the ROI-to-ROI analysis, bidirectional functional connectivity (FC) results were analyzed and only those networks were considered significant which survived at a peak connection threshold (p<0.05) p-FDR corrected and cluster threshold of p<0.05.

Results:

30 bipolar I disorder patients’ fMRI data was available for both baseline and 6-week follow-up. After controlling for other medications, ROI based analysis was carried out using SPM to measure resting state functional connectivity and change in it after receiving six weeks treatment with Endoxifen. There was significant decrease in functional connectivity in the areas of Right Sensorimotor Cortex, right amygdala

and default mode network on the right side which is in consonance to the existing literature of these areas being involved in the phase of acute mania with increased functional connectivity.

Conclusion

Endoxifen treatment led to decrease in functional connectivity among patients suffering from bipolar I disorders.

Keywords: Endoxifen, Bipolar Disorder, Functional Connectivity, Large Brain Networks

Effect of Vortioxetine on sexual function in patients of major depressive disorder: A Review of Literature

Arthik Shetty, Prashant Devkare, Shruti Dharmadhikari, Amey Mane and Suyog Mehta

Background and Aims

Sexual dysfunction is a common symptom of depression, but also a common adverse effect of antidepressant drugs, like serotonin–norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs), which is also one of the main reasons for treatment discontinuation. A meta-analysis reported treatment-emergent sexual dysfunction (TESD) incidence ranging from 26 to 80 % depending on treatment (sertraline, venlafaxine, citalopram, paroxetine, fluoxetine, imipramine, escitalopram). Recent evidence favors 5-HT1A receptor agonists (e.g. vortioxetine) in facilitating sexual performance among patients with MDD. The aim is to assess effect of Vortioxetine on sexual function in patients with major depressive disorder.

Methods

To summarize the relevant studies, researched on PubMed and Google Scholar

Results

A double-blind study reported that vortioxetine had significantly greater improvements in CSFQ-14 (Changes in Sexual Functioning Questionnaire Short Form) total score (8.8 ± 0.64, mean ± standard error) vs. escitalopram (6.6 ± 0.64; P = 0.013). Additionally, the treatment difference between vortioxetine and escitalopram was statistically significant only in men (≤ 41 years of age as compared with those older). Another study showed 17.6% lower rate of sexual dysfunction in patients on vortioxetine compared with those on duloxetine. A study conducted in healthy adult volunteers, both doses of vortioxetine were associated with less sexual adverse effects than paroxetine (statistically significant with 10 mg/d of vortioxetine).

Conclusions

Based on these observations, vortioxetine can be a reasonable treatment choice compared to other antidepressants in patients with MDD, especially young males, experiencing sexual dysfunction during antidepressant therapy.

POSTER ON GARDNER DIAMOND SYNDROME

Dr. Mohini Malik¹, Dr. Saloni Seth², Dr. Shiv Prasad³

1.Postgraduate Resident, Department of Psychiatry and Drug De-addiction Centre, Lady Hardinge Medical College, New Delhi, India-110001

2.Senior Resident, Department of Psychiatry and Drug De-addiction Centre, Lady Hardinge Medical College, New Delhi, India-110001

3.Professor & Head, Department of Psychiatry and Drug De-addiction Centre, Lady Hardinge Medical College, New Delhi, India-110001

BACKGROUND: Gardner Diamond Syndrome, also known as Psychogenic purpura, autoerythrocyte sensitization syndrome, is a rare distinctive, localized cutaneous reaction pattern mostly affecting psychologically disturbed adult women. Repeated crops of bizarre, tender, ill-defined ecchymotic lesions most commonly located on the arms and legs characterize the condition. Although the exact mechanism of injury is not well understood, it is hypothesized that these patients have autoantibodies to phosphatidylserine, which is a phospholipid membrane component in erythrocytes. Early diagnosis of this condition will not only minimize the cost of the medical evaluation but will also benefit the patient.

AIM: We present a case of a 72-year-old female who developed painful purpuric nodules and plaques over thighs and legs with the history of Moderetae depressive disorder on psychiatric evaluation.

CASE HISTORY: A 72-year-old female was referred from Dermatology OPD to Psychiatric outpatient unit with complaints of painful purpuric nodules and plaques over thighs and legs. Complete blood cell count including platelet count, bleeding time, clotting time, prothrombin time, and antinuclear antibodies were carried out but were negative. On Psychiatric evaluation patient reported of sadness of mood, anhedonia, lethargy due to ongoing interpersonal issues at home. Based on the clinical course and laboratory features, the diagnosis of psychogenic purpura was made and the patient was put on Sertraline 50 mg/day and clonazepam 1 mg/day. No recurrence of the cutaneous lesions was seen during a follow-up period of 6 months.

CONCLUSIONS: Psychogenic purpura is a rare syndrome characterized by spontaneous, painful inflammatory ecchymoses. Psychological evaluation of these patients may show hysterical and masochistic traits, depression, anxiety, and inability to deal appropriately with hostile feelings. However, the precise mechanism of this syndrome is not well-understood. Our patient displayed typical ecchymoses preceded by emotional stress, had depressive symptoms, and had no aberration in a battery of laboratory tests.

Abstract for e-poster presentation in ANCIPS.: Hyperkinetic conduct disorder as a risk factor for switch from unipolar to bipolar disorder

Dr. Mukul Dhobale (junior resident), Dr. Shalini Sarangi (junior resident), Dr. Anshul Yadav (senior resident), Dr. Roshan Khanande (associate professor)

Central Institute of Psychiatry, Ranchi

Introduction- Presence of baseline conduct disorder, school behaviour problems, a positive family history of a mood disorder in a parent are the predictors and Attention Deficit Hyperactivity Disorder (ADHD) is a risk factor for switches from unipolar to bipolar disorder. ADHD has bidirectional association with Major Depressive Disorder as well as Bipolar Disorder. ADHD also has increased risk of behavioural addictions such as Internet Gaming Disorder.

Aim- To study whether Hyperkinetic Conduct Disorder is a risk factor for switches from unipolar to bipolar disorder over time.

Method- A 18 year old male, presented with increased activity, difficulty concentration since early childhood. Demanding behaviour for 4 years, excessive use of mobile phone for 4 years, period of low mood, lack of appetite, decreased interaction for 4 months followed by switch to irritability, cheerfulness, anger outbursts, excessive phone use on Tab. Fluoxetine, T. Olanzapine

Results- A diagnosis of Hyperkinetic Conduct Disorder along with Internet Gaming Disorder and Bipolar Disorder was considered clinically. The patient showed significant improvement over the period of 3 weeks on Tab. Sodium Valproate and Tab. Clonidine

Conclusion- Given the presence of Hyperkinetic Conduct Disorder along with Behavioural Addiction, these characteristics can help clinicians in management of youth with Major Depressive Disorder

Case presentation- A 18 year old male, presented with increased activity, difficulty concentration since early childhood, demanding behavior for 4 years, excessive use of mobile phone for 4 years, episodes of low mood, excessive hand washing, lack of appetite, decreased interaction followed by switch to irritabilty, demanding behavior, anger outbursts, excessive phone use after receiving T.Fluoxetine, T. Olanzapine. A diagnosis of Hyperkinetic Conduct Disorder along with Internet Gaming Disorder and Bipolar Disorder was considered and showed significant improvement over the period of 3 weeks with T. Sodium Valproate, T. clonidine.

Discussion- Given the hyperkinetic conduct disorder along with internet addiction, these characteristics can help clinicians in their treatment of youth with Major Depressive Disorder.

Hysterosis strikes back? The intriguing intersection of Psychosis and MRKH: A case report

Dr. Shevya¹, Dr. Abhinav²

^1,2Department of Psychiatry, Government Medical College and Hospital, Sector-

32, Chandigarh

Aims and objectives: To present a case report of psychosis in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH)

Background: There is plenty of evidence of psychiatric disorders associated with congenital syndromes. MRKH is characterized by congenital aplasia of the uterus and the upper 2/3^rd of the vagina in women showing the normal development of secondary sexual characteristics and genitalia with a 46,XX karyotype. There have been very few case reports highlighting specifically the co-occurrence of psychosis and MRKH.

Case Report: A 19-years old female presented to psychiatry OPD with an illness of about 2-months duration, continuous course characterized by fearfulness and paranoia, thought insertion and disturbed biological functioning leading to significant socio-occupational dysfunction. She was diagnosed with Paranoid schizophrenia as per the ICD-10 criteria. On further evaluation, her informants revealed primary amenorrhea despite normal secondary sexual characteristics. A gynecological and radiological evaluation revealed a right uterine bud, left rudimentary horn with cervical agenesis and partial vaginal agenesis. Family history also revealed ASD in the twin sibling. On initiation of oral Olanzapine 10 mg/day, significant improvement was noted within two weeks.

Conclusion: Mullerian duct anomalies could be associated with psychotic illnesses and need further systemic research to confirm etiological correlation. The co-existence has a great psychological impact and requires a greater deal of attention and comprehensive care, making it especially challenging to treat.

Keyword: Psychosis, mullerian, MRKH

Impact of Perceived Stress among Medical Postgraduate Students of SCB Medical College,Odisha,India and its correlation with Burn Out.

Introduction: Stress in medical education is common and process oriented. It often exerts a negative effect on their academic performance, physical health, and psychological well-being.

Aims: To assess the perceived stress and burnout among PGS of SCB Medical College. And to assess correlation among them.

Materials and Methods: A cross-sectional survey was carried out among the postgraduate students of SCB Medical College, Cuttack, Odisha. Participants were instructed to fill out questionnaire asking about their Depression, anxiety, depersonalization, decrease in level of performance, stress. A 41-item questionnaire was designed to assess the sources of stress and their severity. Coping strategies adopted by students were assessed by using a 22-item stress inventory, and a questionnaire based on 19 institutional stress-reducing factors was used to identify its role.

Results: Stress had positive correlation with depression anxiety component of burnout.68 PGstudents participated in the study. Among them 56 are male,12 are female PGS. 16 are final yr. PGS ,25 are second yr. PGS, 27 are first yr. PGS. Median stress level based on 41 items was evaluated for each student. About 29% (40 students) had median stress level greater than 3. Female students were more stressed (17.19%) than male students (14.93%).

Conclusion: Prevalence of perceived stress is high among medical students. It seems that academic-related problems are greater perceived stressors. Review of academics, exam schedules and patterns, better interaction with the faculty and proper guidance, intervention programs and counseling could certainly help a lot to reduce stress in medical students.

Keywords: Coping factors, institutional factors, perceived stress, burnout

OCD VS ICD

introduction- Impulse control disorders (ICDs) are psychiatric disorders characterized by the failure to resist an impulse or by the temptation to perform an act that is harmful to oneself or to others. A few features of impulsive control disorders overlaps with obsessive compulsive Disorder(OCD). Impulsions and compulsions are often used interchangeably by people for describing their symptoms and both the disorders can acquire one another’s features as in the coarse of illness, there can be a presence of ‘impulsive compulsions’ in OCD and compulsive impulsions in ICD.

Case 1- A 18 year old male patient presented to OPD accompanied by his parent with the complaint of inappropriate touch towards cousin of opposite gender several times. According to patient, he used to open a porn website whenever he holds a phone. As the informant told us that patient also used to wash his bedsheet many times every night after masturbating. All his investigations turned out to be normal. He was diagnosed as a case of Impulse control disorder.

Conclusion- We have discussed a case of impulse control disorder. This type of case have not been discussed previously. Impulse control disorder, is a type of psychiatric illness which is misdiagnosed number of times. Often symptoms of impulse control disorder are confused with obsessive compulsive disorder (OCD). Despite the fact that OCD and ICD are disorders with generally similar symptom dimentions; individual assessment of symptoms, insight levels and comorbidity are vital.

Keywords- impulse control disorder, obsessive compulsive disorder,

Intellectual Disability and Behavioral disturbances in Prader-Willi Syndrome

Dr Rachit Sharma, Dept of Psychiatry, 155 Base Hospital

Prader-Willi syndrome is a complex genetic condition that affects many parts of the body. It affects an estimated 1 in 10,000 to 30,000 people worldwide.

Two girls (aged 7 & 14 years) were brought to paediatrics OPD by parents with complaints of insatiable appetite, accelerated weight gain, increased irritability, stubbornness and poor scholastic performance. Both were referred to psychiatry OPD for behavioural interventions. On evaluation, general physical examination revealed short stature, central obesity, small hyperflexible hands and feet, unusually fair skin and light-colored hairs. Both had facial dysmorphisms in the form of narrow forehead, almond-shaped eyes, fish like mouth were also noted. Genetic studies including Fluorescent in situ hybridization (FISH) revealed Prader Willi syndrome.

IQ assessment using Vineland’s social maturity scale (VSMS) showed mild to moderate level of retardation of intellectual functioning. Behavioural analysis revealed easy to warm up temperament, temper tantrums, poor frustration tolerance and anger outbrusts which would worsen in frequency and intensity when gratification was delayed. Child Behaviour Checklist (CBCL/6–18) revealed externalising factors with scores above 97th percentile.

Parents were psychoeducated about the illness, imparted genetic counseling and were given training for three weeks for behavioural techniques like token economy and contingency management, based on principles of applied behavioural analysis.

Three monthly and six monthly review revealed Child Behaviour Checklist (CBCL/6–18) scores in range of 95 percentile and 93 percentile respectively; which suggested gradual and sustained reduction in scores and welcome improvement in behaviour.

Conclusion: Prader-Willi syndrome is an uncommon condition associated with medical and psychiatric comorbidities. Both of our patients has mild to moderate intellectual disability with behavioral problems. Behavioural interventions are effective in reduction of problematic behaviours in children and adolescents with Prader Willi Syndrome. Multidisciplinary team comprising of Pediatrician, Psychiatrist, Clinical Psychologist and Genetic counsellor proved effective delivery of the holistic treatment.

Is the use of artificial intelligence in radiology a canary in the coal mine for psychiatry?

Dr. Neha Siddhartha

Abstract Body Word Count: 247

Background:

While the use of artificial intelligence (AI) has become standard practice in radiology, the current technology maturity of AI is low in psychiatry.

Aims:

To discuss ongoing practical and ethical concerns regarding implementing AI in psychiatry, using AI in radiology as a comparison.

Arguments for AI:

AI is increasingly being used in all sectors in society, including in systems that have psychiatric correlations. For example, emotion AI has been developed to aid in workplace monitoring and employee hiring. AI therefore may allow for new modalities of treatment, ways to engage inaccessible patient populations, improve patient outcomes, and reduce physician workload.

AI in radiology is most used to identify and classify discrete tumour and nodule lesions, with good reproducibility.

Arguments against AI:

Effective psychiatry care is generally considered to require a personal touch. Even when virtual care is delivered by psychiatrists, some nuances, such as increased aggression, can be missed. Furthermore, widespread AI usage in psychiatry may cause uncertainty regarding the clinician role. Patients may have negative perceptions of AI.

Implementing psychiatry-related AI is complicated by technical and human factors, and safety risks in harm prevention and data ethics. The full ethical and regulatory considerations remain unexplored.

Quality of evidence is a concern in radiology-related AI. Pathology is the gold standard in most clinical imaging research, however the radiologic report is used instead to validate AI findings in studies. This increases the risk of error.

Conclusion:

Psychiatrists need to continue investigating AI and principles for its implementation.

References

Fiske A, Henningsen P, Buyx A. Your Robot Therapist Will See You Now: Ethical Implications of Embodied Artificial Intelligence in Psychiatry, Psychology, and Psychotherapy. J Med Internet Res. 2019 May 9;21(5):e13216. doi: 10.2196/13216. PMID: 31094356; PMCID: PMC6532335.

Hosny A, Parmar C, Quackenbush J, Schwartz LH, Aerts HJWL. Artificial intelligence in radiology. Nat Rev Cancer. 2018 Aug;18(8):500-510. doi: 10.1038/s41568-018-0016-5. PMID: 29777175; PMCID: PMC6268174.

Kelly BS, Judge C, Bollard SM, Clifford SM, Healy GM, Aziz A, Mathur P, Islam S, Yeom KW, Lawlor A, Killeen RP. Radiology artificial intelligence: a systematic review and evaluation of methods (RAISE). Eur Radiol. 2022 Nov;32(11):7998-8007. doi: 10.1007/s00330-022-08784-6. Epub 2022 Apr 14. Erratum in: Eur Radiol. 2022 May 20;: PMID: 35420305; PMCID: PMC9668941.

Monteith S, Glenn T, Geddes J, Whybrow PC, Achtyes E, Bauer M. Expectations for Artificial Intelligence (AI) in Psychiatry. Curr Psychiatry Rep. 2022 Nov;24(11):709-721. doi: 10.1007/s11920-022-01378-5. Epub 2022 Oct 10. PMID: 36214931; PMCID: PMC9549456.

Monteith S, Glenn T, Geddes J, Whybrow PC, Bauer M. Commercial Use of Emotion Artificial Intelligence (AI): Implications for Psychiatry. Curr Psychiatry Rep. 2022 Mar;24(3):203-211. doi: 10.1007/s11920-022-01330-7. Epub 2022 Feb 25. PMID: 35212918.

KIKUCHI FUJIMOTO DISEASE(KFD)

PRESENTING AS MANIA

PRESENTER: DR.V.ABARNA 2^ND YR PG

DR .MAIKANDAAN,PROF AND HOD

DR.PRADEEP .R PROFESSOR

DR VAISHALI. S SENIOR RESIDENT

MADHA MEDICAL COLLEGE AND RESEARCH INSTITUTE , KOVUR.

INTRODUCTION:

KIKUCHI- FUJIMOTO DISEASE also known as HISTIOCYTIC NECROTISING LYMPHADENITIS, is a self limiting disorder with uncertain etiology. There is no known association between kikuchi fujimoto disease and psychiatric disorders until now. Here we report first ever such case of kikuchi fujimoto disease presenting as pyrexia of unknown origin with symptoms of mania.

CASE REPORT:

A 17year old school going male child, who is a known case of Depression under remission, presented to the psychiatry OPD with Fever, tall claims and sleep disturbances for 4 days. At presentation he was restless, performing Kungfu like gestures and claiming to be “bodhidharman” the protoganist from the famous Kollywood Movie “7aam arivu”. A provisional diagnosis of viral encephalitis with organic mania was made and antipsychotics started. After liason with General medicine , antibacterial and anti viral agents like acyclovir were given intravenously, despite which fever persisted. Except for a low WBC count all other blood investigations, CSF analysis,ct brain and MRI brain were within normal limits. After 2 weeks of non remitting fever and generalised lymphadenopathy Neurology opinion obtained an axillary lymph node biopsy was done revealed the diagnosis of histiocytic necrotising lymphadenitis with IHC being positive for CD20,CD45,MPO and K67.

DISCUSSION:

This is the first ever case report of Psychiatric illness precipitated by Kikuchi fujimoto disease and contributes as evidence to the shared viral and autoimmune etiological hypothesis of both psychiatric illness and Kikuchi Fujimoto disease.

Knowledge and attitude towards lesbian gay bisexual and transgender (LGBT) among medical students

Background:

The lack of sensitization and negative attitude towards LGBT people is bound to trickle itself into medical services and the healthcare system as well and LGBT individuals often experience discrimination not only in their everyday lives but also in the healthcare system due to their gender identity or sexual orientation. Studies indicate that the hidden curriculum about LGBT individuals in medical education may affect medical students and future health professionals’ attitudes toward sexual and gender minorities. Therefore, we want to investigate the knowledge of medical students and their attitudes towards LGBT.

Objective:

To assess the knowledge & attitude of medical students regarding LGBT people in the SN medical college.

Methods:

This cross-sectional study will be conducted at the Department of Psychiatry, at Sarojini Naidu Medical College and Hospital, Agra, U.P. Medical students will be explained about the study, and they will be instructed to fill the semi-structured proforma containing sociodemographic details, followed by an assessment via Sex Education and Knowledge about Homosexuality Questionnaire (SEKHQ) and LGBT assessment scale.

Results: Currently 149 medical student’s data have been obtained out of which 72.5% think that they have no adequate knowledge about LGBT, 8.7% believe that transgender people are sinful, and 12% believe that bisexuality is a sin.

Conclusion: This study supports that even medical students lack knowledge about the LGBT community.

Motor Neuron Disease in an individual with Lithium responsive bipolar disorder: A therapeutic challenge

Dr. Nihaz Ceetheerakath *, Dr. Christina George**

*Junior resident, Dept. of Psychiatry

**Professor, Dept of Psychiatry, Dr.SMCSI Medical College, Karakonam

BACKGROUND

Motor neuron disease is a devastating illness which leads to progressive paralysis and eventual death. Bulbar onset motor neuron disease occurs in about 20% of those affected. The first sign is usually slurring of the speech, Dysphagia tends to occur later, when speech difficulties have become significant. A diagnosis of motor neuron disease relies on interpretation of the clinical symptoms and signs and use of investigations to exclude other causes.

CASE REPORT

Mrs. X, 61-year-old widow, with bipolar disorder of 20 years duration, who was maintained well on regular treatment with T. Lithium 800mg and T. Quetiapine 150mg. She presented with complaints of slurring of speech, reduced responsiveness, difficulty in swallowing food and water intake for 5 days. MRI Brain, CSF study and EEG were normal. Necessary investigations to rule out other causes of weakness of bulbar onset were done. Motor Neuron Disease was diagnosed based on clinical presentation.

Serum Lithium levels were high, and lithium was withdrawn. Manic symptoms returned in about a month. A prolonged admission required lithium to be restarted. Multiple attempts to stop lithium in view of progressive dysphagia and erratic oral intake were followed by relapses.

Although Ryles tube feeding was attempted, she was not cooperative. Hence a plan was made to maintain her on moderate doses of Quetiapine and low dose of Lithium 400mg and Sodium valproate 400mg was added. Close monitoring of Lithium levels was done. The high risk involved was explained to the family in liaison with the neurologist.

DISCUSSION

The complexity of care for patients with serious disabling neurological illnesses and difficult to treat Mental disorders require appropriate care with risk management in discussion with all stakeholders.

MOVEMENT DISORDER IN EARLY ONSET SCHIZOPHRENIA- DIAGNOSTIC CHALLENGES

Bannupriya Selvaraj (2^nd year PG)

Parthsarathy Ramamurthy (Associate Professor, Department of Psychiatry)

Shobana Sundaram (Neurology department)

Pradeep Thilakan (Head of the department, Department of psychiatry)

BACKGROUND: The prevalence of neuropsychiatric symptoms in Parkinson’s disease is well established, irrespective of disease stage. Early onset cases pose a unique challenge due to their diverse clinical manifestations. To highlight this here we present a case of a 15year old male who developed a neuropsychiatric symptoms and signs of Parkinson’s disease.

CASE REPORT: In this case report we present a 15year old boy who presented with constellation of symptoms including bent knee posture, social withdrawal, declining academic performances, auditory hallucinations associated with significant impairment in socio-occupational functioning. Neurological examination revealed parkinsonian features such as resting tremors, cogwheel rigidity, shuffling gait and glabellar tap. A detailed mental status evaluation uncovered challenges in establishing rapport, poor eye contact and limited verbal output. He exhibited an anxious affect, persistent auditory hallucinations, impaired personal and social judgment and poor insight. Considering early onset Parkinson’s disease as potential diagnosis, in order to rule out the possibility genetic testing was done.

CONCLUSION: This case exemplifies the intricate interplay of motor and psychiatric symptoms in early onset Parkinson’s disease with psychosis. With prevalence rates differing in early onset cases, multidisciplinary approach is vital for accurate diagnosis and effective management, underscoring the complexities of this condition.

‘A boat in the stormy sea’: A case report on systemic steroid induced Delirium and relapse of Psychosis in a patient with Pemphigus vulgaris

Dr Annu Jose(Pg Resident) Dr Neetu Kurian( Assistant Professor) Dr Nisha.A. (Professor & HOD)

Department of Psychiatry , MOSC Medical College, Kolenchery

INTRODUCTION

Glucocorticoids are widely prescribed for a variety of diseases and are known to cause neuropsychiatric as well as somatic side effects.¹ This is a case report of a psychotic patient in remission, well maintained on low dose psychotropics, developing florid psychosis and delirium on initiation of steroids for the management of pemphigus vulgaris, highlighting the importance of awareness, early recognition, and the benefits of multidisciplinary approach in its management.

CASE REPORT

Mr.A, a 61-year-old male having psychotic disorder for 45 years, well maintained on Risperidone 4mg and Clonazepam 1mg, staying in a psychiatric rehabilitation centre for the past 27 years, presented to ER with vesiculobullous lesions over face, trunk, and extremities. He was diagnosed with pemphigus vulgaris around 6 months ago, and was on OP management from Dermatology. MSE on admission revealed intact cognitive functions and absence of obvious psychotic features.

He was admitted under dermatology and was started on systemic steroids (methyl prednisolone 80 mg IV on day 2 along with antibiotics for his skin lesions. From day 6 onwards he started developing persecutory delusions and 2nd person auditory hallucinations and started becoming irritable. On subsequent days, he started becoming disoriented. Systemic examination and blood parameters did not reveal any other causes for delirium.

Mr.A was transferred under Psychiatry unit as he was grossly agitated, and risperidone was cross titrated to oral haloperidol 15mg ( on day 12). He started picking on the bullae, which in turn, worsened the skin lesions. Supportive care, psychoeducation of care-givers, and liaison between the treatment teams continued. It was decided to start him on immunosuppressant (mycophenolate mofetil), and the steroids could be subsequently tapered. His delirium as well as psychotic symptoms, and overall, the skin lesions, started subsiding. He was optimized on 20mg Haloperidol at the time of discharge.

Table 1.

Relationship between steroid doses and emergence of psychotic symptoms and cognitive impairment

Steroid dose	BPRS score	MMSE score
80mg (IV)	18	28
80mg (IV)	32	27
48mg (oral)	47	18
64mg (oral)	57	12
40mg (oral)	20	28

During further OP follow ups, Mr.A remained stable with the skin lesions subsided, no more troubled by psychotic symptoms and delirium -on Mycophenolate mofetil 1080mg and haloperidol 15mg.

DISCUSSION

Neuropsychiatric manifestations of systemic steroids use are very common.¹ The possible pathophysiology includes glucocorticoid-induced hippocampal dysfunction associated with decreased hypothalamic corticotropin-releasing hormone (CRH) and circulating ACTH hormone levels.² While psychiatric patients are at higher risk, all patients should be considered to have the potential to develop steroid-induced neuropsychiatric symptoms.³

Early recognition of these symptoms is key to initiating effective interventions. Initial treatment typically includes tapering or discontinuing the steroids when possible.⁴ In our patient, even though systemic corticosteroids remain the gold standard treatment for pemphigus vulgaris, due to severe neuropsychiatric manifestations, steroids were tapered and immunosuppressant was added. The liaison between the two teams helped in proper and timely dose titrations of psychotropics and dermatology medications, which kept Mr.A in balance.

CONCLUSION

Awareness and early recognition of neuropsychiatric manifestations, and timely multi-dimensional team approach helps in better patient care and outcome in steroid-induced relapse of psychosis and cognitive impairment.

References:.

1. Lu Y, Ann L, McCarron R. Steroid-induced psychiatric symptoms: What you need to know. Curr. Psychiatry. 2021 Apr;20:33-8.a

2. Kazi SE, Hoque S. Acute Psychosis Following Corticosteroid Administration. Cureus. 2021 Sep 19;13(9):e18093. doi: 10.7759/cureus.18093. PMID: 34692307; PMCID: PMC8525047.

3. Huynh G, Reinert JP. Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases. J Pharm Technol. 2021 Apr;37(2):120-126. doi: 10.1177/8755122520978534. Epub 2020 Dec 2. PMID: 34752563; PMCID: PMC7953074.

4. S, Efthymiou O, Stefanaki C, Rigopoulos D. Management of pemphigus vulgaris: challenges and solutions. Clin Cosmet Investig Dermatol. 2015 Oct 21;8:521-7. doi: 10.2147/CCID.S75908. PMID: 26543381; PMCID: PMC4622091.

A CASE OF BEHAVIOURAL VARIENT OF FRONTOTEMPORAL DEMENTIA PRESENTING AS CATATONIA, A DIAGNOSTIC CHALLENGE

DR BONTHU JOELRAJU

INTRODUCTION:

Frontotemproal dementia is a heterogenous disorder with distinct clinical phenotypes associated with multiple neuropathalogic entities. Presently, the term FTD can be especially challenging and is relatively underdiagnosed. FTD patients are often initially misdiagnosed as major depression disorder., bipolar affective disorder, or schizophrenia. Misdiagnosis can delay early and appropriate diagnosis, and adequate patient management. The aim is to describe the clinical features of a case of FTD , with common symptoms of behavioural disturbances along with catatonia as an unusual presentation and the challenges faced in diagnosis as well as management of the symptoms.

CASE PROPER:

A 40 years old male, hindu, married , named Mr.L.D, farmer by profession, hailing from a lower middle class nuclear family and rural background, with no significant family history and well-adjusted premorbid personality presented with chief complaints of decresed interaction for the last 2 years and violent behavior towards family members from last 2 years and loss of speech since 6 months, poor self-care, and decreased intake of food since 1 month.

On examination MSE revealed, passive attitude, constrained voluntary postures, evasive behaviour , difficulty in spontaneous acts, untidy , vacant look, not maintaining eye contact, not following commands , no emotional responsiveness with mutism except uttering few phrases in a perseverated manner.

DISCUSSION:

Our patient developed an insidious change in personality characterized by physical aggressiveness against anyone who attempted to feed or groom him. His speech becomes increasingly non-sensical until his verbal output became restricted to a few words, echolalia and preservation. his emotions became coarse and he lost his usual social graces and manners. He eventually progressed into a stoppage of speech except utterance of few phrases. MRI showed predominant atrophy of the anterior and lateral temporal lobe. These findings were consistent with a clinicoanatomical diagnosis of probable FTD. The diagnosis of FTD was further supported by asymmetrical hemispherical atrophy, which is typical of frontotemporal degeneration.

