POSTERS

. 2015 Jan;57(Suppl 1):S113–S159.

POSTERS

PMCID: PMC4333352

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A case report on parapherenia at an early age

Neha Sayeed

cip, India, neha.

E-mail: s.cip@gmail.com

Keyword: Delusion, neurosis, cognitive behavior therapy.

Background: This case is having psychiatric symptoms manifestation resembling psychosis. The diagnostic clarification gives a picture of a neurotic case. It resembles a case of parapherenia at an early age but the onset is usually at a later age. Pharmacological treatment and psychological therapy treated the individual successfully. So, there is a need for understanding this entity by the mental health professionals.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Establishing a psychosomatic clinic: Opportunities and challenges

Vikas Menon, Siddharth Sarkar, Shijo Thomas

JIPMER, India,

E-mail: drvmenon@gmail.com, sidsarkar22@gmail.com, shijoppan@gmail.com

Keyword: Psychosomatic, somatoform, clinic, starting

Introduction: Establishing a specialized clinic can help in focused attention towards a particular disorder and building an expertise in the management of the condition. We describe our experience and challenges in setting up a clinic for dealing with psychosomatic disorders.

Materials and Methods: The Psychosomatic Clinic was opened in the department of psychiatry of JIPMER, Puducherry, India. The weekly clinic was aimed to cater to patients with unexplained somatic symptoms seeking treatment referred from any department of the hospital. The services in the clinic were provided by a multimodal team comprising the psychiatry consultant, resident, psychiatric social worker and clinical psychologist.

Results: Fifty three patients were registered in the clinic in the first 8 months of service. Of them, 27 were females (50. 9%), 43 were married (81. 8%), 35 belonged to a nuclear family (66. 0%), and 32 were employed (60. 4%). The median age of the sample was 35 years (range 14 to 60 years) with median education being 6^th standard and median per-capita income of Rs 1200 per month. The most common diagnoses included depression in 15 patients (28. 3%), undifferentiated somatoform disorder in 10 (18. 9%) and somatoform pain disorder in 8 (15. 1%). Somatization disorder was encountered in only 1 subject and 2 individuals were found to have physical disorder only. The referral diagnosis matched with the clinic diagnosis in 18 out of 42 patients (42. 9%) where a referral diagnosis was provided. Forty four of the patients were prescribed medications, 23 were offered some form of psychotherapy and 7 were suggested referrals to other departments.

Discussion: The results are partially in line with existent literature. The clinic provided opportunity for detailed assessment of patients with psychosomatic disorders. It provided an opportunity for better training for the residents, as well as furthered experience of clinical psychologist and psychiatric social workers. Further plans include formal collaboration with medicine department, and establishing groups for psychotherapy.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Case report-NMS in a mentally retarded patient with low dose of T. Risperidone

Shyam Sundar^*, Abu Philip, Deepa Braganza

Christian Medical college, India.

E-mails: drsam111@gmail.com, deepa@cmcvellore.ac.in

Keyword: Mental retardation, neuroleptic malignant syndrome, Risperidone.

Background: NMS appears to have increased incidence rate in people with intellectual disabilities although the exact mechanisms behind this are not clear. In people with mental retardation, the classical symptoms may not be always present and also might be difficult to elicit as most of them are not able to have an effective verbal communication. The early detection of NMS in this special population is a challenge. Also, the chances of long term morbidity and mortality secondary to NMS remain high in people with mental retardation. This case report describes about a patient with moderate mental retardation who developed NMS secondary to treatment with just 2mg of Tab. Risperidone. The diagnosis of NMS was difficult in this case as patient was not able to have effective verbal communication (secondary to mental retardation) and also considering the fact that NMS is least expected with such a minimal dose of anti-psychotic medication. We would recommend that psychotropic drug use in people with mental retardation requires special precaution and they should be closely monitored for development of any adverse effects. This case report also supports previous studies employing ECT as an effective and safe therapeutic option for people with mental retardation in the recovery phase of NMS. More detailed studies need to be done to find out the various factors associated with low tolerance of this special population to various psycho-tropic drugs.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A comparative study on early onset and late onset alcohol dependence patients

Prabhu Nagarajan, Karthik Murugan Selvaraj

Sri Ramachandra medical college & research institute, India,

E-mails: drmyprabhu@gmail.com, drkarthikms2008@gmail.com

Keyword: Alcohol dependence, severity, early onset, and late onset.

Objectives: The present aimed to compare the early onset and late onset alcohol dependent patients on their demographic, family history of alcohol dependence, severity of dependence and alcohol induced psychiatric disorders.

Methodology: For this purpose, cross sectional structured assessment of these variables was carried out in a sample of 50 patients with early onset and 50 patients with late onset dependence.

Results: Patients in the early onset group mostly were young adults, school dropouts, hailed from urban background and belonged to low socio economic strata. In the late onset group, most were middle aged males, completed their schooling and graduation, hailed from urban background and belonged to low to middle socio economic strata. As we aimed, the current study clearly showed the age of onset of drinking, duration of drinking and age of onset of dependence, amount of alcohol consumed were significantly different between two groups. The family history of alcohol dependence was significantly more in early onset dependent drinkers. Furthermore the severity of alcohol dependence was more in early onset dependence. However there was no significant difference in the prevalence of alcohol induced psychiatric disorders between the groups.

Conclusion: This study demonstrated that the early onset and late alcohol dependents patients were significantly different in their age of onset of drinking, age of onset of dependence, family history of alcohol dependence, and severity of dependence.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Serum cholesterol and first episode psychosis: Links to suicidality

Amresh Shrivastava, Megan Johnston¹, Avinash Desousa², Nilesh Shah³

¹University of Western Ontario Canada, Canada, ²University of Toronto Canada, Canada, ³Lokmanya Tilak Municipal Medical College, India,

E-mail: dr.amresh@gmail.com, mjo@utoronto.ca, avinashdes888@gmail.com, drnilshah@hotmail.com

Keyword: Cholesterol, suicide, schizophrenia, first episode psychosis

Background: Suicide is the most common cause of mortality in schizophrenia. Dysregulation of cholesterol, specifically lower levels is common in suicide. Cholesterol plays an important role in distinguishing suicidal from non-suicidal patients, indicating that suicidality is determined by many different factors including the time of treatment in schizophrenia and the relationship of suicidality in psychosis and cholesterol remains complex.

Aim: The present study examines levels of cholesterol in a cohort of early psychosis with low and high suicidality.

Materials and Method: Sixty admitted patients with a DSM-IV diagnosis of early psychosis (schizophrenia) were assessed for mild and severe suicidality by using the SIS-MAP. Psychopathology was assessed with the PANSS and HDRS. The data on serum cholesterol was compared between the groups showing low and high suicidality and psychopathology.

Statistics: ANOVA and other statistical measures were used.

Results and Discussion: Serum cholesterol showed no abnormality (210 mg/dl, NS) in the cohort of early psychosis patients. Patients with low-suicidality (SIS-MAP <10) also did not show any abnormality in levels of cholesterol (203 mg/dl, NS). Low levels of cholesterol were observed in a subgroup with severe suicidality (SIS-MAP >30 ; 156 mg/dl, P < 0.3) and severe depression (HDRS >20, 156 mg/dl P < 0. 03).

Conclusions: The study shows that serum cholesterol does not show any abnormality in early psychosis however, lower levels are observed in patients of psychosis with severe suicidality. The finding raises some undetermined aspect of correlations among cholesterol, depression in psychosis, and severity of suicidality.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Poster

Nathalia Elizabeth Chacko, Sathesh Elizabeth Vadasseril¹

vazhayil house, India, ¹medical college kottayam, India,

E-mail: nathalia.ec@gmail.com

Keyword: Duration of untreated psychosis, premorbid adjustment, first episode psychosis, executive dysfunction

Background: Patients with psychosis exhibit wide-ranging impairments on neuropsychological tasks, compared to healthy subjects, including tasks measuring memory, attention, and executive function. However, lack of methodological rigor prevents firm conclusions about selective deficits in the first episode psychosis. A further delineation of dysfunctional cognitive processes would provide information about the neurobiology of the disorder as well as contribute to its rehabilitation.

Objectives: To study the relationship between duration of untreated psychosis, premorbid illness factors, and clinical symptoms in patients with Executive dysfunction.

Materials and Methods: 30 first episode psychosis patients from psychiatry ward of medical college kottayam was taken as cases and 30 healthy people(matched for age, sex, education)were taken as control. Both were subjected to tests of executive function under similar conditions, and the cases and controls were compared in terms of their performance on tests of executive functioning. An intragroup analysis was done among cases to see the correlation between their performance on tests of executive functioning and premorbid adjustment score, PANSS, duration of untreated psychosis. The results were obtained by statistical analysis on SPSS software.

Results: There was significant difference between the performance on tests of executive functions by cases and controls. There was negative correlation of duration of untreated psychosis& premorbid adjustment score with executive functions, but there was no significant association of symptom profile with executive functions.

Conclusion: Executive Functioning was poor when the premorbid adjustment score was high, and when the duration of untreated psychosis increased. In patients with poorer premorbid adjustment, there was poor executive functioning, and in people with longer duration of untreated psychosis, there was poor executive functioning Few relationships were found between clinical and neurocognitive indices, suggesting that the two domains are relatively independent. So we can conclude from the present study that longer duration of untreated psychosis had a neurotoxic effect on cases and premorbid adjustment was a marker of the neurodevelopment.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Testosterone and its relevance to psychopathology in first episode schizophrenia

Amresh Shrivastava, Megan Johnston¹, Avinash Desousa², Nilesh Shah², Robbie Campbell³

University of Western Ontario Canada, Canada, ¹University of Toronto Canada, Canada, ²Lokmanya Tilak Municipal Medical College, India, ⁴Western Unversity Regional Mental Health Care London Ontario Canada, Canada,

E-mails: dr.amresh@gmail.com, mjo@utoronto.ca, avinashdes888@gmail.com, drnilshah@hotmail.com, robbiecampbell@gmail.com

Keyword: testosterone, schizophrenia, first episode psychosis, psychopathology

Background: Neurohormones are well known modulators of neurochemical changes and play a significant role in the pathophysiology of schizophrenia. Dehydroepiandrosterone sulfate (DHEAS), Neuroactive steroids, and other sex hormones, may have an adjunctive role in reversing or slowing the progression of negative symptoms. This study examines level of testosterone in First episode schizophrenia to see if it changes with treatment.

Materials and Method: Sixty admitted patients with a DSM-IV diagnosis of DSM IV non-affective schizophrenia spectrum disorder (early psychosis) were assessed is a naturalistic cross-sectional, cohort study. Psychopathology was assessed with the PANSS and HDRS and locally developed scale for assessment of Suicidality (SIS-MAP). Patients were treated for 6 months duration, in a ‘treatment as usual’ design in naturalistic impatient and outpatient setting in an Early Psychosis Intervention program at the regional mental health care center. St Thomas, Ontario, Canada. Levels of testosterone were estimated at the baseline and at the end of three months of treatment.

Result: Patients who completed the study (n = 29) the study were having mean age 32. 2 (9. 2) Years, duration, of illness 9. 8 (3. 5) months, positive symptom score 25. 8 (7. 5), negative symptom score 18. 8 (6. 8), SISMAP score of 23. 0 (11. 1) (suggests moderate suicide risk). Base line Testosterone level was 11. 0 (9. 1) and post treatment 9. 1 (7. 9). Both levels were lower that normal limits (18-144) mmol/ml. positive symptoms at base was s significantly associated with the change in Testosterone (P =. 032).

Conclusion: Testosterone level patients of first episode schizophrenia in early phase lower than normal limit and remains lower after 6 months treatment with antipsyhcotics. Positive symptoms were found to be significantly associated with change in pre and post treatment levels of testosterone.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychiatric treatment as anti-stigma intervention: objective assessment of stigma by families

Amresh Shrivastava, Megan Johnston¹, Avinash Desousa², Sushma Sonavane², Nilesh Shah²

University of Western Ontario Canada, Canada, ¹University of Toronto Canada, Canada, ²Lokmanya Tilak Municipal Medical College, India.

E-mail: dr.amresh@gmail.com, mjo@utoronto. ca, avinashdes888@ gmail.com, sushma_son@rediffmail.com, drnilshah@hotmail.com

Keyword: Stigma, treatment, schizophrenia

Background: Stigma related to mental illness is linked with suicide, violence, and lack of self care, and thus should be treated as a clinical condition. For effective intervention, objective information about the impact of stigma is required in order to offer the best client-centred care.

Aims: The present study seeks to answer the question of how stigma and discrimination are perceived to be experienced by their patient family members, to determine factors helpful for development of anti-stigma intervention programs.

Statistics: Appropriate measures were used in the assessment.

Materials and Method: Three hundred family members of patients with schizophrenia provided their perceptions on aspects of stigma including anti-stigma interventions. There were two types of intervention strategies suggested 1) clinical measures, and 2) public health measures. The predominant strategy was clinical measures which encompassed areas of availability of treatment, complete treatment, relapse prevention, and early intervention.

Results: Furthermore, caregivers’ emotional involvement (64. 8%) in treatment was seen as an important measure to reduce stigma. No social and public awareness is going to bring change in patients’ lives if stigma is not addressed at an individual level in a client-centric manner.

Conclusions: The responses of patient relatives clearly bring out this opinion when they suggest potential treatment components as intervention measures.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Delusional parasitosis: An analysis of 25 cases

Harshall Sathe, Avinash Desousa, Sushma Sonavane, Anup Bharati, Nilesh Shah

Lokmanya Tilak Municipal Medical College, India,

Email: satheharshall9@gmail.com, avinashdes888@gmail.com, sushma_son@rediffmail.com, dranupsb@gmail.com, drnilshah@hotmail.com

Keyword: delusional parasitosis, delusional disorder

Background: Delusional parasitosis (DP) is a condition in which a person has the unshakeable and mistaken belief of being infested with parasites. It is one of commonest delusional disorders that presents to the psychiatrist

Patients and Methods: All patients with DP were seen in a tertiary general hospital of Mumbai. The case histories of all 25 patients were discussed and variations in presentations were discussed.

Results: The patients with DP were predominantly above 30 years of age, with medical co-morbidities and presented with a variety of symptoms and signs. The patients were prescribed various antipsychotics including the atypical antipsychotics. Response was variable, and the patients often defaulted follow-up.

Conclusions: An approach to the management of DP is proposed together with a review of the literature and need of further research.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Neuroendocrine factors in first episode psychosis: Focus on TSH

Amresh Shrivastava, Avinash Desousa¹, Nilesh Shah¹

University of Western Ontario Canada, Canada, ¹Lokmanya Tilak Municipal Medical College,

E-mail: dr.amresh@gmail.com, avinashdes888@gmail.com, drnilshah@hotmail.com

Keyword: Thyroid, TSH, schizophrenia, first episode psychosis

Background: Thyroid hormones play an important role in the emotional regulation in people suffering from schizophrenia. Low level of TSH is observed in psychosis due to increased sensitivity of adrenoreceptor and dopaminergic activity and relationship between suicidal behavior and hypothalamic-pituitary thyroid (HPT) axis.

Aim: The present study examines the role of thyroid hormone in early phase of schizophrenia, particularly in relation to suicide attempt.

Materials and Methods: We recruited 60 patients of schizophrenia as per DSM-IVTR criteria. Primary outcome criteria was the level of TSH in patients with diagnosis of early psychosis and its correlation with severity of psychopathology.

Statistics: Fischers test and unpaired t test was used where needed.