CONCLUSION:

In absence of the alternative aetiology like organic disease, history of psychiatric disease or psychotropic medication history, the most likely a etiology of catatonia maybe attributed FTD in this patient. But this case had a poor response to common drugs used in such a case for managing behavioural as well as catatonic symptoms. This warrants more studies, extensive search for aetiology along with holistic and critical neurological and psychiatric approach for diagnosis and management of such varied clinical presentation.

A case of bipolar mood disorder(BMD) due to traumatic brain injury(TBI)

Introduction:

The prefrontal cortex, amygdala, hippocampus, and other structures regulate emotions . This neutral circuitry, when disrupted due to factors like Traumatic brain injury(TBI) , can result in mood-related disorders with prevalence range of 7% to 66%,of which ~9.1% have BMD.

Case report

A 74 year old male patient was brought to psychiatry opd with presenting complaints of Overtalkativeness, high talks, flights of ideas, cheerfulness with occasional irritability, decreased need for sleep . These complaints were present continuously after 1.5 years of head injury in RTA , which occured 25 years before . He was given tab Valproate 1000 mg with various antipsychotics for sufficient period and dosages but did not improve. Pt was off treatment since last 7 years, patient’s MMSE was 24/30. Patient had no other neurological or psychiatric symptoms. Then we gave trial of tab Valproate 1000mg, risperidone 4mg and benzodiazepines, but complaints persisted . Then patient’s mri was done,which showed findings of encephalomalacia of left frontal and b/l temporal lobe.

Discussion

The spectrum of mood disorders have been seen after TBI .In addition, there are number of studies suggesting that mania associated mainly with frontal, subcortical limbic structures and temporal lobe and according to one meta-analysis greater right(60.7%) than left(11.4%) and b/l(21.7%) region Involvement . In our case we had findings of encephalomalacia in left frontal and b/l temporal lobe.

Conclusion

Generally such patients have improved on treatment, but taking In account of our case , we can hypothesize that atypical findings in tbi patients may lead to treatment resistant mood disorders.

Case Report Abstract: A case of cerebrovascular accident associated with steroid abuse

Dr. G Devi Priya¹, Dr. K S V R Naga Pavan kumar², Dr. N N Raju³ Postgraduate ¹, Assistant Professor², Hod and Professor³

Department of Psychiatry, Gayatri Vidya Parishad institute of healthcare and medical technology, Visakhapatnam.

Background:

A cerebrovascular accident (CVA) is an emergency medical condition characterized by an acute compromise of the cerebral perfusion or vasculature. The leading cause of ischemic stroke is hypertension whereas clotting disorders, carotid dissection, and prescription drug abuse are common causes in the younger populations. Here we present a case of steroid abuse leading to CVA.

Case summary:

A 54-year-old male was brought to casualty in a drowsy state with c/o unilateral left sided pain, tingling sensation and numbness. On CNS examination, noted to have homonymous hemianopia. No past history of physical comorbidity like hypertension. On evaluation, MRI Brain(P) revealed subacute infarct in thalamus. On further probing, patient was noted to use tab. Dexamethasone 4mg twice a day continuously for 3 years which was prescribed to him by a physician in 2020 when he was diagnosed with covid-19. After stabilizing the patient, liaison with neurology and further management was done to treat steroid dependence.

Conclusion:

Covid outbreak has caused significant disruption in lives of many individuals. Unmonitored steroid usage led to adverse neuropsychological consequences.

Cerebrovascular accident, Steroid, Covid.

Author for correspondence:

Dr. G Devi Priya, PG in Psychiatry,

Gayatri Vidya Parishad institute of healthcare and medical technology, Visakhapatnam.

Mobile: 7569676361, email: soniagiduturi@gmail.com

A Case of Desynchronosis on Mood disorders

BACKGROUND

Jet lag can be understood in the context of the human circardian system and occurs as a consequence of circardian misalignment caused by crossing time zones too rapidly for the circardian system to keep pace.

HISTORY

Mr.Y 39 year old married male hailing from Thiruvarur.He worked as a sales man in a gold shop in Malaysia around 2 months.He brought to hospital with brothers(elder and younger).Reason for consultation was reduced sleep,increased anger outburst with family members as well as in work place,using obscene words,irritable,taking bath multiple time,overfamilarity,extravagancy,spending too much time in phone,calling relatives and talking to them for long hours which was unusal to other family members.Stressor was he was Moved to Malaysia with brother and mother(sudden change in work place).He moved to Malaysia on 30/7/22 from Chennai around 3pm and arrived by 9.20pm at Kuala Lumpur. Came back on 5/9/22.

History of similar episode in past.Past history of 4 mania episode.First episode was in 2005.Symptoms last for 1month.For which religious measures had done.

In 2009- Moved to Dubai.Symptoms last for 1month

In 2011- Moved to Malaysia.Symptoms last for 2 to 3 months,for which treatment taken from pvt psychiatric centre as ipcare.MECT given.

In 2013-Moved to Malaysia similar episode which last for 2 to 3months.For which had taken treatment from Pvt Psy clinic at Tanjore.Medication taken for one month and stopped.

DISCUSSION

Individual with mood disorder to circardian disruption,transmeridian travel would likely to be high risk endeavour leading to onset or relapse in mood.

CONCLUSION

There were limited evidence that transmeridian travel precipitate mood episodes,this poses difficulties in identifying suitable way to mitigate the effect of transmeridian travel in mood disorder.However ,in the absence of mood specific guidelines,some guidance can be given based on our current understanding of the relevance of circardian disruption to both jetlag and mood disorder.Due to the rarity I would like to present this case.

A Case of Fahr’s Syndrome presented with Depression

Introduction

Fahr’s Syndrome which is defined by the presence of Striato-Pallido-Dentate calcifications is a rare polymorphic entity often associated with hypoparathyroidism. We describe a case of depression which turned out to be Fahr’s Syndrome.

Case Report

A 23-year-old male presented with low-mood, reduced interest, concentration and sleep with unstable gait and giddiness since six months and showed partial improvement with Escitalopram 10mg. There was no improvement in unstable gait and giddiness and high index of suspicion prompted further investigations. CT brain showed calcification in basal ganglia, thalamus, cerebral and cerebellar hemisphere. His Calcium, D3 and Parathormone were significantly low. He was started on high dosage vitamin-D3. Patient showed improvement in all symptoms and was weaned off antidepressants after a month. On telephonic follow up after three months, he is on vitamin d3 only, has no psychiatric or physical symptoms and is working regularly as a video editor.

Discussion

This case highlights the importance of being vigilant towards the presence of symptoms that do not fit into the typical picture of an illness. Mindful observation of the patient can help diagnose organic causes of psychiatric disorders. Our case shows that Fahr’s Syndrome, although rare, is one of the organic causes of Mood-Disorders and our patient’s symptoms completely improved with the standard management of Fahr’s Syndrome.

There have also been reports of ocd, bipolar-disorder, psychosis and dementia apart from MDD in Fahr’s Syndrome.

A case report of multimodal hallucinations in Schizophrenia

Dr Shama BR (Postgraduate), Dr Divyashree NS (Senior resident), Dr Madhusudhan S (Associate Professor) Dept of Psychiatry, BMCRI.

Hallucinations can be unimodal or multimodal. Traditionally, hallucinations are often assumed to occur unimodally, one modality at a time; where in multimodal hallucinations (MMHs) occur in more than one modality simultaneously and emanate from a single source. MMHs have been reported in severe mental disorders including schizophrenia. Here we report a case with MMHs in a patient with paranoid schizophrenia with an illness duration of 4 years.

We report a case of a male patient with MMHs involving auditory, visual, tactile senses, somatic passivity and delusion of persecution and control. At the same time, he could either feel the movements of the doll inside him and hear its voice, sense the burning feel, or see the doll and hear its voices. A common source for the voice and a doll like image is his deceased mother. The patient was treated earlier with psychotropics despite which he couldn’t attain the baseline level. The patient was not able to concentrate on work and hence significant socio occupational dysfunction. There is a significant family history of query psychosis in 3-4 members. His investigation reports were within normal limits. The patient was treated with psychotropics. Organic causes were ruled out with neuroimaging.

The uniqueness of this case is the presence of hallucinations in different modalities, from a common source.

A case of ODD with congenital adrenal hyperplasia simple virilizing type.

Dr Namita Sahu1, Dr. Pradeep Patil2

1.Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email- namita0694@gmail.com, Mobile-8459514397.

2.Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email- dr.p.s.patil2012@gmail.com, Mobile- 8999248979. Presenting Author- Dr Namita Sahu, Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra.

Email- namita0694@gmail.com

Mobile-8459514397.

A case of oppositional defiant disorder in simple virilizing congenital adrenal hyperplasia.

BACKGROUND:

Simple virilizing congenital adrenal hyperplasia is a moderate form of non-salt wasting congenital adrenal hyperplasia characterized by elevated androgen production and decreased cortisol levels due to a 21 hydroxylase deficiency. High testosterone levels are linked to co-morbid conditions in psychiatry, according to a study where mood disorders are more prevalent.

CASE PRESENTATION:

We report the case of a 4-year-old male who presented with a history of a growth spurt and irritability with abusive behavior and decreased interaction since 1.5 years. USG s/o multiple cystic lesions in b/l kidneys and investigation revealed Cortisol 2.71, Potassium 2.8, FSH 0.66 LH 0.216. He was referred to psychiatry OPD i/v/o behavioral disturbances and detailed evaluation diagnosed as a case of Oppositional Defiant Disorder.The patient was then lost to follow up.

CONCLUSION: A rare case of psychiatric disorder in patients with CAH.

A Case Of Olfactory Reference Syndrome In A Young Adult

Dr. Banumathi Rajkumar, Post Graduate Student, Department of Psychiatry, Tirunelveli Medical College

Dr. Seenivasan MD (Psychiatry) – Assistant Professor, Department of Psychiatry, Tirunelveli Medical College

INTRODUCTION

Olfactory reference syndrome(ORS) is characterized by the erroneous belief that the individual emits a foul or unpleasant body odour, associated with significant distress and functional impairment. The condition is further characterized by the belief that others take special notice of the unpleasant odour, prompting repetitive behaviour to remediate the situation. The data about this condition is limited and unreliable due to its delusional nature and the characteristic secrecy and shame therefore its prevalence is not well established in the general population.

CASE REPORT

A 21 Year male came with complaints of persistently emitting rotten egg smell from his body aggravated by sweat, increased self consciousness, with frequent usage of deodorants, repetitively seeking reassurance, inattention and impairment at work with strong conviction that people are taking notice and talking about his odour with multiple hospital visits for the same complaints with no significant improvement of symptoms for the past 4 months insidious in onset and gradually progressive in nature. Patient is not a known case of seizure disorder or any medical illness with no family history of psychiatric illness.

The Patient’s General Physical Condition was normal. Mental Status Examination revealed PMA- Normal, Talk -Relevant and Coherent, QTR and RT Normal, Thought-form, stream-Normal

Content- Delusion of Reference, Obsessional thought about body odour was present, Perception- Olfactory hallucination was present, Mood- Anxious, Affect-Restricted.

Routine Investigations- Normal CT Brain Study- Normal Dermatology, ENT, General Medicine opinion was obtained which was Normal. Brown Assessment of Beliefs scale-22

DISCUSSION

Olfactory reference syndrome is included in DSM-5 In other specified Obsessive-compulsive and related disorder as ‘Jikoshu-kyofu’ (Jiko-onself, Shu-odour, kyofu-fear) characterized by fear of having an offensive odour. It is important to exclude other somatic causes including temporal lobe epilepsy, pituitary tumours, inflammation in frontal, ethmoidal or sphenoid sinuses. Treatment involves SSRI or antipsychotic agents or SSRI/antipsychotic combination and CBT.

Currently Olfactory Reference syndrome is included in ICD-11 as Olfactory Reference Disorder(6B22) with subdivisions 6B22.0 olfactory reference disorder with fair to good insight, 6B22.1-Olfactory Reference Disorder with poor to absent insight and 6B22.Z-Olfactory reference disorder unspecified, which is all a part of obsessive-compulsive or related disorders(BlockL1-6B2). Previously in DSM-4 TR and in ICD-10, ORS patients with no insight may meet the criteria for a Delusional disorder(Somatic type).

CONCLUSION

Patients suffer significant discomfort, functional impairment and also reduced quality of life. Due to the varied clinical picture, the diagnosis is often delayed. Therefore greater awareness of this condition will help the patients get appropriate referral to psychiatric services.

REFERENCES

Thomas E, Voges J, Chiliza B, Stein DJ, Lochner C. Sniffing out olfactory reference syndrome. S Afr J Psychiatr. 2017 Jan 31;23:1016.

Abstract for Kochi ANCIPS 2024: A Case of Schizoaffective Disorder and Generalised Anxiety Disorder with Spontaneous Ejaculations

Deeksha Chakrabarty, Irina Tardif, Rachel Carpenter

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

Email : chakrabartydeeksha44@gmail.com

Background : The autonomic nervous system, consisting of the sympathetic and parasympathetic pathways, plays an important part in the symptomatology of both anxiety and ejaculations. Even though there is a well-known association between anxiety and sexual arousal, the literature only finds two case reports documenting the association between anxiety and spontaneous ejaculations. In this case report, we describe a 30-year-old male with ongoing perceptual disturbances and spontaneous ejaculations that occur without prior sexual arousal, who benefited from pharmacological therapy with Risperidone.

Case Report : A 30 y/o African-American male with no documented past psychiatric history who was brought to the emergency room by his grandmother for bizarre and erratic behaviour developing over the past 1-2 years. Upon evaluation, he exhibited flight of ideas, rapid pressured speech, hyper-religiosity and paranoid delusions with religious undertones. The patient also reported having frequent and distressing spontaneous ejaculations in the setting of anxiety and loud noises since 6 years which were not preceded by penile erection or stimulation, and that they were not associated with sexual arousal. The patient reported cessation of spontaneous ejaculations and improvement in symptoms of mania with administration of oral Risperidone, which was subsequently transitioned to long-acting injectable Paliperidone for better compliance.

Conclusion : Ejaculation is a physiologic process that is regulated by the autonomic nervous system, primarily by the sympathetic neuronal pathways of the pelvic plexus that secrete norepinephrine. Anxiety decreases parasympathetic activity, thereby inhibiting penile erection while simultaneously increasing sympathetic activity, which could trigger ejaculation. Therefore, the neuronal pathways between anxiety and ejaculations are linked, and are not necessarily associated with penile erection. Antipsychotics have documented side effects of sexual dysfunction; hence, Risperidone was selected as it would effectively manage both the symptoms of psychosis and spontaneous ejaculations simultaneously.

A CASE OF SSPE, ACUTE FULMINANT VARIANT

Introduction

Subacute Sclerosing Panencephalitis is a progressive, disabling and lethal brain disorder related to measles infection, developing many years after infection.

Case history

A 17 year old male patient presented to psychiatry OPD with odd behaviour, increased self esteem, pacing around and difficulty in performing his painting work since 2 months.

Elsewhere he was diagnosed with Schizophreniform disorder and was prescribed antipsychotics. Even after taking medications for 4-5 days there wasn’t much improvement, MRI brain and EEG were normal.

And he got admitted. His symptoms were giving primary impression of BMD. On serial MSEs, there was progressive decline in attention, concentration & cognition. After a couple of days he started having jerks in all limbs and also 1-2 episodes of urinary incontinence. This made us go for repeat EEG. It showed typical findings of SSPE within 15-20 days of previous EEG. Then the patient was transferred to medicine ward. CSF examination showed positive findings for measles IgG antibodies.

Discussion

The adolescent age group shows mixed features and the patient presented with a psychological stressor with symptoms which can be confused with Conversion Disorder. But in detailed history presence of fever with rashes was found and absence of vaccination in early childhood.

On Regular follow-up of the patient showed rapid progression of the disease as within a month he became comatose and needed long term ventilator support, eventually tracheostomy was done.The course was suggestive of rare variant of SSPE,Acute Fulminant Type.and his jerks persisted even after giving all the available anticonvulsants in maximum doses.

Conclusion

A thorough neurological examination and proper vaccination history to rule out organicity is helpful to diagnose a patient with a psychiatric condition.

A Case of Treatment Resistant Obsessive Compulsive Disorder without insight in a case of Gender Incongruence.

Dr. Bhaskar Das, Second Year Post-Graduate Trainee, Department of Psychiatry, NRS-MCH

Obsessive-Compulsive Disorder is characterised by the presence of persistent obsessions or compulsions, or most commonly both. Most Common form of Obsessions are Doubts, and Most common form of compulsion is Contamination.

Treatment Resistant OCD is defined as improvement in Y-BOCS Score of <25% even after using first and second line of management

Case Summary

A 21 year Old Patient, Male-assigned at Birth, comes to NRS Psychiatry OPD complaining of Discomfort with dirt contamination and compulsive washing, Religious obsessions since Childhood. During Puberty, he started having thoughts of people spying on his genitals when he’s urinating. He developed discomfort with his secondary sexual features and embarrassed of his masculine features, considering them as Dirt and started keeping his genitals hidden between his thighs and balloon up pants so that his crotch is not visible and people couldn’t find out about his male genitalia. He started medications and continued for 3 years with improvement but stopped them in 2020 in Lockdown restrictions. Symptoms appeared again in greater intensity including his discomfort of genitalia. Medications started again, but symptoms didn’t resolve after first and second line of management.

Conclusion

Mental health needs of LGBTQIA+ population needs to be emphasised. The symptomatology of various common mental illness may have a unique presentation which must be delineated properly to avoid misdiagnosis and have good treatment outcome.

A case report of a 23 year old male with multiple psychoactive substance use.

Presenter : Dr Jayin Thekkinedath Chacko ,Post Graduate, Department of Psychiatry ,Subbaiah Institute of Medical Sciences, Shimoga

Dr Shubrata K S, Professor, Department of Psychiatry ,Subbaiah Institute of Medical Sciences, Shimoga

Dr Harisha Delanthabettu , Professor and HOD, Department of Psychiatry, Subbaiah Institute of Medical Sciences, Shimoga

Dr Sai Komal, Assistant Professor, Department of Psychiatry, Subbaiah Institute of Medical Sciences, Shimoga

Dr Ragashree, Senior Resident, Department of Psychiatry, Subbaiah Institute of Medical Sciences, Shimoga

Dr Lavanya S Pujar, Post Graduate, Department of Psychiatry ,Subbaiah Institute of Medical Sciences, Shimoga

Background: The 2019 Magnitude of Substance Use in India survey showed pharmaceutical opioids to be the second most commonly abused opioids (0.96%), after heroin (1.14%). ADHD is one of the most frequently co-occurring disorders in early-onset substance use disorder (SUD). Studies show that among adults with SUD, 10.8 percent met criteria for ADHD. This case report explores the complexity of a patient’s life that shows diverse nature of multiple substance use.

Aims: To report an interesting case of Polysubstance dependence with special mention of dependence to Tapentadol.

Methods: A 23-year-old man presented to our center with Tapentadol use for 5 months. He had tried various substances between the ages of 16 and 23 years. Tobacco use had started at a very early age of 7 years.

Over a span of next 16 years, the patient had used various substances like Alcohol, Nitrazepam, Cocaine, Cannabis, MDMA, Codeine and the latest being Tapentadol. He would crush the Tapentadol tablets, dissolve it in distilled water and sometimes in plain water and would inject it using insulin syringe 4-5 times/day upto 800 mg/day. He fulfilled criteria for dependence to Opioid.

Results: A diagnosis of Mental and behavioral disorders due to multiple drug use and use of other psychoactive substances was made. ADHD was found on further evaluation. Management was done as per protocol.

Conclusion: This case is unique due to the fact of very early onset of substance use, the wide range of substances abused, and significant high doses of Tapentadol administered intravenously.

A CASE REPORT OF A 49YEAR OLD FEMALE COMPLAINING OF ‘PUS’ LEAKING OUT OF HER HEAD

Background: A 49year old female came with complaints of Headache since 7 years, Backache since 3 years, Claiming that pus/blood/water coming out of her body since 6 months, PV bleeding since 5 days along with multiple somatic complaints, disrupted socio-occupational functioning, along with history of numerous doctor consultations taken and multiple investigations done.

Differentials:

Delusional Disorder

Somatoform Disorder.

Illness anxiety Disorder (Hypochondriasis)

Factitious disorder.

Conclusion: A diagnosis of delusional disorder was made and an adequate treatment plan was formulated consisting of ECT’s and oral drugs.

A Case report of anxiety cloaking obstructive sleep apnoea

INTRODUCTION

Symptoms of Obstructive Sleep Apnoea (OSA) tends to be similar to some of the psychiatric conditions and often overlooked. Here we explore a patient with long-standing disturbed sleep, anxiety with sudden onset breathlessness which was attributed by OSA.

CASE DESCRIPTION

This is a case of 55-year-old woman, who was overweight presented with persistent symptoms of anxiety along with sudden onset episodes of breathing difficulty, headache, choking sensation accompanied by sleep disturbance for 1 year. She’s a known case of Anxiety disorder NOS with co-morbid hypertension & hypothyroidism. Patient had consulted multiple private practitioners and was evaluated for the same, but symptoms were attributed to psychiatric causes. Endocrinological workup was within normal limits. Pulmonary examination revealed a Severe Apnoea Hypopnea Index of 80 on polysomnography. Patient was diagnosed with severe OSA comorbid to anxiety. Treatment with continuous positive airway pressure resulted in improvement of symptoms.

CONCLUSION

In the presence of an existing psychiatric illness, a medical co-morbidity with similar presentation, tends to get missed. Hence it is advisable that medical specialists including psychiatrists keep in mind the probable diagnosis of OSA in such conditions.

Dr. Priyanka Jha¹, Dr. Shishir Kumar², Dr. Arun Bhat³, Dr. Shrinivasa Bhat U⁴

1-Junior Resident, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

2-Associate Professor, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

3-Assistant Professor, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

4-Professor and Head of Department, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

A case report of carbamazepine induced Steven Johnson Syndrome (SJS) in a moderate Intellectual disability patient.

Dr. Nivedita Chandrashekhar Hebbar¹ Dr Bhuvaneshwaran²

¹post graduate student, Department of Psychiatry, Tirunelveli Medical College

²Associate professor, Department of Psychiatry, Tirunelveli Medical College

Background: Carbamazepine is an iminodibenzyl drug initially introduced as an anticonvulsant; it’s beneficial effects on mood were noted and was Started to use as mood stabilizer. SJS is a benign pruritic rash occurs in 10-15% of persons treated with carbamazepine. A small fraction of them may experience life threatening syndromes like SJS /TEN( toxic epidermal necrolysis)

A 24 year old unmarried male, known case of moderate Intellectual disability with behavioural disturbance on psychotropics and tablet carbamazepine 600mg/day past one month; brought by family members with c/o sleep disturbance, Anger and irritability and multiple erythematous macules with dark purpuric centres present over oral mucosa, bilateral upper limbs ( elbow and flexor region) with normal palms and soles. On physical examination patient febrile BP:90/70 mmHg. Systemic examination within normal limits. On mental status examination patient was agitated with dysphoric mood and inappropriate affect. Laboratory Investigation revealed anaemia (Hb:9%) and neutrophilia. During hospital stay , the offending drug (Carbamazepine) was stopped, supportive treatment was given with Iv inj. Dexamethasone, antibiotics, antihistamines. Lesions resolved with generalized scaling and was discharged. During follow up no older or new lesions were present.

Conclusion: It’s imperative that prescribers should consider possibility of life threatening skin lesions during carbamazepine use.

A Case report of Coprophagia & Urodipsia in OCD

Dr K Rajkumar ,Dr S Adithya , DR YSSR Rao

Postgraduate , Assistant Professor , Professor & HOD ,Kakatiya Medical College

INTRODUCTION

Coprophagia & Urodipsia , an unusual form of behaviour ,where in they consume faecal matter and drink urine .

Both these behavioural disorders and their management becomes inconclusive

CASE REPORT

A 32 year old unmarried female who studied till MBA, currently unemployed presented with complaints of repeated thoughts of abusing god ,eating faeces, drinking urine and compulsive act of drinking urine , eating faeces. symptoms started after she lost her job interviews 3 months ago began to Think negatively about the future , avoid food intake , used to avoid prayers ,happen to see articles about drinking urine , eating faeces on internet , patient initially did not like the taste and had vomited the content & developed fever for 3 days .gradually patient began to collect faeces & urine in small jars and used to consume in little amounts. In the 1^st month of illness patient began to consume twice a week ,increased the frequency and amount in the next 2 weeks, parents noticed this behaviour in the last month of her illness & brought for admission.

DISCUSSION

On application of Y BOCS ,score was 28/40, with corroborative MSE findings being obsessional thoughts ,compulsive acts , patient was being diagnosed as Obsessive Compulsive disorder . We used biological model & explained about harmful effects , ERP was done , activity iIN scheduling and also simultaneously pharmacotherapy with fluoxetine which has a good response , patients behaviour reduced by more than 70%

REFERENCES

• Ghaziuddin N, Mc Donald C : Clinical study of adult coprophagia .British Journal of psychiatry .

• Lingeswaran , et al : Entomophagy and coprophagy in schizophrenia.

• Heela Azizi et al : Pathophysiology and management of coprophagia.

• Aleksandra Bacewicz and Katherine Martin : Coprophagia in an 8 yr old hospitalised patient.

• Michael D McGee M.D, Thomas G . Gutheil M.D : Coprophagia and Urodipsia in a Chronic Mentally ill Woman.

A case report of multimodal hallucinations in Schizophrenia

Dr Shama BR (Postgraduate), Dr Divyashree NS (Senior resident), Dr Madhusudhan S (Associate Professor) Dept of Psychiatry, BMCRI.

Hallucinations can be unimodal or multimodal. Traditionally, hallucinations are often assumed to occur unimodally, one modality at a time; where in multimodal hallucinations (MMHs) occur in more than one modality simultaneously and emanate from a single source. MMHs have been reported in severe mental disorders including schizophrenia. Here we report a case with MMHs in a patient with paranoid schizophrenia with an illness duration of 4 years.

We report a case of a male patient with MMHs involving auditory, visual, tactile senses, somatic passivity and delusion of persecution and control. At the same time, he could either feel the movements of the doll inside him and hear its voice, sense the burning feel, or see the doll and hear its voices. A common source for the voice and a doll like image is his deceased mother. The patient was treated earlier with psychotropics despite which he couldn’t attain the baseline level. The patient was not able to concentrate on work and hence significant socio occupational dysfunction. There is a significant family history of query psychosis in 3-4 members. His investigation reports were within normal limits. The patient was treated with psychotropics. Organic causes were ruled out with neuroimaging.

The uniqueness of this case is the presence of hallucinations in different modalities, from a common source.

A case report of Pregabalin use

CASE REPORT:25-year-old single, 12th pass, Muslim Nuclear Family, Middle Socio economic Status, Rural Background, resident of Poonch Jammu was referred to the psychiatric department due to excessive talking, reckless spending and decreased sleep (YMRS score at the time of admission was 34).A thorough investigation also uncovered an excessive daily pregabalin capsule use (15–20 per day).

MANAGEMENT:All customary investigations were sent, and everything turned out to be as expected. The results of an immunoassay urine drug screen for frequently tested drugs were negative. Patient was treated with Tab Olanzapine 10 mg BD, Tab Lorazepam 2 mg BD (which was eventually tapered off gradually), and Tab Divalproex Sodium 500 mg BD. After twoweeks of admission, the patient was discharged (YMRS score of 18) and then transferred to the addiction unit. Three years ago, the patient began taking a single dose of two capsules (each having 75 mg) every day, which was gradually increased to 20 tablets. His withdrawal symptoms, which included excruciating physical aches, restlessness, and insomnia, would last for 24 hours before going away.

CONCLUSION:Pregabalin has an addictive potential, especially in patients with co-occurring disorders and physicians should be aware of this.

A case report of psychogenic cough

Psychogenic factors are known to be a possible cause of persistent cough in children. Psychogenic Cough is difficult to diagnose due to the lack of extensive research, diagnostic tests, and inclusion or exclusion criteria. A 13 year old boy presented with complaint of persistent cough since 6 months, sudden in onset, barking type of sound, harsh and non productive. The frequency increased with more attention being given to the patient. The cough was not associated with any signs of infection. History of being bullied in school and also his symptoms exacerbated in school. The symptoms would subside at night when asleep. He was taken for multiple consultations to different doctors and was treated with antihistamines, antibiotics, analgesics, cough suppressants, and other medications but showed no improvement in his symptoms. Physical examination and routine blood investigations done were found to be within normal limits. Hence, non-organic cause of cough was considered. A cough of psychogenic origin is usually croupy, barky, and explosive and disappears during sleep. It maybe a form of secondary gain for kids who are scared of school or a way for them to express their anger towards their parents. The doctor’s understanding that there might be psychogenic reasons for persistent cough could help them diagnose it earlier, so they don’t have to do the same tests over and over again, which can be costly and time-consuming.

E POSTER : ABSTRACT: A case report of Systemic Lupus Erythematosus presenting as Catatonia

Presenting author: Dr.V.Deepa , Post graduate II year ,Thanjavur medical college,Thanjavur,Tamilnadu

Co Authors:

Dr.K.Balamurali,M.D.,D.M., Associate professor (HOD incharge), Dr.G.Anbazhagan D.P.M.,M.D(Psy) Senior Assistant Professor., Department of Psychiatry,Thanjavur medical college,Thanjavur,Tamilnadu.

Background:

Catatonia , a neuropsychiatric condition is marked by posturing, mutism and stupor. It has been linked to schizophrenia, infections, medications, and autoimmune conditions such systemic lupus erythematosus (SLE) . We present a case report of systemic lupus erythematosus with catatonia that responded to immunosuppressive therapy and benzodiazepines.

Case report:

A 23 year old female presented with mutism, psychomotor retardation, withdrawal to painful stimuli, no food intake, poor self care, crying spells, withdrawn to self and sleep disturbances for 10 days. On examination, she was found to have puffiness of face , cheilitis, bilateral pitting pedal edema, a discoid rash over the anterior aspect of neck. She was admitted and evaluated. Later she started developing multiple rashes all over the body.

Investigations:

All routine investigations were done. Hemoglobin was found to be 7 gm/dl.

p-ANCA was found to be strongly positive.

Discussion: Patient was diagnosed with primary NPSLE based on ds-DNA . She was started on benzodiazepines. Rheumatologist opinion was sought and the patient was started on corticosteroids and azathioprine.