Results and Discussion: We found that 13 (21%) patients of 60 were hospitalized with a suicide attempt within preceding 5 days. Mean TSH level was 5. 8 which was slightly higher than cut-off point. There was no significant difference in TSH levels between those who had attempted suicide and those who did not, before the admission into the hospital. Further level of TSH was not found to correlate with total PANSS score, positive symptoms or negative symptoms score.

Conclusion: The present study shows presence of higher TSH levels in early psychosis and inverse correlation with suicide potential in patients suffering from schizophrenia. Further it shows presence of high suicide risk and possibility of hypothyroid state. The study argues more careful screening for suicide in patients with early psychosis amongst patients who are admitted without an attempt of suicide.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Obsessive compulsive disorder following resection of a cerebellar vermian mass

Harshall Sathe, Avinash Desousa, Nilesh Shah, Anup Bharati

Lokmanya Tilak Municipal Medical College, India,

E-mail: satheharshall9@gmail.com, avinashdes888@gmail.com, drnilshah@hotmail.com, dranupsb@gmail.com

Keyword: Cerebellum, vermis, obsessive compulsive disorder

Background: The cerebellum has been implicated in the neurobiology of various neuropsychiatric disorders like autism, ADHD, schizophrenia and obsessive compulsive disorder. The cerebellar cognitive affective circuits play an important role in the pathogenesis of symptoms in these disorders.

Objective: The paper describes a case of an adolescent who had a space occupying lesion in the vermis of the cerebellum which was removed neurosurgically and then developed obsessive compulsive disorder.

Results: The various antecedents, history and progress of the case is discussed and connection between cerebellar function and the emergence of obsessive compulsive symptoms are postulated. Various trajectories are debated and discussed.

Conclusion: The cerebellum is a vital structure from a neurobiological perspective and this area warrants further investigation

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Narcolepsy following the removal of a craniopharyngioma: A case report

Hardik Sheth, Avinash Desousa, Nilesh Shah

Lokmanya Tilak Municipal Medical College, India.

E-mails: shethhardik88@gmail.com, avinashdes888@gmail.com, drnilshah@hotmail.com

Keyword: Craniopharyngioma, narcolepsy, sleep

Background: Craniopharyngiomas are rare tumors of the pituitary gland and very little has been documented about psychopathology associated with the lesion. The pituitary gland via its various axes however has intense ramification for al psychiatric disorders.

Objective: The paper describes a case of a child who had a craniopharyngioma which was neurosurgically resected following which he developed narcolepsy.

Results: The various mechanisms linking craniopharyngiomas and narcolepsy are discussed along with the presentation and progress of the case and the treatment options available. The role of organic lesions and endocrine factors in the development of narcolepsy are debated.

Conclusions: This is an interesting clinical finding and shall need further investigation and discussion

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Childhood onset trichotillomania: comorbidity and presentation

Chandan Narankar, Avinash Desousa, Sushma Sonavane

Lokmanya Tilak Municipal Medical College, India.

E-mails: chandan.narankar@rediffmail.com, avinashdes888@gmail.com, sushma_son@rediffmail.com

Keyword: Childhood onset trichotillomania, hair pulling, child psychiatry

Background: Childhood onset trichotillomania (TTM) is associated with significant morbidity, comorbidity, and functional impairment. Important questions remain unanswered about its phenomenology, comorbid symptoms, functional impact, and treatment utilization in youth.

Objective: The current study was decriptive and clinical and designed to provide an initial description of these factors using a convenience sample.

Materials and Methods: A survey of all patients with childhood onset trichotillomania seen over the past 10 years.

Results: Surveys completed by 78 cases aged 6 to 15 were analyzed. Scalp hair was the most common pulling site, followed by eyelashes and eyebrows. Multiple presentation which varied and huge comorbidity was reported both primary and secondary. Implications of comorbidity for treatment are discussed. Treatment options used and efficacy were studied.

Conclusions: This study represents the largest survey of childhood onset trichotillomania in India conducted so far, and thus provides a good description of trichotillomania.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Cerebroprotein hydrolysate in dementia: An analysis of 24 cases

Mosam Phirke, Avinash Desousa, Nilesh Shah, Sushma Sonavane, Anup Bharati

Lokmanya Tilak Municipal Medical College, India.

E-mails: mosamphirke86@gmail.com, India, avinashdes888@gmail.com, India, drnilshah@hotmail.com, sushma_son@rediffmail.com, dranupsb@gmail.com

Keyword: Cerebroprotein hydolysate, dementia, cognition, MMSE

Background: Cerebroprotein hydrolysate is a protein derivative that contains a mixture of neuroproteins and has been documented to be useful in the management of dementia. Unlike other dementia drugs like the anticholinesterases it needs to be given in an injectable form and needs regular monitoring.

Objectives: The case series describes a series of patients with various types of dementia, head injury and other neurodegenerative conditions that received cerberoprotein hydrolysate along with other psychopharmacological treatments

Materials and Methods: All patients received treatment on an inpatient basis and were given intravenous cerebroprotein hydrolysate while one patient received the intramuscular version.

Results: Most patients in the case series showed improvement in various areas of mental status, memory and certain areas of neurological function. This was documented via clinical assessment and interview of the patient and relatives as well as via Mini Mental Status Examination (MMSE) and Adenbrooks Cognitive Examination Revised (ACER). The results are discussed in the light of the failure of many drugs to produce significant improvement in dementia.

Conclusions: Cerebroprotein hydrolysate is a useful treatment option in head injury, dementia and other neurodegenarative disorders and needs further exploration.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A study on internet and smartphone addiction amongst school children in an urban setting

Payal Sharma, Avinash Desousa, Sushma Sonavane, Nilesh Shah

Lokmanya Tilak Municipal Medical College, India.

E-mails: sharmapayal0809@gmail.com, avinashdes888@gmail.com, sushma_son@rediffmail.com, drnilshah@hotmail.com

Keyword: Internet addiction, smartphone addiction

Background: Internet addiction is now recognized as a disorder under research in DSM 5. Smartphone addiction is a new entity that has been recognized as a behavioural addiction worldwide. These two addictions are rising and are more common in the adolescent population.

Objectives: The following study is an asessment of school children from grade 7 to grade 10 and looks at the prevalence of internet addiction and smartphone addiction in this population.

Materials and Methods: All the subjects were administered the Youngs Internet Addiction Scale and Smartphone Addiction Inventory and the scores obtained were assessed and analyzed in the light of various demographic factors.

Results: The results are not fully yet tabulated as the analysis is underway.

Discussion: The results shall be discussed in the light of various factors and causes for increased prevalence of these disorders shall be discussed and mechanisms shall be hypothesized.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Disruptive mood dysregulation disorder: A case series

Radhika Majlikar, Avinash Desousa, Nilesh Shah, Sushma Sonavane

Lokmanya Tilak Municipal Medical College, India.

E-mails: radhika409@yahoo.com, avinashdes888@gmail.com, drnilshah@hotmail.com, sushma_son@rediffmail.com

Keyword: Disruptive mood dysregulation disorder, depression, irritability

Background: Disruptive mood dysregulation disorder (DMDD) is a new child psychiatry disorder under the mood disorders section in DSM 5. There is scarcity of research on the disorder as well ias its course and prognosis.

Objectives: The present paper gives a brief clinical summary of the construct of DMDD and certain clinical implications and variables related to the same. A case series of 5 cases are discussed.

Results: The nature and presentation of these cases and diagnostics of DMDD are discussed along with treatment options and management issues. There is also discussion on the neurobiology and long term management of these patients.

Conclusions: DMDD is a disorder which is very relevant in child psychiatry practice and needs further exploration and research.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Personality profile and academic performance: Relationship in clinical year of medical education

Virendra Vikram Singh, Pookala Shivaram Bhat, Surender Sharma

Armed Forces Medical Services, India.

E-mails: virvik@gmail.com, bhatshivaram@rediffmail.com, sursharma_79@yahoo.com

Keyword: Personality, academic performance, medical students, clinical year

Background: Besides Cognitive abilities, a blend of personality characteristics is thought to be important for people to be successful as medical students. Previous studies from west found that students scoring high for conscientiousness have been more likely to have higher grades. We earlier found similar result for undergraduates in first year of medical education in India. Is it true for clinical year as well?

Objective: To study the relationship of personality profile of medical students in clinical year with their academic performance.

Materials and Methods: Study was conducted in a government medical college in Pune. 98 students of final year MBBS participated in the study. They completed 240 item NEO-PI-R questionnaire for assessment of personality domains of five factor personality theory. For academic performance percentage of aggregate marks scored in final (clinical) year university exam were recorded. Pearson correlation coefficient was calculated for relationship. Multiple regression analysis of the personality domains was also performed with percent marks as dependent variable.

Results: Students scored in marginally high range for Neuroticism, average for Extroversion, Conscientiousness and Openness and marginally low for Agreeableness. Conscientiousness and Agreeableness domains were found to be significantly correlated with academic performance after controlling for other significant contributors like gender and academic performance in XII class. Personality significantly predicted academic performance.

Conclusions: Personality factors predict academic performance in medical education. Addition of personality profile to commonly used cognitive abilities increases the predictability of academic performance in medical education. Some selectors in west have advocated the use of this knowledge in selecting medical students. Assistance and selective focusing during medical education are other areas it can be useful.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Gratification behaviour in a young children course and management

Aditya Pandurangi, Swapna Satyanarayan

DIMHANS, India.

E-mails: pandurangi.aditya@gmail.com, pandurangi.swapna@gmail.com

Keyword: Gratification Disorder, Infantile Masturbation, Behavioural techniques, gratification behaviour

Background: Masturbation (Gratification behaviour) is rarely seen in young children. It occurs in 90% to 94% of males and 50% to 60% of females at some point in their lives. Gratification behaviour in excess leading to discomfort and disability (gratification disorder) is rarely seen in young children. It occurs in children between age of 3 months and 3 years with a second peak incidence at about the adolescent age.

Objective: Though the concept of childhood masturbation was recognized as early as 1909, there is limited literature regarding the treatment methods and long-term follow-up of children with masturbatory behaviour.

Methodology: A 26 month old child, who presented to us with gratification behaviour was followed up for 18 months. The parents were counseled and 6 sessions of behaviour therapy was carried out.

Result: Reassuring the parents and behaviour therapy helped in stopping the masturbatory behaviour completely. But the re-emergence of such episodes suggests that such children need regular follow up and continuation of behavioural management.

Conclusion: Gratification behaviour can be seen in young children and it is not pathological. Reassuring the parents and following regular behaviour techniques by parents help in reducing the masturbatory behaviour. Waxing and waning of the symptoms may be present.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Pre Morbid adjustment in Schizophrenia: A comparison with Bipolar Affective Disorder using Pre morbid adjustment scale.

Anagha Abhoy Sinha, Prakash Balkrishna Behere

JNMC, DMIMS (DU), Sawangi Meghe, Wardha, India.

E-mails: anaghasinha19@gmail.com, pbbehere@gmail.com

Keyword: Schizophrenia, bipolar affective disorder, adjustment, pre morbid

Background:

Aims & Objectives-
To find if patients of schizophrenia and Bipolar affective disorder show poor social adjustment in childhood and adolescence compared with healthy subjects
To find how large are their effects and which domains of functioning are affected.

Methodology: In a cross- sectional study, carried out by purposive sampling, 150 patients were included, 60 (schizophrenia), 60 (Bipolar affective disorder-BPAD), 30 (controls), attending the services of Department of Psychiatry at JNMC, AVBRH Wardha, where the diagnosis was made on the basis of ICD -10. The GHQ-12 was used to assess and select the controls for this study. The Modified pre morbid adjustment scale was applied to all patients from three groups, after obtaining a written and informed consent from them.

Results: The patients with schizophrenia had significantly poorer adjustment in adolescence and adulthood as compared to BPAD and controls. The Bipolar patients showed a poor score at work as compared to Schizophrenia and Controls in adolescence. The P value for each of the four groups was significant. The average score for Schizophrenia was 0. 18 +/- 0. 2. This was much higher than Bipolar. (0. 12+/- 0. 01) & Control (0. 09 +/- 0. 04), indicating adjustment to be worse in schizophrenia.

Conclusion: Pre morbid adjustment is worse in patients who later develop Schizophrenia when compared to Bipolar and Controls. The difference between normal individual’s adjustment to that of patient developing Schizophrenia later in life appears to be severe.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Levosulpride induced parkinsonism

Shahbaaz Ali Khan, Shagufta Ali Khan¹

Base Hospital Delhi Cantt, ¹Freelance, India, Shagufta. India.

E-mails: shahbaaz323@yahoo.com, khan@gmail.com

Keyword: Levosulpride, parkinsonism, adverse effect, antipsychotic

Background: Parkinsonian side effects like rigidity, tremors, and slowness are well known adverse effect of antipsychotics. Levosulpride is a novel drug with antipsychotic, antidepressant, antiemetic and antidyspeptic actions. It is used extensively by the general physicians and Gastroenterologists for non specific dyspepsia, Acid peptic disease, GERD etc either singly or in combination. There is no evidence with respect to adverse effect profile of Levosulpride in the Indian literature.

Case Summary: We report a case of Levosulpride induced parkinsonism with elevated serum prolactin level in a female patient with fracture femur.

Discussion: There are very few evidence of the occurrence of DIP induced by Levosulpride in the Indian literature till date. In the present case reported by us, patient experienced the distressing adverse effect of Parkinsonism which was misinterpreted as aftermath of fall and fracture femur. After discontinuation of Levosulpiride, DIP resolved.

Conclusion: DIP is important because it is frequently either unrecognized or misdiagnosed as PD. In addition, parkinsonism in DIP patients is sufficiently severe to affect daily activities and may persist for long periods of time even after cessation of the offending drug. This assumes increased importance in the present scenario where almost every patient presents with GI related symptoms especially dyspeptic symptoms and is frequently prescribed Levosupride as a prokinetic drug. This is even more relevant in the elderly group. So physicians should be careful and watchful in prescribing Levosupride for common GI related symptoms such as dyspepsia esp in elderly patients and should monitor these patients’ neurological signs, especially parkinsonism and other movement disorders, when prescribing these drugs. Clinicians should routinely ask patients about the adverse effects at each visit. This would help in early recognition of distressing adverse effects and their timely alleviation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A study of psychiatric Co-morbidity in alcohol dependence syndrome

Pankaj Kanwar, Ravi Chand Sharma, Dinesh Dutt Sharma

Indira Gandhi Medical College, Shimla, H. P, India.

E-mails: kanwar.pankaj1@gmail.com, dr.ravicsharma@gmail.com, dineshdutt@yahoo.com

Keyword: Alcohol dependence, co-morbidity, mood disorders, abstinence

Aim: The aim of this study was to describe the demographic variables, drinking history and psychiatric co-morbidity in alcohol dependent subjects.

Material and Methods: In this study, 40 consecutive patients were enrolled. After a minimum 14 days of sobriety, patients who fulfilled ICD-10 criteria of alcohol dependence were interviewed for data collection using Alcohol Use Disorders Identification Test (AUDIT), MINI (Version-6. 0) and a specially designed sociodemographic and clinical interview Performa. Subjects with substance abuse except tobacco were excluded from the study. Main group comparison used chi-square test for categorical variables and the t-test for continuous variables.