Conclusion: Primary NPSLE is a heterogeneous condition that poses an intricate diagnostic and therapeutic challenge. Early diagnosis and treatment is necessary for the effective management of this illness.

• Email of presenting author: deepavijayan309@gmail.com

• Phone no: 6381762735

A CROSS SECTIONAL STUDY OF VIOLENCE AGAINST WOMEN AMONG THOSE ATTEMPTED DELIBERATE SELF HARM WHO PRESENT TO VICTORIA HOSPITAL

Dr Triveni M Gowdar ( 3rd year Postgraduate), Dr Madhusudhan (Associate Professor),

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

Background: Violence can negatively affect women’s physical, mental, sexual, and reproductive health. Talking about mental health, violence can lead to depression, post-traumatic stress and other anxiety disorders, sleep difficulties, eating disorders and suicide attempts. According to previous studies violence is seen in women who have attempted on life. If the association between self-harm and violence is established, women who are at risk can be prevented from attempt on life.

Aim: To assess relationship between DSH and exposure to violence.

Methods: Data from 30 people who attempted DSH are included in this study. Columbia -suicide severity rating scale applied to evaluate suicidal ideation and behaviour. Severity of violence against women scale is used to assess the severity of violence. Relationship between DSH and exposure to violence is assessed.

Results: The initial analysis revealed, out of 30 ,5 had severe suicidal intention,5 had moderate to severe suicidal intention, 4 had moderate suicidal intent, 5 had severe suicide lethality score, 4 had undergone severe violence, 7 had moderate violence. The common mode of attempt in severe violence is poisoning, where as in women with no exposure is poisoning and hanging.

Conclusion: Lethality and severity of suicidal intent among those who attempted DSH is found to be increased with exposure to violence.

A Curious Case of Rowell’s Syndrome

Introduction:

Rowell’s syndrome is a rare autoimmune disorder characterized by a combination of systemic lupus erythematosus (SLE) and erythema multiforme-like skin lesions. It can also have significant neuropsychiatric manifestations like cognitive dysfunction, mood disorders, psychosis, seizures and peripheral neuropathy. Vascular injury mediated by antiphospholipid antibodies and autoimmune/inflammatory reaction with increased blood-brain barrier permeability have been proposed as a mechanism of neuropsychiatric manifestations.

Case Details:

We present a case of a 54 year old female, who was apparently alright 3 years ago when she started having complaints of lupus erythematous lesions over nose and malar region and erythema multiforme-like skin lesions over palms and lips along with fever, pain in the knees and shoulders. Investigations revealed increased ESR and fibrinogen, positive ANA, presence of anti Ro/SSA and a diagnosis of Rowell’s syndrome was made. One month later, the patient started having persecutory delusions, insomnia and angry assaultive behaviour. The patient was prescribed Tab Olanzapine, which she stopped after 1 year, on perceiving improvement.

Currently, the patient has come with complaints of painful, pruritic, erythematous plaques all over the body along with high grade fever, pain in her knees since 15 days. On examination, the patient did not have any active psychiatric symptoms. Due to past history of psychiatric symptoms occurring after skin lesions, the patient has been asked to follow up in 2 weeks.

Conclusion:

Neuropsychiatric symptoms can occur during or after the onset of Rowell’s syndrome, which needs to be monitored and treated.

Keywords: Rowell’s Syndrome, Neuropsychiatry, Psychosis

Dr. Iyer Seetharaman Venugopalan, Dr. Delnaz Palsetia, Dr. Alka Subramanyam

Department of Psychiatry, TNMC and BYL Nair Hospital, Mumbai

Email address: dr.iyer30@gmail.com

“A rare case of a gelastic seizure with hypothalamic hamartoma in a 11 year old child “ - A Case Report

Dr. Keyurkumar Rathod1, Dr. Disha Vasavada² Dr. Pooja Shatadal2, Dr. Ritambhara Meha3

1:First Year Resident, 2: Assistant Professor, 3: Prof. and Head, Psychiatry Department, Government Medical College ,Surat

Introduction:

Gelastic seizures are an extremely rare form of epilepsy presenting with recurrent bouts of inappropriate stereotyped laughter sounds but without mirth. Such laughter bouts may occur as an isolated event, commonly lasting less than 30 seconds. Gelastic seizures are often associated with hypothalamic hamartoma. Which may present with the triad of gelastic seizure , precocious puberty and developmental delay.

Case Report:

A 11-year-old male presented to psychiatric OPD with chief complaints of poor scholastic performance and episodes of uncontrolled laughter, seeing a ghost like appearances in front of him during these episodes- each of which lasted for about 15-30 seconds only.

The child experienced first episode of seizure at 3 months of age. The first episode presented as up rolling of eyeballs, excessive crying and decreased feeding associated with fever. Pediatrician started syrup phenobarbital (20mg /5ml) - 2.5ml BD. At three years of age patient had an of episode of uncontrolled laughter for 15 to 30 seconds associated with running towards parents and clinging to them. On consultation he was started on syrup valproate (20mg /5ml) 2.5 ml BD. Patient currently has similar episodes 4 to 5 times a day. Patient was also found to have developmental delay and poor scholastic performance. On IQ assessment patient was found to have borderline intellectual functioning. Patient’s recent imaging of the brain [MRI] showed hypothalamic hamartoma. Patient’s EEG was found to be with in normal limit.

Discussion with Conclusion:

gelastic seizures are a type of seizures having atypical presentation. Knowledge of such atypical presentation is important so that the diagnosis is not missed especially considering this patient had normal EEG. Subsequently MRI revelaed hypothalamic hamartoma which is often associated with gelastic seizures. Patient showed improvement on anti epileptic edications.

Gelastic seizure , hypothalamus hamartoma, developmental delay.

A rare case of Ekbom Syndrome, post-craniectomy

INTRODUCTION

Psychotic disorder is ~6 times more likely post traumatic brain injury. Common presentations usually are persecutory delusions and auditory hallucinations.

Here is an interesting case of a patient who presented with quite atypical psychotic features of Delusional Parasitosis (“Ekbom Syndrome”) following traumatic brain injury.

Ekbom syndrome or Delusional Parasitosis is a persistent belief that one is infested with pathogens.

CASE DETAILS

23 y/o lady, post-op. case of Right F-T-P craniectomy, following acute SDH was referred from Neurosurgery for complaints of behavioural disturbances and repeated skin-picking at site of injury.

On MSE, patient reported delusional parasitosis and tactile hallucinations of insects crawling over injury site. Her scalp showed excoriations and bald patches, as she would repeatedly attempt picking the “crawling insects” that she could feel. She would pluck out hair follicles from injury site, even misidentifying them as insects on some occasions.

On serial MSEs, depressive cognitions emerged, secondary to her beliefs. Affect was tearful and insight grade 1.

DISCUSSION

Patient was treated with T. Olanzapine titrated to 20 mg, and T. Duloxetine 60 mg. On these, patient showed significant improvement in psychotic symptoms over the course of 1 month and underwent cranioplasty 1 month later.

CONCLUSION

Although development of psychotic symptoms following head injury is common, literature reporting delusional parasitosis with tactile hallucinations post Traumatic Brain Injury is scarce.

Its occurrence, especially localised presentation at the site of injury, can be considered a rare presentation of psychotic disorder following traumatic brain injury.

A rare case of Sertraline induced galactorrhea with normoprolactinemia

Dr. Karan¹, Dr. Ira², Dr. Prinka³

^1,2,3Department of psychiatry, Government Medical College and Hospital,

Sector-32, Chandigarh

Background: Galactorrhea is the spontaneous discharge of milk from the breast which is not associated with pregnancy, childbirth, or lactation. Some antipsychotic drugs are known to block tuberoinfundibular dopaminergic (D2) pathway which ultimately leads to increased prolactin secretion causing galactorrhea. The occurence of galactorrhea with antidepressants is rare, mostly SSRIs have been reported but no clear pharmacopathology has been established for the same.

Aims and objectives: To present a case report of sertraline induced galactorrhea with normoprolactinemia

Case report: A 32-year-old female with 14 year history of recurrent depressive disorder with current episode of six years duration, presented to us with complaints of galactorrhea for 1 month. The patient had a medical history of seizure disorder with the last episode two years back. When presented to us, the patient was taking T. Sertraline 100mg OD, T. Desvenlafaxine 100 mg hs, T. Levetiracetam 1250 mg/day with a history of recent increase in the dose of Sertraline. There wasn’t any abnormality in prolactin levels or brain imaging and her menstrual cycles were regular.

A suspicion of SSRI induced galactorrhea was made and T. Sertraline was stopped, no change in any other medication was done. Patient noticed improvement 3 days after the stoppage of therapy and galactorrhea completely stopped 10 days after the stoppage of Sertraline. A Naranjo ADR probability scale was applied and a score of 6 was obtained.

Conclusion: Galactorrhea can occur as a rare side effect of Sertraline even in presence of normal prolactin level.

Keyword: Sertraline induced galactorrhea.

A rare case of Trichotillomania in Borderline Personality Disorder

Presenting author: Dr.Su.Poornima, 3^rd year Postgraduate, Thanjavur medical college hospital.

Co Authors:

Dr. K.Balamurali M.D, D.M. HOD (incharge)

Dr.G.Anbazhagan D.P.M.,M.D(Psy) Senior Assistant Professor., Department of Psychiatry, Thanjavur medical college hospital, Thanjavur,

Background : Trichotillomania or hair-pulling disorder, is characterized by the repititive removal of hair from the body.Patients who are affected by borderline personality disorder are known to develop trichotillomania as a self-harming behavior.

Case report: A 34 year old married female, presented with loss of scalp hair and repeated hair plucking behaviour for past 10 years . she had started pulling her hair whenever she developed interpersonal conflict with family. She had multiple suicidal attempts and non suicidal self injurious behaviour since teenage and pre marital relationship and abortions . In the back ground of traumatic family relationships and frequent marital disharmony her hair plucking behaviour gradually increased. Physical examination revealed areas of baldness diffusely over the scalp region . On examination, she expressed feeling frustrated, lonely, and depressed with labile affect. In NIHM-TSS scale her score was severe and in NEO personality inventory high score in neuroticism and openness. She was diagnosed as Trichotillomania with Borderline Personality Disorder . Started on pharmacotherapy and psychological intervention

Discussion: Current treatment strategies for trichotillomania in the presence of co-morbidity, to be individualised for better outcome.

Conclusion: Diagnostic approaches to trichotillomania must consider the phenomenological similarity of other psychological disorders.

Mail id: poorni.su@gmail.com

Phone number : 9789435945

A RARE CASE REPORT OF KLEINE-LEVIN SYNDROME IN A FEMALE PATIENT

Dr Adnan Jamil^a, Dr Varaha Venkat Gantait^b , Dr Imon Paul^c, , Dr Anamika Das^d

^aPost-graduate trainee, ^bAssistant Professor, ^cProfessor and HOD , ^dAssistant Professor

Dept of Psychiatry, IQ City Medical College & Hospital, Durgapur, WB.

Background

Kleine-Levin syndrome(KLS) is a unique but rare sleeping disorder characterized by episodic hyperphagia and hypersexuality. Each episode lasted for a brief duration varying from a week to 1-2 months with symptom free inter episodic period. The disease process and manifestations are unpredictable, with variations in duration as well as frequency. The pathophysiology continues to be poorly understood. It predominantly affects adolescent males, and literature is scarce in reports of the syndrome affecting females.

Case presentation

A 22-year-old female presented to our side with complaint of episodes of excessive sleepiness and frequently falling off to sleep during daytime. Her initial presentation was 6 years back. The episode lasted for about 45 days with symptoms of hypersomnolence, hyperphagia and increased libido followed by complete recovery. Subsequently every year mostly in winter she experienced similar episodes however the severity and duration of each episode gradually decreased with complete inter episodic recovery. In this episode she also started showing symptoms of forgetfulness, irritability, low energy, excessive eating, aggression along with hypersomnolence and increased libido. Her general, systemic, and laboratory examinations were within normal limits. Based on psychiatric examination and assessment, a diagnosis of Kleine Levin syndrome was made and she was put on psychopharmacological therapy and she improved gradually.

Discussion

We discuss here about a case which meets the modern classification of KLS and responded adequately to treatment. Reporting the case will help us to recognize and explore the myriad clinical presentations including unusual presentations in females and management of this rare disease.

A rare case report of Olanzapine induced paralytic ileus.

Background: Olanzapine is an atypical anti-psychotic with 5HT2A/D2 antagonism. Constipation is a common side effect with second generation antipsychotics due to their anti-muscarinic effects. However, reports of constipation leading to paralytic ileus due to Olanzapine are rare.

Aims: Here we discuss a rare case report of Olanzapine induced paralytic ileus in a young male.

Methods: An 18-year-old male presented with one-month complaints of psychotic behaviour and was admitted to psychiatry ward. He had no prior history of any gastrointestinal complaints. Blood investigations were within normal limits. He was started on Tb. Olanzapine 10mg which was gradually uptitrated to 20mg. On day 6 of admission patient started complaining of constipation which persisted despite dietary modifications and laxatives and progressed to abdominal distension with multiple vomiting episodes. Xray Erect abdomen showed multiple air fluid levels and USG showed distended bowel loops. CECT abdo+pelvis did not show any mechanical obstruction. Surgery referral was done and paralytic ileus was diagnosed.

Results: Patient was managed conservatively and Tb Olanzapine was cross-tapered with Tb. Aripiprazole. His abdominal complaints resolved and there was improvement in his psychotic symptoms as well.

Conclusion: Constipation as a side effect of antipsychotic medications has received little attention. Olanzapine leading to paralytic ileus in an otherwise healthy individual is a rare but potentially fatal complication. Clinical staff should be aware of this association and actively screen, monitor and provide early intervention to obviate need for active surgical intervention when using second generation antipsychotics.

A rare case report- risperidone induced retrograde ejaculation

Harpuneet¹, Vijay Kumar Saini², Parth Singh Meena³, Mahendra Jain⁴

1.Resident, Department of Psychiatry, JLN Medical College, Ajmer, 7009842756, harpuneetkaur50@gmail.com

2.Assistant professor, Department of Psychiatry, AIIMS, Jodhpur

3.Professor, Department of Psychiatry, JLN Medical College, Ajmer

4.Senior Professor and HOD, Department of Psychiatry, JLN Medical College, Ajmer.

Atypical antipsychotics are widely used for schizophrenia and bipolar disorder but they can lead to various distressing sexual dysfunctions, particularly risperidone, which can result in medication non compliance among patients. Sexual dysfunction related to hyperprolactinemia is commonly described, but ejaculatory disturbance due to potent alpha1 adrenergic antagonism may also occur, and has been reported frequently with certain typical antipsychotics such as thioridazine, but rarely with atypical antipsychotics. Hereby, presenting the case of a 29-year-old male with BPAD type 1 who was admitted to our psychiatric inpatient ward with severe manic symptoms with psychotic features. He was already on treatment for psoriasis as well. On admission, he was treated with oral risperidone which was gradually hiked upto 8mg within 2 weeks and patient was discharged on similar doses. At the time of first follow up after 2 weeks since discharge he reported retrograde ejaculation. Comprehensive medical and psychiatric evaluations were performed. Risperidone was cross tapered with lurasidone up to 40mg/day with resolution of distressing sexual dysfunction. The absence of decreased libido or erectile dysfunction indicates that alpha1 adrenergic antagonism and not low serum testosterone due to hyperprolactinemia is the etiology for this side-effect. This case emphasizes the need for routine inquiry into sexual dysfunction during atypical antipsychotic therapy.

Paper Title: A systematic review of caregiver interventions for early childhood language development in low-income settings

First Author: Piyali Misquitta

Second Authors: Gideon Salter, Paul Gering, Danielle Matthews

Background: Language abilities at school entry predict future reading skills, academic achievement and vocational success. Interventions to promote early childhood language development have targeted caregiver responsive behaviours. However, incomplete reporting has prevented their replication and uptake.

Aims: This review summarised and evaluated components of caregiver

interventions designed to promote early childhood language development. This could help professionals assess available interventions to make clinical and policy decisions.

Methods: A systematic review of three databases, psychINFO, Web of Science, and Scopus, was conducted in April 2023. Studies were included if they reported randomised controlled trials of caregiver interventions targeting language outcomes in children below 5 years of age and from low-income backgrounds. The Template for Intervention Description and Replication (TIDieR) framework was used to extract data. Risk of bias was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis was conducted.

Results: The search identified 4503 records, of which 20 reports with 21 trials were included. Most of the studies included were book-reading interventions for children below the age of 2, were less than six months in duration, and recruited only mothers. Most interventions were delivered at home by implementors from varied educational backgrounds.

Conclusions: Poor reporting of intervention adherence and randomisation procedures were noted in the studies. Future studies need to address the lack of an underlying theoretical framework in caregiver interventions. Alternative assessments for non-native speakers of English also need to be developed. The studies included highlight the benefits of digital technologies at every stage of intervention.

A unique case of galactorrhea caused by tramadol dependency in a 32-year-old female- a case report

Presenting author: Dr.R.Meenakshi , Post graduate II year ,Thanjavur medical college,Thanjavur.

Co Authors:

Dr.K.Balamurali,MD.,DM., Associate professor (HOD incharge), Dr.G.Anbazhagan D.P.M.,M.D(Psy), Senior Assistant Professor, Department of Psychiatry,Thanjavur medical college,Thanjavur.

Background: Tramadol is an atypical, synthetic, centrally acting analgesics. Its antinociceptive effects are mediated by combination of µ opioid agonist and SNRI action.

Clinical presentation: A 32 years old female, presented with over the counter use of Injection Tramadol for post appendicectomy abdominal pain. She started taking daily upto 300mg IM. She started craving for the drug and started having nausea, vomiting, abdominal pain on withdrawal. She reduced her food intake and lost upto 25kgs. After 4 years of daily use , due to abscess in the gluteal region, she started taking IV Tramadol. She developed tolerance and increased the dose to 400mg daily. She started having breast milk secretion. She reported of anger outbursts frequently. The patient had suicidal wishes and attempted suicide by consuming organophosphorous . She was admitted in ward and evaluated.

Investigations: Her BMI fell under underweight. Serum prolactin was found to be elevated.

Discussion: The patient was found to have Tramadol dependence and was treated with benzodiazepines and antipsychotics.

Conclusion: It was claimed that tramadol had low risk of abuse. However, a number of reports on dependence revealed its abuse liability and diversion. This case report emphasizes the need for cautious prescription of Tramadol.

Email: meenakshirajagopal9@gmail.com

Phone number: 7598299060

Accelerated response with adjuvant oral racemic ketamine in a young adult with Major Depressive Disorder(MDD).

Background: Significant therapeutic effects of antidepressants accrue after a few weeks. On the other hand, studies have shown rapid improvement in depressive symptoms with oral ketamine with self-limiting side effects.

Aim: To present a case of 21-year-old female diagnosed with MDD treated with oral Ketamine for rapid improvement in symptoms for exam preparation

Case summary: Patient was diagnosed with MDD without psychotic symptoms and initiated on Tab. Escitalopram 10 mg; partial remission was noted. After 6-months due to stressors her depressive symptoms worsened. She had symptoms characterized by crying spells, difficulty focusing in studies, reduced energy, worthlessness, hopelessness, death wishes. She considered skipping the exam due in 3-weeks, which had three consecutive theory and practical exams separated by 4-days. Escitalopram was increased to 15 mg and for rapid improvement, oral ketamine was advised for which she consented. She scored 16 on Patient Health Questionnaire-9(PHQ9) before starting on ketamine. In out-patient setting, 150 mg of injection ketamine solution mixed in 100 ml of water was administered orally. The first oral-ketamine was administered 6 days before the exam. The effect peaked at 24 hours when she scored 12 on PHQ9 and after 72 hours, it began to decline scoring 14. Subsequently, on noticing waning of the response 4 more ketamine-sessions were planned before her theory and practical exams. During her first session, she experienced nausea, floating sensation, giddiness, dizziness for 2 hour which were minimal and lasted for <1hour in following sessions.

She scored 10 on PHQ9 after last ketamine-session; reported significant improvement in mood symptoms, because of which she could prepare and appear in all the exams.

Conclusion: Ketamine can be a safe and effective adjuvant to antidepressants in MDD to bridge the gap between initiating an antidepressant and its onset of action. Use of ketamine in this regard merits further systematic investigation.

Acute Management of Aggression: Comparative Review of Existing Guidelines

Sarthak Kukreja¹, Raman Deep²

1.Junior Resident, Department of Psychiatry, AIIMS New Delhi

2.Professor, Department of Psychiatry, AIIMS New Delhi

Background:

Acute or emergency management of aggression in patients is a complex challenge, requiring prompt and effective intervention to ensure safety. The expert consensus, literature synthesis and recommendations need to be reviewed to gain insights and provide inputs for an optimal approach for addressing aggression in patients

Aim:

We aim to compare and contrast the evidence-based recommendations from various available guidelines in the last decade, irrespective of the country.

Methods:

We went through the indexed literature (2013-2023) using a systematic search strategy. and reviewed established guidelines, including but not limited to Joint BAP-NAPICU (2018), WFoBP Agitation Consensus (2016), NICE (2015), AAP Project BETA (2012), and Indian CPG for Aggressive Behavior (2023), NICE guidelines, among others.

Results:

Existing guidelines emphasize initial assessment, differential diagnosis, patient safety, and certain tailored management strategies as common broad principles. However, certain variations exist in recommended management strategies, including pharmacological agents. For example, BAP-NAPICU (2018) endorses the use of benzodiazepines like buccal midazolam, IM midazolam, inhaled Loxapine, and ECT but cautions against IM ketamine. In contrast, the WFoBP Agitation Consensus (2016) recommends IM midazolam and IV haloperidol, while AAEP-BETA mentions IM Ketamine. The recommendations are also reviewed issues such as choice of medication if need to repeat, or dealing with aggression in special population groups.

Conclusion:

The evidence-based guidelines serve as valuable resources for manging acute aggression, however must be contextualised to the settings and patient needs. Review also underscores the complexity of managing aggression as well as certain lacunae in the evidence base.

Keywords: Aggression, Guidelines, Recommendations, Acute management

ADOLESCENT ONSET BIPOLAR MANIA: IS AN ECTODERMAL ANOMALY DISORDER

(1) Dr Siddharth Patil (2) Dr Santosh Ramdurg (3) Dr S.P Chaukimath

INTRODUCTION

Bipolar mania is a mood disorder characterized by distinct episodes of mood elevation and depression. It is usually considered to be a functional disorder. recently, few studies have shown they are of organic origin, especially adolescent-onset bipolar disorder. The hypothesis was brain is derived from ectoderm, and a few case reports showed bipolar mania with ectodermal anomalies. It is a rare phenomenon where one patient presented to us with bipolar mania with ectodermal anomalies, macrodactyly and intellectual disability.

CASE DETAILS

An 18-year-old boy, presented with over-talkativeness, elevated self-esteem, overspending and frequent physical fights with family members. He was found to be getting disinhibited and was using alcohol and bidi, which he never used before. Diagnosis of bipolar mania was made. On further assessment, he was found to have macrodactyly of the left thumb and index finger, along with borderline IQ.

DISCUSSION

• Many chromosomal abnormalities are linked with psychiatric illness, but none present with combination of macrodactyly and bipolar mania. Macrodactyly is rare nonhereditary congenital digit enlargement. This is first of its kind with above combination of symptoms.

• A possible hypothesis is that all these originate from ectoderm, and now we can say adolescent mania is an ectodermal anomaly disorder.

REFFERENCES

Stor, M.L.E., Lokhorst, M. M., Horbach, S. E. R., & van der Horst, C. M. A. M. (2022). The long-term progression of macrodactyly. JPRAS Open, 31

Adverse childhood experiences and mental disorders: relationship and pathways of prevention/mitigation

Background

Adverse childhood experiences (ACE) have wide range of consequences including mental disorders and substance use. However, there is dearth of data exploring the association between adverse childhood experiences and mental disorders, specifically in Indian context.

Aims

This review explores the prevalence of various ACEs along with its relationship with mental disorders (including substance use). It also provides an analysis of the strategies for preventing and mitigating ACEs in India.

Methods

A systematic review was conducted by searching a range of databases (PubMed, Google Scholar, Science Direct) with specific keywords adverse childhood experiences, child maltreatment, mental health. A total of 23 studies that discussed one or multiple aspects of ACE were included based on their appropriateness and availability of the full text.

Results

It was found that around 40-50% children experience one or more ACE during their childhood. One of the studies reported that boys were more prone to experiencing ACE. The most common ACE was found to be emotional abuse. Risk of Depressive disorder was significant in adulthood for children who experienced ACE.

Conclusion

The prevalence of ACE is high amongst Indian children. There is a direct correlation between ACE and mental illnesses. A range of approaches can prevent the impacts of ACEs (primary prevention) and respond to ACEs and their consequences (secondary prevention), including policies and legislation programmes to strengthen families, the provision of education and life skill development, and good quality response and support programmes.

ABSTRACT FOR E-POSTER

Amantadine as a promising treatment for tinnitus in Multiple System Atrophy

1.Richa Shukla, Senior Resident Department of Geriatric Mental Health, King George’s Medical University, Lucknow-226003, U.P., India.

E-mail: richa.shukla1510@gmail.com

2.Pooja Misal, Assistant Professor, Department of Geriatric Mental Health, King George’s Medical University, Lucknow-226003, U.P., India.

E-mail : pmisal10@gmail.com

3.Shailendra Mohan Tripathi, Additional Professor, Department of Geriatric Mental Health, King George’s Medical University, Lucknow-226003, U.P., India.

E-mail : smtripathi@kgmcindia.edu

Corresponding Author: Dr. Richa Shukla, Department of Geriatric Mental Health, King

George’s Medical University, Lucknow, U.P, India. Phone: +91-9450848972.

E-mail: richa.shukla1510@gmail.com

Amantadine as a promising treatment for tinnitus in Multiple System Atrophy (MSA)

Background: Tinnitus results from maladaptive neuroplastic changes in central auditory networks, triggered by oxidative stress. Glutamatergic receptors are involved in auditory system depolarization. Chronic dysfunction of glutamatergic system is prevalent in neurodegenerative conditions. Use of glutamatergic antagonists presents a logical approach to treat tinnitus. While causal association between tinnitus and Parkinsons’s disease (PD) is uncertain, it’s presence could serve as risk factor for developing PD.

Aim: To describe relationship between tinnitus and MSA and evaluate role of amantadine in managing tinnitus symptoms in an elderly patient diagnosed with MSA.

Methods: A 67-year old man presented in Geriatric Mental Health OPD with ringing sensation in bilateral ears for 3.5 years, tremulousness in both hands for 1 year, unsteadiness while walking with fear of fall for 1 month. Signs of autonomic dysfunction like urinary frequency and urgency and constipation were also present. Neurological examination revealed impairment in coordination and tandem walking. MRI brain was normal. In consultation liaison with Neurology department, a diagnosis of Multiple System Atrophy (MSA)-Cerebellar was made. Tab amantadine was given upto 100 mg/day. After one week, patient reported more than 50% improvement in tinnitus, with reduction in tremors and gait difficulty.

Result: The patient is currently asymptomatic for tinnitus. Amantadine seems effective in treatment of tinnitus associated with MSA

Conclusion: Tinnitus can serve as an early indicator of neurodegenerative disorders in elderly and amantadine may be a potential treatment option for managing tinnitus in context of MSA.

An Audit on Code White team response

Hari Priya. M, Syed Ummar. I, G. Raghuthaman

Department of Psychiatry

PSG Institute of Medical sciences and Research, Coimbatore

INTRODUCTION

Violence and aggression refers to a range of behaviours or actions that can result in harm, hurt or injury to another person

“Code White” refers to a trained team response to a disturbance that is a behavioural emergency involving clients in health care settings.

NICE Guideline contains recommendations on intervening before violence and aggression occur and on interventions needed to prevent minor violence from escalating into severe. Contols Used are

• Physical restraints(Hands on),

• M echanical restraints(4 point restraints),

• Seclusion

AIM AND OBJECTIVES

To assess if Code White response is appropriate as per Department policy

• To ensure that Code-White is initiated in patients who have definite indication and to analyze if nursing staff in the ward follow all Pre Code-White proceedings.

• To ensure the availability of Code-White team members during the procedure.

• To analyze if Physical restraint policy is implemented according to Department Protocol.

• To ensure if proper documentation is done.