Results: Most of the patients studied were >40 years of age. Majority were employed (84. 5%), lived in nuclear families (78%) and came from rural background (77. 5%). Majority (45%) of patients initiated alcohol drinking between 16-25 years and reported peer pressure (50%) as most significant factor responsible for initiation of drinking alcohol. Mean age of developing alcohol dependence was 25. 12 years (SD = 4. 28). Sizeable number of patients (72. 5%) had made abstinence attempts in the past and most patients (58. 6%) didn’t seek de-addiction services during the periods of abstinence. Craving (45%) was detected as a single most important factor responsible for relapse. Mean AUDIT score for subjects was 27. 7 (SD = 4. 73). Lifetime psychiatric co-morbid disorders were detected in 45%. The patients with co-morbid psychiatric disorders had mean AUDIT score of 30. 11 (SD = 5. 90) and those without psychiatric disorders had mean score of 25. 27 (SD = 3. 905) (t = 3. 10; D. F=38; p = 0. 0036). Psychiatric disorders most frequently associated with alcohol dependence were Major Depressive Disorder (10%), Bipolar Affective Disorder (7. 5%), Dysthymia (5%), Anxiety Disorders (7. 5%) and Antisocial Personality Disorder (5%).

Conclusion: The study indicates that psychiatric disorders are prevalent in alcohol dependents and mood disorders are the most prevalent ones. It was also observed that, co-morbid psychiatric disorders are associated with more severe alcohol problems.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychosocial, psychiatric and clinical implications of diabetic foot ulceration: A prospective analysis

Neeru Bala, Harbandna Sawhney

Government Medical College, Amritsar. (Punjab)-143001, India.

E-mails: jpattri12@yahoo.co.in, drjpattri@gmail.com

Keyword: Diabetic foot ulcer, psychiatric aspects, Antidepressants

Background: Foot ulceration is a very common complication of diabetes. Prevalence of psychiatric disorders is more in patients suffering from diabetic foot ulcers. The present study was carried out to observe and evaluate the various psychiatric disorders experienced by patients with diabetic foot ulceration, their management and the metabolic abnormalities associated with the use of antipsychotic drugs. In this observational study, 293 patients in the age group of 25 to 70 years of either sex having diabetic foot ulcers were followed for a period of 24 months. Semi- structured, conversational interviews were used to know the type and duration of diabetes, duration of foot ulcer, treatment given and the psychosocial effects of foot ulceration. The Hamilton Rating Scale for Depression was used for depression and the Hamilton Anxiety Rating Scale was used for anxiety. Type of antipsychotic drugs given and their metabolic side effects were also noted. Descriptive statistical methods were used to analyze the data.

Results: Among 290 patients, 86 patients were having clinically significant psychiatric symptoms. Sixty four patients had depression, 22 patients had generalized anxiety disorder, three had post traumatic stress disorder and 16 developed postoperative delirium after amputation. These patients were managed with counseling, behavior therapy, SSRI, TCA and SNRI’s. 32 patients had poor glycemic control despite treatment and ten patients receiving TCA’s had uncontrolled hyperglycemia and depression.

Conclusion: Diabetic foot ulcer is associated with increased incidence of various psychiatric disorders, depression being most common. Drugs used to treat depression and associated with metabolic disturbances. Hyperglycemia associated with the use of antidepressants and antipsychotics further worsens the foot ulceration. Hence coordination between different specialities is important to manage the clinical, biological and psychosocial aspects of this critical illness.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Impaired mu wave suppression as a trait marker in schizophrenia

Sayantanava Mitra, S Haque Nizamie, Nishant Goyal, Sai Krishna Tikka

Central Institute of Psychiatry, India.

E-mails: sayantanava@gmail.com

Keyword: Schizophrenia; mirror neuron system; EEG mu waves; trait-marker

Background: The ‘mirror-neuron-system’ (MNS) has been shown to be dysfunctional in patients with schizophrenia. As this system develops at a very early stage in life, investigations into the trajectory of this dysfunction may help clarify its role in generation of schizophrenic psychopathology, as well as its status as a trait-marker in schizophrenia.

Aims and Objectives: Our study aimed at prospectively evaluating MNS using the ‘EEG mu-wave (8-13 Hz) suppression’ paradigm; and associated temporal evolution of psychopathology in schizophrenia patients over 8-weeks antipsychotic treatment. We hypothesised that if above-mentioned dysfunction was associated with disease trait, there would be no change in MNS activity with treatment or upon symptom resolution.

Materials and Methods: Eighteen drug free/naïve right-handed schizophrenia patients (M = 14, F = 4) were recruited using purposive sampling. They were compared at baseline with 18 age-sex-education matched healthy controls, and were followed up for eight weeks. High (192-channel) resolution EEG was recorded while they watched a custom made video-clip, depicting a biological motion and visual noise alternately; on admission (baseline), at four and eight weeks. Simultaneous rating on PANSS was done.

Analysis: The data from 24 electrodes overlying the sensorimotor cortex was analysed using Matlab7. 12, and mu-wave modulation was calculated using log of the ratio of mu power under biological motion versus noise conditions. A negative ratio indicated mu suppression.

Results: Subjects differed significantly from normal controls at baseline (P < 0. 05) and showed significant changes in all PANSS sub-scores (P < 0. 001) over 8 weeks. However, the degree of mu-wave suppression remained unchanged over the study duration.

Conclusion: The present study demonstrates an abnormal and unchanging functioning of the neural circuit responsible for social perception in face of changing psychopathology in schizophrenia patients over 8 weeks of treatment. It suggests that MNS abnormality in schizophrenia might be acquired developmentally, be unrelated to the disease ‘state’ or psychopathology, and thus be a disease trait.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Electroconvulsive therapy in a child suffering from acute and transient psychotic disorder with catatonic features

Udit Kumar Panda, Satyakam Mohapatra, Neelmadhav Rath

Mental Health Institute, SCB Medical College, Cuttack, Odisha, India.

E-mails: uditpanda@gmail.com, satyakgmu@gmail.com

Keyword: Electroconvulsive therapy, child, catatonia

Background: It is well-known that electroconvulsive therapy (ECT) is a safe and effective treatment for various mental disorders in adults. But in children and adolescents, ECT is used almost exclusively as a treatment of last resort when other treatments have failed and when the patient’s symptoms are incapacitating or life-threatening.

Aim and Objectives: To present a case of 10-year-old child with a diagnosis of acute and transient psychotic disorder with catatonic features, where we have used ECT successfully.

Materials and Methods: Master A, 10-year-old male child presented with an illness of one month duration which started with fearfulness, suspiciousness, irritability and decreased sleep. On examination, catatonic features like negativism, immobility, mutism, posturing, rigidity were observed. He was hospitalized with a diagnosis of acute and transient psychotic disorder with catatonic features. He was started on injection lorazepam 4 mg twice daily with tablet olanzapine 7. 5 mg for initial 6 days. He improved minimally with this treatment. Injection lorazepam continued for next 3days. But no further improvement was noticed. So ECT was started. He was given five bilateral ECTs (Pulse width: 1msec, duration: 0. 7sec, frequency: 50HZ, Current: 500-mA, energy: 3J) on alternative days. No adverse effects of ECT were reported. Following resolution of catatonic symptoms ECT was stopped.

Conclusion: Lack of knowledge and experience with the use of ECT among child and adolescent psychiatrists is an obstacle to its appropriate use. So prospective studies exploring the long-term consequences of ECT in children and adolescents are necessary. More education and training is needed so that psychiatrists are comfortable considering and utilizing ECT as a treatment when appropriate.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Antidepressant withdrawal induced mania: A case report

Sarmistha Priyadarshini, Satyakam Mohapatra, Jitendra Verma¹

Mental Health Institute, SCB Medical College, Cuttack, Odisha, India, ¹Department Of Psychiatry, M. R. A. Medical College Ambedkar Nagar, Uttar Pradesh, India.

E-mails: priya.sarmistha@gmail.com, satyakgmu@gmail.com

Keyword: Antidepressant, withdrawal, mania

Background: Manic episode induced by antidepressants is well reported in the literature. However, a paradoxical shift to hypomania or mania upon withdrawal of an antidepressant is not a commonly reported occurrence. These mood switches are considered as a type of “withdrawal or discontinuation syndrome” emerging upon sudden discontinuation or reduction in dose of antidepressants.

Aim and Objectives: To present a case of a patient who experienced manic episode on withdrawal of mirtazapine.

Materials and Methods: Mr. A, 54-year-old male presented to Psychiatry outpatient department (OPD) with complaints of over talkativeness, big talks, irritability, overfamiliarity, decreased sleep for last 7 days. He was receiving treatment from our institution since last 10 years with a diagnosis of bipolar affective disorder. He was maintained on lithium carbonate 800 mg and mirtazapine 15 mg per day since last 6 months. He was euthymic since last 3 months after which it was decided to taper and stop mirtazapine. After one week of stopping mirtazapine the patient presented with above symptoms. Past history revealed five manic and three depressive episodes in last 25 years. Serum lithium level was 0. 98 meq./L. Olanzapine 10 mg per day was added. The patient improved slowly and olanzapine was stopped after 2 weeks

Conclusion: The true incidence of antidepressant withdrawal mania is unknown because it may be underreported as a consequence of under recognition or misattribution. Withdrawal of mirtazapine can cause anxiety, restlessness, depression, insomnia, diarrhoea, vomiting and rarely hypomania or mania. Our patient did not report any other symptom except manic episode. Several hypotheses have been postulated to explain the pathophysiology of antidepressant withdrawal–induced mania. So psychiatrists should remain aware of the phenomenon of antidepressant withdrawal mania.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Critical appraisal of the narcotic drugs and psychotropic substances (amendment) act, 2014

Satyakam Mohapatra, Neelmadhav Rath

Mental Health Institute, SCB Medical College, Cuttack, Odisha, India. satyakgmu@gmail.com

Keyword: Narcotic drugs and psychotropic substances, act, amendment, 2014

Background: The issue of drug abuse in India is complex and multifaceted requiring both health measures and efforts to control trafficking, smuggling and manufacture of illicit drugs. The Narcotic Drugs and Psychotropic Substances Act, 1985 (NDPS) provides the framework for drug abuse control in the country.

Aim and Objectives: The current paper will discuss the important changes made in the Narcotic Drugs and Psychotropic Substances (AMENDMENT) ACT, 2014 along with the appraisal of the amendment.

Materials and Methods: During the implementation of the Narcotic Drugs and Psychotropic Substances (Amendment) Act, 2001 certain anomalies have been noticed. On 8th September, 2011, the Government of India introduced the NDPS (Amendment) Bill, 2011 in the Lok Sabha. The Bill was referred to the Parliamentary Standing Committee on Finance on 13^th September, 2011 for further consideration. This bill was finally passed by Lok Sabha and by Rajya Sabha in February 2014. So the Narcotic Drugs and Psychotropic Substances (AMENDMENT) ACT, 2014 received the assent of the President on 7^th March, 2014, and was published in the Gazette of India, Extraordinary, Part II Section 1, No. 17 dated 10th March, 2014.

Conclusion: In the current amendment, a separate category i.e. “essential narcotic drug” has been created, which will include narcotic drug notified by the Central Government for medical and scientific use. Procedure for availability of these drugs (e. g. morphine for pain management in terminally ill patients) will be easy now. Amendment will enable registered agencies to procure morphine by obtaining a single licence from the respective State Drugs Controller, instead of multiple Government agencies. The NDPS Act now allows for “management” of drug dependence, thereby legitimizing opioid substitution, maintenance and other harm reduction services rather than only relying on abstinence oriented services.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Prevalence and associated risk factors of social anxiety in medical students

Suneet Kumar Upadhyaya

GMERS medical college, Patan, Gujarat¹, India.

E-mail: dr_suneet12@yahoo.com

Keyword: Risk factors, Social anxiety, Students

Background: Social anxiety disorder is the third most common psychiatric disorder with a lifetime prevalence of 13. 3%. It is associated with significant impairment in social, educational and vocational functioning. Indian literature on the risk factors for Social anxiety is sparse. This study is planned to identify the prevalence and risk factors for social anxiety among medical students of GMERS Medical College, Dharpur, Patan.

Objectives: To study the prevalence of social anxiety and its association with risk factors, in medical students of a govt medical college of Gujarat.

Materials and Methods: This cross sectional observational study will be carried out at GMERS Medical College and hospital, Dharpur, Patan. The study participants will be 300 Medical students, 100 each from 3 consecutive batches of first, second and third year. The participants will be explained about study procedure including how to fill up the questionnaire and rating scale. After obtaining written informed consent from the participants, they will be given a semi structured questionnaire for demographic details, and questions about possible risk factors for social anxiety. These risk factor will include parameters of age, sex, per capita family income, domicile, and h/o psychiatric illness in self or family; self satisfaction for weight, physical appearance, and facial appearance; childhood adversities like major upheaveal between parents, sexual, physical or emotional abuse, and family violence. Responses will be coded dichotomously as present or absent. Questions of family violence, physical abuse and emotional abuse will be marked on options of never, rarely, sometimes, often and very often. Then Leibowitz Social anxiety scale (LSAS) will be given. The data will be analyzed with appropriate statistical methods including descriptive and analytical statistics with post tests where applicable.

Result and conclusions: Will be discussed in the conference.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Child psychiatric disorders in DSM-5

Satyakam Mohapatra, Neelmadhav Rath

Mental Health Institute, SCB Medical College, Cuttack, Odisha, India. satyakgmu@gmail.com

Keyword: DSM-5, child psychiartic disorders, changes

Background: In development for more than a decade, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is now a reality. DSM-5 updates disorder criteria to more precisely capture the experiences and symptoms of children.

Aim and Objectives: We will discuss changes made to the DSM-5 diagnostic criteria and texts for child psychiatric disorders.

Materials and Methods: DSM-5 updates disorder criteria to more precisely capture the experiences and symptoms of children. It also features a new lifespan approach to mental health. Rather than isolating childhood conditions, DSM-5’s organization underscores how they can continue to manifest at different stages of life and may be impacted by the developmental continuum that influences many disorders. Disorders previously addressed in a single “infancy, childhood and adolescence” chapter are now integrated throughout the book. In an effort to improve diagnosis and care, two new disorders (social communication disorder, disruptive mood dysregulation disorder) are among the changes made to DSM-5 to provide children with an accurate diagnostic home.

Conclusion: The full impact of the new criteria in DSM 5 on ongoing research studies, clinical practice, and patients’ sense of community and identity may not be fully appreciated until long after the new criteria have been implemented.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A case of OCD with externally imposed ambivalence

Suneet Kumar Upadhyaya¹

Gmers Medical College, Patan¹, Gujarat, India.

E-mail: dr_suneet12@yahoo.com

Keyword: Ambivalance, anal character, ocd

Objective: A case of OCD with externally imposed ambivalence

Materials and Methods: A 24 year old medical intern presented in psychiatry OPD for severe headache whenever he has to take a major decision between two or more options. Even after taking decision, opposite aspect is perceived as more important. This conflict culminates into headache.

He had tourrette’s syndrome of mild intensity since 15 years of age. Being a medical student, he was already aware about his illness. During discussion, he revealed that he still has ambitendency in anal functioning and it started in childhood. The only toilet in his house was located by the side of a narrow passage which was used by his joint family. He used to hold defecation, to avoid embarrassment of toilet sounds whenever he heard someone’s footsteps in passage. While in toilet he always remained alert for holding defecation for any imminent stepping sound from the passage. So his defecation process was composed of frequent ‘holding’ and ‘letting go’.

After discussing management, he was kept on cognitive behavioral therapy, habit reversal technique for tics, and analgesic as and when required.

Result and Conclusion: According to freud, when defenses against anal traits are less effective, the anal character reveals traits of heightened ambivalence which is most typically seen in OCD. This case presented with history of externally imposed ambivalence (EIA) since childhood, and OCD. Literature doesn’t have any report or study of such EIA so its association with OCD can’t be established. However, there is no reason to rule out association of EIA with OCD. In this case this coexistence of EIA and OCD was established because patient was a medical student. If all cases of OCD who have ambivalence are scrutinized for EIA, it may be possible to postulate a hypothesis that EIA is also associated with OCD.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A Case of PTSD successfully managed with pharmacological and psychotherapeutic interventions

Chadala Venkata Naga Saritha, Nukala Srikrishna^*1

Gsl Medical College, India, Saritha. Gsl Medical College¹, India.

E-mail chadala@gmail.com, krishnanukalas@hotmail.com

Keyword: Post traumatic stress disorder, emdr, flashbacks, emotional detachment, Nightmares

Background: A Case of Post-Traumatic Stress Disorder Successfully Managed With Pharmacological And Psychotherapeutic Interventions. We report a case of 25 year old male, taxi driver by profession who witnessed a road traffic accident 3 months back and then developed feelings of fear and anxiety which over days progressed to night mares, flash backs of traumatic event, emotional detachment, and day time imagery. A provisional diagnosis of post-traumatic stress disorder is made and he was successfully managed with SSRI’S and Eye Movement Desensitization reprocessing technique. [EMDR]. Case history and psychological interventions in detail will be presented at the time of poster presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Duloxetine induced myoclonic jerks: A case report

Ravindra Munoli, Samir Kumar Praharaj, Sripathy M Bhat

Kasturba Medical College, Manipal, India.

E-mails: Nm@Hotmail.com, Samirpsyche@Yahoo.co.in, Bhat@Manipal. Edu

Keyword: Duloxetine, SNRI, myoclonic jerks

Aim: To report a case of myoclonic jerks induced by duloxetine.

Materials and Methods: Observation and follow up of a patient on treatment with duloxetine.

Result: A 41 years old lady, diagnosed with dysthymia, had predominant somatic pain symptoms. She was started on duloxetine 20mg/d and on hiking to 40mg/d she developed myoclonic jerks in scalp, limb and abdominal muscles. After stopping duloxetine, the jerks subsided. On Naranjo adverse drug reaction probability scale, score was 7 suggestive of probable association of duloxetine with myoclonic jerks.

Discussion: Duloxetine rarely causes myoclonic jerks. Though product monographs have mentioned it, but it was never reported in a previously normal individual. The mechanism underlying the jerks was unclear. The report stresses on the need to be cautious while prescribing duloxetine in a patient with seizure.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Aripipraziole induced torsion dystonia in a neuroleptic naive patient

Ravindra Munoli, Samir Kumar Praharaj

Kasturba Medical College, Manipal, India.

E-mails: Nm@Hotmail.com, Samirpsyche@Yahoo.co.in

Keyword: Aripiprazole, dystonia, torsion dystonia, atypical antipsychotic, third generation antipsychotic

Background: Aripiprazole is considered as a third generation antipsychotic. It acts by dopamine serotonin system stabilization (DSS) and it is effective against positive and negative symptoms of schizophrenia. It is considered to have a low propensity for extrapyramidal side effects. This case report describes about an 18 year old boy diagnosed with paranoid schizophrenia, who was started on treatment with Aripiprazole 15mg per day. On 5th day, he developed torsion dystonia. On stopping aripiprazole and starting trihexiphenidyl 4mg per day, his symptoms resolved. He was started on treatment with olanzapine 10mg per day and dystonia did not recur. On Naranjo scale for adverse drug Reaction, score was 5 indicating probable adverse reaction because of aripiprazole. Various case reports of aripiprazole-induced acute dystonia report symptoms of neck extension, torticollis, rigidity, and tongue movements. However, torsion dystonia is reported less in literature. The case addresses the issue that despite recent advances in psychopharmacology and claims of lesser extrapyramidal symptoms with newer antipsychotics, still one needs to be cautious of these serious adverse effects.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Mirtazepine unmasking underlying restless leg syndrome:

Ravindra Munoli, Samir Kumar Praharaj

Kasturba Medical College, Manipal, India.

E-mails: Nm@Hotmail.com, Samirpsyche@Yahoo.co.in

Keyword: Mirtazepine, restless leg syndrome, antidepressant

Background: Mirtazepine is an antidepressant used as first line or as an augment for patients with depression. This case describes about a 51 years old lady, diagnosed with dysthymia of 7 years duration, who presented with predominant sleep disturbance. She was started on mirtazepine 7. 5mg at night and it was hiked to 15mg at night after a week. In addition, she had received zolpidem 5mg at night for 1 week. After increasing the dose to 15mg, she had discomfort in both legs, had the urge to move the limbs; after pacing around for 2-3 hours she would feel better. Further, occasionally she had discomfort and urge to move upper limbs also. The symptoms predominantly appeared at night. After stopping the drug, the symptoms disappeared completely and on re-administering, symptoms recurred. Her past history revealed restless leg syndrome 4 years ago which was successfully treated and she remained asymptomatic till the administration of mirtazapine. On Naranjo adverse drug reaction probability scale, score was 9 suggestive of definite association of mirtazapine with restless leg syndrome. Mirtazepine association with restless leg syndrome was documented in literature. Like in previous reports elderly female was the patient here. In addition to dopaminergic hypothesis, nor-adrenergic and serotonergic hypotheses have also been explained to be attributing factors. The report stresses on need to be cautious while prescribing mirtazepine in a patient with restless leg syndrome or akathisia.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Depression literacy among the first year graduate students of a university

Rohan Mendonsa, Samin Sameed, Sowmya Shriyan

Yenepoya Medical College, India.

E-mails: drsaminsameed@gmail.com, drrohan16@yahoo.co.in, rohanitha@gmail.com

Keyword: Depression literacy, adolescents, mental health literacy, university students

Background: Adolescents and young adults differ from adults in their perception and attitude towards health, and particularly about mental health, which can cause delay in seeking timely help. It is highly relevant to study the knowledge and beliefs adolescents have about depression, given the increased vulnerability of this age group and unique characteristics of adolescent depression.

Methodology: It is a cross-sectional observational study in the form of a survey. The study was performed in two waves. The first wave consisted of 88 first year BPT and B. sc nursing students. The second wave consisted of first year MBBS and BDS students. The questionnaire contained 3 case scenarios depicting stressful situation (without depression), mild depression, and moderate depression respectively and questions about help-seeking behaviour in these imaginary situations among the participants.

Results: The sample consisted of 76 females and 12 males, age ranging from 17 to 23, with mean age of 18 - 60 yrs. (SD-1. 27). Eleven out of 88(12. 5%) students wrongly identified the stressful situation as depression. Eight out of 88 (9%) students correctly identified the mild depression scenario as depression. Six out of 88 students (6. 8%) correctly identified the moderate depression scenario as depression. When the students were asked as to whom they would approach when faced with similar situations (depression), majority of them wanted to talk to their friends (54. 54%). Thirty five percent of the students said that they would talk to parents, 21. 59% with siblings and only 2. 2% preferred to talk to psychiatrist/psychologist. Results of second wave survey will be presented and compared with first wave.

Conclusion: Depression literacy among the youth is quite low, and most of them would prefer to talk to their friends during times of stress or depression. Psychiatrists and psychologists are less popular options among this particular age group.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Disulfiram-induced neuropathy: A case report

Manas Ranjan Sahoo, Satyakam Mohapatra, Neelmadhav Rath

Mental Health Institute, SCB Medical College, Cuttack, Odisha, India.

E-mails: Drmanas82@Gmail.com, Satyakgmu@Gmail.com, Satyakgmu@Gmail.com

Keyword: Disulfiram, neuropathy, alcoholism

Background: Disulfiram is widely used for aversive treatment of alcoholism. Neuropathy is one of the most severe side effects of disulfiram therapy.

Aim and Objectives: To report a case of a young man who developed a neuropathy following disulfiram administration, with a virtually complete recovery within 2 months.

Materials and Methods: A 35yr Hindu male, reported to psychiatry outpatient department with complaint of daily alcohol intake of 250-750 ml for last 10yrs. Disulfiram was administered at the dosage of 250 mg twice daily for 2 months, while the patient abstained from alcohol. Then the patient presented with complaint of numbness and tingling sensation of soles of the feet since last 1 month. The disulfiram was discontinued, and he underwent investigations to determine the cause of his neuropathy. Routine laboratory tests including liver functions test, serum B12 and folate assays were within normal limits. Nerve conduction studies revealed small fibre axonal degeneration predominantly sensory type. After stoppage of disulfiram the patient improved gradually within next 2 weeks. Over the next 6 weeks numbness and tingling sensation of soles of the feet disappeared completely.

Conclusion: Disulfiram is reported to be neurotoxic with and without alcohol intake. A metabolite of disulfiram, carbon disulfide, has been shown to be neurotoxic and may be involved in the development of neuropathy. Axonal degeneration has been described as a pathological hallmark of disulfiram toxicity. It is very important to differentiate neuropathy associated with disulfiram use from alcoholic neuropathy. Most patients with disulfiram neuropathy, including ours, received 500 mg or more daily. At daily dosages of 250 mg (or less), patients have rarely developed peripheral neuropathy. Disulfiram should be used at the lowest effective dose, possibly 250 mg daily, and the patient should be told to consult a physician if sensory or motor problems appear at any time during the course of therapy

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Emotion Awareness and Regulation in Persons with Chronic Schizophrenia

Kusum Rai, Sandhyarani Mohanty, Sudhir Kumar

Institute of Mental Health and Hospital, Agra-282002, India.

E-mails: agra@gmail.com, imhh@gmail.com, agra@gmail.com

Keyword: Emotion awareness, emotion regulation, chronic schizophrenia

Background: It is reported that a deficit in the outward display of emotion does not necessarily correspond to a lack of emotional experience in persons with schizophrenia. It is demonstrated that the persons with schizophrenia experience just as much positive emotion as people without schizophrenia when presented with emotionally evocative stimuli. However, people with schizophrenia are less able to maintain their emotional experience in the absence of external stimuli. Research also suggests that people with schizophrenia may experience more negative emotion compared to people without schizophrenia, both in response to evocative stimuli and on trait measures of negative affect. It is also observed that these persons have marked deficits in emotion processing which contributes to their social difficulties and functional disability. Apart from processing deficits, they also have significantly more difficulties in identifying and describing feelings as compared to their healthy siblings and controls. Additionally they have a stronger tendency to suppress their emotions. The present study aims at exploring emotion awareness and emotion regulation in persons with chronic schizophrenia including determining the relationship with measures of psychopathology. 30 Persons with chronic schizophrenia will be sampled from Institute of Mental Health and Hospital, Agra. 30 healthy control participants will be sampled from general population. Following tools will be individually administered on them. (1) Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994) (2) Multi-dimensional Self-Report Emotional Intelligence Scale-Revised (Pandey and Anand, 2008), (3) Emotion Regulation Questionnaire (ERQ; Gross and John, 2003) (4) Global Assessment of Functioning (5) GHQ-12 and (6) PANSS. Correlation Coefficients and linear regression will be performed to explore the relationship of emotion awareness and regulation with global functioning and measures of psychopathology. Mean differences will be estimated between patients group and the control group for emotion awareness and regulation. The detailed results will be presented.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Hysterical mutism: A case report

Andreecia Mn Mawiong, N Heramani Singh, Senjam Gojendra Singh

Department of Psychiatry, Regional Institute of Medical Sciences, Imphal, Manipur, India. andreeciamawiong@gmail.com

Keyword: hysterical mutism, female

Objectives: the purpose of this study is to report a rare case of hysterical mutism admitted at RIMS psychiatry ward.

Materials and Methods: A female patient named Tanjem was observed at opd, family members were interviewed since the patient was not speaking at all to anyone for 2 months and 24 days to get all the possible history. According to mother and some other close family members patient had a close love affair with one person who had ditched her for another girl, since then patient never spoke to anyone which made the parent to get worried. Patient was admitted in the ward for evaluation, In the ward catatonia, psychosis was not detected in the patient. in the ward efforts were made to develop rapport of patient. by day4 in the ward patient start telling three numbers when prompt, by day 6 patient can count 1 till 10, from day 8 she speak one full sentence when prompt, from day 15 she speaks 4-5 sentence and response verbally to queries, from day 17 patient is talking spontaneously and was discharged. all routine investigations were normal, Ncct-brain was also normal, Patient was treated with escitalopram and mirtazapine in the ward.

Results: significant stressor was present, so most probably patient had depression and never want to talk to any one. constant effort is needed to develop rapport of this pt to make her speake.

Conclusion: hysterical mutism is rare about 5% of functional dysphonia, belong to category of conversion disorder in DSM-IV TR, this disorder has raised little interest. to better understand this disorder and improve the care of patients who suffer, renewed interest is needed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Treating somatic delusion with paroxetine: A case report

Vijay Niranjan, Bharat Udey, R C Jiloha

Maulana Azad Medical College, India. dr.vijayniranjan@gmail.com, bharatudey@gmail.com

Keywords: Delusional disorder, somatic type, paroxetine, serotonin

Objectives: To report a case of delusional disorder Somatic type (DDST), who responded well to treatment with Paroxetine.

Methodology: 32 years old male patient presented with persistent belief about his head’s “nerves and vessels being blocked “and his head being numb from inside. The belief was persistent since 8 years and accompanied with acting out behaviors and socio-occupational dysfunction. There was no significant past or family history of psychiatric or medical illness. Physical-Neurological examination, Neuro-imaging, EEG and routine biochemical tests showed no abnormality. Other domains of Mental Status Examination showed no significant abnormality. Patient was treated in the past with various antipsychotics (Haloperidol, Olanzapine, Risperidone) for adequate dose and duration with no significant improvement.

Results: Patient was started with Tablet Paroxetine, from 25 mg/day and increased to 37. 5 mg/day after one week. The drug was well tolerated and patient started to show improvement since the second week of treatment and significant improvement after 3 weeks treatment, as he stopped showing acting out behavior on the belief and its intensity was markedly diminished. The clinical improvement was maintained till 1 year of follow-up with treatment as outpatient basis.

Conclusion: This report suggests that Paroxetine may be an effective and well tolerated treatment option for Delusional disorder-Somatic type and supports the previous views that DDST is associated with serotonergic dysfunction.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Anti-NMDA receptor encephalitis presenting as catatonia: A case report

Starlin Vijay Mythri, Vivek Mathew

Christian Medical College, Vellore, India.

E-mails: starlinvijay@gmx.com, vmathew@cmcvellore.ac.in

Keyword: Anti-NMDA receptor encephalitis, catatonia, neuropsychiatry

Introduction: Anti-NMDA receptor encephalitis is a newly recognised autoimmune condition. With its typical clinical pattern, consistent association with the presence of auto antibodies against NR1 subunit of NMDA receptor and rapid improvement with immunotherapy, this condition is giving insights into the boundaries between psychiatry and other neurosciences and also is opening up avenues for future research.

Case report: Over few years, we in Christian Medical College have been able to identify and manage this condition. In this poster, we would like to present a particular patient who presented initially with a catatonia like picture to a psychiatrist; and then later to our neurology department where after ruling out other aetiologies, NMDA receptor encephalitis was considered in view of the pattern of development of the illness and epidemiological characteristics. After we got the positive antibody test, we saw a gradual improvement in her cognitive function with immunotherapy though the motor deficits persisted.