METHODOLOGY

Prospective Study

A sample size of 17 patients from Psychiatry

Wards for whom CODE WHITE was announced were selected for the study and data was collected by manual documentation

RESULTS AND DISCUSSION

In all patients ,one of the definite indications was present- most common being Aggression and Danger to self or others, 2/3 indications coexisted

Pre Code White Proceedings	Yes	No
One nursing staff calls code white	100%(n=17)
One nursing staff has an eye onthe violent patient	82.35%(n=14)	17.65% (n=3)
The staff – De escalate the situation	76.47%(n=13)	23.53% (n=4)
Personal, patients and co-workers safety ensured	94.11%(n=16)	5.89% (n=1)
Keeping ready tablets, loaded injections, physical restraint	76.47%(n=13)	23.53% (n=4)

Announcement of Code White was followed in all patients(100%),whe reas other Protocols in Pre Code White Proceedings were followed only in <95% of patients

Availability of Code White	Yes	No
Team members
Leader - CNS/Male psychiatry	88.23% (n=15)	11.8% (n=2)
staff/OT Technician/Primary		Female
Therapist		Psychiatry Staff
Atleast 7 Members to handle the violent patient present	76.47% (n=13)	23.53% (n=4)
Patient held physically andgiven injection, if refuses medication	76.47% (n=13)	Already taken oral medication=3, Already received injection=1
Physical hold-released one by one if not assaultative	88.23% (n=15)	Already restrained-1, Becamecooperative-1

Code White team members availability was abided as per department policy only in <90% of cases

Physical restraint policy 10 restrained 7 not restrained	Yes	No
Prescribed medication given – If De escalation not Possible	100%
2nd Nursing staff – inform nursing supervisor and security guard and	47%	53% (n=9)
summon available ward staffs for help	(n=8)
3rd nursing staff – inform primary therapist / duty doctors in 30		50% (n=5)
minutes (if symptoms does not come down)	(n=5)
Physical restraint initiated anytime if there is harm to self or others	100% (n=10)
A nursing staff has explained the key family member and got consent		100%, (n=10)
Physically restrained as gently as possible	50%- (n=5)	50%, (n=5)
Physical restraint not obstructing blood flow	90%, (n=9)	10%, (n=1)
Primary therapist or duty doctor informed immediately after restraint	60%	40%
Nursing staff remains with the patient till restraint is removed	-	100%
Pulse rate –recorded immediately and after every 30 minutes	30%	70%
MSE – Reviewed and documented every 30 minutes	-	100%
Fresh orders obtained from primary therapist or duty doctors after 60 minutes	-
– if patient continues to be violent (n=0)
After 2 hours primary therapist or duty doctor summoned by nursing staff	-	-
to review the patient if patient continues to be violent (n=o)

RECOMMENDATIONS

M embers must receive initial training and regular refresher training(including EM D team members) so that they follow the guidelines. Adequate staffing can be ensured.M andatory consent to be obtained from patient’s attender before restraining.Vitals (Pulse rate) to be checked in all the patients and documented.Re view of Patient and M SE to be done and documented every 30minutes.Debriefing after crisis management to be encouraged and followed

REFERENCES

• NICE Guideline On Violence And Aggression: Short-term Management In Mental Health, Health And Community Settings

• Guidelines: Code White Response (A Component Of P revention And Management Of Aggressive Behaviour. In Health Care),

• P SG Hospital P sychiatry Manual-VersionVII

Case report: Interesting Case Of Schizophrenia with Fregoli syndrome

Dr.Laxmi Nagaraju Koppishetty1,

Dr. Kota Suresh kumar2 ,Dr.Y.Sanjay3,Dr. B.Hari Manasa4

1-Junior Resident,2-Professor &H.O.D,3- Professor ,4-Assistant professor

Department of Psychiatry, Katuri Medical College &Hospital, Guntur, AP

Background:

Frégoli syndrome belongs to the group of delusional misidentification syndromes.The hallmark of Frégoli syndrome is the belief that a familiar person is disguised as a strange person, ie, the familiar person has taken on a different physical appearance but remains the same person psychologically.This entity has heterogonous etiologies including , organic/ affective disorders, or schizophrenia.

Case Report

A 36 years old married female, studied 12th std belonging to LSES hailing from Guntur brought to the psychiatric OPD by her mother with complaints of false belief of having 7 kids ,suspiciousness that her husband has taken different appearances and a movie director is an imposter of her father, hearing of voices ,self talk and wandering spells,decreased sleep.On MSE ,conscious and coherent, normal psychomotor activity,eye to eye contact maintained, speech is increased in volume,tone with normal tempo,thought content revealed Delusion of misidentification and there were 2nd person auditory hallucination.

Conclusion:Patients with Fregoli syndrome often misidentify members of the treatment team, who work closely with the patients. Accurate assessment of the syndrome and potential risk factors for future violence can help clinicians minimize assault risks and provide optimal treatment.

Delusional misidentification, Fregoli syndrome,schizophrenia

Antecedent Psychosis in Huntington`s Disease:: A Unique Case Presentation and Treatment Outcome

Alka Singh¹, Priyanka Hooda²

ABVIMS & Dr. RML Hospital, New Delhi

Background: Huntington’s disease (HD) is an inherited genetic progressive neurodegenerative disease. Psychosis is a rare occurrence in Huntington`s disease (HD) typically manifesting late in the disease course. We present a unique case of a 47-year-old male with known coronary artery disease (CAD) and hypertension (HTN) who developed delusions of persecution and reference preceding the onset of HD symptoms.

Aim: This case report aims to shed light on the unusual presentation of psychosis preceding motor symptoms in HD and to highlight the importance of early recognition and management of psychiatric symptoms in HD.

Case: The patient presented with an 8-month history of untreated delusions of persecution and reference. Four months after the onset of psychosis, he developed Huntington chorea, without any cognitive decline. The patient was admitted for diagnostic clarification and started on low-dose olanzapine (5 mg). Remarkably, he responded well, with complete resolution of psychotic symptoms within 4 months.

Discussion: The association between psychosis and HD is well-documented, occurring in 3-11% of patients. However, the unique feature of this case is the preceding onset of delusions. Psychiatric symptoms often overshadow motor manifestations, leading to diagnostic challenges. The early intervention with olanzapine highlights the importance of addressing psychotic symptoms in HD promptly. The efficacy of low-dose olanzapine in treating psychosis in HD should be further explored.

Conclusion: This case underscores the atypical presentation of HD with psychotic symptoms antedating motor dysfunction. Timely recognition and management of psychiatric manifestations are crucial.

Low-dose olanzapine can be an effective treatment option for psychosis in HD. Further research is needed to better understand the relationship between HD and psychosis, especially in cases with unique presentations like the one presented here.

Assessment of personality in a patient of Psychogenic headache

BACKGROUND

Psychogenic headache results from mental, emotional and behavioral factors without evidence of any physical injury or illness. Onset, development and clinical picture of headaches and the treatment response depends upon the psychological state of the patient. Many studies have focused on the connection between particular personality traits and headache syndromes, as patients with personality disorders respond differently to pain as compared to healthy people. Those with borderline, narcissistic, antisocial and obsessive-compulsive types having more complaints of chronic refractory headache.

AIM

To assess the type of personality in a patient of psychogenic headache

CASE REPORT

A 18 yr old female with migraine like presentation, along with somatic complaints, disturbed sleep pattern, frequent anger outbursts and abnormal body movements was admitted in neurology department. A psychiatric consultation was taken and on evaluation, multiple stressors were elicited and a provisional diagnosis of conversion disorder was made. The patient was transferred to psychiatry ward, where she was evaluated for personality assessment.

RESULT

On personality evaluation with IPDE and MMPI ,cluster B personality traits with impulsive and dependant scores being highest were found. Low dose carbamazepine was added to her treatment profile, on which she showed significant improvement.

DISCUSSION

Patients with personality disorders often present with chronic refractory headache for which they are usually stigmatized, as general people tend to think that pain from psychological source is not “real” and their behaviour is considered to be dramatic with respect to their daily routine functioning.

Behaviour Problems in CleidoCranial Dysplasia: A Case Report

Introduction:

Cleidocranial dysplasia (CCD) is a rare condition with multiple skeletal deformities usually with normal intelligence. Prevalence of same is 1 per million individuals. Cause is mutation in RUNX2 gene. But this case report discusses a very rare behaviour phenotype presenting with psychiatric complaints.

Case description:

A 35 year old female patient presented to Psychiatry OPD with complaints of easy-irritability,sleep disturbance,low-mood,stubborness.Total duration of illness was 13 years without significant improvement on various psychotropics which were given for six months before coming to OPD as per relatives.In past compliance issues were also present seeing the documents brought by relatives During assessment in OPD seeing the facial features such as prominent forehead, depressed nasal-ridge,short stature and minimal improvement on treatment warranted a detailed assessment. Furthermore history of wide anterior fontanelle at birth and teeth abnormality along with x-ray finding suggestive of hypoplastic clavicles confirmed the diagnosis of CCD and subsequent IQ assessment was suggestive of borderline intellectual functioning. Relatives were counselled regarding the condition and patient has been managing well on treatment at present.

Discussion:

Thus this case report highlights the importance of a holistic approach to evaluation which may result in the diagnosis of a rare syndromic condition such as CCD with borderline intellectual functioning which may be wrongly diagnosed as another psychiatric condition.The patient was facing the issues which were commonly faced by person with borderline intellectual functioning including rejection from family members, difficulties in meeting her needs. This was leading to the diagnosis of behavior disturbance rarely seen with behavior phenotype of CCD.

Bipolar Disorder and Grey Matter Heterotopia: A Case Report

Sandeep, Puneet Khanna

Armed Forces Medical Services

INTRODUCTION

• Grey Matter Heterotopia (GMH) is a disorder of neuronal migration.

• There is clear albeit rare evidence of grey matter heterotopia and associated neuropsychiatric manifestations with only very few published case reports .

• We present one such case of Bipolar Affective Disorder (BPAD) with associated Grey Matter Heterotopia.

CLINICAL CASE

• 22 year old male, presented with irritable mood, anger outbursts, overtalkativeness,increased energy levels, reduced need for sleep, reckless and risk-taking behaviour of 3 weeks duration

• History of depressive episode 1 year back: managed with SSRIs.

• No medical/surgical comorbidity.

• Family h/o depression and suicide in mother.

• Neurological examination :WNL.

• MRI Brain-bilateral diffuse subependymal GMH.

• Urine Drug Screen-Negative

• YMRS score-23 (initial), 1 (post treatment).

• Diagnosed as a case of BPAD (current episode Manic without psychotic symptoms).

• Managed with Tab lithium 1200 mg/d, Tab Risperidone 4 mg/d, benzodiazepines and supportive psychotherapy.

DISCUSSION

• Epilepsy, IDD,ADHD and psychotic manifestations of Periventricular Heterotopia are well documented.

• We found around 20 case reports1 of neuropsychiatric manifestations associated with GMH, with only one describing BPAD.²

• Our case highlights one such rare association b/w BPAD and GMH.

CONCLUSION

This case emphasizes the role of neuroimaging as a probable diagnostic marker for BPAD in young adults presenting with first episode of mood disorder.

REFERENCES & CONFLICT OF INTEREST

1. Fry AE, Kerr MP, et al: Neuropsychiatric Disease in patients with Periventricular Heterotopia. The Journal of Neuropsychiatry and Clinical Neurosciences. 2013, 26-31.

2. Borgeois JA, Nisenbaum J, et al: A case of subcortical grey-matter heterotopia presenting as bipolar disorder . Compr Psychiatry 1992;33:407-410

Conflict of Interest-Nil

POSTER PRESENTATION ABSTRACT: Body dysmorphic disorder: Variations in presentations according to Gender.

Dr Sukriti Pruthi, Dr Mohit Agrawal, Dr SP Panda

Background: Body dysmorphic disorder (BDD) is characterized by a persistent preoccupation with perceived defects or flaws which causes self-consciousness and significant distress or impairment in functioning. This is accompanied by excessive or repetitive behaviours related to the appearance concern, such as checking, camouflaging, or attempting to ‘improve’ the appearance of the perceived flaws.

Aim: This article aims to provide a variation in presentation between the two genders, through two cases of BDD.

Methods: We present two cases of patients of BDD, a male and a female. Data concerning their sociodemographic information, clinical presentation, diagnostic variations, and therapeutic interventions collated. The varied presentations are analysed and thereby compared.

Results: The cases provide an array of varied clinical presentations between both the genders, thereby offering a better understanding into the psychopathology and the trajectories of management in the cases of BDD.

Conclusion: The case comparison points towards the differences in the age of onset, the varied clinical presentation and associated co-morbid psychiatric disorders like Depression, OCD, anorexia nervosa, social anxiety, personality disorders or others. It will also help design a better patient-centric treatment outline for Cognitive behavioural therapy and pharmacotherapy.

Caregiver burden in family members of patients undergoing hemodialysis

Presenting author : Dr. Priya Choudhary

Dr. B.S. Shekhawat , Dr. Mithlesh, Dr. Sandhya , Dr. Kishor, Dr. Rohitash

Government Medical College, Kota (Rajasthan)

INTRODUCTION

A population based study calculated the end stage renal disease incidence at 152 per million population. Most common cause of ESRD in India is diabetic kidney disease. First line of care for people with chronic illnesses including patients undergoing hemodialy-sis are the family members. Apart from their critical role in patient care their own physical and mental health may also be affected. Care burden is a negative experience resulting from provision of care and can cause financial, physical and mental distress Which can result in consequences such as lack of hope for social support, disorders in family relations and inadequate care of the patient and eventually the patient gives up the treatment. In most of the studies patients have been given more attention as compared to the caregivers. Therefore, this study is aimed to investigate the care burden in family caregivers of patients undergoing hemodialysis.

AIMS & OBJECTIVE

To explore the level of burden in the caregivers of patients undergoing haemodialysis.

MATERIAL & METHODS

This descriptive analytic study was carried out from Jan to June 2023 after approval from ethical committee. The population of this study consisted of all the caregivers of hemodialysis patients who were referred to GMC Kota. One caregiver was considered for each patient. Purposive sampling was done in a consecutive way.

INCLUSION CRITERIA FOR THE PATIENT:

• Patients who gave informed consent.

• Patients who passed at least 3 months from their onset of dialysis

• Patients who didn’t have any psychiatric and neurological disorder.

• Patient having no history of renal transplantation.

• Patient not currently being a candidate for the transplantation.

INCLUSION CRITERIA FOR THE CAREGIVERS:

• Main caregiver of the patient’s choice

• Caregiver should be one of the close relative of the patients (wife, daughter, son, mother, father, sister, brother)

• Caregiver having no known psychiatric and neurological disorders.

• Caregiver not providing any other chronic patient with care at home.

Table 1.

Frequency distribution of demographic characteristics of the patients and caregivers

EXCLUSION CRITERIA

Unwilling to participate in the study.

Giving care for another patient with chronic illness at home

TOOLS USED

Zarit care burden questionnaire to assess caregiver burden

Sociodemographic questionnaire

RESULTS

The mean score of the caregiver’s caring burden was 44.98±6.8 There was a reverse relationship between caring burden score and duration of the illness (p= 0.007, r=-0.17). There was no significant relationship between the care burden score and age of the caregivers (p=0.35, r=0.06) and income level of caregivers (p=0.07, r= - 0.12). There was no significant relationship between the care burden score and number of dialysis sessions. the mean score of care burden in working caregivers was significantly higher than non-working ones(p=0.03).

Variable	Participants	Patients n (%)	Mean±SD (Range)	Caregiver n (%)	Mean±SD (Range)
Sex	MALE	19 (38)		14 (28)
	FEMALE	31 (62)		36 (72)
Age (year)			54.30±12.87		48.19±12.80
Marital Status	Single	17 (34)		06 (12)
	Married	31 (62)		43 (86)
	Divorced	01 (02)		00 (00)
	Widow	01 (02)		01 (02)
Education	Elementary	26 (52)		22 (44)
	High school diploma	18 (36)		15 (30)
	Associate degree	04 (08)		05 (10)
	Bacheolar’s degree or	02 (04)		08 (16)
	higher
Employment	Employed	06 (12)		16 (32)
	Housekeeper			23 (46)
	Student			03 (06)
	Unemployed	44 (88)		01 (02)
	Retired	01 (2)		07 (14)
Months Elapsed Since Diagnosis			64.31± 42.88
No. of dialysis sessions per week			2.80±0.4

CONCLUSION

Family members experience moderate to severe level of care burden due to their role as a caregiver of patients undergoing hemodialysis. Middle aged women with low education and who are from lower socio-economic strata contributes to the majority of family caregivers. Care giving burden increases with an increase in the patient care duration and is higher in working caregivers compared to non-working ones. . Increased care burden can lead to decreased level of patient care which can affect the treatment outcome of hemodialysis patients.

REFERENCES

1. Joseph SJ, Bhandari SS, Dutta S, Khatri D, Upadhyay A. Assessing burden and its determinants in caregivers of chronic kidney disease patients undergoing haemodialysis. Open J Psychiatry Allied Sci. 2021 Jul-Dec;12(2):96-100. doi: 10.5958/2394-2061.2021.0001 7.3. Epub 2022 Apr 11. PMID: 35496347; PMCID: PMC9049166.

2. Pio TMT, Prihanto JB, Jahan Y, Hirose N, Kazawa K, Moriyama M. Assessing Burden, Anxiety, Depression, and Quality of Life among Caregivers of Hemodialysis Patients in Indonesia: A Cross-Sectional Study. Int J Environ Res Public Health. 2022 Apr 9;19(8):4544. doi: 10.3390/ijerph1908454 4. PMID: 35457412; PMCID: PMC9032362.

CONFLICT OF INTEREST

No conflict of interest.

Case report of obsessive compulsive disorder with rare compulsion of jumping.

Dr. Kokkalla Sai Sreeja, Dr. P. Kishan, Dr. P. Sai Krishna, Dr. N. D. Sanjay Kumar, Dr. R. Shiva Kumar

Background:

Obsessive-Compulsive Disorder is a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions.

Obsessions are intrusive and unwanted repetitive thoughts, ideas, images, urges, or impulses that often lead to a marked increase in anxiety or distress.

Compulsions are repetitive behaviors or mental acts that are done in response to obsessions, or in a rigid, rule-bound way and which relieve the distress caused by obsessions.

These recurrent obsessions or compulsions cause severe distress to the person. The obsessions or compulsions are time-consuming and interfere significantly with the person’s routine, occupational functioning, usual social activities, or relationships.

Here is a case of 36-year-old male patient who had sustained several fractures and malunion from past 5 years due to jumping had been referred by orthopaedic surgeon for behavioral assessment. On evaluation patient was diagnosed to be having OCD as per ICD-10. He had repetitive thought to jump in a peculiar way and sustained fracture of right lower limb bones. Detailed history is suggestive of symptoms from 5 years. This signifies the mean delay in psychiatric consultation and lack of awareness of OCD symptoms among other medical professionals. This case signifies the need of improving awareness among medical health professionals and general population to reduce morbidity.

Case report of unusual presentation of compulsive acts in a subject recovering from Major depression with catatonia

Dr. M. Apoorva, Dr. P. Kishan, Dr. P. Sai Krishna, Dr. N. D. Sanjay Kumar, Dr. R. Shiva Kumar

Background:

Catatonia is a state of increased tone in muscles at rest abolished by voluntary activities. Signs of catatonia include abnormal posturing, social withdrawal, mutism and muscular rigidity. Catatonia is commonly seen in mood disorders, schizophrenia and various medical conditions. Majority of the cases of catatonia associated with mental illness involve depressive disorder or bipolar disorder. Prevalence of catatonia in Indian psychiatry settings is 9.45% -10%. Compulsive acts are repetitive behaviours or mental acts that are done in response to obsessions, or in a rigid, rule-bound way. The majority of compulsive acts are concerned with cleaning (particularly hand-washing) and repeated checking.

A 35year old male patient diagnosed with Major depression with catatonia as per ICD-10 and on treatment from 9 months was brought by mother with complaints of repeated washing of hands, increased duration of bathing from 1 month. There are very few case reports of compulsive acts in a subject recovering from depression and on regular follow up. This case highlights such unusual presentation.

Catatonia with co-occurring organic and psychiatric etiology: A case report

Dr Dazelle S¹, Dr Subashree K², Dr Shivanand Kattimani³

Junior Resident, Psychiatry; 2 Senior Resident, Psychiatry, 3 Professor, Psychiatry, JIPMER, Puducherry;

INTRODUCTION

A 30-year-old married female with no known medical comorbidities, previously diagnosed with acute and transient psychotic disorder, and currently not on any medications, has been maintaining well for 3 years. She presented with complaints of headache, catatonic symptoms (BFCRS 25), grasp reflex, auditory hallucinations, disorganized behaviour and poor self-care.

AIMS & OBJECTIVES

To formulate a comprehensive management plan for a “difficult to treat case of catatonia” due to both organic and psychiatric etiology co-occurring.

MATERIALS & METHODS

Lorazepam challenge test was positive however there was no complete resolution of catatonic symptoms with Lorazepam 20mg, and a Non-Contrast CT imaging revealed a hypodense lesion in the watershed of the frontal region. Further evaluation revealed it to be a cerebral venous thrombosis (CVT).

RESULTS

The patient was treated with warfarin 5mg OD along with acute phase management with injection enoxaparin 60 mg twice daily S.C. dosing. The resolution of catatonia also brought to light the presence of psychotic symptoms, for which an optimized dose of tab olanzapine 15 mg was continued. While the contribution of each etiology to catatonia was evident, quantifying the proportion of each proved challenging.

CONCLUSION

The possibility of ECT was difficult as the chronicity of the organic condition could not be well established. Practical difficulties in conducting imaging studies for a severely catatonic patient were evident.

REFERENCES

Rogers JP, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2023 Apr;37(4):327-369. doi: 10.1177/02698811231158232.

CONFLICT OF INTEREST

None

Childhood Onset Catatonic Schizophrenia

INTRODUCTION:

Childhood-onset schizophrenia is rare: its prevalence is about 50 times lower than the one observed in adulthood. It is also frequently unrecognized, notably because its clinical aspect varies with age. Catatonia is a psychomotor syndrome which can include motor, mental, behavioral and vegetative symptoms.

CASE PRESENTATION:

A 13 year old female was brought with complaints of decreased interaction, maintaining odd posture, staring spells, standing spells and refusal to eat or drink for 3 months. Patient had a history of psychotic features in the past in the form of suspiciousness, muttering and gesturing to herself, feeling that people want ill of her for 1.5 years for which the patient was on antipsychotics with about 60% improvement in symptoms.

Patient was admitted to the psychiatry ward, where a medicine referral was sought and organicity was ruled out. Patient was treated with Tab Lorazepam (6mg) and Tab Aripiprazole(15mg). ECTs were considered for the patient, however were not administered due to dissent of the parents. The patient showed improvement on above medications and was discharged from the ward.

DISCUSSION:

Childhood onset schizophrenia (COS) and catatonia (C) are rare and severe psychiatric disorders. A number of environmental factors, including prenatal maternal infections and perinatal complications, may also be implicated in the pathogenesis of schizophrenia, in addition to genetic factors. The management of schizophrenia in children and adolescents should be based on a multimodal therapeutic plan, including drug therapy and individual psychotherapy, along with family, social and educational interventions.

Introduction

Clinical presentation in children and adolescents with major mental illness varies. This study was to understand the variation in presentation of clinical features in this area especially in Indian context.

Objectives

The objective of this study: To describe the clinical profile in children and adolescents with psychosis and mood disorders

Methodology

Cross-sectional study in tertiary care Centre. Children and adolescent meeting the inclusion criteria were assessed and interview was based on K-SADS (Kiddie- Schedule for Affective Disorders and Schizophrenia) questionnaire.

Results and discussion

This study included 38 subjects with 25(66%) in the depression, 7(18%) in mania, 6(16%) in Psychosis group. Mean age of presentation in depression group was 15.2 years. Mean duration of depressive episode was around 23 ± 8.6 weeks. Predominant symptom was irritability and low mood followed by sleep disturbances, rejection sensitivity, lack of reactivity to positive stimuli, worthlessness and then anhedonia and easy fatiguability. Rejection sensitivity and lack of reactivity was associated with suicidality. In mania group, predominant symptoms were elevated mood, irritability, decreased need for sleep, pressure of speech followed by agitation and distractibility.

Conclusion

This study shows variable presentation like sleep disturbances in various phases, suicidality and factors associated with it like rejection sensitivity. Lower levels of anhedonia and anergia. Strengths of this study was it had a cross sectional design and was based on standardised questionnaire. Limitations of this study is that its hospital based and predominant inpatient sample. Further studies with longitudinal designs are necessary.

Consecutive Koro and Cotard Syndromes in Patient with Chronic Psychotic Depression

Background

Koro is the belief that one’s own genitalia are shrinking or disappearing and death will ensue thereafter. Cotard syndrome is an uncommon psychiatric condition characterized by the appearance of nihilistic delusions concerning one’s own body or life, one of the consequences of which is self-starvation because of negation of existence of self. The authors report a case of a consecutive presentation of both syndromes in a patient with Chronic Psychotic Depression for 12 years with associated self-starvation.

Clinical case

A 58 years old married male patient, studied LLB, resident of Delhi, presented to our casualty with illness of duration 12 years having an insidious onset and continuous course. The symptoms at the time presentation were low mood, anhedonia, easy fatigability, ideas of worthlessness, helplessness, guilt and delusion of nihilism with the belief that his body had been gradually disintegrating over 12 years starting from his penis, with recent exacerbation of symptoms characterized additionally by ideas of hopelessness, suicidal ideation and attempt at starvation of self. Delusion of nihilism which had continued in the background of depressive mood contained Koro during the initial part of illness and consecutively progressed to Cotard syndrome.

Conclusion

Chronic depression with psychotic symptoms persisting for 12 years has never been described in literature. There is one case report which mentions concurrent Koro and Cotard syndrome. There is need of understanding of the etiology of both syndromes and their relationship with each other.

COVID 19 pandemic related perceived Stress, Insomnia, Depression and Anxiety Among Rural primary care Health Workers: A mediation analysis.

Introduction: Mental health of the healthcare workers is affected during COVID pandemic due to direct handling of suspected and confirmed cases. Neurobiological mechanisms that mediate stress and depression/anxiety are very well established but psychological mechanisms which for the same are not well established.

Aims: To assess the prevalence of anxiety, depression, insomnia and perceived stress among ASHA, MHPs, ANMs and other certified healthcare workers of rural areas of Telangana. Assess the factors that mediate stress with depression / anxiety Methods: 300 healthcare workers from across ten PHC’S across five districts were selected. All the participants self-reported their anxiety, depression, sleep problems and perceived stress related to the pandemic on the selected tools. Socio-demographic and other relevant data pertinent to the context of stress and pandemic were also taken.

Results: The mean score (SD) on Insomnia severity index, GAD-7, COVID -PSS and PHQ – 9 scale was 5.94 (5.6), 4.21 (4.5), 11.28 (6.9) and 3.89 (4.8) respectively. Age lower than 35 and family members being covid positive were significant predictors of depression and anxiety, respectively. Greater number of family members and covid positive status were significant predictors of insomnia. While the effect of stress on anxiety was indirect through the mediation of insomnia and depression, the effect of stress on depression was direct as well as through the mediation of anxiety.

Conclusion: The above results highlights the importance of measures to address sleep related issues in individuals who are going through psychosocial stressors so as to prevent development of depression / anxiety.

Crisis or Psychosis?: A case report illustrating the shared symptoms between impending sickle cell crisis and psychosis

Vasa, Jeel¹; Jyrwa, S²; Khushoo, V³; Gohad, D⁴; Jaiswal, SV⁵.

¹Junior Resident, ²Associate Professor, ⁴Senior Resident, ⁵Additional Professor, Department of Psychiatry, All India Institute of Medical Sciences Nagpur,

³Assistant Professor, Department of Medical Hematology, All India Institute of Medical Sciences Nagpur.

Background:

Anxiety and depression are well-documented comorbidities in patients with sickle cell disease (SCD), but acute psychosis as a complication in SCD is uncommon. Here we discuss the management of psychosis in a patient with SCD.

Aims & Objectives:

To study the relationship between psychosis and impending vaso-occlusive crisis. We advocate a holistic approach to the management of patients with SCD.

Method:

Mr VD, a 30-year individual, known case of SCD had low-grade fever of unknown origin and headache for 4 days, followed by withdrawn behaviour, thought insertion of sexual content, 3rd person running commentary-type auditory hallucinations with self-gesticulating behaviour. He was hospitalized under psychiatry for behavioural management. On admission, he was investigated for fever, started on T. Olanzapine 10 mg for behavioural management. On day 3, the patient developed breathlessness, panic attack, vague abdominal pain, and recurrence of low-grade fever. Further evaluation showed deranged LFTs, P pulmonale on ECG, repeated SpO2 fluctuations accompanied by an exacerbation of the psychotic symptoms. Thus, in view of suspected impending vaso-occlusive crisis, haematology consultation was sought and the patient was started on antibiotics with rigorous hydration and blood transfusion. Thereafter, there was significant resolution of the physical and psychiatric symptoms within 24 hours.

Result: The patient presenting with psychotic symptoms later diagnosed as having an impending vaso-occlusive crisis responded well to antibiotics with a blood transfusion which helped in diminishing the psychotic symptoms.

Discussion and Conclusion: The symptoms of impending vaso-occlusive crisis in sickle cell disease may be misdiagnosed as worsening of psychiatric symptoms and must be treated with caution and multidisciplinary approach.

Cross-sectional study on prevalence of psychiatric comorbidities and quality of life in patients with psoriasis in a tertiary healthcare centre in Goa

Background

Psoriasis is a chronic inflammatory disorder mainly affecting skin and joints and its clinical course is characterised by remissions and exacerbations. Psoriasis per se may not be a life-threatening disease, but the affected individuals have significantly impaired quality of life, which does not necessarily correspond with the severity of disease.

Aim

To estimate psychiatric comorbidities in patients with psoriasis vulgaris.

Methods

Patients with diagnosis of Psoriasis Vulgaris in Dermatology department of Goa Medical College, Bambolim, Goa was assessed cross sectionally with the help of MINI plus scale, WHO quality of life index, PASI Score and a Semi-structured questionnaire for sociodemographic and clinical correlates. Data collected was analysed for correlation between severity and psychiatric comorbidities in patients.

Results

Study result revealed an increased prevalence of psychiatric disorders in patients with psoriasis, adjustment disorder being the most common diagnosis made. There was no correlation found between the severity of psoriasis and prevalence of psychiatric disorders.

Conclusion

There is an elevated burden of psychiatric co-morbidity in psoriasis patients. We recommend that clinicians conduct universal screening of depression, anxiety, and suicidality among their psoriasis patients.

Deciphering the Enigma: Exploring nonspecific MRI patterns and their relationship with alteration in personality

Introduction

Personality changes attributed to medical conditions, such as those linked to white matter changes on MRI brain scans, present intriguing clinical challenges. Patient may display marked behavioral, cognitive, and emotional stability alterations. Research on such cases revealed significant white matter abnormalities, potentially implicating vascular disease or demyelinating disorders. These changes emphasized the need for early diagnosis and tailored interventions to mitigate their impact on individual’s life.

Case details

17-year-old male presented with complaints of behavioral disturbance in form of, easy irritability, scalding family members with hot spoon, beating family members with sticks, breaking objects. Such behaviour was sudden in onset and present since last 1-1.5 months. Patient was admitted. EEG suggestive of bilateral temporo-parietal epileptic changes and normal MRI. Patient was given Carbamazepine 600mg and Aripiprazole 7.5mg. Patient was well maintained on above treatment for 6 months after which he had reappearance of previous symptoms along with self harming behavior. EEG was repeated and found positive with MRI suggestive of nonspecific demyelinating changes of bilateral fronto-parietal region. Patient was diagnosed with personality changes due to another medical condition. Patient was started on Sodium Valproate 1000mg, Risperidone 4mg, Lithium 900 mg, Fluoxetine 20mg along with behaviour therapy. Patient is well maintained on subsequent follow-up.