Discussion: The nature and function of NMDA receptors and patho-physiology involved in the development of this particular encephalitis is discussed. The great opportunity and avenue for research in this area is discussed along with an appeal to temper the enthusiasm by considering the historical lessons which psychiatry has learnt from Karl Jaspers’ critique of General Paresis of Insane. The nosological status and broader conceptualization of catatonia is reviewed. The need for newer ways of investigating, teaching and practicing psychiatry has been emphasized.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Gender difference in lipid profile in first episode mania

Anjana Rao Kavoor, Daya Ram¹, Sayantanava Mitra²

Institute of Mental Health and Hospital, Agra, India, ¹Central Institute of Psychiatry, India,

E-mails: anjanarao31@gmail.com, sayantanava@gmail.com

Keyword: Bipolar disorder, deranged lipid, cholesterol

Background: Lower lipid levels have been reported in patients with affective disorders, both during symptomatic as well as remission states. Though the phenomenon is poorly understood, this abnormality is well established in western populations. In India, this has been reported in male mania patients in past. This lower lipid level has further been hypothesised to be responsible for increased impulsivity in these patients, and thus may predict poorer outcomes over time.

Aims and Objectives: Present study intends to compare lipid profiles bewteen groups of drug-free/naive male and female patients with first episode mania. First episode mania has been proposed as a valid marker for bipolar disorder, and these patients would be free from a long exposure to disease-related stresses and psychotropic medications. We hypothesise that the lipid levels will be deranged in both the groups as compared to normal; and will also be closer to each other than in unaffected controls, thus reflecting a basic disease-specific lipid abnormality.

Materials and Methods: Fifteen male and female patients; matched for age and obesity status, with a diagnosis of Mania as per ICD-10 DCR will be recruited through purposive sampling. After obtaining informed consent, and collecting relevant socio-demographic and clinical data in a custom-made sheet; a 12-hour fasting venous blood sample will be collected. Total cholesterol, HDL, LDL, VLDL and Triglyceride levels will be measured. Lipid profile of the two groups will be compared against available population normal for each gender (using independent sample t-test), and also between the two groups (males and females). Socio-demographic and clinical data will be compared using Chisquare test/independent sample t-test, as required.

Results and Discussion: Results will be discussed at the time of presentation

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Social cognition in Individuals at clinical high risk for psychosis: an Indian Study

Deyashini Lahiri Tikka, Amool Ranjan Singh¹, Masroor Jahan², Sai krishna Tikka³

Central Institute of Psychiatry, India, deyashini. ¹RINPAS, India, ²RINPAS, India, ³Central Institute of Psychiatry, India.

E-mails: lahiri@gmail.com, sisamool@yahoo.com, masroorjahan@yahoo.com, cricsai@gmail.com

Keyword: Individuals at risk for psychosis, social cognition, indian scenario

Background: Social cognitive deficits have been demonstrated in groups at high risk for developing psychosis but the degree of deficit in Indian population is not explored yet. Such knowledge may further our understanding of the importance of these deficits in the development of psychosis in Indian scenario.

Materials and Methods: Culturally appropriate standardized tool to comprehensively test social cognition in India-Social Cognition Rating Tools in Indian Setting (SOCRATIS) was used to assess social cognitive dysfunction in high risk individuals. PRIME Screen- Revised (PS-R) was applied on 492 subjects from general population in the age group of 18-25 years. 50 subjects were identified and social cognition in them was compared with age, gender, education matched healthy controls. Social functioning was assessed on the Social Occupational Functioning Scale (SOFS) and correlated with various social cognitive indices.

Results: Both groups were comparable in socio demographic characteristics. Significantly lower Emotion recognition Index (P <. 01), Personalized Bias (P <. 01), First and second order theory of mind function (P <. 001), Social Perception Index (P <. 001) and Social Cognition Composite Index (P <. 001) relative to healthy controls was found. Individual with high risk for psychosis also showed lower social functioning. However, no significant correlation of social cognitive measures and social functioning was noted.

Conclusion: In Indian population as well, Social cognitive deficits in all domains are prevalent in individuals at high risk for developing psychosis.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Neurodevelopmental hypothesis of schizophrenia: From a gamma perspective

Sai Krishna Tikka, Shamsul Haque Nizamie, Nishant Goyal

Central Institute of Psychiatry, India.

E-mails: cricsai@gmail.com, sh.nizamie@gmail.com, psynishant@gmail.com

Keyword: Schizophrenia, neurodevelopment, gamma oscillations

Background: Neurodevelopmental model of schizophrenia has gathered the strongest evidence in modern past. Developmental insults during the prenatal and postnatal period lead to abnormal neural synchrony resulting in the development of aberrant cortical networks that are unable to support the maturation of gamma oscillations. Consequent reorganization of these cortical networks during adolescence and early adulthood manifests as cognitive dysfunction and psychotic symptoms. Understanding schizophrenia as a neurodevelopmental disorder from a gamma perspective is a recent advance.

Materials and Methods: The present paper is a synthesis of findings of studies conducted by the team on gamma oscillations at KS Mani Center for Cognitive Neurosciences, Central Institute of Psychiatry, Ranchi.

Findings

Abnormal (increased) gamma oscillatory activity (GOA) in schizophrenia patients with developmental anomalies
Together with developmental anomalies, GOA could classify patients with schizophrenia better from their relatives and healthy controls.
Abnormal GOA fulfils for a neurophysiological endophenotype for schizophrenia.
Abnormal (increased) GOA in schizophrenia patients with greater Schneiderian first rank symptoms (FRS).
Significant intrafamilial correlation for GOA measures.
GOA not useful in differentiating sporadic and familial schizophrenia.
GOA in schizophrenia is modulated by transcranial magnetic stimulation.

Conclusions: While being helpful as a combined endophenotype along with developmental markers, GOA with developmental anomalies when present together proposes for being a separate neurodevelopmental subgroup of schizophrenia. Lack of coherence between sporadic and familial cases along with strong intrafamilial correlation indicate a combined environmental-genetic basis for GOA. GOA deficits might define neurodevelopmental underpinnings for other clinical signs like FRS as well. GOA modulation throws more light on the link between neurodevelopment and neural plasticity.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Effect of MRI-guided transcranial magnetic stimulation of right inferior parietal lobule on schneiderian first rank symptoms in schizophrenia

Sai Krishna Tikka, Shamsul Haque Nizamie

Central Institute of Psychiatry, India.

E-mails: cricsai@gmail.com, sh.nizamie@gmail.com

Keyword: rTMS, inferior parietal lobule, first rank symptoms, schizophrenia

Background: With the conventional treatment strategies, schizophrenia patients with Schneiderian first rank symptoms (FRS), especially during the acute phase, have a poorer long-term outcome than schizophrenia patients without FRS. FRS have been localized to the right inferior parietal lobule (rIPL). With involvement of specific neural networks connected to right parietal cortex, FRS has been suggested to represent a distinct clinical dimension from other psychotic symptom dimensions and hence suggesting a need to consider alternate treatment strategies. To the best of our knowledge, rIPL stimulation and its effect on FRS in schizophrenia is yet to be conducted.

Materials and Methods: FRS are assessed according to definitions given by Mellor (1970) and also on their modified broad and narrow definitions. Patients having one or more FRS according to the narrow criteria; or two or more according to the broad criteria are being grouped as schizophrenia with FRS. A specific score sheet was constructed to assess the FRS on frequency, preoccupation, conviction and interference with routine activities on a five point likert scale. Further, this study is being conducted by randomizing schizophrenia patients with FRS into two groups- active and sham. A baseline and a repeat assessment of FRS after completion of rTMS sessions would be completed. The patients’ high resolution MRI images would be uploaded into the Neuro-navigation software and rIPL would be identified. Neuronavigation- rTMS would be set for an inhibitory paradigm- continuous theta-burst i. e. 900 pulses at 80%MT applied as bursts of three pulses (50 Hz) repeated at 5 Hz in each session. Active rTMS or sham rTMS treatment 5 days a week for 2 weeks would be delivered.

Results and Discussion: To be presented at the conference.

*The study is funded by Department of Biotechnology, Ministry of Science and Technology, Government of India under INCRE Fellowship.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

The relevance of avoidant/restrictive food intake disorder; the new DSM-5 diagnosis: A review

Ananya Mahapatra, Rishi Gupta, Rajesh Sagar

All India Institute of Medical Sciences, New Delhi, India.

E-mails: nnyaa09@gmail.com, mailrishigupta@gmail.com, rsagar29@gmail.com.

Keyword: Avoidant/restrictive food intake disorder

Background: The criteria for the DSM-IV diagnosis of Feeding disorder of infancy of early childhood have been significantly expanded in the DSM-5 and the new diagnosis has been named Avoidant/restrictive food intake disorder (ARFID). This proposed diagnosis includes patients of all age groups and also encompasses a section of patients earlier subsumed under the category of Eating disorder NOS.

Objectives: The present review explores existing literature pertaining to the diagnosis of ARFID.

Methodology: The electronic databases MEDLINE (via PUBMED) and EMBASE were searched using the keywords “avoidant restrictive food intake disorder” and “ARFID”. Only original studies and case reports, published in English, involving patients with a diagnosis of ARFID were included.

Results: A total of 127 results were obtained, out of which 44 were relevant to the topic. Eleven articles met our inclusion criteria, comprising of 4 case reports, 4 retrospective chart reviews, 2 retrospective case-control studies, and 1 cross-sectional study. No meta-analyses, clinical trials or prospective studies were found. Majority of studies have been conducted in the paediatric and adolescent age group. The patients of ARFID group were more likely to be of younger age, with longer duration of illness and higher rates of co-morbidity. The female preponderance was not marked in this group.

Conclusion: This review indicates that patients of ARFID present with significant differences in both socio-demographic and clinical parameters. This subgroup of patients presents with more severe symptoms, and should be the subject of further clinical attention. ARFID emerges as a potentially important diagnosis in patients of younger age group. There is a scarcity and need for research in exploring this new entity in adult population.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Unusual physical outcome of a sign of mental illness

Sushma Swaraj, Saumil Dholakia

Christian Medical College Vellore, India,

E-mails: anshsushma@gmail.com, dholakiasaumil@gmail.com

Keyword: Physical disability; Posturing; Schizophrenia; Unusual outcome

Background: Posturing is one of the classical manifestations in patients with Schizophrenia. The patient maintains strange positions voluntarily for extended periods of time. However, this voluntary posturing may rarely lead to structural physical deficits as evidenced by the case presented below.

Case report: A 21 year old male patient known to have Schizophrenia presented to our department of Psychiatry with symptoms of posturing at the elbow joint and difficulty in extending his elbow to full range. The duration of this symptom was about six months and according to the relatives his elbows were flexed even during sleep. There was a good temporal correlation between the onset and progression of posturing symptoms and development of physical deficit. On examination his elbow could not be extended completely and he also felt pain during attempted extension movement.

We referred him to our Physical Medicine and Rehabilitation department for further evaluation. They could extend both his elbows up to 10 degree short of full extension with pain. There was no obvious bone deformity. X-ray of elbow joints was normal. Their final diagnosis was bilateral elbow flexion contracture secondary to posturing. He was placed on a programme of physical rehabilitation which included physical exercises and application of braces. He showed partial improvement in his condition after therapy.

Discussion and Conclusion: There have been only few reports of muscle contractures developing in patients with prolonged posturing due to mental illness¹. However, awareness about this potentially disabling consequence of prolonged posturing is important to prevent or recognise early physical disability. Treatment of underlying mental illness and referral for physical therapy and rehabilitation are keys to management.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Conversion disorder: Still a fertile ground for clinical error? A case of heidenhain variant CJD.

Rishana A T, Anisha Nakulan, Shiny John

Amala Institute of Medical Sciences, India.

E-mails: rishanairshad@gmail.com, anisha_nakulan@rediffmail.com, shinyskd@gmail.com

Keyword: conversion disorder, Heidenhain variant CJD, behavioral neurology, misdiagnosis

Introduction: Recent studies show that the rate of misdiagnosis of conversion disorder at follow-up is only 5%-10%. Following case illustrates that high level of vigilance needs to be maintained for a missed diagnosis of neurologic disorder in cases of conversion disorder even now.

Referral: A 66 year old gentleman with significant depressive and anxiety symptoms with apparent difficulty in vision and difficulty in hearing, referred by neurologist as a case of conversion disorder.

Initial assessment: History revealed memory impairment, mood variations, anhedonia, clumsy walking, executive dysfunction, reduced vision leading to accidents and hearing difficulty, which was comprehension difficulty. No previous psychiatric illness. Ophthalmological evaluation ruled out visual defects. Sensory ataxia and sensory aphasia present. Neuropsychiatric assessment showed frontal, temporal, occipital and dominant parietal lobe dysfunction. Blood investigations detected raised ESR of 42 mm/hr. MRI showed tiny chronic lacunar infarct in left mid brain. PET scan showed minimum hypometabolism of the left occipital pole.

Progress: Rapid decline in cognitive functions and ataxia over 8 days accompanied by fever and frequent myoclonic jerks. Initial MMSE score of 25 rapidly declined to 7 in eight days. Patient referred to a higher neurology center for expert management. He died after 4 months of progressive worsening of symptoms. In this patient with rapidly progressive dementia, presence of visual symptoms and myoclonic jerks, a provisional diagnosis of Heidenhain’s variant of CJD is considered.

Discussion: Behavioral symptoms is a common reason for misdiagnosis of Heidenhain’s variant of CJD. This case reflects the potential for misdiagnosis of a rapidly progressive fatal neurological disorder as conversion disorder. Despite the current trend of over-reliance on diagnostic modalities by doctors, the importance of a clinical diagnosis is unquestionable. There is an ever increasing need for psychiatrists to keep up to date with developments in behavioral neurology.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Topiramate for olanzapine-induced weight gain: A systematic review and meta-analysis

Samir Kumar Praharaj, PSVN Sharma

Kasturba Medical College, Manipal, India,

E-mails: samirpsyche@yahoo.co.in, psvn.sharma@manipal.edu

Keyword: Topiramate, olanzapine, weight Gain, systematic review, meta-analysis

Background: Olanzapine is an atypical antipsychotic that is useful in schizophrenia and bipolar affective disorder; but its use is associated with troublesome weight gain and metabolic syndrome. A variety of pharmacological agents have been studied in the efforts to reverse weight gain induced by olanzapine, but current evidence is insufficient to support any particular pharmacological approach.

Objective: To conduct a systematic review and meta-analysis of randomized controlled trials of topiramate for the treatment of olanzapine-induced weight gain.

Materials and Methods: Studies will be identified using online searches of PUBMED/MEDLINE and Cochrane database (CENTRAL), supplemented with manual search of cross-references. The search will be restricted to publications in the English language. Systematic review and if possible, meta-analysis will be performed to see the effect size of the treatment on body weight, waist circumference and body-mass index (BMI).

Results: Will be presented later.

Discussion: Will be presented later.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Very low dose amitriptyline for clozapine-associated sialorrhea

Siddhartha Sinha, Jayati Simlai, Samir Kumar Praharaj¹

Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS), Ranchi, India, ¹Kasturba Medical College, Manipal, India.

E-mails: sidsin69@gmail.com, jayatisimlai@gmail.com, samirpsyche@yahoo.co.in

Keyword: Clozapine, sialorrhea, hypersalivation, amitriptyline

Background: Background: Clozapine is the antipsychotic of choice for resistant schizophrenia, but its widespread use is limited by adverse effects. Sialorrhea is a common and troublesome adverse effect seen with clozapine which leads to poor compliance. Several treatment strategies are advocated. No single treatment is considered superior. Amitriptyline, a tricyclic antidepressant, has been found to be useful for clozapine-associated sialorrhea at 87–100 mg per day.