Conclusion

This case highlights the challenging nature of diagnosing and managing complex behavior disturbances in adolescents, especially when associated with unusual EEG finding and MRI abnormalities. The successful long-term stabilization of the patient with a combination of medications emphasizes the value of an integrated approach in addressing such cases.

1.Dr. Aman Chaudhari

Second year resident Dept of Psychiatry, PDU Govt. medical college,

Rajkot, Gujarat.

2.Dr. Kalpesh Chandrani

Associate Professor, Dept of Psychiatry, PDU Govt. medical college,

Rajkot, Gujarat.

Delirium across various specialities: Record review of phenomenology and clinic-descriptive analysis

B A Ashima Azeez, Ankit Kumar, Jagriti Yadav, Purushottam Jangid

Department of Psychiatry, Institute of Mental Health, Pt. B D Sharma University of Health Science, Rohtak

Presenting Author- B A Ashima Azeez,ashimaazeez@gmail.com, Free Poster Presentation

Background: Delirium is understood as a complex neuropsychiatric syndrome that is characterized by disturbances in consciousness, orientation, memory, thought, perception, and behaviour due to one or more structural and/or physiological abnormalities. It is associated with significant morbidity if untreated. Aims: To evaluate the Phenomenology and clinical profile of Delirium among inpatients referred to Consultation Liaison Psychiatry (CLP) services in a tertiary care hospital setting. Methods: A Retrospective study was conducted in the CLP services, Department of psychiatry, PGIMS, Rohtak. CLP data was screened for patients with referral for Delirium from various specialities from 1/07/23-30/09/23. The data was then analysed for phenomenology and clinical profile of patients. Results: A total of 31 patients with diagnosis of delirium were referred to CLP services from various specialties during study period. The mean age for the study population was 48. There was a male preponderance (71%). Most of the referrals were from medicine department (35%) followed by surgery and orthopedics (25% each). The commonest presenting symptoms were disorientation (100%) followed by sleep-wake cycle disturbance (71 %), language abnormalities (58%), attention deficits (58%), psychomotor agitation (39%), and perceptual abnormalities (35%). Out of the total 31 participants, 48% presented with hyperactive delirium followed by mixed (29%) and hypoactive delirium (23%). Oral antipsychotics (38%) were most commonly used intervention followed by benzodiazepines (36%) and injectable antipsychotics (13%). Conclusion: As Delirium is a largely preventable and potentially treatable condition, clinicians at all levels need to be aware of its phenomenology and management.

Delirium, phenomenology, neuropsychiatric emergency, Antipsychotics

Abstract for Poster: Dhat syndrome in women; An often under-recognized entity

Dr. M.Ravichand¹, Dr. G.Sravani², Dr. N.N.Raju³

Post graduate, Department of Psychiatry, GVPIHC&MT¹ Assistant Professor, Department of Psychiatry, GVPIHC&MT²

HOD & Professor, Department of Psychiatry,GVPIHC&MT; Former President of Indian Psychiatri Society ³*Gayathri Vidya Parishad Institute of Health Care and Medical Technology

Background

Dhat syndrome is a well-recognized culture bound syndrome in India and described by Professor N.N.Wig in 1969 in males. However similar symptoms are also seen in females as described by a few authors(Chaturvedi S et al.,1988;Sandeep Grover et al.,2014) where patients attributed depressive and anxiety symptoms to vaginal discharge.

Case Summary

We present a patient who was referred from our Obstetrics and Gynecology department, in view of significant distress related to whitish vaginal discharge and was requesting for hysterectomy inspite of repeated reassurances after investigations. Patient had concerns related to loss of energy that she attributed to the discharge and worried about her health and her family if she lost her energy. She also had depressive symptoms was started on Tab. Escitalopram 10mg and counseled regarding menstrual cycle related changes. Patient was noted to have improvement in symptoms and did not have any further concerns during the subsequent follow ups.

Conclusion

We would to bring to attention to psychological aspects of these symptoms that are likely to be missed. Further such descriptions can help us to improve our understanding with relation to this entity and prevent aggressive interventions.

Author for correspondence:

Dr. M.Ravichand, PG in Psychiatry,

Gayatri Medical College, Visakhapatnam.

Mobile: 9849324032,

Mail: moodravichand@gmail.com

Diagnostic dilemma of a case of schizophrenia with trance and possession

Dr. Asmita Goswami, Dr. P. S. Patil

1.Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email- blue.asmita@gmail.com, Mobile- 9674284274

2.Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe

Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email-dr.p.s.patil2012@gmail.com, Mobile- 8999248979.

Presenting Author- Dr Asmita Goswami, Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra.

Email- blue.asmita@gmail.com

Mobile- 9674284274

Background

Possession states manifest in various different ways depending on the local culture and beliefs. It is characterized by a transient alteration in identity whereby one’s normal identity is temporarily replaced by a spirit, ghost, deity, or other person. The clinical challenge lies in differentiating it from psychosis and culturally sanctioned “possession” states. This case illustrates a similar situation where the clinical picture was complicated by the presence of dissociative symptom and psychotic symptoms together over a period of time. Emerging link between trauma and possession trance and because of its cultural bias it is currently being under-diagnosed and under-treated.

Case presentation

30yr, married female educated till class 12, currently a homemaker. Belonging to low socio-economic hindu extended nuclear family. Brought in to the hospital by her husband with the complaints of irritability, muttering to self, feeling of being controlled, abnormal body movements, occassional hearing of voices from within her body and delusion of reference over a period of 7yrs which is insidious in onset, episodic in nature and gradually progressive in course.

Conclusion

Even with the complete history of the patient, diagnosing psychotic disorder becomes difficult when it presents with dissociative symptoms. So it becomes a challenge for the treating psychiatrist in terms of pharmacotherapy and psychotherapy.

Divergent Psychiatric Diagnoses in Encephalomalacia: A Comparative Case Series of Two Patients with Focal Brain Lesions

Dr. Jugal Rathod, Jr. Resident

Dept. of Psychiatry

Parul Institute of Medical Sciences and Research, Vadodara, Gujarat.

Background:

Encephalomalacia, characterized by the softening or loss of brain tissue, is a rare condition associated with diverse clinical manifestations. This case series presents two unique cases of encephalomalacia-related psychiatric symptoms in adults, shedding light on the complex interplay between psychiatric and neurological pathologies.

Case Presentation:

Case 1: A 19-year-old female presented with auditory and visual hallucinations, persecutory delusions, and cognitive deficits. Neuroimaging revealed chronic ischemic infarcts and encephalomalacia in the left fronto-parietal lobe. She received a diagnosis of schizophrenia with concurrent neurological abnormalities and showed symptomatic improvement with antipsychotic medications.

Case 2: A 20-year-old male experienced recurrent unresponsive episodes triggered by stress. Neuroimaging revealed encephalomalacia in the basal ganglia and corpus callosum. Initially suspected as epileptic seizures, the final diagnosis was conversion disorder with coexisting neurological findings. Treatment included an SSRI and benzodiazepine, resulting in significant symptom improvement.

Discussion & Conclusion:

The study highlights the importance of neuroimaging when assessing psychiatric patients with neurological issues, aiding accurate diagnosis and treatment decisions. It underscores the need for individualized approaches addressing both psychiatric and neurological components.

Keywords:

Encephalomalacia, Schizophrenia, Conversion disorder, Adult

Electroconvulsive Therapy in a patient with Anti-NMDA Encephalitis with refractory Seizures.

Vinay Chauhan¹,Niteen Abhivant², Ivan Netto³, Shaunak Patel⁴,

Introduction

Anti-NMDA receptor encephalitis is autoimmune encephalitis presented with neuropsychiatric symptoms such as behavioural disturbances, apathy, insomnia, hyper sexuality, psychosis, eating disorders and seizures.

Case Details

A 22 year old male presented with the complaints of decreased sleep, irritability, assaultive, demanding behavior and increased appetite since a year. He was a known case of seizure disorder since childhood and had multiple episodes of seizures and abnormal behavior while on anti-epileptics and antipsychotics with poor response to treatment. MRI Brain findings showed encephalomalacia with gliosis in frontal and medial temporal lobe on left side. Antibodies assay was done and positive for CD8 cells.

He was treated as an indoor patient with Tab. Haloperidol 15mg/day Tab. Trihexyphenidyl 4 mg/day, Tab Valproate 800mg/day in divided doses.As the patient showed minimal improvement on above drugs he was given a course of 6 modified ECT’s. He showed marked improvement on above treatment and was discharged from the ward.

Conclusions

Patients of mental and behavioral disturbance with Anti-NMDA Encephalitis who show poor response to anti psychotic and anti epileptic combination may show marked improvement with a course of ECT’s.

Enhancing Resilience: Electroconvulsive Therapy As A Transformative Intervention In Somatic Symptom Disorder; A Case Report

Introduction

Somatic symptom disorder (SSD) is characterised by somatic symptoms that are very distressing, resulting in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms, without any apparent organic cause. The number of effective treatment modalities for SSD remain limited with no formal indication of ECT in SSD.

Case History

A 46 year old female, presented with complaints of, abdominal pain, headache, aching calves, knee pain, avoiding sunlight due to fear of skin allergy and rashes, since 9-10 months. She consulted multiple physicians and almost all the relevant investigations were done to rule out organicity, but none were conclusive. Even after reassurances from multiple physicians, patient had continuous distressing thoughts about her symptoms, followed-by repeatatively getting her investigations done. Patient was then referred to us, admitted and diagnosed as SSD, as per DSM-5. She was given adequate trials of psychotherapy and psychotropics for adequate period in optimal doses yet improved minimally, at the end of 4 months.

Later, as the last resort, she was planned for ECT, and after 3 ECTs in a week, patient reported significant improvement in all her complaints. The score on somatic symptom scale-8 reduced to 3 from 18.

Discussion

ECT may be an effective treatment option for severe and refractory SSD and clinicians may consider ECT in severe forms of somatoform disorder with socio-occupational impairment. There are few studies available which support the same notion and it requires more studies further to be established with conviction.

Exploring the Enigma- Neuropsychiatric Manifestations of Salmonella Encephalopathy : A rare case report

I Akhila1, Kumar Ajay2, Mishra Sucharita3

1Post Graduate Junior Resident, Department of Psychiatry, All India Institute of Medical Sciences, Raipur, E-mail : akhilaik333@gmail.com

2Associate Professor, Department of Psychiatry, All India Institute of Medical Sciences, Raipur, E-mail : ajaypgimer2016@gmail.com

3Senior Resident, Department of Psychiatry, All India Institute of Medical Sciences, Raipur,

E-mail : sucharitamishra8@gmail.com

Introduction

Enteric fever is a multi-systemic illness predominantly caused by Salmonella enteric serotype typhi . Although the initial symptoms are fever , chills, anorexia and loose stools/ constipation, it can occasionally present with atypical symptoms that can make the diagnosis difficult. We present the case of a 19 years old male, with culture- positive Salmonella typhi encephalopathy who presented with neuropsychiatric symptoms.

Case details

A 19 years old male patient with history of Salmonella encephalopathy with resolved MODS warranting ICU admission one month ago, presented with behavioural abnormalities, emotional lability, decreased and incoherent speech for one month, and decreased sleep and disruptive-aggressive behaviour for 10 days. He was given Tab Quetiapine 50 mg which was hiked till 600 mg, Tab Clonazepam 1 mg and Tab Naltrexone 50 mg. Frontal lobe function tests could be performed partially well by the patient. During the one month hospital stay, he improved mildly for the first two weeks, his speech amount increased from being aphasic one month ago to 1-2 sentences and frequency of aggressive outbursts decreased, however, symptoms like childish behaviour, irritability and labile mood lingered. MRI brain and EEG were done and were normal. A final diagnosis of post-encephalitic syndrome was made on discharge. On follow-up visits upto 3 months, the above-mentioned symptoms persisted without change.

Conclusion

Neuropsychiatric manifestations of Salmonella encephalopathy are rare and often under- diagnosed. This case explores the disease’s various manifestations in a young male and its progression, which can greatly advance our knowledge of the condition.

Keywords

Salmonella encephalopathy, neuropsychiatric

Conflict of interest

NIL

Fluoxetine-induced SVT: A Case Report

Puneet Khanna, Virendra Vikram Singh, Parveen

Armed Forces Medical Services

INTRODUCTION

• Fluoxetine causes small decrease in mean heart rate with no effect on QTc interval and is considered cardiac safe.

• There have been few isolated case reports of rare Supraventricular Tachycardia (SVT) associated with Fluoxetine.

• We present one such case of Fluoxetine-induced SVT.

CLINICAL CASE

• 35 year old male, a case of Moderate Depressive Episode on Cap Fluoxetine 40 mg/d (for last 2 weeks) presented to emergency department with complaint of sudden onset palpitations of around 1 hr duration.

• No associated chest pain, shortness of breath, nausea or sweating.

• No medical/surgical comorbidity.

• H/o RHD in 1st degree relative.

• Physical examination: Pulse-146 bpm, BP-126/82 mm HG, RR-20/min. Systemic exam: NAD.

• Cardiac monitor showed SVT at a rate of 146 bpm and it was confirmed on 12 lead ECG.

• 2D Echo: NAD

• 24 Hr Holter monitoring:

• Max HR-134 bpm, Min HR-44 bpm

• Managed with oral Diltiazem with which cardiac rhythm reverted to normal sinus pattern.

• Fluoxetine was stopped: no recurrence of SVT on follow-up.

DISCUSSION

• To the best of our knowledge, there are only 2 published case reports of Fluoxetine induced VT at therapeutic dosage (20 mg/d for 3 weeks): a 54-year-old woman who developed SVT (200 bpm) and a 74-year-old woman who developed Torsades de Pointes.^1,2

• Our case highlights the same in a healthy middle aged man.

CONCLUSION

Despite clear cardiac safety evidence of Fluoxetine, a subset of individuals may be prone to SVT and clinicians need to be vigilant of same.

REFERENCES & CONFLICT OF INTEREST

1. Gardner SF, Rutherford WF, Munger MA, et al: Drug induced SVT: A case report of fluoxetine. Ann Emerg Med 1991 ;20:194-197.

2. Appleby M, Mbewu A, Clarke B: Fluoxetine and ventricular torsade--ls there a link? Int J Cardio 11995;49:178-180.

Conflict of Interest: Nil

Folie A Famille - Presenting clinical presentation in Indian context -

¹Daljot, ²Shivangi Mehta

^1,2Department of Psychiatry, Government Medical College and Hospital, Sector-

32, Chandigarh

Aims and objectives: To present a case report of induced psychosis.

Background: Folie a famille or shared psychosis or induced delusional disorder refers to the production of delusional belief in an individual by virtue of ongoing and close contact with the affected individual referred to as the primary or inducer. The affected individuals may develop an altered understanding of reality as a result of shared delusion system.

While delusions are the defining characteristic of folie a famille, induced hallucinations provide another level of intricacy to shared psychosis. This intriguing phenomenon raises the possibility of impairment of sensory experiences in addition to cognitive ones.

Case Report: A 38-year-old female presented with an illness of 2.5 months duration, of acute onset and continuous progressive course characterized by paranoid delusions, delusion of love, delusion of reference, over-grooming, over-religiosity, isolation at home, increased psychomotor activity, auditory and visual hallucinations, and aggression with significant socio-occupational decline. She was diagnosed as a case of Paranoid Schizophrenia as per the ICD-10 criteria. From past few weeks, her 17-year-old daughter and 10-year-old son started sharing some of her paranoid delusions along with auditory, and visual hallucinations, depression and self-harm. The patient was started on antipsychotics and upon resolution of symptoms, symptoms of her children also resolved. This case presents the unique opportunity to discuss the scope of shared psychotic system in folie a famille.

Conclusion: Folie a famille is challenging to treat as separation of such patients is difficult at home and legally too.

Keyword: Folie a famille.

References:

1. Enoch D, Puri BK, Ball H. Uncommon psychiatric syndromes. Routledge; 2020 Nov 23.

2. Wehmeier PM, Barth N, Remschmidt H. Induced delusional disorder: A review of the concept and an unusual case of folie à famille. Psychopathology. 2003 Apr 11;36(1):37-45.

3. Ulzen TP, Carpentier R. The delusional parent: Family and multisystemic issues. The Canadian Journal of Psychiatry. 1997 Aug;42(6):617-22.

4. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. World Health Organization; 1992.

From compulsion to complication: Trichotillomania and Rapunzel syndrome-a case study

INTRODUCTION

Trichotillomania is a chronic, mental disease of impulse control, characterized by repetitive, compulsive, and self-induced hair pulling. Trichophagia is characterized by the compulsive habit of eating one’s hair. A trichobezoar is a mass or lump composed of hair that has accumulated in stomach and GI tract. Rapunzel syndrome is manifestation of trichobezoar that extends into small intestines.

CASE DETAIL

A 46-year-old female patient was admitted in surgery ward for complaints of abdominal pain, vomiting, weakness, decreased appetite and hair loss from scalp. CT abdomen and pelvis showed grossly distended stomach and duodenum with abrupt transition at duodenum jejunal junction. As per history given, she had complaints of pulling out of hair and eating of pulled hair since 5 to 6 years. After pulling of hair from scalp she had feeling of pleasure and relief from anxiety. She was unable to control Such behaviour despite insistence by relatives and significant hair loss. Patient was diagnosed Rapunzel syndrome (from surgery department) and trichotillomania (from our side). she was started treatment with cap fluoxetine (20mg/day) and tab clonazepam (0.75mg/day) and showed good response with above treatment in subsequent follow ups.

DISCUSSION

This case signifies the importance of early intervention and psychological support for individuals struggling with trichotillomania. By addressing the underlying mental health issues and providing therapeutic intervention we can prevent the progression of hair pulling behaviours and development of Rapunzel syndrome.

1.Dr SubhashKumar Chandera

Second year resident Dept of Psychiatry, PDU Govt. medical college,

Rajkot, Gujarat.

2.Dr. Kalpesh Chandrani

Associate Professor, Dept of Psychiatry, PDU Govt. medical college,

Rajkot, Gujarat.

From Restless to Restful - A case report on role of Ropinirole Vs Pramipexole in Restless Leg Syndrome (RLS).

INTRODUCTION

RLS is neurological disorder characterised by an irresistible urge to move the legs, often accompanied by uncomfortable sensation mostly occurring during rest. Ropinirole and Pramipexole are dopamine agonists used primarily in RLS. Ropinirole having highest affinity of D3 receptor, whereas Pramipexole is having more affinity for D2 receptor.

CASE HISTORY

A 55 years old male presented with complaints of crawling sensation in both lower limbs and restlessness which was worsened while asleep, especially during night time since last 5 years. After admission all relevant investigations were performed and diagnosis of Restless Leg Syndrome (RLS) was confirmed. Patient was well maintained on Sodium Valproate (2000), Clozapine (50), Propranolol (20), Diazepam (10) for his Bipolar disorder. Even after correction of iron profile he was not having improvement in crawling sensation. He was given Pramipexole (0.5) which was hiked up to 1 mg and continued for 3 months. With that he had only minimal improvement. So, he was again admitted and Pramipexole was switched to Ropinirole, starting with 0.5 mg and hiked up to 1 mg. After which he had marked improvement in crawling sensation and restlessness. Patient is currently well maintained on Sodium Valproate (2000), Clozapine (25), Eszopiclone (3) and ROPINIROLE (1) since > 6 months and working regularly.

DISCUSSION

Ropinirole showed better control in crawling sensation, restlessness and patient had better quality of sleep-in restless leg syndrome which was observed in above case. Which can be attributed to Ropinirole’s longer duration of action and high affinity for dopamine receptors.

Dr Miteshkumar Rajgor (First year resident)

Dr Gopi Gajera (Assistant Professor)

Dept. of Psychiatry, PDU Govt. Medical college, Rajkot, Gujarat.

Functional urological syndromes: A case report to highlight the necessity of a multidisciplinary approach for management.

Background: Functional urologic disorders are related to altered functioning of the lower urinary tract without structural abnormality. Investigations may reveal dysfunction, but the aetiology is unclear. There is a high comorbidity of psychological symptoms with these conditions with significant distress affecting quality of life.

Case discussion: We present the case of a 22-year-old young lady, referred to psychiatry with significant urologic and psychological complaints, in the absence of any structural abnormality in the lower urinary tract. She was referred for psychological interventions, with a provisional diagnosis of somatoform disorder. A further detailed urological evaluation revealed features of dysfunction in the filling phase and voiding phase. She was started on symptomatic management from urology. The detailed urologic evaluation provided more pharmacological and non-pharmacological options to address her specific urinary complaints. She continued psychiatric interventions which helped her in managing the anxiety related to her distressing symptoms.

Conclusion: The absence of structural causes may suggest an apparent psychological causation to urological symptoms. However, a comprehensive evaluation to identify functional urological syndromes provides further options for the management of specific distressing symptoms. The interface between urological and psychological symptoms in these disorders is complex where aetiologies are unclear, overlapping and possibly multifactorial. A holistic approach where urologists and psychiatrists collaborate to provide comprehensive care to the patient is essential for improving outcomes.

ADDRESS FOR CORRESPONDENCE :

DR.SHALINI.P

Post graduate registrar

Christian medical college ,vellore

PH:7904011388

shaluvjp@gmail.com

Gambling disorder in a patient with Intellectual Disability : A Case Report

Dr Avani Sharma, Dr Darshan S. , Dr. Lekanksh Shukla

Department of Psychiatry, NIMHANS, Bengaluru

Introduction

Although literature is limited ,there is a clear overlap between some of the common attributes experienced by people with intellectual disability and people who experience harm from gambling, creating concern that people with disability may be subject to the same risk of gambling harm but may not be aware of the risk or indeed supports available.

CASE

32 Y/ Male/ Mr S/ with externalizing traits with h/o ADS, TDS, CDS , presented to us with h/o gambling , onset at 16 y of age, dependence since age of 22 y, with Craving, loss of control, tolerance with significant monitory loss, interpersonal issues and impaired self esteem . On evaluation, patient was noticed to have deficits on cognitive assessment and was found to have minor physical anomaly, hence was evaluated for Intellectual disability and was diagnosed with mild intellectual disability.

Discussion

People with intellectual disability are engaging with gambling products in a similar way to the general community. A person with an intellectual disability may have difficulties with adaptive functioning, including conceptual processing, social skills, communication and independent decision-making potentially placing them at greater risk of gambling harm.

Hailing to a new life: success story of dialectical behaviour therapy in a case of BPD

Dr. Sunetra Adhikary¹,Dr. Kamala Deka²

1.Post Graduate Trainee. Department of Psychiatry, Jorhat Medical College and Hospital, Jorhat

2.Professor & Head of the Department, Department of Psychiatry, Jorhat

Medical College and Hospital, Jorhat

Mobile no: 9163562200, Email: mbbskpc.sha@gmail.com

Dialectical behaviour therapy (DBT) has been one of the most effective treatments for individuals with borderline personality disorder. The main struggle for BPD is emotional dysregulation, so treatment revolves around decreasing and managing emotional dysregulation. Here I am going to report a case of 20years 12^th passed, Hindu, unmarried female hailing from urban, upper middle class background who was brought to JMCH Psychiatry OPD by grandparents with complaints of repeated self-mutilating behaviour, suicidal attempts, emotional instability, multiple relationships and poor interpersonal relationship for past 9 years and feeling of aloofness for past 3 years, lack of interest to all activities and sleep disturbances with occasional cannabis and alcohol consumption. Significant traits of personality was resentfulness, impulsiveness and rigidness. She was slow to warm up child. General physical examination showed multiple self inflated cut injury over all limbs. MSE revealed dysphoric Mood and impulsivity. Diagnosis was made as borderline personality disorder with depression. All baseline investigations were within normal limits. She was initially on sodium valproate and Sertraline which was switched to lithium carbonate and clonazepam later. Psychosocial management consisted of psycho education,environment modification family counselling and group therapy. To control fluctuation, reduce self-mutilating behaviour, control impulsivity DBT was given. Our six months DBT consisted of four parts(weekly, psychotherapy and skills training, Emergency consultations, and supervision /consultation meeting). Individual psychotherapy and skills. Training sessions were conducted for 24 times for this patient. Overall after one year follow-up of completing DBT, her self injurious behaviour and frequency of suicidal ideation were no more. She started continuing her study and started a bakery. She has good cordial relation with her mother, stepfather and step sister and living a healthy happy lifestyle.

Hidden Struggles: Androgen Insensitivity Syndrome and mental health- a case report

INTRODUCTION:

Androgen Insensitivity Syndrome (AIS) is a rare genetic condition where body’s cells are unable to respond to androgens. This case explores a patient’s journey with AIS, who had developed comorbid depressive and panic disorder due to multiple psychological stressors regarding her illness.

CASE DESCRIPTION:

21-year-old woman, a monozygotic twin, sought help for a persistent one-year history of low mood, irritability, decreased concentration, frequent crying, enduring thoughts of death, and history of self-harm attempts twice. In the past month, she had experienced recurring panic attacks. She has diagnosed with Complete Androgen Insensitivity Syndrome (46 XY) and had not undergone menarche, causing feelings of isolation and sadness related to her condition. She had been on hormone replacement therapy for five years to address concerns about underdeveloped secondary sexual characteristics but had stopped taking her medication for the past month, largely due to feelings of hopelessness. Her depressive symptoms were exacerbated by peer comments about her appearance and challenging family dynamics. Following a comprehensive evaluation, she was started on Tab.Escitalopram, initially at 5mg HS, later increased to 10mg. Psychotherapy was introduced to address her understanding of the illness, promoting acceptance, and addressing family dynamics, leading to significant improvements in her overall well-being.

CONCLUSION:

A holistic approach, encompassing both physical and emotional aspects, is essential for the well-being of patients having complex medical condition. It also emphasizes the significance of providing support, empathy, and psychological intervention to help individuals with AIS cope with their unique circumstances and achieve a higher quality of life.

Dr.Manali Sau¹, Dr. Srinivasa Bhat U²

1-Junior Resident, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

2-Professor and Head of Department, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

INSTITUTE: K.S. Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru – 575018, Karnataka, India

E-MAIL ID: manali.sau@gmail.com

PHONE NUMBER: 9620737808

Impulsivity and Executive Functioning in Patients with Alcohol Dependence Syndrome - An Observational Study

Tanmay Agrawal1, Bikram Kumar Dutta1, Virendra Vikram Singh2

Armed Forces Medical Services

INTRODUCTION

• Alcohol dependence syndrome (ADS) is a biopsychosocial problem.

• Impulsivity (IM) and Executive Functionimg (EF) are important cognitive factors contributing to its development and maintenance.

• Understand the role of IM, EF and their associated with ADS and explore likely areas of intervention.

AIMS & OBJECTIVES

• Aim: To study impulsivity and executive functioning in patients of ADS.

• Objectives:

1. To evaluate IM

2. To evaluate EF

3. To compare IM and EF among age and gender matched controls.

MATERIALS & METHODS

• 80 patients of ADS and 80 controls.

• Consecutive sampling technique

• (SAD-Q)

• Barratt’s Impulsivity Scale(BIS-11)

• Wisconsin Card Sorting Test

• Trail Making A/B and VFT

• Bi-variate analyses was done using the Chi square test and independent t-test.

• SPSS v21 IBM

RESULTS

Statistically significant differences in IM and EF b/w patients of ADS and controls.

CONCLUSION

• Patients with ADS have difficulty in IM and EF as per the tests conducted in this study.

• During interventions for patients with ADS, measures of cognitive remediation should be taken as a part of the treatment program.

REFERENCES

• Roberts, A.C., Robbins, T.W., & Weiskrantz, L. (1998). The prefrontal cortex: Executive and cognitive functions. New York: Oxford University Press

• Hoffman P L, Tabakoff T. Alcohol dependence: a commentary on mechanisms. Alcohol & alcoholism . 1996; 4: 333-340.

CONFLICT OF INTEREST

NONE.

Incubus phenomenon: A Case Report on Sexual Hypnogogic Hallucination with Sleep Paralysis

Presenter-Dr Arpita Laha, JR-2,MD Psychiatry,NRS-MCH Background

Incubus in Latin means night hag or night mare, taken from the verb ‘incubare’ once referred to a minor demon or fallen angel who in guise of a man positioned itself on top of a sleeping woman to aggressively/sexually harass them.

In contemporary world it is conceptualized as a paroxysmal REM related sleep disorder characterized by sleep paralysis associated with compound hallucinations, stereotypical presentation being a metaphysical being/creature positioning itself on thorax, exerting pressure and carrying out aggressive and/or sexual acts.

Case summary

A 19 years old hindu college going girl presented to the Psychiatry OPD with chief complaints of being sexually assaulted by a demon(shadow) after 5-10 minutes of falling asleep for past 2 years. During this time she felt a sensation of being choked and could not move her body parts.The frequency increased from 4 times a month to 2 times a week and was so distressing that she avoided evening naps completely.Her blood investigations revealed no abnormality,MRI BRAIN,EEG ,USG W/A and Polysomnography was done.

Result

Subject was treated with Imipramine and showed marked response.

Conclusion

Although incubus phenomenon was never included in DSM V TR and ICD11, it is a distressing and serious phenomena hampering functioning of individual.It is often misdiagnosed as Schizophrenia,so awareness is very important.

Internalised Stigma among Male Government employees with Alcohol Use Disorder.

BACKGROUND

People with alcohol use disorders (AUD) face more stigma when compared to other mental disorders. There are no studies from India about the internalised stigma among the government employees with AUD .

AIMS: To estimate the extent of internalised stigma among male government employees suffering from AUD and to compare the occurrence of relapses and depressive symptoms between patients of alcohol dependence syndrome having internalised stigma versus patients with no or minimal internalised stigma.

METHODS:

A cross sectional survey among 57 male in patients from a large government organisation admitted with AUD for de-addiction and follow ups in a psychiatric centre of the same organisation. Persons with comorbid severe mental illnesses were excluded. Informed consent obtained and discussion about the stigma prior to administration of hindi version of internalised stigma of mental illness scale (ISMI). Mean scores above 2.5 in sub domains or total score were considered to be positive for stigma . Levels of internalised stigma was based on mean score of ISMI: 2-2.5 low, 2.5 -3 moderate, and 3 and above high stigma. Patients scoring 10 and above in PHQ 9 hindi version were considered to have depressive symptomatology.

RESULTS: The number of AUD patients reporting high,moderate, and low internalised stigma were 3 (5%), 6 (11%) and 33 ( 58%) respectively. We did not find an increased number of relapses among the persons reporting high internalised stigma versus the people with lesser mean scores in each of 5 sub domains of ISMI (Alienation, Stereotype endorsement, perceived discrimination, social withdrawal and stigma resistance). We found increased symptoms of depression among those who scored above the cut off value of 2.5 in ISMI inventory ( Chi Sq 8.9194, p = 0.002).

CONCLUSION: The extent of moderate to high internalised stigma was 16% in our sample. These patients had increased depressive scores but no increased relapses.

Abstract for e-Poster: Ketamine: A Paradigm shift in the management of depression- A case series

Background: Major depression affects about 350 million people, making it the leading cause of disability worldwide. Most of the treatments available today have a long onset of action, usually 3–4 weeks. Shortcomings in the effectiveness of antidepressant treatments probably contribute to the enormous public health burden of depression. Despite the recent progress in the field of understanding and management of depression, improvement is too slow among eventual responders. Hence, there is an indisputable need for rapidly acting antidepressants, with ketamine being a key candidate. The usual mode of administration of ketamine is intravenous, however oral route has also been described in the literature. Oral ketamine is particularly appealing for its ease of use with the potential for high accessibility and lack of adverse effects associated with its iv counterpart.

Aim: To study the effect of ketamine administered in an oral form on depressive symptoms

Method: A total of 05 cases of Depressive episode were taken in this case series. The patients were diagnosed using the ICD11 diagnostic criteria. All those who continued to be non-responders to treatment or who required an immediate resolution of depressive symptoms were taken in this study. The ketamine was administered to the patients in an oral form which was prepared by mixing the intravenous form of ketamine available in 300 mL of juice. The dose for each patient was titrated based on individual response and adverse effects reported. The depressive symptoms were quantified using the Beck’s Depression Inventory (BDI) and Hamilton Depression Rating Scale (HDRS), administered before and after ketamine administration.

Results: The dose of ketamine ranged from 1.5-2 mg/kg administered over 45 min. The sessions required by each patient ranged from 2-6 sessions over a total duration of 2-4 weeks. All patients demonstrated a significant reduction in the BDI and HDRS score on Day 2 of ketamine administration. However, this was a noted to be a transient effect.

Conclusion: This case series highlights the pivotal role of oral ketamine in the management of depressive episode leading to a quick however transient resolution of depressive symptoms.

Levetiracetam induced behavioural disturbances : A case series

Dr Mariya M J, Dr Priya Sreedaran, Dr Sachin N

Introduction :

Levetiracetam is an antiepileptic drug used to treat partial, myoclonic, and tonic-clonic seizures. Levetiracetam is known for its psychiatric adverse effects in 13.3% adults. Most common behavioural symptoms associated with Levetiracetam include agitation, emotional lability, anger, depression, nervousness and depersonalization. The cause of these behavioural disturbances is still unknown. There have been case reports on Levetiracetam induced Mania in patients with no past history or family history of psychiatric illnesses and no steroid use, with striking temporal correlation.

We present case series of 3 patients who presented to us in OPD with behavioural disturbances mainly aggression, irritability in 2 patients and 1 patient presented with mania symptoms within a month of starting Levetiracetam. All had history of seizures and post seizures Levetiracetam was started and 2 patients were on 1000mg and 1500mg.

Naranjo score was 11 in first 2 cases and 9 in 3rd case. No past or family history of psychiatry illness in family. Patients were treated with low doses of antipsychotics and changing one to another AEDs resulted in symptomatic remission.

Conclusion:

Rapid titration of the drug, pre-existing psychiatric or neurological illness such as epilepsy, female gender, learning disability have been addressed as possible risk factors. In patients with Bipolar affective disorder, Levetiracetam has shown to produce manic or hypomanic symptoms.

Early identification and necessary modifications in AEDs when symptoms appear will help to improve quality of life of patient. Psychiatrists and neurologists need to be aware about the possibility of Levetiracetam induced behavioural disturbances.

Looking at euthanasia from a psychiatric lens: a critical review and synthesis of internationally published literature in the context of psychiatric disorders

Sarthak Kukreja¹, Ajith Aditya¹, Raman Deep²

1.Junior Resident, Department of Psychiatry, AIIMS New Delhi

2.Professor, Department of Psychiatry, AIIMS New Delhi

Background:

Euthanasia is a complex issue that encompasses various arguments involving ethical, medical, and legal aspects. This controversy has led to the creation of strict guidelines and mandatory mental health assessments for euthanasia and assisted suicide (EAS).

Aims: We aimed to review the published indexed literature with a focus on articles that report published data or commentaries pertaining to euthanasia in context of individuals with psychiatric disorders

Methods:

A synthesis of the relevant medline/pubmed literature, using relevant search terms, inclusive of research studies, reports and commentaries on euthanasia in psychiatrically-ill patients from countries where euthanasia has been legalized.

Results:

The discourse on euthanasia is dynamic and ever evolving. Psychiatric training reinforces the concept of suicide prevention in psychiatrically ill patients, that conflicts with issues about assisted suicide. In review of quality studies, significant proportion requesting as well as completing EAS had depressive symptoms, that correlated significantly with desire for euthanasia. Literature indicates increase in desire for life-sustaining medical therapies following treatment of depression. In countries with legalized EAS, the criteria has gradually expanded to include cases such as dementia and psychiatric disorders, and age group has now included minors in some countries. Deaths where euthanasia was approved on the basis of mental illness or dementia have risen over a decade. There are concerns pertaining to coercion, burden or economic arguments, especially in individuals with mental ill-health.

Conclusion: Policy and procedural issues surrounding euthanasia and assisted suicide in context of psychiatric disorders poses major challenges, even in countries where such practices are long-sanctioned.

Euthanasia, physician-assisted suicide, mental disorders, psychiatry

Mortality in Alcohol dependence patients

Aim: To determine the burden and causes of mortality among alcohol dependence patients

Background: Alcohol consumption has escalated rapidly in many countries over the past decade. Mortality from all causes increased with heavier drinking, particularly among adults under age 60 with lower risk of cardiovascular disease. [¹]

Methods: The consent from families of the deceased was taken for the study. The deceased who fulfilled the ICD -10 criteria of Alcohol dependence syndrome were taken for the study.

Results: The study showed the burden of mortality in patients with alcohol dependence syndrome especially in patients with longer duration of use, associated physical comorbidities and also comorbid psychiatric illnesses.

Discussion: Mortality in alcohol dependence patients is associated with comorbid physical illnesses, psychiatric illnesses and longer duration of use.

References: Thun, M. J., Peto, R., Lopez, A. D., Monaco, J. H., Henley, S. J., Heath, C. W., Jr, & Doll, R. (1997). Alcohol consumption and mortality among middle-aged and elderly U.S. adults. The New England journal of medicine, 337(24), 1705–1714. https://doi.org/10.1056/NEJM199712113372401

Introduction

Multiple sclerosis is an immune mediated inflammatory disease that attack myelinated axons in central nervous system whereas migraine is characterized as recurrent attacks or episodes of headache accompanied by gastrointestinal symptoms such as nausea or vomiting and hyperesthesia manifested by photophobia or phonophobia and headache generally has pulsatile quality.Headache has been reported as subtle symptom of the onset of multiple sclerosis .

Here we have discussed a case

Case: A 25 year female presented to opd with complaints of severe right side frontal throbbing headache accompanied by nausea, phonophobia and blurring of vision and which aggrevated by walking or climbing stairs .All these symptoms were present since 11 months .Patient was diagnosed as migraine without aura and was started on prophylactic treatment with SNRI ,beta blocker and 5-HT 1B/1D agonist but patient showed poor response even after 1 month on this medication.Patient also complained about fatiguability ,low mood and blurring of vision and apathy.MRI was done to rule out organic cause and findings suggestive of demyelinating lesions were found and patient was refered to neurology and diagnosis of multiple sclerosis was made.

Conclusion:

Here we discussed a case which presented with symptoms of migraine without aura but on MRI confluent T2/flair hyperintense foci in left parietal periventicular white matter and subcentimetric discrete T2/flair hyperintense foci in deep and periventicular white matterof bilateral fronto parietal and right temporal lobes were found suggestive of multiple sclerosis.This type of case has never been discussed before.

Navigating Early-Onset Schizophrenia: A Comprehensive Case Analysis

INTRODUCTION:

Schizophrenia is a challenging mental disorder, especially when it manifests early in life. Early-onset variants necessitate specialized care due to their varied presentation and unique challenges.

CASE REPORT:

A 20-year-old male from an urban Hindu middle-class background began exhibiting troubling behaviors at 13. These included social isolation, cognitive dulling, apathy, and episodes of intense anger leading to self-harm. Over time, he displayed repetitive behaviors like excessive hand-washing and continuous adjustments of his attire. However, what stood out were his beliefs: he felt an asymmetry in his body, with one side appearing lower and heavier, and the distressing notion that his nasal and penile orifices were closing. Communication with him was challenging due to his repetitive, low-toned speech & hesitancy. To overcome this, clinicians relied on written reports and his own pictorial representations to understand his complaints. A regimen of Olanzapine, Fluoxetine, Clonazepam, injectable Lorazepam, and other antipsychotics brought about marked improvement, especially in his speech and interpersonal interactions. But some issues persisted, like inner uneasiness. Post-treatment, he unfortunately became unreachable for follow-ups.

DISCUSSION:

This case highlights the intricacies surrounding early-onset schizophrenia. The varied symptoms, from obsessive behaviors to deeply-rooted false beliefs and bodily sensations, highlight the importance of a holistic and tailored treatment approach. The unique communication challenges encountered emphasize the role of alternative communication methods in formulating the diagnosis, monitoring & treatment.

CONCLUSION:

Diligent observation, adaptive communication, and individualized treatment are crucial in managing early-onset schizophrenia, ensuring better patient recovery.

Neuroacanthocytosis: compulsive self-harm; A case report

Background: Chorea-acanthocytosis belongs to the Neuroacanthocytosis syndromes, exceptionally rare, with onset usually between third and fifth decade, commonly presenting with limb and orobuccal chorea. Other neurologic features may include seizures, dystonia, parkinsonism and oculomotor impairment. It appears to present with higher rates of neuropsychiatric complications like dysexecutive syndromes, obsessive compulsive disorder, depression, psychosis and cognitive impairment of varying intensity. Symptomatic management of which significantly reduces the burden of illness for patients and caregivers.

Case: A thirty-five-year-old woman presented to our out-patient department with primary complaint of involuntary lip, buccal mucosa and tongue biting, associated with some anxiety symptoms. She was already diagnosed with Neuroacanthocytosis by neurophysician. Patient was treated with tablet fluvoxamine, atypical antipsychotics (tablet clozapine and blonanserin) and low dose anxiolytic. Patient showed marked improvement in compulsive lip biting and associated anxiety symptoms, and is currently well maintained with treatment.

Neuro-Psychiatry Interface: A rare case series on psychiatric comorbidities in neurological patients attending Neuro-Psychiatry Clinic from India

Dr Raj Yalgi- Primary Presenter, PG Resident, Department of Psychiatry, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India 410209

Dr Darpan Kaur- PG Guide, Professor of Psychiatry, Neuro-Psychiatry Clinic In Charge, Department of Psychiatry, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India 410209

Dr Rakesh Ghildiyal, Professor and HOD, Department of Psychiatry, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India 410209

Introduction: Neuro-Psychiatry is a fascinating interface arena. There is sparse literature on Neuro-Psychiatry interface from developing countries such as India. We report a rare case series of psychiatric comorbidities in neurological patients attending Neuro-Psychiatry Clinic at a Tertiary Medical College and Hospital in India.

Aims and Objectives: To report interesting case series of psychiatric comorbidities in neurological patients attending Neuro-Psychiatry Clinic.

Methods: Case Series.

Case 1, 9 year old male with Antigliadin IgG Gliadinopathy was diagnosed with Post Encephalitic Sequelae with ASD and ADHD features with EEG abnormality and started on T Risperidone 1 mg. Case 2, 63 year old with watershed infarct was diagnosed with Major Depressive Disorder with Psychosis and started on C Fluoxetine 20 mg and T Olanzapine 5 mg. Case 3 , 34 year old male with pituitary Microadenoma, and hypothyroidism was diagnosed with Mixed Anxiety Depression and started on T Sertraline 50 mg and T Clonazepam 0.25mg. Case 4, 34 year old male with diplegic CP with congenital hydrocephalus was diagnosed with Intellectual Disability and Self Injurious Behaviour and advised T Risperidone 1 mg. Case 5, male with Tuberculoma was diagnosed with Major Depression and advised T Escitalopram 10 mg. Further dosage titration, relevant Neuropsychological Testing and inter disciplinary therapy and rehabilitation was advised and the patients clinically responded well.

Conclusion: We conclude that psychiatric comorbidities can exist in patients with rare neurological conditions. There is need for further research, awareness, training, service development and multidisciplinary care approaches in Neuro-Psychiatry.

PRESENTATION TYPE: POSTER PRESENTATION: OBSESSED WITH DIAGNOSIS, DELUDED BY CRITERIA

PRESENTERS:

1.Dr Snigdha Awasthi, Fellow In Child And Adolescent Mental Health, Department of Psychiatry, TNMC & BYL Nair Hospital, Mumbai

2.Dr Prajakta Patkar, Assistant Professor, Department of Psychiatry, TNMC & BYL Nair Hospital, Mumbai

3.Dr Henal R Shah, Professor (Addl.), Department of Psychiatry, TNMC & BYL Nair Hospital, Mumbai

BACKGROUND: In the pediatric population, obsessive-compulsive symptoms often go unnoticed as ritualized behaviours are often a part of the normal development of the child. Other times, the presentation overlaps with other disorders, such as autism and early-onset psychosis.

AIMS & METHODS: This case series aims to present five cases of obsessive-compulsive disorder (OCD) in children and adolescents and the difficulties in differentiating it from other diagnoses, particularly psychosis.

RESULT: Over the years, obsessive-compulsive symptoms have been reported as a manifestation of over-valued ideas lying on a continuum of obsessional doubts to delusional certainty. This suggests a common underlying mechanism related to a decreased capacity to inhibit behaviors or thoughts. While the Diagnostic and Statistical Manual-5 (DSM-5) now recognizes that insight in OCD lies on a spectrum, ranging from good insight to absent/delusional insight, in an actual clinical scenario, it often becomes difficult to differentiate, especially in the pediatric population. Moreover, in 10% of pediatric cases, OCD may often represent a prodrome of a psychotic disorder. It, therefore, becomes imperative for clinicians to keep an open mind in this population and be mindful of the fact that it’s difficult to categorize patients into OCD or psychosis and that both are part of a continuum and may vary with the child’s cognitive development in particular.

CONCLUSION: OCD in children and adolescents is often a difficult diagnosis due to its overlapping nature with other disorders of pediatric population and requires due vigilance and longitudinal observation of cases in clinical practice.

abstract

Dr Abdul raheman, Post Graduate Resident, Mandya Institute of Medical Sciences, Mandya ——————————————————————

Olfactory reference syndrome, a case report.

Background:

Olfactory Reference Syndrome (ORS) is a condition in which individuals believe that they emit an unpleasant, foul, body odour. Odours include anything foul-smelling and originate from the genitals, rectum, or skin.

Case:

A 20-year-old male student with well-adjusted premorbidly, with no significant past or family history, presented with a three-year duration of illness characterized by a firm belief that a foul-smelling odour emanated from his bowel, like that of dirty socks, which gradually progressed to being present almost always, particularly in his classroom. He attributed this smell to his masturbatory practices which he began practising since 16 years of age. He noticed classmates shifting their eyes away, touching their nose, clearing their throat and moving away from him. Hence, he sat in the back seats and refused to attend social affairs and showed a decline in academic performance.

On MSE, affectively, he was apprehensive and preoccupied with his foul odour, with ideas of reference. He did not reveal other hallucinations or show formal thought disorders, with intact judgement and grade 3 insight.

Diagnosis of Olfactory reference syndrome was made according to DSM V and responded well with Escitalopram 20 mg and Resperidone 4 mg. Currently, patient is on regular follow up.

Conclusion:

When the presence of ORS is suspected, physicians should screen the patient for symptoms of ORS; refer to a mental health provider for additional assessment and treatment.

“One thing leads to another”- A complex interplay between obsessive compulsive disorder and multiple substance use in dependence pattern: a case report

Shivam Gakkhar¹

1-Post Doctoral Fellow, Centre for Addiction Medicine, NIMHANS, Bengaluru

BACKGROUND

Co-morbidity in OCD is a rule rather than exception. Mood disorders, anxiety disorders and neurodevelopmental disorders are common with OCD. Little is known about co-morbidity of substance use disorders (SUD) in OCD.

AIMS

To describe about a case of OCD who later developed stimulant and opioid dependence and how the obsessions determined the pattern of substance use and vice versa.

METHODS

Mr N, 50-year-old male developed obsessions about contamination and “just right” phenomenon with compulsions at 17 years of age. At 22 years, he started “chasing” heroin. Subsequently, due to constipation, patient felt better as he would not have to go to washroom and time spent in compulsions became negligible. At 24 years, he tried “crack cocaine” to help with his low mood. By 25 years, he started using both substances in dependence pattern. At 35 years, patient underwent haemorrhoidectomy due to prolonged constipation. At age of 40 and 42 years, patient had myocardial infarction following overdose of crack cocaine due to “just right” nature of his obsessions as he bought equal quantities from all dealers he knew and consumed all at once.

RESULTS

Current pattern involves crack use to alleviate anxiety symptoms, which is followed by heroin use to counter crack withdrawal and to get sleep along with constipation. Subsequent opioid withdrawal resulting in dysphoric mood and diarrhoea worsens the obsessions and anxiety and the whole cycle repeats.

CONCLUSION

SUD in context of OCD can be life threatening and requires multi-pronged approach for management, preferably in hospital setting.

Organic mood disorder post cerebellar tumor excision

Dr Imyarila Longkumer¹, Dr. Pradeep Patil²

1.Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email- imyarila@gmail.com, Mobile- 7005195402.

2.Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra. Email- dr.p.s.patil2012@gmail.com, Mobile- 8999248979.

Presenting Author- Dr Imyarila Longkumer, Junior Resident, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Sawangi Meghe, Wardha, Maharashtra.

Email- imyarila@gmail.com

Mobile- 7005195402.

Background: Organic mood disorders are those that exhibit changes in mood resulting from an established neurological or other medical ailment. The areas responsible for mood and behavioural changes are temporolimbic, subcortical brain stem and frontal lobe. But beyond its role in motor coordination, the cerebellum is also increasingly understood to have a role in regulation of emotions.

Case presentation:

We report a case of a 28 year old male diagnosed with organic mood disorder with Koro like symptoms post cerebellar tumour excision, presented in the emergency room with relapsed depressive symptoms for the last 7 months and agitation for 2 days. He was admitted and continued with the same medication he was on i.e., Amitriptyline 75mg/day, Olanzapine 10mg/day both of which was tapered and stopped and Escitalopram 20mg/day. He was started on Quetiapine 75mg and Sodium Valproate 400mg/day. On neurological examination- he was observed to having titubation, ataxic gait, scanning speech with positive cerebellar signs. On Mental status examination he was conscious, increased psychomotor activity, irritable mood and with suicidal ideations.

Conclusion:

Organic mood disorder is challenging in terms of the treatment and more so when the illness affects the biopsychosocial aspect of life. Disability secondary to it also hinders in it’s management. Counselling of the patient and family apart from pharmacotherapy is a must.

BLDE (DU)’S SHRI B.M. PATIL MEDICAL COLLEGE HOSPITAL AND RESEARCH CENTRE

Panic attack associated with urticarial rash: a rare case report

Introduction: According to ICD-11, panic attacks are discrete episodes of intense fear or apprehension accompanied by the rapid and concurrent onset of several characteristic symptoms e.g. palpitations or increased heart rate, sweating, trembling, shortness of breath, chest pain, dizziness or light-headedness, chills, hot flushes, fear of imminent death. Panic attack causing urticarial rash is very rare or not even reported.

Case report: Patient is a 32-year-old male who came to psychiatry OPD referred by dermatologist with a rash that was not resolving with medication. During interview it was found out that rash occurred after patient had a feeling of intense fearfulness associated with palpitations, sweating and simultaneous appearance of itchy, red coloured, raised rash over neck, and arms, which stayed for some time and disappeared gradually. This used to occur one or twice in a week and was happening for 2-3 years whenever patient had these feelings of fear-fullness. Patient reported that whenever he had anxiety, he would get rash but dermatologist inferred that the rash was causing him anxiety so it took long time to take psychiatry consultation. The patient is not a known case of Diabetes, hypertension or any other physical comorbidities. Routine investigations were within normal limits. Patient was started on Anti-anxiety drugs (SSRI). Patient followed up after 1 month and reported that both urticarial rash and anxiety symptoms have come down.

Conclusion: The response of both the urticaria and panic disorder to selective serotonin reuptake inhibitor antidepressants may suggest a common pathogenic factor involving serotoninergic mechanisms.

PEDUNCULAR HALLUCINOSIS

Dr Swavab Jr- Psychiatry ,GOVT. MEDICAL COLLEGE KOZHIKODE

INTRODUCTION

Peduncular hallucinosis (PH) is a rare form of visual hallucination often described as vivid, colorful visions of people and animals. Mostly cases reported with lesions in the thalamus and/or midbrain

In 1922, the French neurologist Jean Lhermitte documented PH of localized damage to the midbrain and pons. Hallucinations were naturalistic, complex, scenic, mostly visual, . Patients experienced their hallucinations as genuine and were unable to discriminate their percepts from reality

DISCUSSION

Visual hallucinations can be associated with those with migraines, epilepsy, and neurodegenerative diseases, delerium,substance use disorders etc. Peduncular hallucinosis is an important but uncommon cause of hallucinations. It is usually caused by an ischemic lesion or a mass. Usually the lesion is identified in the thalamus or the mesencephalon,midbrain or cerebral peduncles, hence the name, there is no definite consensus on the underlying etiology of peduncular hallucinosis

So it is important to note that in chronic infarction also in the focus of lesion emerged with late onset PH

HISTORY

55 year old male with acute onset of sleep disturbances 1week duration , fear and suspiciousness irritability, and visual hallucinations patient described visions of animals and people that are vivid more evident during dark, as well as miniature in nature. In between he was aware that they were not real. Visions occurred both in daylight and at night also but more during night time With past history of cerebro vascular accident, congenital ptosis right side, coronary artery disease , Nicotine dependence syndrome now in remission Hypertension and recently detected Diabetes mellitus,

CONCLUSION

New onset hallucinations in a patient with no prior psychiatric history presenting with concerns for stroke should prompt neurologists to strongly consider peduncular hallucinosis.

So in cases of probable brain stem/peduncular or thalamic strokes, therapist must enquire about visual hallucinations with the patient as it may be the presenting symptom in those scenarios Also patient may not need long term psychotrops as symptoms improved with low dose therapy for shorter period only

EXAMINATION

On general physical examination Vitals stable Bilateral mild pedal Oedema present

When he arrived at the OPD ,no focal neurological deficits

On mental status examination mood being anxious and visual hallucinations are present

Cognitive functions are within normal limits On investigation-MRI Brain study shows-Chronic infarcts involving right hemipons and right half of upper midbrain with peduncle involved

MRA advised from radiology for possible intervention if any, neurology opinion sought and started on medication, From our end started low dose risperidone 1mg and improved within 3weeks

Contact

REFERENCES

1. Davidson’s principles and practice of medicine,

2. Benke, T. Peduncular hallucinosis. J Neurol 253, 1561–1571 (2006)

3. Talih FR. Innov Clin Neurosci. 2013 May;10(5-6):28-31. PMID: 23882438;

Email: dr.swavab@gmail.com

ABSTRACT FOR E-POSTER: Positive Mental Health Clinic in a Medical University: Our Experience

Dr Nisha A George¹, Dr (Brig)P S Bhat (Retd)², Dr Anil Korade³, Dr Anuraag Aedma⁴, Suhas Jamale⁵

¹Junior Resident

²Professor & HOD

³Associate Professor

⁴Assistant Professor

⁵Clinical Psychologist

Presenting Autor: Dr Nisha Anna George

Junior Resident

Dept of Psychiatry

Rural Medical College, Loni, Maharashtra-413736

Contact details: Dr Nisha Anna George

Mobile: 7045915217

Email: drnishag12@gmail.com

Conflict of Interest: Nil

Words: 243

Positive Mental Health Clinic in a Medical University: Our Experience

Dr Nisha A George, Dr (Brig)P S Bhat (Retd), Dr Anil Korade , Dr Anuraag Aedma, Suhas Jamale

Background:

The stress of medical education is very well known leading to higher mental health morbidity among students. They are prone to anxiety, depressive disorders, high levels of psychological distress negatively impacting their academic performance, predisposing to substance use, and push into other maladaptive coping strategies. Hence there is a need to establish positive mental health clinic separate from Psychiatry Department for better acceptance, accessibility, and availability.

Aim:

To run a positive mental health clinic by psychiatrists of medical college in a rural medical university providing preventive, promotive and curative mental health service to medical and paramedical students with confidentiality and avoiding perceived stigma.

Method:

Positive Mental Health Clinic was established in administrative block of university run by faculty of Department of Psychiatry. Wide publicity was given and walk in service was provided. Total confidentiality was ensured, and appropriate intervention was provided to needy students.

Results:

74 Medical, 17 Dental, 25 paramedical undergraduates and 13 Medical, 1 dental, 3 paramedical postgraduate students availed this service during the last one year. Majority were on self-referral followed by referral from authorities. Anxiety, depression, deranged biodrives, interpersonal issues were the commonest clinical features followed by suicidal ideation.

Conclusion:

Establishment of a positive Mental Health Clinic in a medical university in administrative block and run by psychiatrists was well received by student community and authorities. Recommended that this model may be replicated in other medical colleges also.

Dr. JESNA T. J.

PG Resident - 2022 batch

Department of Psychiatry

Travancore Medical College,

Kollam,Kerala

Rare case of Marchiafava Bignami Disease mimicking as Wenicke’s Encephalopathy

BACKGROUND

Marchiafava Bignami Disease(MBD) is a rare disorder characterised by demyelination and necrosis of Corpus Callosum and adjacent subcortical white matter. Though unclear etiology, it is presumably attributed to combination of alcohol induced neurotoxicity and deficiency of vitamin B . Symptoms -cognitive impairment, gait disturbance, behavioral abnormalities, visual hallucination, dysarthria, pyramidal tract lesion, stupor .

CASE REPORT

33 year old male presented with memory impairment,diploplia and unsteady gait for 1 week, tremors and vomiting 2 days. On examination: consious , oriented , decreased attention, impaired recent memory. CNS examination: brisk reflexes ,coarse tremors, ataxia . History of alcohol dependence for the past 25 years. Blood routine : elevated total count, hepatic and pancreatic enzymes. USG abdomen confirmed diagnosis of acute pancreatitis. Patient admitted and started on parenteral antibiotics and detoxification. Ophthalmology evaluation done to rule out any other causes of diploplia. After 2 days, patient developed visual hallucination ,agitation, and confused behaviour. Diagnosis of Wernicke’s Encephalopathy was considered , treated with 400mg/day of parenteral thiamine , showed mild improvement. MRI Brain- T2 hyperintensity in Corpus Callosum.

OUTCOME:

Considering a likely diagnosis of MBD, dose of thiamine adjusted to 1500mg/day , benzodiazepines continued . Patient showed gradual clinical improvement in a week .

CONCLUSION

Report of a patient who presented with Wenicke’s Encephalopathy like symptoms, later diagnosed to have MBD on further evaluation. Based on this case and review of literature, we stress the importance to consider MBD in patients with ataxia, opthalmoplegia , confusion.

Prader Willi Syndrome with Moderate Intellectual Disability - A Case Report

Dr.M.Vijayaraj *, Dr B C Jahnavi, Dr.Radha Krishna Raju *** Post Graduate*, Assistant Professor**, Professor and HOD*** Department of Psychiatry, S V Medical College, Tirupati.

Introduction:

Prader Willi Syndrome is a rare and complex genetic disorder with prevalence of 1 in every 15000 to 30000 births, with numerous implications on metabolic, endocrine, neurologic systems, with behavior and intellectual difficulties. PWS is characterized by severe hypotonia with feeding difficulties in the first year of life, Global developmental delay, and hyperphagia with development of morbid obesity at about three years of age. It is also recognizable by typical facial features, strabismus, and other musculoskeletal conditions.

Case description:

A 12-year-old female child was brought to Psychiatry OPD by her parents with complaints of delayed milestones, increased food intake associated with significant weight gain since 4 years of age, stubbornness, anger outburst, attention seeking behavior. She had history of Shortness of breath on and off during sleep since 7 years of age. On Examination, child looks Obese with decreased muscle tone in bilateral upper limbs and lower limbs. On DST, she was found to have moderate intellectual disability. Laboratory Investigations revealed that she had type 2 diabetic mellitus and MRI of the brain showed diffuse cerebral atrophy, Mild thinning of corpus callosum, Asymmetry of lateral ventricle (right > left) and grossly thinned out anterior pituitary gland. PWS was suspected based on clinical features and investigations and it was confirmed by molecular DNA analysis.

Conclusion:

PWS is a genetic disorder with Intellectual Disability, Obesity with or without Hypogonadism. Comprehensive management plan involving inputs from pediatrician, Medical/Surgical gastro-enterologist, psychiatrist, special educators, occupational therapists, Family Therapists and community services. She was treated with Growth hormone therapy after confirmation using molecular genetic study. Currently, she was prescribed T.Metformin 500 mg BD for Type 2 DM and is maintaining well. For behavioral problems , behavioral therapy was advised on session basis and Syrup Sodium valproate was prescribed during night based on body weight.