Objective: To study the effect of very low dose amitriptyline (10 mg per day) in a patient with clozapine-associated sialorrhea.

Results: There was rapid and complete resolution of sialorrhea after three days without any emergent adverse effect.

Conclusion: Very low dose amitriptyline may be helpful in some patients with clozapine-associated sialorrhea.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Ekbom’s syndrome and pontine infarct: A case report

Narayan R Mutalik, Vinod A, Sreeraj VS, Bhaskar Mara

S. N. Medical college & HSK Hospital, Bagalkot Karnataka, India.

E-mails: narayanmutalik@gmail.com, avnode28@gmail.com, drvs8sreeraj@gmail.com, bmara21@gmail.com

Keyword: Delusional Parasitosis, Ekbom’s Syndrome, Pontine Infarct, Formication

Background: Delusional parasitosis also known as Ekbom’s syndrome is a form of psychosis whose victims acquire a strong delusional belief that they are infested with parasites, whereas in reality no such parasites are present. Pontine infarcts are one form of brainstem infarction. Infarcts in the pons are typically focal in nature. Several studies have related the lacunar infarcts and psychotic disorders.

Case Presentation: We are presenting a case of 70 years old male married, educated till 5th std, who was a watchman from rural background. He had reported to the clinic with complaints of worms crawling all over the body and under the skin (formication), decreased sleep since 3 months. As he used to repeatedly scratch his skin, consulted dermatologists multiple times. A full work-up including general physical examination revealed no abnormality. Mental status examination revealed delusional parasitosis and tactile hallucinations. Routine investigations revealed no abnormality. CT brain showed lacunar infarct in left pontine region. Patient improved with low dose risperidone.

Conclusions: Delusional parasitosis can be due to hypochondriac nature in obsessive compulsive spectrum and secondary to formication. Neurobiology implicated commonly is a lesion in basal ganglia(similar to OCD). But in this case it could be the sensory pathway through the pons being affected which could be leading to tactile hallucinations. This case illustrates a rare combination of pontine infarct with delusional disorder. Authors would like to emphasize that clinicians should be aware of this rare presentation which poses significant clinical challenges and drug interactions between psychotropics and medications for medical conditions.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Effect of gallic acid on antioxidative enzymes activities in depression

Sudhakar Pemminati

AUA College of Medicine & Manipal University, India.

E-mail: pemmineti@yahoo.com

Keyword: Gallic acid depression antioxidant enzymes

Background: During acute depressive episodes, patients had significantly higher activity levels of antioxidant enzymes, such as superoxide dismutase (SOD) and catalase (CAT), as compared to healthy controls. Studies indicate that free radicals and their derivatives play a role in some neuropsychiatric disorders, such as depression.

Aim and Objective: The aim of this study was to investigate the effect of gallic acid on antioxidant enzymes in depression.

Materials and Methods: The depression induced to animals by both acute and chronic administration of gallic acid in forced swim test (FST) and tail suspension test (TST). Mice weighing 25-30g were used in this study. Standard drug (imipramine) and test drug gallic acid were suspended in normal saline. The vehicle (10ml/kg, p. o), imipramine (10mg/kg, p. o) and gallic acid (0. 8mg/kg, 2. 0 mg/kg, 4. 0 mg/kg, p. o. respectively) were administered one hour prior to acute study. In chronic study, all drugs were given for 10 days and the last dose was given one hour before the experiment. Duration of immobility was noted in both the models. Superoxide dismutase (SOD) and catalase (CAT) levels in plasma were determined by pre and post treatment of test drug. The results were expressed as mean ± SEM and analyzed for statistical significance using one-way ANOVA followed by Dunnet’s test.

Results: Depressed animals, control group, had higher SOD and CAT levels than those of gallic acid treated animals. After treatment with gallic acid, SOD and CAT levels of the animals were significantly decreased to normal levels.

Conclusion: The present study findings suggest that, depression is associated with elevated levels of SOD and CAT. Treatment with gallic acid may have reduced effect on SOD and CAT levels.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Acute dystonia associated with Sertraline: A case report and review of the literature

Siddhartha Sinha, Satyakant Trivedi¹, Rishikesh V Behere², Jayati Simlai

Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS), Ranchi, Jharkhand, India, ¹People’s College of Medical Sciences, Bhopal, Madhya Pradesh, India, ²Kasturba Medical College, Manipal, Karnataka, India.

sidsin69@gmail.com, satyakanttrivedi@gmail.com, rvbehere@gmail.com, jayatisimlai@gmail.com

Keyword: Dystonia, sertraline

Background: Extra pyramidal symptoms (EPS) associated with antidepressants is an uncommon presentation. The most common type of EPS due to SSRIs reported has been akathisia followed by dystonia, psuedoparkinsonism, and tardive dyskinesia. Fluoxetine has been more commonly reported in literature to be associated with EPS.

We report a case of a 47 year old female who presented with acute dystonia within 2 hours of receiving sertraline and review the literature for factors predisposing to dystonia with SSRI’s.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Fahr’s Syndrome with pseudopseudohypoparathyroidism: A case report

Narendra Kumar MS

Mysore Medical College and Research Institute, India.

E-mails: drheggere@gmail.com

Keyword: Fahr’s Syndrome, Fahr’s Disease, Pseudopseudo hypoparathyroidism, psychosis

Summary: Fahr’s syndrome is characterized by symmetrical and bilateral intracerebral calcifications, located in the basal ganglia. We report a case of Fahr’s disease (FD) in a 13 year old patient who presented with neuropsychiatric symptoms, seizures, and features of pseudopseudohypoparathyroidism. On CT scan head, she showed bilateral calcific densities in basal ganglia, cerebellum and other regions.

Case Report: A 13 year old girl presented to our hospital psychiatry department with 10 days history of fearfulness, crying spells, excessive sleepiness and 3 episodes of paroxysms of involuntary movements each lasting for half a minute 2 days prior to the presentation. 3 months prior to this, she had 7 days history of talking and laughing to self, irrelevant talk, fearfulness, withdrawal, excessive sleeping along with expression of fear of death for which patient was treated for 20 days and had remitted with Tab. Risperidone 2 mg and Tab. Trihexyphenidyl 2 mg per day. She did not have any contributory past medical or family history. On Examination Patient was restless, pacing within the ward and talking to self. Significant was her short stature, tachycardia, round facies, hyperteloric eyes, vacant expression On neurological examination She had generalized hyperreflexia, blunt facies, cogwheel rigidity and postural tremors. She had pancytopenia which couldn’t be evaluated. Thyroid and parathormone levels were normal. Plain CT scan head revealed multiple calcific densities present bilaterally in basal ganglia, subcortical matter of parietal lobes, left temporal lobe and cerebellum. USG Abdomen-revealed multiple small calcific lesions in both the kidneys. Considering the above clinical and laboratory details, a diagnosis of Fahr’s disease with pseudopseudohypoparathyroidism was made.

Discussion: This patient had majority of symptoms towards a diagnosis of Fahr’s disease and the stand out feature was the pseudopseudohypoparathyhroidism along with neuropsychiatric symptoms which the psychiatrists should be aware of.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Sociodemographic profile of women substance dependents in swami vivekanand DDTC, amritsar

Neha Aggarwal, Parshotam Dass Gargi¹, Harsh Chalana²

¹Shri Guru Ramdas institute of medical sciences & research, Amritsar, India, ²Government Medical College Amritsar, India, ³Shri Guru Ramdas institute of medical sciences & research, Amritsar, India.

neha.spmc@gmail.com, gargpdass@gmail.com, harsh_chalana@yahoo.co.in

Keyword: Sociodemographic female substance dependent amritsar

Background: There is evidence that women may become dependent more quickly on a number of illicit substances, engage in more HIV-risk behaviours and have higher mortality rates if they inject drugs.

The study was done to understand the problems of female substance dependents better so as to contemplate on primary and secondary prevention strategies to decrease drug dependence.

Objectives: To study sociodemograpic and clinical profile of women attending Swami Vivekanand de-addiction centre in Amritsar, Punjab.

Materials and Methods: The data was analyzed for the 4697 patients registered in Swami Vivekanand DDTC, Department of Psychiatry, Govt. Med. College, Amritsar from June 2011 to Dec, 2013. Their histories were reviewed for age of onset, marital status, education, employment, family type, locality, religion, income, substance type and duration of use, use by intravenous route and family history. The data was collected, arranged and analyzed using the SPSS version 15. 0 for Windows.

Results: Out of 4697 patients registered in SVDTTC, 16 were females. The age of onset of drug abuse in 68. 75% of females were between 20-40 years of age. Most of the females had education up to tenth or less(75%), were married(68. 75%), unemployed or housewives(68. 75%) and lived in urban areas(62. 5%). Females living in joint familes were 56%. The duration of use was less than one year in 43. 75%. Most of female patients were taking opioids, most commonly heroin(37. 5%) followed by propoxyphene(31. 25%). Injectable drug users and family history of drug abuse was found in 25%.

Conclusion: In the study women represented 0. 34% of total patients which may be an underrepresentation because of greater stigma for women and their childcare responsibilities. To alleviate the problem, gender sensitization, raising awareness and gender-responsive services through political advocacy, networking and linkages at a variety of levels and involvement of management to promote gender mainstreaming is the need of the hour.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A case of Craniopharyngioma: Atypical presentation with psychiatric manifestations

Aamani M

Alluri Sitharamaraju Academy of Medical Sciences, India.

E-mails: aamanimurari@yahoo.com

Keyword: Craniopharyngioma, atypical presentation.

Background: A case of Craniopharyngioma-Atypical presentation with psychiatric manifestations.

Introduction: Craniopharyngioma is a rare, intracranial, dysontogenic, suprasellar neoplasm with prevalence of 2 in 1, 00, 000 population. They are slow growing, invasive, arising from epithelium derived from Rathke’s pouch remnants. Headache, visual disturbances, features of endocrinal dysfunction is the most common presentation with a bimodal distribution in children (5-14 years) and in adults (45-70 years). Intracranial brain tumours can be neurologically silent, at times and can manifest with psychiatric symptoms.

Case Report: A 45 year old male, had symptoms of feeling sad and unhappy, frequent crying spells, loss of interest in life, irritability, sudden outbursts of aggression, headache and occasional blurring of vision for 18 months, following his mother’s death. They did not consult a Psychiatrist due to stigma. His vision gradually deteriorated to near total loss of vision in approximately 6 months & then consulted an Ophthalmologist & Neurophysician. CT Brain revealed features suggestive of Craniopharyngioma. Meanwhile, patient presented with severe headache, bloody vomitings and memory disturbances, suggestive of raised ICT. He underwent emergency V P shunt procedure & later surgical excision of the tumour. Patient is on Hormone Replacement therapy and Radiation therapy, since then. Patient presented with irritability, sudden aggressive outbursts, suicidal intention, 15 days after surgery. Psychiatric consultation was done and on medication for almost 1 year. Patient was in near total remission for almost 2 years. Patient, now presented to our Department of Psychiatry, with gradual exacerbation of the previous symptoms in three months with two suicidal attempts, rescued by his attendants. Patient is on Tab. Risperidone 2mg B. D, Tab. Trihexiphenidyl 2mg B. D, and Tab. Escitalopram 10 mg O. D for 6 months and in near total remission for 3 months.

Conclusion: This case report depicts an atypical presentation of Craniopharyngioma with predominant psychiatric manifestations.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Self esteem and social anxiety in Patients of acne vulgaris

Dimple Dinesh Dadarwala, Hemangee S Dhavale, Bindoo S Jadhav

K. J. Somaiya medical college and research centre, Sion, Mumbai - 400022, India.

E-mails: dimple_dadarwala@yahoo.co.in, drdhavale28384@gmail.com, blmaru@gmail.com

Keyword: Acne, self esteem, social anxiety

Introduction: Acne vulgaris, a chronic inflammatory disorder of pilo-sebacious unit, can lead to psychological distress and affect social functioning. Predominant adolescent prevalence of acne - a time of significant physical, emotional and social development, distribution of lesions mostly on face, strong emphasis on external appearance by media and society can negatively affect self-esteem in acne patients. Self-esteem issues can cause feeling of embarrassment, decrease in self confidence, effect on opposite gender relationships and fear of being judged by others as unattractive which may result in social anxiety.

Aims and Objectives:

To study self esteem and social anxiety in patients with acne.
To study association between self esteem and social anxiety in these patients.

Materials and Methods: 100 patients of acne were studied in tertiary teaching hospital in urban area. Self esteem and social anxiety were assessed using Rosenberg Self Esteem Scale (RSES) and Liebowitz Social Anxiety Scale (LSAS) respectively. Data was pooled and subjected to statistical analysis by Chi-square test to find out association between self esteem and social anxiety.

Results: Two third (66%) of the patients showed lower scores on RSES. One third (36%) of the patients had total scores more than cut off on LSAS. 48. 5% of the patients with low self esteem on RSES had LSAS scores more than cut off.

Conclusions: Association between low self esteem and social anxiety in patients with acne was highly significant. Thus acne vulgaris has the potential to cause significant negative impact on psychosocial functioning.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Study of domestic violence in female patients of schizophrenia

Bhakti Hemant Murkey, Pradeep Sharma, Vijay Choudhary, Arvind Jinger, Gunjan Solanki

SMS Medical college, India.

E-mail: doctor.bhaktii@gmail.com,

Keyword: Domestic violence, schizophrenia, anxiety, depression

Introduction: Schizophrenia is a chronic illness which not only burdens the patient but also the care-givers. Behavioral problems in Schizophrenia lead to domestic violence especially on females in our society in various domains. The current study aims to study whether a co-relation exists between the level of psychopathology and domestic violence and the impact of this violence on the patients in terms of anxiety or depression.

Materials and Methods: 30 female patients diagnosed with Schizophrenia (as per ICD 10 criteria) were recruited from OPD at Psychiatric Center, Jaipur. The Positive and Negative Symptom Scale, Scale for Domestic Violence (Hindi version), Hamilton Rating Scale for Depression and Hamilton Rating Scale for Anxiety were applied. SPSS 20 was used for statistical analysis.

Results and Conclusion: The total score of Domestic Violence was not found to be significantly associated with either Positive or Negative symptom scores. Domestic Violence was found to be significantly associated with total Anxiety and Depression scores (p<0. 05). This emphasizes the need to undertake measures to prevent domestic violence and thus prevent anxiety and depression in patients of Schizophrenia, leading to an improvement in the overall outcome of treatment.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Study of differential expression of impulsivity in bipolar mania and depression

Bhakti Hemant Murkey, Pradeep Sharma, Gunjan Solanki, Vijay Choudhary

SMS Medical college, India.

E-mail: doctor.bhaktii@gmail.com,

Keyword: Impulsivity, mania, depression

Introduction: Impulsivity is conceptualized to stem from affective symptoms underlying both polarities of Bipolar Disorder. The type of impulsivity affected impacts symptomatology over different phases of the illness.

Aim: To compare expression of impulsivity in patients of Bipolar Mania and Bipolar Depression in relation to severity of illness.

Methodology: 60 patients of Bipolar disorder (30 of Mania, 30 of Depression) were recruited. The severity of current episode was assessed using the Young’s Mania Rating Scale in patients of Mania and the Hamilton Rating Scale for Depression in patients of Depression. Impulsivity was assessed in all patients using the Barratt’s Impulsivity scale (Hindi version). The statistical analysis was done using SPSS 20.