‘Predictors of postpartum psychiatric disorders: findings from rural tertiary care hospital-based study’

Dr.Amithab M Nambiar¹,Yashas.B.P² ,Dr.Vinay.H.R³

1-Junior resident,Department of psychiatry,Adichunchanagiri Institute of Medical Sciences (AIMS), Adichunchanagiri University,Mandya district, Karnataka, India.

2-Undergraduate student, Adichunchanagiri Institute of Medical Sciences (AIMS),Adichunchanagiri University,Mandya district, Karnataka, India.

3-Associate professor, Department of psychiatry ,Adichunchanagiri Institute of Medical Sciences (AIMS),Adichunchanagiri University, Mandya district, Karnataka, India.

ABSTRACT

INTRODUCTION

Postpartum blues and postnatal depression are common psychiatric disorders during the initial post-delivery period. Studies show that Post partum blues are seen in up to 50% of mothers and Postpartum depression is approximately 4 to 11 times more common among women who have postpartum blues. Despite the serious consequences, Postpartum psychiatric disorders are often unrecognized, especially in rural areas. This study was carried out with a research question that do factors like obstetric and psychosocial factors have any predictive value for development of postpartum blues and subsequently Postpartum depression in a rural set up.

AIMS

To find incidence and association of obstetric and psychosocial factors with the occurrence of post-partum blues and depression among women delivering babies at rural tertiary care center.

METHODS

A longitudinal study was conducted at AIMS B.G. Nagara lasting for 3 months including all women who delivered at the center and was willing to take part in the study. Stein’s maternity blue scale and Edinburgh Postnatal Depression Scale were used. Incidence was calculated and significance was assessed with student ‘t’ test for continuous variables and Chi-square for categorical variables.

RESULTS

The incidence of postpartum blues and depression was very low and hence the association with obstetric and psychosocial factors was even not statistically significant.

CONCLUSION

The incidence of postpartum psychiatric disorders is less in rural areas and obstetric and psychosocial factors have less predictive value regarding their occurrence.

Psychological picture of an inflamed brain: Case report of an atypical presentation of LGI 1 Autoimmune encephalitis

INTRODUCTION

Autoimmune encephalitis is an emerging and unique clinical entity that causes severe neuropsychiatric symptoms; often indistinguishable from other conditions that cause similar symptoms, making it very challenging to diagnose.

CASE DESCRIPTION

A 15year old male presented with history of two episodes of GTCS, short term memory loss, hyperactivity, agitation, aggression and multiple impulsive DSH attempts with high lethality. Patient was diagnosed to have Mood disorder NOS and was started on mood stabilizer and antiepileptic medications. He was further evaluated for organic causes in view of atypical presentation and minimal improvement with medications. Although MRI brain and EEG was normal, CSF Analysis was positive for antibodies against LGI 1. Patient is currently on long term immunomodulation and on antipsychotics for behavioural disturbances. In spite of the above treatment, patient showed only modest improvement.

CONCLUSION

One should consider organicity in any patient especially children who has atypical presentation and poor response to psychotropic medications. Our case illustrates the need for considering autoimmune encephalitis as a differential for any patient with such presentations as the prognosis depends on rapidity of detection and management.

Dr. Nandana Muralidharan¹, Dr. Yashwanth M H² Dr. Arun Bhat³, Dr. Shrinivasa Bhat U⁴.

1- Junior Resident, Department of Psychiatry, K.S. Hegde Medical

Academy, Mangaluru, Karnataka, India

2 – Senior Resident, Department of Psychiatry, K.S. Hegde Medical

Academy, Mangaluru, Karnataka, India

3 - Assistant Professor, Department of Psychiatry, K.S. Hegde Medical

Academy, Mangaluru, Karnataka, India

4 - Professor and Head of Department, Department of Psychiatry, K.S.

Hegde Medical Academy, Mangaluru, Karnataka, India

Category: Poster: Psychosis as an initial presentation of systemic lupus erythematosus : A rare case report

Presenting author: Jigisha Das

Affiliation and designation of presenting author: First-year Postgraduate (MD, Psychiatry), Institute of Mental Health, Department of Psychiatry, Osmania Medical College, Hyderabad, Telangana.

Email of presenting author: anajigisha23@gmail.com

Phone no: 7008307317

Co-authors:

1.G J Vijay Mathews, Assistant Professor of Psychiatry, Institute of Mental Health, Department of Psychiatry, Osmania Medical College, Hyderabad, Telangana.

2.Rajshekhar Bipeta, Professor of Psychiatry and Deputy Superintendent, Institute of Mental

Health, Department of Psychiatry, Osmania Medical College, Hyderabad, Telangana.

Background

Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune inflammatory disease affecting multiple organ systems with a female preponderance. Studies reported that 21-95% of the patients may have neuropsychiatric manifestations, ranging from cognitive deficit, lupus headache, psychosis, seizures, peripheral neuropathy, and cerebrovascular events. Amongst these, psychosis is a rare manifestation (7-8%). However, there is a lack of adequate research and case reports on psychosis as a predominant neuropsychiatric manifestation prior to diagnosis of SLE.

Case description:

A 40-year-old woman presented to the psychiatry department with a 15-year history of continuous illness characterized by irritability, assaultive behaviour, aimless wandering, persecutory delusions, impaired household functioning, and decreased sleep. She was diagnosed with paranoid schizophrenia. She had a three years history of difficulty in walking, joint swelling and tenderness, oral ulcers and significant weight loss. After general medicine and rheumatology consultation, she was diagnosed with SLE with polyarthritis and ANA 4+.

Discussion:

Psychiatric manifestation as an initial presentation is a challenge for diagnosing SLE due to the stigma associated with mental illness and lack of knowledge and awareness about SLE and other arthritides.

Conclusion:

Consultation-Liaison psychiatry with other medical specialities and proper awareness about mental and physical illness will be useful to prevent the worsening of both psychosis and SLE.

Psychosis or Poisoning? A case report on the neuropsychiatric presentation of mercury and lead poisoning.

Vasa, J¹; Jaiswal, M¹; Jyrwa, S²; Gohad, D³; Jaiswal, S⁴.

¹Junior Resident, ²Associate Professor, ³Senior Resident, ⁴Additional Professor, Department of Psychiatry, All India Institute of Medical Sciences Nagpur

Background: Morvan’s syndrome is an autoimmune disorder of peripheral and central nervous system mediated by anti-voltage gated potassium channel (VGKC) antibodies. The current case emphasizes the emerging concept that autoimmune illnesses may present at first with psychiatric symptoms and heavy metals may play a role in the etiopathogenesis of the same.

Aims & Objectives: To advocate for importance of considering heavy metal exposure as an etiological factor for psychiatric manifestations.

Method: Mr. MP, 30-year-old male who presented with complaints of acute onset aggressive behavior, 2nd and 3rd person auditory hallucinations, delusion of persecution, delusion of infidelity for 8 days along with generalised fasciculations was admitted to the psychiatry department. The patient was initiated on T. Olanzapine 10 mg. On exploration, the patient had earlier developed complaints of diarrhoea with maculopapular rash and consumption of alternative medications. On day 4 of admission, the psychiatric symptoms worsened as the patient became increasingly violent and attempted to abscond. The symptoms evolved to a high-grade fever, weakness in lower limbs, neck rigidity, increased fasciculations, and urinary incontinence the next day. T. Olanzapine was discontinued. After a negative fever profile, the clinical impression of subacute onset LMN quadriparesis with acute delirium secondary to autoimmune encephalitis was kept by the physician. On investigation, along with high blood levels of mercury and lead, the Anti-VGKC and Anti-LGI1 antibodies were positive. The patient was diagnosed with Toxin-induced Morvan Syndrome, and Inj. Methylprednisolone 60 mg was started. The psychiatric symptoms subsided and the patient was discharged on immunosuppressants.

Result: This case report highlights the psychiatric presentation of VGKC antibody-mediated Morvan’s syndrome with elevated blood heavy metal levels being successfully managed with immunosuppressants as opposed to the initial treatment of antipsychotics.

Discussion and Conclusion: The neuropsychiatric manifestations of lead and mercury poisoning overlap with the exacerbation of symptoms of psychosis and must be treated with caution and multidisciplinary approach.

PSYCHO-SOCIAL VARIABLES OF SUBSTANCE USE AMONG ADOLESCENTS: A TERTIARY CARE HOSPITAL- BASED STUDY

Background and aim: Substance abuse is fast becoming one of the major health related issue for adolescents. Adolescent substance use differs from that of adults in that progression from casual use to dependence occurs more quickly, more likely to use multiple substances and are at higher risk of presenting with psychiatric and medical co morbidities. It is important to look at various factors associated with substance abuse. [

Methods: The Semi-structured case records and Drug Abuse Monitoring System proforma from January 2022 to December 2023 were reviewed for the adolescents between 10-19 years, presenting to our State Drug Dependence Treatment Centre. The data thus obtained was analysed and tabulated.

Results: A total of 112 adolescents presented to our de-addiction treatment centre from January 2022 to December 2023. The average age was 17.41±1.82 and 106(94.64%). Primary substance of use was opioids 76 (67.85%). Out of these forty five (59.21%) adolescents resorted to intravenous opioid use with mean age of initiation 17.60 years. Thirty one (68.88 %) had high risk behaviour in the form of sharing of needles and opioid overdose. Conduct traits and legal involvement was there in opioid users.

Conclusion: Adolescent substance use is less recognized and even less is the treatment-seeking. Our findings also highlight that in our society drug use pattern is changing from traditional to new synthetic and pharmaceutical ones. Intravenous opioid use is an emerging crisis among adolescents. There is urgent need to reach out to this population with preventive as well as harm reduction strategies.

Keywords: Intravenous opioids use, adolescence, high risk behaviour

Rapid Cycling Bipolar Affective Disorder in Intellectual Disability: A Case Report and Review of Literature

Introduction

Diagnosing Bipolar Affective Disorder (BPAD) in the background of intellectual disability is often challenging. There are limited studies addressing this scenario. Here we discuss, a case of Rapid Cycling BPAD in a patient with Mild Intellectual Disability.

Case Report

A 35 year old male presented with complaints of elevated mood, increased goal directed activity, reduced need for sleep, big talks, over-talkativeness and overfamiliarity occurring in episodes since 2018. These episodes would occur every one or two months lasting 10-14 days. On further exploration, the patient had history of poor scholastic performance and needed assistance in performing instrumental activities of daily living. He had difficulty doing simple written and verbal calculations and had poor general fund of knowledge. There was history of BPAD in his father. Patient had taken treatment from a private practitioner previously on which his mood symptoms would resolve but he would continue to show aggressive behaviour directed at family members. After taking treatment from our OPD, for two years, the patient showed improvement wherein he stopped having affective episodes along with improvement in his aggression. The patient was put on 1000mg Sodium Valproate and upto 4 mg of Risperidone on which the patient is currently maintaining well and following up on OPD basis.

Discussion

BPAD in persons with intellectual disability is difficult to diagnose, as such persons have poorer ability to communicate their mood verbally and many of the diagnostic criteria for Bipolar Affective Disorder depends upon verbal expression of mood symptoms. Another reason for this might be seeing symptoms and signs of the clinical condition as consequences of lack of intellectual capacity. Rapid Cycling BPAD in people with Intellectual Disability may differ from its occurrence in non-ID people in terms of a relative preponderance in males, an increased likelihood of rapid cycling onset in those with an early (prepubertal) onset of affective disorder and a different response to prophylactic drugs.

REMITTED MAJOR DEPRESSIVE DISORDER PATIENTS HAVE COGNITIVE DYSFUNCTION –A HOSPITAL BASED STUDY

Background

Major Depressive Disorder (MDD) is one of the frequently encountered psychiatric disorders which has a chronic course with high tendency to recur. Cognitive functions like psychomotor speed, attention, memory and executive functions seem to be impaired in depression. This study focuses on understanding the profile of cognitive dysfunction in remitted phase of depression.

Materials and methods

This cross-sectional study was conducted in medical college, Bihar involved 62 patients 31 each in case and control based on random sampling technique. HAMD Rating Scale was used to screen the cases for remission. Whilst GHQ-12 to screen the healthy controls. Trail making test A and B, Digit symbol substitution test, Visual memory test and Digit span test were used to assess cognitive function.

Results

1. 1Statistically significant difference between cases and controls in Trail Making Test A, Trail Making Test B, Digit Forward (DF), Digit Backward (DB).

2. 2Negative correlation between age and DF, DB; Number of episodes and DF, DB. There was a negative correlation between age and, Digit symbol substitution test (DSST); number of episodes and DSST.

3. 3No significant difference between ages of both groups

Conclusion

Cognitive dysfunction persists even after remission from depressive symptoms. There is high need to address cognitive impairment in depression to improve functional recovery and quality of life of patients with major depressive disorder. Assessment of cognitive deficits and strategies for cognitive remediation should become routine part of management of MDD.

RESISTANT CATATONIA IN A CASE OF YOUNG ONSET PARKINSON’S DISEASE

Dr Pradyumna (3^rd year post graduate), Dr Shankar K (Associate Professor), Department of Psychiatry, Bangalore Medical College and Research Institute, Bangalore

Introduction: Parkinson’s disease (PD) is known to have associated nonmotor manifestations including psychiatric symptoms like depression and psychosis. Catatonia has been reported extremely rarely in patients of PD. Mutations with dominant and recessive forms of inheritance are known to contribute to risk of PD. The case described here is a rare example of catatonia in a patient with young onset PD having PARK14 (PLA2G6) gene mutation.

Case presentation: A 29-year-old man, from southern India, born of a consanguineous marriage, had a progressive illness over two years, characterised by social withdrawal, with slowness in activities, and tendency to stare and maintain postures. Examination revealed mutism, negativism, waxy flexibility, posturing, rigidity of all limbs with postural and autonomic instability. Systemic examination was normal and investigations unremarkable. While catatonic symptoms minimally responded to lorazepam and memantine, a transient response was seen with Bi-temporal ECT with no adverse events, his parkinsonian symptoms were partially responsive to dopaminergic agents. Whole exome sequencing revealed a homozygous pathogenic variant in the PLA2G6 gene.

Discussion: Though PD is commonly associated with nonmotor manifestations including psychiatric symptoms like depression and psychosis, catatonia is not a usual manifestation. It is pertinent to highlight the ambiguity of neurological motor symptoms with catatonic signs, particularly for rigidity, autonomic symptoms, spasticity, unresponsiveness, having important diagnostic implications and delaying effective treatment.

REVIVING LIVES WITH ECT IN A CASE OF DEPRESSIVE CATATONIA

Dr. Srinithi. S. O, Dr. Ahalya, Dr. Poorna Chandrika

INTRODUCTION:

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. ECT is the definitive treatment for catatonia. Current understanding of catatonia’s pathophysiology links it to the current understanding of ECT’s mechanism of action.

CASE REPORT:

Mrs. D, a 72-year female reported to IMH with C/O diet refusal, irritability, decreased sleep for 2 days. On MSE, PMA was decreased. She gave brief replies that were irrelevant at times and had an irritable affect. MRI brain was normal. BFCRS was 29. TSH was 0.01 mIU/ml. In the ward, she was found to have rigidity, mutism and gegenhalten, had to be maintained on IV fluids and Ryle’s tube feeding. She was diagnosed with catatonic stupor and planned for ECT. One session of ECT was given after obtaining high risk consent in view of her advanced age and comorbid hyperthyroidism. After the first session of ECT, she had dramatic improvement in symptoms and BFCRS reduced to 6.

DISCUSSION:

Catatonia and ECT share an interwoven past over the last century. In spite of being among the safest and most effective of known neuropsychiatric treatments, ECT remains underutilized.A multitude of factors likely influence underutilization. Principal among them are suboptimal recognition of catatonia by psychiatric and non-psychiatric physicians, mismanagement of catatonia when recognized and remaining neuroscience gaps in our understanding of the pathophysiology of catatonia and corresponding mechanisms of therapeutic action of ECT.

Risperidone induced Priapism in a patient with Delusional Disorder

Dr. Shekina Victor , Dr. Santosh Kumar , Dr. Srisudha

Department of Psychiatry , Christian Medical College , Vellore

Background:

Priapism is a prolonged, painful penile erection occurring in the absence of sexual arousal or stimulation. It is a urological emergency which can lead to persistent erectile dysfunction if treatment is delayed.

Antipsychotics induced priapism amounts to 50% of cases triggered by medications . The common causative drugs include trazodone, thioridazine and chlorpromazine. Risperidone induced priapism is reported less commonly. This report details a patient with Delusional disorder treated with risperidone monotherapy and developed Priapism .

Case report:

A 31 years old gentleman admitted in the Psychiatric ward with a diagnosis of Delusional disorder was started on Risperidone and during up-titration to 4mg, started having painful erections which lasted for more than four hours . He was evaluated in the Department of Emergency Medicine and received intracavernosal Injection Phenylephrine following which it resolved. Risperidone was continued due to its potency, but priapism recurred. The temporal correlation of priapism after starting risperidone raised the probability of Risperidone induced Priapism, and hence stopped, following which he was asymptomatic.

Conclusion :

Risperidone is a widely used antipsychotic and monitoring of Risperidone related side effects including the rare ones is inevitable.The occurrence of antipsychotic-induced priapism is a critical short-term event with alarming behavioural problems secondary to psychosis. In long term, this can negatively impact compliance.

Author for correspondence :

Dr. Shekina Victor

Department of Psychiatry

Christian Medical College , Vellore

Email: drvshekina@gmail.com

Contact number : 8870892295

Schizo-Obsessive disorder: A clinical predicament

Vishav Damathia1, Isha Batra2, Nitin Kumar3

Background:

The psychotic and obsessive-compulsive symptoms (OCS) has been noted since the 19^th century in co-occurrence, with low prevalence rates ranging from 1 to 3.5 percent. Recent studies have consistently found a much higher prevalence of both OCS (25%) and OCD (12%) in patients with schizophrenia.

Aim:

The overlap between OCD and schizophrenia spectra is quite clinically challenging yet ubiquitous. Phenomenologically, obsessions can be readily mistaken for delusions. Conversely, schizophrenic motor symptom domain can be misconstrued as compulsions. We present a case of Schizo-Obsessive Disorder requiring an interdisciplinary approach for diagnosis and management.

Case:

A 26 year old unmarried male with past history of admission for acute onset symptoms of schizophrenia with complete resolution of target symptoms on Tab Olanzapine 20mg over 2-3 months and presented with repetitive intrusive distressing own thoughts (self harm and harm to others, contamination, sexual images, counting, symmetry, pathological doubts) associated with acts (i/f/o hitting/slapping/throwing objects/ trying to harm self) and aggravation in symptoms over 2 months with PANSS on admission 48 and YBOCS 24 and marked socio-occupational decline.

Discussion:

We will discuss the clinical presentation in detail and difficulty in managing the target symptoms the case presented with.

Conclusion:

The co-occurrence of OCD and Schizophrenia may cause difficulty in managing the symptoms. Although the transition of an obsessive into a psychotic symptom seems to be a rare event, it is possibly a sign of poor prognosis in the schizo-obsessive spectrum.

Serotonin toxicity - A case report

Suma T Udupa, Sivapriya Vaidyanathan, Ravindra N Munoli, Samir Kumar Praharaj

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

Background

Serotonin toxicity is a potentially life-threatening adverse drug reaction in the context of an SSRI treatment resulting from therapeutic drug use, intentional self-poisoning, or inadvertent interactions between drugs. The classic presentation is the triad of autonomic dysfunction, neuromuscular excitation, and altered mental status.

We report a case of serotonin toxicity following monotherapy with sertraline.

Case Summary

Mr M, a 31-year-old single male presented to us and was diagnosed with recurrent depressive disorder, current episode severe without psychotic symptoms, moderate personality disorder with negative affectivity and anankastia, and nicotine dependence. He was started on Sertraline 50mg and trazodone 25mg was added on sos basis for sleep. During his visit a week later, he reported of symptoms of anxiety and few discreet episodes of autonomic arousal. Dose of sertraline was increased to 75mg and clobazam was added and trazodone was stopped.

Within the next week he presented with history of profuse sweating, palpitation, diarrhoea, feeling panicky, restlessness and double vision which were worsening over the period. On examination, his pulse was 112/min, blood pressure 150/96 mm of Hg, temperature and respiratory rate was normal, CNS examination revealed hyperreflexia. A diagnosis of serotonin toxicity was made using revised diagnostic criteria by Radomski et al.

Sertraline was discontinued and was continued on clobazam. Patient improved within a span of a weeks’ time.

Conclusions

Clinicians should be aware of this dreaded adverse effect of antidepressant as successful management relies on prevention and early recognition. It may occur following monotherapy with low dose of sertraline.

Severe Hypothyroidism Manifesting as Acute Mania with Psychotic Features: A Case Report

Introduction: Abnormal thyroid hormone levels have been linked with a variety of affective and psychotic disorders. Although the associations of depression and mania with hypothyroidism and hyperthyroidism,­ respectively, are well described, mania in the setting of hypothyroidism is unusual. We present a case of acute mania precipitated by hypothyroidism as a result of postpartum thyroiditis,­ an autoimmune disorder of the thyroid gland that affects­ 5–7% of women in the first postpartum year.

Case Presentation: A 30 yr. old Married female presented with symptoms of irritable mood, talkativeness, increased psychomotor activity, decreased need for sleep and suspiciousness of 1 week duration ,6 months after delivery. The patient had no past or family history of psychiatric illness or, any thyroid dysfunction. Her baseline investigations were within normal limits. Thyroid function revealed low T3 (0.6ng/ml), low T4 (1.6mcg/dl) and raised TSH (>100 uIU/ml). Further investigations revealed elevated levels of thyroid peroxidase antibody (anti-TPO >1000 IU/ml). The patient was started on levothyroxine replacement 100mcg, divalproex 500 mg b.i.d and olanzapine 10 mg BT. The patient’s mania and hypothyroidism gradually improved within 2 weeks with TSH levels of 60.61uIU/ml and anti -TPO levels 586 IU/ml. Currently the patient is doing well on divalproex 500mg BT, olanzapine 5mg BT and levothyroxine 100mcg.

Conclusion: This case highlights the importance of thyroid screening in individuals with mood and psychotic disorders, particularly in cases lacking past and family history of mental health disorders.

keywords: Acute mania, Postpartum thyroiditis, Autoimmune disorder.

Sleep related rhythmic sleep disorder a case report.

Dr. Albert Vincent Joseph, Dr. Jennifer Sangeetha, Dr. V. Venkatesh Madhan Kumar

BACKGROUND: Sleep-related rhythmic movement disorder (SRRMD) is characterized by repetitive rhythmic motor behaviours involving large muscle groups that occur predominantly during stage N1 sleep. SSRMs are common in infants and children but they usually spontaneously resolve before adolescence. This case presents a rare adult case of SRRMD.

CASE DESCRIPTION: A 17 year old boy presented with complaints of head banging, anger outbursts, aggressive behaviour, sleep disturbances. He also had alcohol abuse, tobacco and cannabis abuse. He is on antiepileptics from 4years of age. There is no delay in achievement of developmental milestones. Family history of psychiatric illness present in brother. On examination no focal neurological deficits could be elicited. On MSE his psychomotor activity was increased and no thought or perceptual disturbances was present. Detailed investigations was done and was diagnosed as Sleep-related rhythmic movement disorder and was treated with and he showed much improvement and was discharged.

DISCUSSION: Our case describes a patient who had SRRMs that commenced in childhood persisting well into early adulthood. Reported cases of SRRMD persisting after adolescence are few, and have been associated with sleep apnea, REM sleep behavior disorder, and RLS, while many remain idiopathic such as the case with this patient. While benzodiazepines are still first line for SRRMD, further work up and investigation into possible comorbid conditions could yield insight into the etiology and offer alternative treatment options to patients.

References:

1. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3^rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.

2. Mayer G, Wilde-Frenz J, Kurella B. Sleep related rhythmic movement disorder Revisited. J Sleep Res. 2007;16(1):110–116.

3. Attarian H, Ward N, Schuman C. A multigenerational family with persistent Sleep related rhythmic movement disorder (RMD) and insomnia. J Clin Sleep Med. 2009;5(6):571–572.

SLOW ELIMINATION OF LITHIUM FROM BODY:- A RARE CASE REPORT

Introduction

Lithium has been a cornerstone of the treatment of bipolar disorder for decades and is first-line treatment for maintenance therapy. Lithium has a very narrow therapeutic index which is very close to its therapeutic range. Lithium is excreted primarily in the urine, and the elimination half-life is approximately 24 hours. In patients with chronic intoxication, the half-life can be prolonged up to 72 hours

Case details

73-year-old female presented with Tremulousness of hands and body, altered sensorium, disorientation, and decreased appetite for 1 week; on evaluation, it was found that she is a case of bipolar disorder maintained well on lithium 800mg for the past 20 years.

Following an episode of UTI, she developed tremors with restlessness. She was later diagnosed with Hypertension, for which ARB was given, which further increased her tremors. Then, she was started on Tab Syndopa and Trihexyphenidyl, which worsened her condition. On admission, all blood workups and radio imaging were normal, including kidney function test.

Serum Lithium on day 1 was 2.4 Meq/L later decreased to 0.6 Meq/L after 7 days of stopping all medications.

DISCUSSION

The delayed elimination of lithium from the body is expected in elderly patients for up to 58 hours. Still, in this case, the delay was way more than expected with normal function kidneys.

As the patient did not have any other endocrine and renal pathology, the lithium rebound phenomenon can explain the delay in eliminating lithium.

Sociodemographic and clinical profile of patients with first episode depression: A retrospective chart review from a tertiary care center in India.

Samarth S Shetty*, Arpita Sharma, Pavithra Jayasankar, Nellai K Chithra, Rashmi Arasappa, Muralidharan Kesavan.

Department of Psychiatry,

National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India *samarth.shetty3397@gmail.com: 9901680991

Objective:

There is a lack of research on the socio-demographic and clinical details of first episode of depression (FED). This study aims to explore the sociodemographic and clinical profile of FED patients in India.

Methodology:

A retrospective chart review (n = 580) of patients diagnosed with major depressive episode as per ICD-10 was conducted at a tertiary care centre in India from Jan 1 to Dec 31, 2009. 449/580 patients had first episode of depression. The details extracted include sociodemographic and clinical details on depressive symptomatology using a semi-structured assessment proforma. Institutional Ethical Committee approval was obtained. SPSS version 27.0 was used for the analysis.

Results:

The sample had a mean age of 36 years (SD=13.15), male-to-female ratio 0.9:1, rural-to-urban ratio 1.58:1. Marital status: married 68.8% (n=309), single 25.8% (n=116), widowed 4% (n=18), separated 0.9% (n=4), divorced 0.4% (n=2). Average education 10.9 years (SD=5.05). Unemployed 4.9% (n=22), mainly housewives 33% (n=147) and students 9.7% (n=43). Family history of psychiatric illness 35.4% (n=157). Comorbidities: diabetes 12.9% (n=58), hypertension 11.6% (n=52). Symptoms: guilt 14.3% (n=64), insomnia 51% (n=229), psychomotor retardation 7.1% (n=32), psychomotor agitation 7.6% (n=34), somatic syndrome 43.2% (n=194), loss of appetite 47.4% (n=213), weight loss 13.1% (n=59), anhedonia 63.7% (n=286), loss of libido 11.8% (n=53). Depressive cognitions 73.1% (n=328), mainly helplessness 23.2% (n=104). Psychotic symptoms: delusion 13.4% (n=60). Atypical symptoms 5.1% (n=23). Suicidal ideation 20.3% (n=91), previous attempts 8.2% (n=36).

Conclusion:

These findings can guide targeted interventions and public health initiatives to improve depression management in the country. Further research is needed to explore the dynamics of depression over time.

Depression, sociodemographic profile

Solvent Induced Psychosis and its Management

INTRODUCTION:

Solvent use is the intentional inhalation of volatile substances to achieve an altered mental state. Solvent-induced psychosis has been clinically identified among patients suffering from dependence on volatile solvents.

CASE PRESENTATION:

A 23 year old male was brought with complaints of decreased sleep, abusive and aggressive behaviour, suspiciousness and hearing of unreal voices, smiling and muttering to self since 8 days. Patient had a history of huffing of paint thinner along with friends since 5 years and increased use since few months.

Patient was admitted in psychiatry ward. A medicine referral was sought to rule out any organic cause. Patient was treated with antipsychotics and benzodiazepines. The patient showed improvement on medications and was discharged from the ward. Thereafter patient continued his follow up in opd and long term psychological interventions along with pharmacological approach were considered for him.

DISCUSSION:

Studies on inhalant use from India are scarce and robust studies are currently available on treatment approaches, and all published treatment guidelines have been based on expert consensus. Many other aspects of solvent dependence, including course and outcome, have not been studied, despite the fact that use of solvents is associated with significant mortality, morbidity and psychosocial dysfunction. There is an urgent need for a concerted effort to develop effective evidence based interventions to tackle this issue.

“Steroid-Induced Psychosis in a Systemic Lupus Erythematosus Patient: A Complex Case Report”

Background: Systemic Lupus Erythematosus (SLE) is an autoimmune disease often managed with corticosteroids to control inflammation and symptoms. This case report highlights a unique and complex clinical scenario of steroid -induced psychosis in a patient with SLE, emphasizing the intricate interplay between the underlying autoimmune condition and corticosteroid therapy.

Case Presentation: A 30-year-old female with a history of SLE presented with worsening joint pain and cutaneous manifestations. Due to the disease flare, she was prescribed high-dose corticosteroids. Within weeks of initiating treatment, the patient exhibited abrupt-onset hallucinations, delusions, and severe agitation. Comprehensive evaluation excluded primary psychiatric disorders. The diagnosis of steroid-induced psychosis in the context of active SLE was established. Corticosteroid tapering, immunosuppressive therapy adjustment, and initiation of antipsychotic treatment led to a gradual resolution of psychotic symptoms.

Discussion: The case underscores the complexity of managing SLE patients when psychiatric symptoms arise as a consequence of corticosteroid use. It highlights the need for a multidisciplinary approach, including rheumatologists and psychiatrists, to optimize patient care and outcomes.