Results: The total score of impulsivity in patients of both groups correlated with the severity of illness (P = 0. 09 for Mania, P = 0. 08 for Depression) but failed to reach the cut-off for statistical significance. The severity of illness correlated significantly with Motor impulsivity (P = 0. 004) especially motor hyperactivity (P = 0. 057) in Mania and with Attentional impulsivity (P = 0. 026), Attention (P = 0. 034) and Cognitive Instability (P = 0. 036) in Depression.

Conclusion: Impulsivity increases with severity of both Mania and Depression. Patients with raised psychomotor activity, attention deficits and cognitive instability are more likely to manifest impulsivity symptoms like risk-taking behaviors or suicidal attempts. This highlights the importance of proper management of symptoms of inattention, cognitive instability and raised motor activity in Bipolar patients and thus, prevent adverse outcome.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Pentazocine dependence in sickle cell anaemia: A case report

Prashant Gupta, Prabhu Dayal

All India Institute of Medical Sciences, New Delhi, India.

E-mail: spg_aiims@yahoo.co.in, drpd@rediffmail.com

Keyword: Pentazocine, injection, sickle cell anaemia

Introduction: Sickle cell anaemia is a chronic condition characterized by recurrent episodes of acute severe painful crises. Injectable opioids are the mainstay of management of painful crises. Little clarity exists regarding role of sickle cell anaemia in the onset of substance dependence.

Aim: To demonstrate pentazocine dependence in a patient with sickle cell anaemia.

Methodology: Detailed clinical interview in a specialist de-addiction centre (NDDTC).

Results: A 29 year old male diagnosed with sickle cell anaemia in early childhood, had recurrent painful vaso-occlusive crises requiring symptomatic in-patient management, including injectable opioids. Patient received injectable pentazocine during one such crisis at 16 years of age. Apart from pain relief, patient also experienced a high. With worsening of frequency of crises and financial problems associated with recurrent hospitalisations, patient tried self-medicating with pentazocine. Use continued due to pain relief and the feeling of well-being. Gradually, daily use of injections started even when the pain crises were resolved. Withdrawals, tolerance and craving appeared which were unrelated to pain symptoms. Outpatient detoxification was unsuccessful but patient remained abstinent from injections on oral dextropropoxyphene. He kept relapsing to previous pattern of pentazocine use with every sickle cell crisis. Patient had good psycho-social support and was motivated to quit. OST could not be provided due to logistic issues. Inpatient management was advised which the patient did not comply with.

Discussion: Pseudoaddiction, i. e., pain related behaviours which resemble dependence, is often documented in sickle cell patients. Higher estimates of addiction in such patients are frequent which might lead to undertreatment. But actual prevalence is largely unknown. Our patient had diagnosable opioid dependence. Management of such patients pose a big challenge.

Conclusion: More research is needed on the association of sickle cell anaemia with substance dependence and the management of this condition.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Revisiting the case of Phineas gage-diagnosis & management; dilemma

Nashat Usman Ghani, Supriya Vaish, S. Sudarsanan, Sandeep Choudhary, Satish Budania

Subharti Medical College, Meerut, Uttar Pradesh, India,

E-mails: nashatusman@yahoo.com, drsupriyavaish@gmail.com, sudi_sudi@rediffmail.com, choudhary_sadee@rediffmail.com, satishbudania@gmail.com

Keyword: Neuropsychiatry sequelae, phineas p. gage, traumatic brain injury

Background: The case of Phineas P. Gage revolutionized neuropsychiatry leading to immense amount of research on the bi- directional relationship of brain and behaviour. In discussion is a similar case with the purpose to generate speculations regarding the management where usual anti-epileptics, mood stabilizers or antipsychotics fail to manage the altered personality changes.

Objective: Case discussion to emphasise the dilemma related to management of neuropsychiatry sequelae of traumatic brain injury.

Materials and Methods: Mr. A, forty five year old married male brought by his wife to the psychiatry OPD following admission in the de-addiction ward, with history of changes in personality over a period of past five years following a head injury. According to his wife, he became very argumentative, irritable, and abusive and gradually increased alcohol intake to an amount where he would consume even during daytime. He started remaining suspicious towards family blaming them for trying to frame him, harm him and regarding the character of his wife. He stopped going to work leading his family to be financially dependent on his elder brother. Pre-morbidly he was a well-adjusted individual with cordial relationship with family and friends, a diligent worker and a social drinker. MRI findings:

Large CSF signal intensity with peripheral gliosis area noted in the bilateral frontal region,
Left lesion shows communication with the frontal horn of left lateral ventricle,
Right lesion shows suspicious communication with frontal horn of right lateral ventricle.

Result: During admission, he was put on a mood stabilizer, an antipsychotic and two anti-epileptics and had to be discharged on patients request following poor compliance on follow up.

Conclusion: Neuropsychiatric sequelae of traumatic brain injury are not as rare as previously thought. The diagnosis is straightforward however the pharmacological management is still sketchy and thus needs to be actively discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Technology addiction among subject seeking ayurvedic treatment

Hemant Kumar Gupta, Manoj Kumar Sharma¹

Acamh&Ns, Nimhans, India, ¹Nimhans, India.

E-mails: hemantgupta04@yahoo.com, mks712000@yahoo.co.in

Keyword: Technology addiction among subject seeking Ayurvedic Treatment

Background: Background Technology addiction refers to repeated tendency by an individual to engage in some specific activity(cell phone use, internet use and being on Facebook etc), despite harmful consequences to his/her health, mental state, or social life.

Materials and Methods: Survey methodology using technology addiction survey, was used to collect information among 100 subjects attending inpatient & outpatient setting of Ayurvedic Center.

Results: It revealed presence of addiction to internet, social networking sites and mobile texting. It has relationship with psychosocial variables.

Conclusion: Presence of addiction to technology among subjects seeking ayurvedic treatment, implicate the need for screening as well as promotion of healthy use of technology.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Knee-buckling (Negative Myoclonus) associated with Clozapine: Is there a dose-response relationship?

Samir Kumar Praharaj, Nishanth Vemanna, PSVN Sharma

Kasturba Medical College, Manipal, Karnataka, India.

E-mails: samirpsyche@yahoo.co.in, nishanth_vemanna@yahoo.com, psvn.sharma@manipal. edu

Keyword: Clozapine; myoclonus; knee buckling

Background: Among the adverse effects of clozapine, agranulocytosis, myocarditis and seizures are considered severe and limit its widespread use. Clozapine-induced myoclonus can present as jerky muscle contraction (positive myoclonus), or a brief lapse of muscle activity (negative myoclonus), with the former being more common.

Objective: To describe the association of knee-bucking episodes with clozapine in a 31-year old male with treatment-resistant schizophrenia.

Results: There were episodes of knee-bucking which was observed at clozapine 600 mg per day which was suggestive of negative myoclonus and there was a reduction of frequency with lowering of dose and complete disappearance at clozapine 300 mg per day. Following increase in dosage there was recurrence of these episodes, which responded to dose reduction.

Conclusion: Negative myoclonus is an uncommon adverse effect of clozapine which shows a dose-response relationship.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Comparison study of nicotine dependence among patients of schizophrenia, BPAD with mania and general population.

Priyanka Priya, Shantanu Bharti¹, Anju Agarwal², Anshuman Tiwari³, Ajay Kohli⁴

Era’s Lucknow Medical College, India

E-mails: ppriya16n@gmail.com, shantanubharti@gmail.com, anjubadhan@gmail.com, drajaykohli@gmail.com

Keyword: Nicotine dependence, schizophrenia, BPAD (mania)

Objective: To compare the nicotine dependence between patients of Schizophrenia, BPAD (Mania) with general population.

Materials and Methods: This study includes 150 samples containing 50 each from Schizophrenia, BPAD(Mania) and general population without any psychiatric illness. The patient in the study are taken from adult Psychiatric OPD of Era’s Lucknow Medical College and Hospital, Lucknow for six months time period satisfying our defined inclusion criteria. Patients are being diagnosed according to ICD-10 diagnostic criteria. Severity of illness will be assessed by appropriate rating scales. Severity of nicotine dependence will be assessed by Fagerstrom Test for Nicotine Dependence (FTND & FTND- ST).

Results & Conclusion: As this is an ongoing research, results would be shared at the time of presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Influence of empathy on quality of life in advanced cancer patients

Ramakanth Paniharam, Ramakrishna Podaralla¹, Padma Shilpa V²

Deccan College of Medical Sciences, India.

E-mails: p.ramakanth69@gmail.com

Keyword: mpathy palliative care quality of life

Background: Now a days, lot of Cancer patients in advanced stage are dying in a pitiable state suffering with total pain which includes physical, social, spiritual and financial factors. Empathy plays an important role in alleviating their Quality of Life worsening in their last days of lives.

Objective: To study the influence of Empathy on symptoms of depression, distress and other aspects of quality of life in advanced cancer patients receiving Palliative Care.

Materials and Methods: The study was cross-sectional in nature. Fifty patients with advanced cancer from a hospital at Hyderabad were assessed with the following instruments: the visual analog scale for pain (VAP), M. D. Anderson symptom inventory (MDASI), Hospital Anxiety Depression Scale (HADS), Functional assessment of cancer therapy-Palliative Care (FACT-pal), and Functional assessment of chronic illness therapy- (FACIT).

Results: Depression and anxiety were negatively associated with empathy. Empathy was significantly correlated with fatigue (r = –0. 423, P = 0. 002), symptom distress (r = –0. 717, P < 0. 001), memory disturbance (r = –0. 520, P < 0. 001), loss of appetite (r = -0. 399, P = 0. 004), drowsiness (r = –0. 400, P = 0. 004), dry mouth (r = -0. 381, P = 0. 006), and sadness (r = –0. 720, P < 0. 001). Empathy was positively associated with all the other aspects of QOL measures. Predictors such as palliative care well-being (^t = 2. 840, P = 0. 008), distress (t = –2. 582, P = 0. 015), sadness (^t = –2. 765, P = 0. 010 and mood (t = 2. 440, P = 0. 021) were significantly correlated with Empathy.

Conclusions: This study stresess that empathy is an important component of the quality of life of advanced cancer patients, and is closely related to the physical and psychological symptoms of distress. It should be addressed adequately in palliative care settings.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Prevalence and risk factors of depression and anxiety in patients of Diabetes Mellitus in a tertiary care centre

Pratibha Gehlawat, Rajesh Rajput, Rajiv Gupta, Deepak Gahlan

Pt B. D Sharma, University of Health Sciences, Rohtak, Haryana. 124001, India

E-mails: hunt4prat_01@rediffmail.com, drrajeshrajput@outlook.com, rajivguptain2003@yahoo.com, deepakgahlan@gmail.com

Keyword: Depressin, anxiety, diabetes mellitus, prevalence, risk factors.

Background: Diabetes is one of the most common chronic diseases and affects virtually every organ of the human system. Depression and anxiety is common among patients with diabetes and associated with worse diabetes outcomes.

Aims and Objective: To study the prevalence and predictors of Depression and Anxiety in patients of Type 2 Diabetes Mellitus (T2DM) in Pt. B. D. Sharma, PGIMS, Rohtak, a tertiary care centre in northern India.

Materials and Methods: Four hundred and ten consecutive patients having T2DM and four hundred and ten healthy controls matched for age and sex attending the Endocrine OPD of a tertiary care center of northern India were included in the study. Socio-demographic and relevant clinical variables were collected. They were evaluated for depression and anxiety using Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale (HAM-A) respectively.

Results: It was found that a significantly larger proportion of diabetic patients had depression (26. 3% vs. 11. 2%, p = 0. 001), anxiety (27. 6% vs. 12. 7%, p = 0. 001) and comorbid depression and anxiety (21. 0% vs. 7. 3%, p = 0. 001) as compared to healthy controls. Diabetic women had higher depression (17. 1% vs. 9. 3%) and anxiety (17. 6% vs. 10. 0%) than men. The major predictors for severe form of depression and anxiety among T2DM cases were age, female sex, insulin therapy, retinopathy, nephropathy and IHD.

Conclusion: The present findings reveal that diabetic cases had significant higher depression and anxiety as compared to healthy controls. The risk factors for depression and anxiety were age, female sex, insulin therapy and diabetic complications.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Obsessive compulsive disorder: Onset at 78 years of age “A case report”

Arpit Parmar, Rajeev Ranjan, Rajesh Sagar

All India Institute of Medical Sciences, India.

Emails: dr.arpitparmar@yahoo.in, rajeevranjan5@yahoo.co.in, drrajeshsagar@gmail.com

Keyword: OCD, late onset, geriatrics

Objectives: Although obsessive compulsive disorder (OCD) is a common psychiatric disorder with female preponderance, the mean age of onset of OCD has a wide range, between 21. 9 to 35. 5 years (Weissman et al,. 1994). Most patients (65%) develop OCD before the age of 25 years and only 15% of cases of OCD present after age of 25 years (Rasmussen SA et al., 1992). Males seem to present with an earlier mean age of onset than females. In cases presenting with the age of onset after 40 years, one should Look for possible organic causes (Koran 2000). This mainly consists of neurological illnesses including encephalitis, parkinson’s disease, tourette’s syndrome, cerebrovascular lesions, brain tumors etc. Particularly frontal lobe involvement appears to be a characteristic of such patients. OCD typically appears to be chronic disorder with waxing and waning course.

Materials and Methods: We present a case of an old aged female, known diabetic and hypertensive, who presented with OCD with an onset at the age of 78 years with predominant symptoms of obsessive doubts of dirt and contamination and compulsive washing, all of which started after familial conflicts. She was started on tab fluoxetine 20 mg to which she showed response and her YBOCS score came down to 8 from initial score of 18.

Results: Patient showed atypicality in the form that illness started after the stressor, acute onset with no evidence of any neurological illness and good response to treatment within a month. Relevant clinical issues, pertaining to late onset OCD are reviewed and discussed in the report.

Conclusion: The case report adds to the limited literature on late onset OCD and their atypicality in symptomatology, course and prognosis.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Aripiprazole induced skin rash: A case report

Santanu Nath, Aparajeeta Baruah, Kamal Narayan Kalita

Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, India.

E-mails: santanu@gmail.com, draparajeetabaruah396@gmail.com, knkalita@gmail.com

Keyword: Aripiprazole, skin rash, schizophrenia, adverse reactions.

Objectives: Skin rashes are one of the adverse reactions that can occur after using both typical and atypical antipsychotics. Such reactions are rare and can occur in varying severity. Aripiprazole, an atypical antipsychotic drug, can cause skin rash though not much of it has been reported in literature till date. The present case report shows development of skin rash that occurred as an adverse affect in a boy suffering from schizophrenia on receiving Aripiprazole.

Materials and Methods: The study was done on a 21 year old Bengali boy suffering from schizophrenia who was admitted in a tertiary mental hospital in North-east India. The antipsychotic, Aripiprazole was administered to him as pharmacotherapy. Development of skin rashes were tracked by photographing the rashes and these rashes were also followed up after discontinuing Aripiprazole.

Results: Pin-head sized, scarlet red coloured, pruritic, non-scaly, macular skin rashes without any mucosal involvement developed after 9 days of starting Aripiprazole in absence of any other systemic signs and these rashes started to diminish after discontinuing the drug.