Conclusion: The occurrence of steroid-induced psychosis in patients with SLE is a challenging clinical scenario. Clinicians must be vigilant regarding the potential psychiatric side effects of corticosteroids, especially when managing autoimmune disorders. Prompt recognition and the implementation of tailored treatment plans that address both the underlying autoimmune disease and the psychiatric symptoms are crucial for achieving favorable outcomes in these complex cases. This report underscores the importance of interdisciplinary collaboration in managing such cases effectively.

Street heroin withdrawal delirium in 18 year old male : a case report

1)Dr. Varun Bansal, Junior Resident, Department of Psychiatry, J.L.N. Medical College, Ajmer

2)Dr. Mahendra Jain, Senior Professor and Head, Department of Psychiatry, J.L.N. Medical College, Ajmer

3)Dr. Parth Singh, Professor, Department of Psychiatry, J.L.N. Medical College, Ajmer

4)Dr. Charan Singh, Associate Professor, Department of Psychiatry, J.L.N. Medical College, Ajmer

1:Presenting Author

2,3,4:Co-authors

Background- Opioid withdrawal symptoms are characterized by severe muscle cramps and bone aches, nausea/vomiting, diarrhea, rhinorrhea, lacrimation, fever, yawning, pupillary dilatation, restlessness, hypertension, tachycardia, piloerection and temperature dysregulation. Complications like delirium and convulsions are more recognized in alcohol withdrawal and are rarely reported in opioid withdrawal. The incidence of opioid withdrawal delirium is unknown worldwide, although few case reports in the adult population have been published.

Case report- A case of a 18-years-old male who used to take smack/street heroin for last 4 years and presented to the emergency room with sign and symptoms like altered sensorium, restless and agitation, not recognizing family members and picking behavior suggestive of delirium. Regular intake of street heroin (smack) was confirmed by the family members.

The treatment included rehydration using intravenous fluids and managing delirium using low dose haloperidol and opioid agonist tramadol parenterally. The patient recovered fully in next two days without any residual complications.

Conclusion- Although delirium is not a common presentation in opioid withdrawal but patient can present with this life-threatening complication, so it warrants that patient with opioid withdrawal should be carefully monitored and the chance of developing this complication should be detected and treated as early as possible.

CROSS-SECTIONAL STUDY OF QUALITY OF LIFE IN MALE HIV SEROPOSITIVE CASES

PRATEEK YADAV

LF 160322

OBJECTIVES

To evaluate psychological aspects of Quality of Life in male HIV seropositive cases on ART.

METHOD

86 patients on Highly Active Anti Retro-viral Therapy (HAART) for at least 3mths, admitted in a tertiary centre were taken up for study. Socio-demographic and HIV related information was obtained, by structured questionnaire. QOL instrument modified to suit the Indian cultural settings, developed by National AIDS Research Institute was used.

Results

Out of 10 domains lowest scores are seen in the domains of Daily living activities, Appetite and food, Social support and Cognitive function. Domains of Pain, Sleep and Emotions show a better score and other domains scored midway. Domains of Physical health, Physical activity and Daily activity show fall in the score with the fall in CD4 count which was statistically, highly significant. The domain score for Social support, Feeling & emotion and Pain in the >500/µl category of CD4 count was the highest compared to the other two categories of CD4. Correlating the QOL with Age the domains of physical health, physical activity and cognitive functioning show a higher score in younger. In terms of marital status the QOL score was high in almost all domains for the single individuals. Marital status, living with the family and education did not show association with the QOL in this study sample.

Conclusion

An overall better QOL is seen in this study, which could be due to all of the patients being on HAART which has shown to improve the QOL and also that all were employed and had access to free medical care. QOL in certain domains decreased as the CD4 count decreased, thus the need for adherence to ART, which will reduce the disease progression and improve the QOL.

Successful Treatment of Catatonia in a Patient with Alzheimer’s Dementia

Introduction: Catatonia is a clinical syndrome characterized by striking behavioural abnormalities that may include motoric immobility or excitement, profound negativism or echolalia or echopraxia. Amongst psychiatric causes, affective and psychotic are common. Its association with dementia is well documented but rare.

Case description: 62 year old female with past history of Bipolar affective disorder (BPAD) since 33 years and a positive family history of dementia in father. Patient presented with complaints of recent memory impairment, impaired executive functioning, assistance with daily chores, verbal perseveration, apraxia since 10 months. Since 1 month patient had mutism, posturing, staring, active and passive negativism and poor oral intake suggestive of catatonia. Patient showed no improvement with injection lorazepam but improved with electroconvulsive therapy (ECT). Mini-mental status examination was applied and patient was found to have severe impairment. A diagnosis of Alzheimer’s Dementia with Behavioural and psychological symptoms of dementia (Catatonia) with BPAD in remission was considered.

Discussion: Catatonia in dementia is rare but not uncommon. Catatonia occurring as part of clinical picture of dementia has been reported with almost all types of dementia. Geriatric patients with catatonia must be assessed for history of dementia. As per studies the prevalence of catatonia in dementia ranges from 16 – 43%.

Conclusion: Catatonia in dementia though a rare presentation it can still present as major manifestation of dementia. Catatonia is challenging to treat sometime in elderly, but ECT could be an option.

The Clinical Utility of Pramipexole as an Adjunctive Agent in Schizophrenia : A case series

Dr. Aashi Srivastava, Dr. Deepthi RA. , Prof Dr. Sudipta K Das, Dr. Swayanka Samantray, Dr. Bhumika Mishra, Dr. Udit Panda, Dr. Pranab Mohapatra ,Dr. Jigyansa Pattnaik, Prof Dr. JPR Ravan Department of Psychiatry, KIMS, Bhubaneswar.

Introduction:

Negative symptoms and side effects of antipsychotic medications present significant challenges in the clinical management of schizophrenia. We present following cases where pramipexole as an adjunctive in treatment led to improvement.

Case Series:

Case 1 - In a 38 year old male with chronic schizophrenia and persistent primary negative symptoms despite Clozapine. Addition of pramipexole up to 0.375mg twice daily caused improvement in motivation, expressiveness and social engagement. Negative symptom scores on the PANSS decreased by 50% after 2 weeks. The clozapine dose could also be reduced.

Case 2 - A 48 year old male with schizophrenia who developed restless leg syndrome (RLS) affecting sleep. Pramipexole upto 0.75mg before bedtime improved RLS and residual negative symptoms like apathy and social withdrawal.

Case 3- A 36 year old female with chronic schizophrenia and significant negative symptoms who was unresponsive to atypical antipsychotics , pramipexole 0.25mg twice daily led to partial yet clinically meaningful improvement in depression and cognitive functioning.

Discussion:

Pramipexole is a dopamine D2/D3 receptor agonist. It improves negative symptoms by acting on postsynaptic D2 receptors in the meso-cortical pathway and enhancing prefrontal Dopamine. As a D3 receptor agonist, it increases motivation and interest via action on Nucleus accumbens. It additionally restores dopaminergic balance in RLS.

Conclusion:

Addition of pramipexole as adjuvant may achieve early remission of negative symptoms in schizophrenia refractory to antipsychotics . It also benefits antipsychotic induced side-effects and post-psychotic depression. Further study is warranted given the high disability imposed by persistent negative symptoms.

Abstract for poster presentation: Therapeutic Potential of Psychedelics in Psychiatry

Background: The resurgence of interest in the therapeutic potential of psychedelics is transforming the landscape of psychiatric treatment.

Aims: This poster presentation dwells into the intersection of psychedelics and psychiatry, focusing on their potential in the treatment of mental health disorders and the need for a paradigm shift in understanding and acceptance.

Methods: Highlighting recent clinical trials and research, this presentation explores the mechanisms through which psychedelics, including psilocybin, MDMA, and LSD, impact the brain and consciousness.

Results: The use of psychedelics in psychiatry indicate promising developments in the treatment of various disorders like Treatment Resistant Depression (TRD), Anxiety disorders, Post Traumatic Stress Disorder (PTSD) and substance use disorders. They were safe, tolerable and no serious adverse events were reported. Neuroimaging data revealed altered patterns of brain connectivity following psychedelic therapy, particularly in regions associated with emotional regulation and self-referential thinking. Participants frequently reported experiencing profound, mystical-type experiences during sessions, associated with improved psychological well-being and reductions in psychiatric symptoms.

Conclusion: These results underscore the potential of psychedelics as a valuable adjunct to conventional psychiatric treatments. However, further research is necessary to optimize dosing protocols, investigate the long-term effects, and identify the most suitable patient populations. Ethical and regulatory frameworks should be developed to ensure responsible and safe use in clinical practice.

To Study the Pattern of Consultation Liaison references in Psychiatry initiated from Emergency department.

Dr. Shashwat Swaroop Srivastava

Presenting Author, PG Resident, Department of Psychiatry, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India.

Dr. Shubhangi Dere

Associate Professor, Department of Psychiatry, Mahatma Gandhi

Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India.

Dr. Rakesh Ghildiyal

Professor and HOD, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India.

Introduction:

There is a Scarcity of literature on the emergency Consultation Liaison Psychiatry in developing country like India.

Aims and Objectives

To Study the Pattern of Consultation Liaison references in Psychiatry initiated from Emergency department. Objectives were to study the profile of socio Demographic profile, clinical symptoms and psychiatric intervention of patients presenting in emergency department.

Methods

Data of all psychiatric consultation liaison references given by emergency department of a tertiary care hospital in Navi Mumbai from July 2022 to June 2023 were considered for this research.

Result

Total of 144 patients were assessed having males and females 56.25% and 43.75% respectively. Most common age range of patients were 21-30 years. Commonest psychiatry references were substance intoxication/withdrawal (28.5%) and second most common was Panic attack (25.1%) followed by altered sensorium (23.5%). Most common class of drug prescribed was Benzodiazepines (59.72%).

Conclusion

This study highlights the need of psychiatric services in emergency setting. It is the need of the hour to provide all clinicians the skills to identify and manage psychiatric symptoms in emergency departments.

Topic for E Poster - Paraphilic behavior possibly associated with Olanzapine treatment in a patient with Schizophrenia

According to an increasing number of documented instances, second-generation antipsychotics (SGA) therapy may also cause hypersexuality. Despite the fact that ,Aripiprazole is a medication with a known risk for hypersexuality, it is still unclear if Olanzapine is the cause of hypersexuality. According to earlier research by Maria-Ioanna Stefanou et al, hypersexuality may be an uncommon side effect of olanzapine therapy.

Case Presentation

A 65-year-old man with schizophrenia who was initially receiving treatment as an inpatient for six years came with auditory hallucinations and thoughts of persecution. Within 14 days of beginning Olanzapine, he displayed exhibitionistic and sexual conduct. Within a week of quitting Olanzapine, all symptoms vanished, and he was then prescribed Risperidone.

Conclusion

The temporal correlation between the emergence of hyper sexuality and the start of SGA treatment with Olanzapine and the complete remission of hypersexual behavior one week after discontinuation suggest a possible link between Olanzapine and hypersexuality, even though a causal relationship between behavioral changes and Olanzapine cannot be definitively established

Trance and Possession disorder in male: A rare case report

Dr Tricia Gadagkar¹ , Dr Manoj Shettar² , Dr Arun Gadad³ , Dr Sachin B S⁴ , Dr Abhay Matkar⁵

Possession disorder is a condition where a person is possessed by an external force or strange soul. Here the person temporarily loses sense of personal identity and full awareness of the surroundings. It is commonly seen among people living in the eastern part of the world. This disorder has preponderance in women. We report a case of 28 year old married Hindu male person with primary school education from rural background with history of possession disorder in mother, presented to us with possession attacks, depressive symptoms since 2 months due to underlying stress. A diagnosis of trance and possession disorder with moderate depression without somatic syndrome was made. He showed remarkable improvement with supportive psychotherapy, stress management techniques and with Escitalopram. This case is being reported in order to highlight the significance and cultural importance of possession disorder in men.

¹Second year Post graduate

Department Of Psychiatry

SDM College of Medical Sciences & Hospital

Shri Dharmasthala Manjunatheshwara University

Sattur, Dharwad

India.

²Associate Professor Department Of Psychiatry

SDM College of Medical Sciences & Hospital Shri Dharmasthala Manjunatheshwara University Sattur, Dharwad

India.

³Associate Professor

Department Of Psychiatry

SDM College of Medical Sciences & Hospital

Shri Dharmasthala Manjunatheshwara University

Sattur, Dharwad

India.

⁴Associate Professor Department Of Psychiatry

SDM College of Medical Sciences & Hospital Shri Dharmasthala Manjunatheshwara University Sattur, Dharwad

India.

⁵Professor and Head of Department

Department Of Psychiatry

SDM College of Medical Sciences & Hospital

Shri Dharmasthala Manjunatheshwara University

Sattur, Dharwad

India.

Treatment of first episode depression: A retrospective chart review from India

Arpita Sharma*, Samarth S Shetty, Pavithra Jayasankar, Nellai K Chithra, Rashmi Arasappa, Muralidharan Kesavan. Department of Psychiatry

National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India as6824352; 9596917381

Objective:

Treating depression is challenging due to varying symptoms, and limited treatment details exist for the initial episode. The aim of this study was to understand the treatment profile of first episode depression in India.

Methodology:

A retrospective chart review of patients (n = 580) diagnosed with depressive episode as per ICD-10 criteria between January 1 and December 31, 2009 was conducted at a tertiary care centre in India. 449/580 patients had a first episode of depression in 2009. Details collected include severity of the depressive episode, treatment details namely pharmacological, psychological and non-invasive brain stimulation methods/combination of the above, response and remission. Analysis was performed using SPSS version 27.0.

Results:

Among the participants, 48% (n=215) had moderate depressive episodes, 10.5% (n=47) had mild depressive disorder, 17.8% (n=90) had severe depression, and the rest had recurrent depressive disorder during follow-up. 94% (n=422) received pharmacological treatment alone, 2% (n=9) received psychotherapy, 3.8% (n=17) received a combination of pharmacotherapy and psychotherapy, and 0.2% (n=1) received pharmacotherapy with electroconvulsive therapy. 97.1% (n=436) received antidepressants, with escitalopram prescribed to 48.6% (n=218), fluoxetine to 14.5% (n=65). Adjunct benzodiazepines were given to 39.9% (n=179), mood stabilizers to 4% (n=18), and antipsychotic agents to 16.5% (n=74) for augmentation. After the initial antidepressant trial, 56.5% (n=131) showed response, and 29.3% (n=68) achieved remission.

Conclusion:

This hospital-based study on depression treatment in India provides valuable insights to improve prescribing quality and treatment outcomes. The findings will guide future efforts to enhance treatment effectiveness.

Depression, Antidepressants, Outcome.

Understanding diagnostic dilemmas in childhood posttraumatic stress disorder with psychotic symptoms – A case report.

Dr Anirban Dutta, Dr Harshini Manohar

Presentation: poster

Introduction - The association of Post Traumatic Stress Disorder (PTSD) with psychosis has important diagnostic, treatment implications. We present a case of 13-years-old girl who presented with PTSD and psychotic symptoms and discuss considerations related to diagnosis and management.

Case Details - A 13-years-old female, slow to warm up temperament, family history of psychosis in maternal grandmother, past history of obsessive-compulsive symptoms, presented with illness duration of three months characterized by academic decline, decreased social interaction, hearing voices, persecutory ideas, anger outbursts, decreased self-care, sleep disturbances, separation anxiety and one suicidal attempt. There was temporal correlation of exposure to traumatic events of flood and murder of a stranger with illness onset. Findings of initial examination and serial observations were predominantly fearfulness, inappropriate laughter, self-muttering, poor eye contact decreased speech output, pointing towards possible psychotic disorder, and demonstrated improvement with risperidone 6mg. However, significant separation anxiety and avoidance persisted alongside sleep disturbances. Improvement in psychotic symptoms facilitated further exploration of phenomenology, the child’s experiences, pointing towards trauma sequelae and diagnosis of PTSD. Hence SSRI sertraline was considered.

Attempt to taper antipsychotic resulted in resurfacing of psychotic symptoms, functional decline.

She attained stable improvement with combination of sertraline 150 mg and aripiprazole 20mg.

Discussion- Identification of the association of psychotic symptoms with PTSD in the pediatric population is important for the appropriate management. In this case, the psychotic symptoms resolved only with a higher dose of antipsychotic, which may often be required in primary psychotic disorders than often in trauma-related disorders, pointing towards a more severe form of PTSD or comorbid disorders.

“Unmasking the Itchy Truth: Urticaria Unveiled by Bupropion”

Background: Bupropion, a commonly prescribed medication for depression,smoking cessation also used in OCD.It has been associated with various adverse reactions. Among these, urticaria, a hypersensitivity skin condition characterized by pruritic wheals, is a rarely reported side effect. We present a case of bupropion-induced urticaria to shed light on this uncommon but important clinical concern.

Aims: This case report aims to describe the clinical manifestation of urticaria in a patient following bupropion initiation and to raise awareness about the potential dermatological side effects of this medication.

Methods: We conducted a comprehensive assessment of a middle aged female patient who developed urticaria shortly after starting bupropion for obsessive & compulsive disorder. The patient’s medical history, clinical presentation, physical examination, laboratory findings, and detailed medication history were reviewed.

Results: The patient developed a generalized pruritic rash, with characteristic wheals, within two weeks of starting bupropion. After discontinuing the medication, the urticaria resolved rapidly. No other potential causes of urticaria were identified through clinical evaluation or laboratory investigations.

Conclusion: Bupropion-induced urticaria is a rare but clinically significant adverse effect that clinicians should be aware of, especially when prescribing bupropion to patients. Timely recognition and discontinuation of the medication may prevent unnecessary discomfort and complications associated with urticaria. This case underscores the importance of vigilance for dermatological side effects in patients taking bupropion and the need for further research to better understand the underlying mechanisms of this reaction. Healthcare providers should consider alternative treatment options when managing patients at risk for urticaria during bupropion therapy.

“Unmasking the Itchy Truth: Urticaria Unveiled by Bupropion”

Background: Bupropion, a commonly prescribed medication for depression,smoking cessation also used in OCD.It has been associated with various adverse reactions. Among these, urticaria, a hypersensitivity skin condition characterized by pruritic wheals, is a rarely reported side effect. We present a case of bupropion-induced urticaria to shed light on this uncommon but important clinical concern.

Aims: This case report aims to describe the clinical manifestation of urticaria in a patient following bupropion initiation and to raise awareness about the potential dermatological side effects of this medication.

Methods: We conducted a comprehensive assessment of a middle aged female patient who developed urticaria shortly after starting bupropion for obsessive & compulsive disorder. The patient’s medical history, clinical presentation, physical examination, laboratory findings, and detailed medication history were reviewed.

Results: The patient developed a generalized pruritic rash, with characteristic wheals, within two weeks of starting bupropion. After discontinuing the medication, the urticaria resolved rapidly. No other potential causes of urticaria were identified through clinical evaluation or laboratory investigations.

Conclusion: Bupropion-induced urticaria is a rare but clinically significant adverse effect that clinicians should be aware of, especially when prescribing bupropion to patients. Timely recognition and discontinuation of the medication may prevent unnecessary discomfort and complications associated with urticaria. This case underscores the importance of vigilance for dermatological side effects in patients taking bupropion and the need for further research to better understand the underlying mechanisms of this reaction. Healthcare providers should consider alternative treatment options when managing patients at risk for urticaria during bupropion therapy.

Unravelling Schizophrenia’s Symptomatic Tapestry: A Case Study

INTRODUCTION:

Exploring the often-overlooked distinction between adverse extrapyramidal, negative, and catatonic symptoms in schizophrenia research. These symptom sets pose challenges due to their phenomenological overlap. We present a case report of a patient on oral antipsychotics, exhibiting residual negative symptoms and subtle catatonic features, shedding light on this complex issue.

CASE DESCRIPTION:

A 28-year-old unmarried male, diagnosed with Paranoid Schizophrenia for two years, initially showed a remission of positive symptoms with oral antipsychotics. However, history revealed social withdrawal, reduced spontaneous speech, and coaxing for food and self-care. During In patient care, on further mental status examination, patient was seen to be having reduced blink rate, reduced psychomotor activity, speech having increased reaction time , reduced tone, tempo, volume, poverty of speech, flat affect which initially resembled negative symptoms. However, with no evidence of Extrapyramidal Symptoms and the persistence of above symptoms alongside the emergence of ambivalence, raised a suspicion of catatonia. As a result, the Bush Francis Catatonia Rating Scale was administered, and a Lorazepam challenge test was conducted, resulting in a substantial reduction in the score. Subsequent amelioration was achieved through the administration of Tab.Lorazepam at 6mg/day, followed by a gradual tapering regimen, with no recurrence of catatonic symptoms.

CONCLUSION:

This case underscores the complexity of distinguishing schizophrenia symptoms, emphasizing the potential for misinterpretation. It highlights the importance of careful assessment and the need for clinicians to remain vigilant in considering catatonia in atypical presentations. Precise symptom differentiation is vital for accurate diagnosis, prognosis, and the development of effective treatment strategies in schizophrenia.

Dr. Mekhala Divakar¹, *Dr. Ankitha M Shenoy², Dr. Jonathan³, Dr. Smitha T⁴, Dr. Shrinivasa Bhat U⁵

1-Junior Resident, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

2-Senior Resident, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

3- Senior Resident, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

4- Assistant Professor, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

5- Professor, Department of Psychiatry, K.S. Hegde Medical Academy, Mangaluru, Karnataka, India

Unravelling the Association of Long-COVID Neuropsychiatric Sequelae with Symptomatic COVID, Vaccination and Life Events: A Cross-Sectional Study

Poulami Laha¹*, Guru S Gowda¹, V Senthil Kumar Reddi¹, Harish T¹, Sydney Moirangthem¹, H B Veenakumari², B Binukumar³

1 – Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India

2 – Department of Neuromicrobiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India

3 – Department of Biostatistics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India

Aims/objectives: Worldwide, several studies have examined neuropsychiatric sequelae in Long COVID. However, there are limited studies from India on post-COVID neuropsychiatric sequelae and the impact of individuals’ vaccination status and life events on those. This study aims to determine the point prevalence of neuropsychiatric sequelae in individuals recovering from COVID-19 and examine the association of symptomatic COVID, vaccination and life events on these symptoms.

Methodology: This is a cross-sectional study. We randomly selected 2,282 individuals aged 18 to 60 years who had previously tested positive for COVID-19 between June 1, 2020, and March 31, 2022, at the NIMHANS. Among them, 927 individuals who met the study criteria were assessed through telephonic interviews using post-COVID neuropsychiatric manifestations screening tool and life stress inventory. Descriptive statistics, Chi² test, T-test, and ANOVA test were used for data analysis.

Results: The point prevalence of neuropsychiatric sequelae among post-COVID patients observed 22 months after COVID-19 infection was 21.5%. Of individuals who experienced life events, 70.8% (17 out of 24) developed neuropsychiatric sequelae. Long COVID neuropsychiatric sequelae are significantly associated with increased age [t(925)= -5.14, p=0.001], female gender (X²=13.6; P<0.001), symptomatic COVID infection(X²=41.6; P<0.001), hospital admission(X²=53.8; P<0.001), oxygen supplementation(X²=34.8; P<0.001), multiple times of COVID infection(X²=64.2; P<0.001). Vaccination before COVID infection is protective against neuropsychiatric sequelae (X²=12.5; P=0.002).

Discussion: This finding suggests that the symptomatic COVID-19 infection, vaccination and life events play a role in the development of long COVID neuropsychiatric symptoms. Importantly, these findings are comparable to studies conducted in Western countries, highlighting worldwide impact of COVID-19.

Conclusion: Long COVID neuropsychiatric sequelae are linked to both the severity of the COVID-19 infection and various life events. Vaccination prior to infection found to be protective. This finding underscores that the repercussions of COVID-19 extend beyond its physiological impact, indicating that life events contribute significantly to the well-being of COVID-survivors.

“Whispers of Temptation” – The Connection between Auditory Hallucinations and Substance Use Disorder in Schizophrenia Patients.

Dr. Alvin Joseph, Dr. Sachin Nagendrappa, Dr. Priya Sreedaran

Introduction

Schizophrenia and substance use disorder (SUD) are chronic conditions that impose significant burdens on individuals and society. Research has revealed a substantial prevalence of SUDs in individuals with schizophrenia or first-episode psychosis, with rates for various substances, such as illicit drugs, cannabis, alcohol, and stimulants. The self-medication hypothesis suggests that some individuals with schizophrenia may resort to substance use as a means to alleviate symptoms or counter the side effects of antipsychotic medications.

Case Series

1. Mr. A, a 34-year-old man with a 5-year history of drug-naïve schizophrenia, presented with predominantly auditory hallucinations. At one point, he heard voices urging him to use cannabis. Although the voices did not improve, he continued using cannabis because he believed it enhanced his attention. With Risperidone treatment, his hallucinations improved, and he voluntarily ceased using cannabis.

2. Mr. D, an 18-year-old male with a 6-month illness duration characterized by predominantly negative symptoms, reported a dependence on nicotine, with a family history of substance dependence but no history of psychosis. He noticed improved mood and motivation after smoking, leading to an increase in daily cigarette consumption. Treatment with Amisulpiride resulted in symptomatic remission, accompanied by a reduction in smoking.

3. Mr. G, a 24-year-old postgraduate student, exhibited academic decline, withdrawn behaviour, delusions of persecution and reference, and a 2-year history of untreated illness. Upon hospitalization, cannabis use was discovered. After initiating Olanzapine treatment, he reported using cannabis to aid concentration for exams. With symptom improvement and psychoeducation, he discontinued cannabis use.

Discussion

This case series sheds light on a unique presentation of substance use disorder in schizophrenia patients, notably linked to auditory hallucinations. The “reward deficiency syndrome” hypothesis proposes that individuals with reduced reward-related brain activity may turn to substances as a form of self-medication. This behaviour might precede psychosis and potentially alleviate cognitive deficits and negative symptoms. Additionally, the high prevalence of substance use in the close relatives of individuals with schizophrenia could be attributed to reward circuitry abnormalities or attempts to self-medicate milder symptoms. Conversely, the cumulative risk factor hypothesis suggests that the co-occurrence of schizophrenia and SUD arises from a combination of factors, including cognitive impairments, social isolation, limited opportunities, poverty, victimization, and adverse social environments. Managing both conditions concurrently pose challenges, leading to worse outcomes and increased susceptibility to illness and injury. The diathesis-stress model further underscores the role of neurobiological vulnerability and environmental stressors, including substance use, in the development of schizophrenia. This multifaceted interplay between auditory hallucinations, substance use, and schizophrenia warrants further investigation to inform tailored interventions for affected individuals.

E poster: Abstract: William-Beuren’s Syndrome- A case report

Presenting author: Dr U. Indhu Priyadharshini, 3^rd year Postgraduate, Thanjavur medical college hospital.

Co Authors:

Dr. K.Balamurali M.D, D.M(Neurology) Professor & HOD incharge Dr.G.Anbazhagan D.P.M.,M.D(Psy) Senior Assistant Professor., Dr.A.R.Shanmugapriya D.C.H.,M.D(Psy),Assistant Professor, Department of Psychiatry, Thanjavur medical college hospital, Thanjavur, Tamilnadu

Background:

It is an autosomal dominant disorder due to 7q11.23 deletion which is characterized by distinctive facies and multisystem involvement. The patients have distinct personality characteristics, developmental delay, and intellectual disability.

Case report:

A 3-year-old male child came with a history of global developmental delay and language deficit. The child was not able to identify objects and was uttering only monosyllables. He was clinically evaluated and psychologically assessed and found to have mild deficit in social and adaptive functioning based on Vineland social maturity scale. The child also had dysmorphic facies, micro-cephaly and hypothyroidism. Congenital right inguinal hernia correction done. MRI brain shows features suggestive of Arnold-Chiari type 1 malformation with hydromyelia.

Discussion:

The above-mentioned features were suggestive of William syndrome and has been proved by chromosomal microarray analysis which showed heterozygous deletion of 2.8Mb of 7q11.23.

Conclusion:

Developmental disabilities are addressed by early intervention programs, special education programs. These programs include speech-language, physical, occupational, eating, and sensory integration therapy.

Mail id: dharshini990@gmail.com

Mobile number: 9600599167

Category - Free Poster: Valproate induced psoriasis: An anomalous relationship

1.Principal author - Dr. Anusha Aggarwal (LOM/A61/23) - Junior Resident, Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, 248001, Uttarakhand, India

Co-Authors -

2.Dr. Neeti Kumari - Professor, DVL, Shri Guru Ram Rai Institute of Medical and Health Sciences, 248001, Uttarakhand, India

3.Dr. Shobit Garg (LF1906502018) - Professor, Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, 248001, Uttarakhand, India

4.Dr. Mohan Dhyani (LF130272): Professor and Head of Department, Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, 248001, Dehradun, Uttarakhand

Correspondence:

Dr. Anusha Aggarwal

Junior Resident, Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India

Pin code: 248001

Email address: aggarwalanusha32@gmail.com Phone no.: 8054671984

Word count: 236 (Abstract)

Background: Psoriasis is a common skin disorder with unknown etiology which may be induced or triggered by medications, infections, and stress. Drugs including sodium valproate may exacerbate pre-existing psoriasis, or precipitate the illness, but there only have been few cases reported till date where valproate is the associated drug.

Aims: We report a patient with exacerbation of psoriasiform drug eruption associated with the use of sodium valproate

Methods: Patient is a 53yr old male, diagnosed with psychosis and epilepsy and was started on sodium valproate 2 years back for the same. He is a known case of psoriasis for last 5 years with no family history. For last few weeks there were development of multiple sharply demarcated erythematous indurated scaly plaques of variable size. Citing non- response to methotrexate therapy, sodium valproate was suspected as an exacerbating agent and the patient was then referred to psychiatry department.

Results: The daily dose was reduced to 250mg and after 5 days, his lesions cleared up to a substantial amount. Patient was started on lacosamide 200 mg in divided dose for controlling the seizures. Patient was continued on paliperidone (6 mg per day) for comorbid psychotic symptom

Conclusion: Valproic acid may exacerbate psoriasis by acting as a superantigen through the major histocompatibility complex. Since it has a half -life of around 15 hours, this may explain why the subject’s skin lesions significantly improved within a week after the medicine was stopped.