Conclusion: Aripiprazole has propensity to cause skin rashes as one of its adverse effects.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Quality of life in patients with breast cancer receiving post-operative radiotherapy

Savita Kundu, Rajiv Gupta

PT. B. D. Sharma Pgims, Rohtak, India.

E-mail: kundusavita3@gmail.com

Keyword: Quality of life, breast cancer

Background: Breast cancer is the most common cause of cancer death among women and the most frequently diagnosed (one in four) cancer among women in most of the countries worldwide. Quality of life is a multidimensional construct and measuring quality of life in breast cancer patients is of importance in assessing treatment outcomes.

Objectives: To evaluate quality of life in post mastectomy patients with breast cancer receiving radiotherapy.

Materials and Methods: Patients who were mastectomized referred to Department of Radiotherapy of Pt. B. D. S. PGIMS, Rohtak, fulfilling the exclusion and inclusion criteria, were taken for study. Written and informed consent was taken from all the participants. Participants were evaluated at 3 points of time, at the start of radiotherapy/day 0, at 4 weeks/day 28 i. e. during radiotherapy, after 3 months of I^st assessment i. e. day 90 using EORTC QLC -30 and B-23.

Results: The study comprised of a total of 74 patients. However, thirteen out of 74 patients were excluded due to various medical comorbidities.

A statistically significant difference in mean scores at different time points (baseline, at 1 month, at 3 months) was observed in physical functioning (91. 04, 90. 16, 87. 86) role functioning (89. 34, 82. 78, 90. 98), emotional functioning (84. 15, 80. 73, 87. 56), social functioning (69. 94, 58. 74, 85. 79), global quality of life (59. 01, 59. 01, 67. 07) nausea, vomiting (4. 09, 1. 63, 00), fatigue (21. 85, 32. 42, 32. 24), pain (21. 03, 25. 40, 34. 97), sleep (9. 28, 8. 74, 4. 91), financial difficulties (43. 16, 26. 77, 26. 77), sexual enjoyment (54. 69, 52. 23, 74. 12), systemic therapy side effects (14. 12, 10. 53, 9. 36), breast symptoms (4. 09, 14. 2, 24. 18), arm symptoms (19. 49, 29. 87, 41. 16) and upset by hair loss (25. 68, 13. 66, 00).

Conclusion: Radiotherapy significantly affects various dimensions of quality of life in patients with breast cancer.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Factors affecting non-compliance among psychiatric patients in the regional institute of medical sciences, imphal.

Md Munnawar Sameer Husasain, Ching Gou Maan¹, Ningombam Heramani Singh¹, Raj Kumar Lenin Singh¹

Vydehi Institute of Medical Sciences & Research Centre, Whitefield, Bangalore, India, ¹Regional Institute of Medical Scinces, Imphal, India.

E-mails: Munnawar1986@gmail.com, mcaroline920@gmail.com, N.heramnai@yahoo.co.in, leninrk@yahoo.com

Keyword: Socio-demographic characteristics, non-compliance, psychiatric illness, reasons

Background: Non-compliance can be defined as a discontinuation or failure of proper medication intake without prior approval from the treating physician Objective: This study was carried out with an objective to assess different reasons of medication non-compliance in a sample of out-door psychiatric patients and to evaluate the correlation between clinical variables and causes of non-compliance to drugs.

Materials and Methods: Data was collected from a non-probability sample of 50 follow-up patients in the age group of 18- 60 yrs of age attending outpatient department of RIMS, Imphal. Information regarding socio-demographic characteristics was recorded. A questionnaire designed for this purpose was administered to examine the factors that cause non-compliance. Data was analyzed using SPSS for window 20. 0 version. Chi-square analysis was done for variable of interest.

Results: Non-compliance to drug treatment is most common in between 21-30 years of age groups, more in females 72% than males 28%, those who are married(60%) than single(40% ), and with low education(28%) & low socio-economic status(54%). Reasons for non-compliance were feelings of wellness(26%), paranoia to medication(22%), lack of insight to the illness(14%), medication side effects(10%), hopelessness of cure & poor support (8%) respectively, financial problems (6%), no improvement(4%), too much of medication(2%). The commonest psychiatric illnesses leading to non-compliance were schizophrenia (26%), BPAD (18%), MDD (14%), psychosis (10%), epilepsy & OCD (8%) each, GAD (6%), somatization disorder & substance induced psychosis(4%) each, panic attack with agoraphobia (1%). Data analyses explored significant associations between age, income and psychiatric illness with causes of non-compliance to drugs (P<0. 01).

Conclusion: Non-compliance is quite common in psychiatric patients. Medical practitioners need to be aware of it and address this problem because compliance is directly related to the prognosis of the illness.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Kleine-levin syndrome (KLS)-experience of ten cases

Sudipta Ghosh, Sikha Mukhopadhyay, Pradeep Kumar Saha

Institute of Psychiatry, IPGMER, Kolkata, India.

E-mails: sudipta_dr@yahoo.co.in, sikhamukho54@gmail.com, pradeepnimhan@gmail.com

Keyword: Kleine-Levin Syndrome, hypersomnia, Lithium

Aims & Objectives: Kleine-Levin Syndrome (KLS) is a rare disorder characterized by episodic hypersomnia and altered behavior lasting for days to weeks. Symptoms may include megaphagia, irritability, disorientation, derealization, lethargy and increased sexuality. We aim to describe clinical features, course and outcome of treatment in 10 cases with KLS attending a tertiary psychiatric centre in Kolkata.

Methodology: Information regarding family history and details of onset of illness, past and presenting episodes was collected. Baseline biochemical and hematological tests, EEG, MRI brain and neuropsychological evaluation were performed. Patients were followed up for 20 months.

Results & Conclusions: This case-series describes symptoms of episodic hypersomnia, associated behavioral alterations, cognitive disturbances and the subjective experiences of 10 KLS patients. Most of the patients had onset of symptoms in early adolescence with return to premorbid levels in the intervening periods. Relatively later onset cases(>18years) and patients having initial more number of episodes had more relapses in follow up period even with treatment. KLS causes diagnostic confusion with primary psychiatric disorders, and poses a therapeutic challenge, though Lithium and/or Modafinil may be effective.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Sexual function in women in rural Tamil Nadu: Disease, dysfunction, distress and norms

Shonima A Viswanathan, Jasmin Prasad, K. S Jacob, Anju Kuruvilla

Christian Medical College, Vellore, India.

E-mails: shonimaav@gmail.com, jasminp@cmcvellore.ac.in, ksjacob@cmcvellore.ac.in, sanju@cmcvellore.ac.in

Keyword: Sexual function, prevalence, distress, explanatory models

Background: Female sexual disorders are complex, diverse and associated with multiple biological, medical and psychological factors. They are often not recognized, diagnosed and managed. Whereas there are many studies from the West, epidemiological data on FSD from the Indian subcontinent are limited.

Objectives: We examined the nature, prevalence and explanatory models of sexual concerns and dysfunction among women in rural Tamil Nadu.

Materials and Methods: Married women between 18 and 65 years of age, from randomly selected villages in Kaniyambadi block. Vellore district, Tamil Nadu, were chosen by stratified sampling technique. Sexual functioning was assessed using the Female Sexual Function Index (FSFI). The modified Short Explanatory Model Interview (SEMI) was used to assess beliefs about sexual concerns and the General Health Questionnaire-12 (GHQ-12) was used to screen for common mental disorders. Sociodemographic variables and other risk factors were also assessed.

Results: Most of the women (277; 98. 2%) contacted agreed to participate in the study. The prevalence of sexual dysfunction, based on the cut-off score on the FSFI, was 64. 3%. However, only a minority of women considered it a problem (4. 7%), expressed dissatisfaction (5. 8%) or sought medical help (2. 5%). The most common explanatory models offered for sexual problems included an unhappy marriage, stress and physical problems. Factors associated with lower FSFI included older age, illiteracy, as well as medical illness and sexual and marital factors such menopause, poor quality of marital relationship, history of physical abuse, and lack of privacy.

Conclusions: The diagnosis of female sexual dysfunction needs to be nuanced and based on the broader personal and social context. Our findings argue that there is a need to use models that employ personal, local and contextual standards in assessing complex behaviours such as sexual function.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Autoimmune encephalitis presenting with behavioral changes, seizures, dystonia and regression in a pediatric patient A case report

Abigail Ruth Gojer, Venkateshwaran Rajaram

CMC Vellore, India

E-mails: abigailrg@gmail.com, drwaran005@gmail.com

Keyword: Anti-basal ganglia antibodies, neuropsychiatry, autoimmune encephalitis

Introduction: Anti-basal ganglia antibodies (ABGA) have been associated with movement disorders and psychiatric disturbances in children. The syndrome associated with positive antibodies is a relatively new one and particularly relevant to psychiatrists, because most patients are initially seen by psychiatric services. With a recognizable clinical picture, availability of a diagnostic test in the form of detecting the presence of auto antibodies targeting the basal ganglia due to molecular mimicry, as well as good improvement with immunotherapy, this condition needs to be explored more.

Case Report: We have been identifying and treating this disorder quite regularly at Christian Medical College. In this poster, we would like to present a pediatric patient who presented to our Psychiatry unit with multiple psychiatric manifestations following new onset seizures and right sided dystonia. He was referred to our Neurology colleagues and responded well to immunomodulation after being diagnosed with ABGA encephalitis, the other possible aetiologies being ruled out.

Discussion: The nature and function of ABGA and the patho-physiology involved in the development of this particular encephalitis is discussed. The possibilities regarding further research in this field, as well as the fine line between psychiatry and neurology is also reviewed. The need for being aware of such modifiable conditions and the implications of the same in psychiatric clinical practice is also emphasized.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Disulfiram induced psychosis A case report

Nihar Ranjan Rath, Satyakam Ranjan Mohapatra, Neelmadhab Ranjan Rath

SCB Medical College, India.

E-mails: ntrath@gmail.com, satyakgmu@gmail.com

Keyword: Disulfiram, psychosis, alcohol dependency

Background: Disulfiram is being used an aversive therapy in alcohol dependency since last 60 years. Psychosis is a very rare yet serious side effect of disulfiram.

Aim and Objectives: To report a case of a young man who developed psychosis shortly following dose escalation of disulfiram which subsided after discontinuation of drug.

Materials and Methods: A 32 yr hindu male with history of chronic alcohol abuse in excess of 750 ml of more than 5 yrs duration presented to our OPD with alcohol withdrawal seizure. Disulfiram was started at the dose of 250 mg at bed time which was increased to 500 mg on subsequent visit as aversive therapy. He developed behavioural problems like easy irritability, fearfulness, decreased sleep & auditory hallucinations within 7 days of the dose escalation. Routine blood tests were within normal limit apart from raised values of AST, ALT, carbohydrate deficient transferrin, gamma glutamyl transferase & fatty changes in ultrasound findings. Urine analysis for other addictive substances were negative. Disulfiram was stopped & he was treated with olanzapine 10 mg twice daily, symptoms started subsiding in 2 days & he became asymptomatic in 5days. Medicines were tapered & were discontinued in 20 days & he remained asymptomatic in subsequent follow up after 6^th & 10^th week.

Conclusion: Disulfiram is reported to produce acute transient psychosis. Its inhibition of betahydroxylase enzyme with subsequent increase in dopamine concentration in mesolimbic circuits is implicated for this. Its very important to differentiate between disulfiram induced psychosis & other causes of psychosis like substance induced psychosis. Risk is dose dependant with 500 mg or higher & in people with positive past or family history for psychosis. At daily doses of 250 mg chances of developing psychosis is very low. Disulfiram should be started with lowest effective dose 250 mg daily or less & proper observation should be maintained for new onset behavioural problems when escalating dose.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A study of depressed non diabetic post menopausal women. Is there any association of fasting plasma glucose and LH levels ?

Aditi Ranawat, Ram Kumar Solanki¹

Mahatma Gandhi Medical college Jaipur, India, ¹Dr. S. N. Medical College Jodhpur, India.

E-mails: aditiranawat@yahoo.co.in, solanki_ramk@yahoo.co.in

Keyword: LH, FPG, post menopausal

Aims and Objectives:

To assess the levels of LH and FPG in depressed non diabetic post menopausal women.
To compare and ascertain correlation of LH and FPG among depressed non diabetic post menopausal women.

Methodology: A prospective cross sectional comparative study conducted at the department of psychiatry, SMS Medical College Jaipur. Forty depressed non diabetic post menopausal women diagnosed on the basis of ICD-10 and fulfilling the inclusion and exclusion criteria & willing to participate in the study were recruited. Thirty non depressed non diabetic post menopausal women were also recruited for comparison.

The socio demographic characteristics, illness details were recorded in structured performa after proper consent. The hindi version of Beck’s depression self rating scale administered to all the subjects for assessment of severity of depression.

The fasting blood sample of all the subjects were taken on next morning between 9 to 9: 30 am and all the tests done at central lab, SMS Medical College, Jaipur. All the findings recorded and suitable statistical analysis done and results discussed.

Results: There were significant decrease in levels of LH in depressed group as compared to control group. Marginally decreased level of fasting plasma glucose was seen in depressed non diabetic post menopausal women.

Conclusion: Disturbed hormonal levels seen in depressed non diabetic post menopausal women as compared to non depressed women and there was definite association of LH & FPG to depression and its severity.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Medical students attitude towards suicide attempters: An exploratory study

Mamta Rajput, Amit Jagtiani¹, Savita Chahal¹, Rajiv Gupta¹, Naresh Nebhinani²

AIIMS Jodhpur, India, ¹PGIMS Rohtak, India, ²AIIMS Jodhpur, India.

E-mails: mamta_rajput45@yahoo.co.in, jagtiani10@hotmail.com, savidocchahal@gmail.com, rajivguptain2013@yahoo.co.in, drnaresh_pgi@yahoo.com

Keyword: Attitudes, medical students, self-harm, suicide

Backgroud: Majority of health professionals have unfavorable attitudes towards patients presenting with self-harm, which further compromises their willingness and outcome of care. This study was aimed to assess the medical students’ attitudes towards suicide attempters.

Methods and Material: 205 medical students from final year MBBS were recruited through total enumeration method.. ‘Suicide opinion questionnaire’ was administered to assess their attitudes towards suicide attempters.

Results: Nearly half of the students were males, from urban locality, with the mean age of 21. 9 years. Only minority had previous exposure to suicide prevention programmes and management of such cases. Again, only minority of the students have seen any patient presented with suicide attempt. Majority of the students agreed for mental illness, disturbed family life, and depression as major push to attempt suicide. They held favorable attitude for only one-third of the attitudinal statements, and they were uncertain for rest two-third of the statements.

Conclusions: Their uncertain response highlights the need for enhancing educational exposure of medical students and new staff at the earliest opportunity, to carve their favorable attitude towards patients presenting with self-harm.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychosis in a patient with Immunoglobulin G4 (IgG4) related disease

Akhil Abhijnhan, Rajesh Gopalakrishnan, Anju Kuruvilla

Resident-Department of Psychiatry, Christian Medical College-Vellore, India.

E-mails: akhil.abith@gmail.com, rajeshgop@cmcvellore.ac.in, sanju@cmcvellore.ac.in

Keyword: IgG4 related disease, acute psychosis, Risperidone.

Introduction: IgG4 related disorder is a newly recognized fibro-inflammatory condition with specific clinical, pathological and serologic features. It can involve one or multiple organs, usually presenting with the development of a mass in the affected organ. Reports of neuropsychiatric manifestation of this disorder have so far been limited to pachymeningitis, adenohypophysitis, infundibulo-hypophysitis and panhypophysitis.

Case report: We report the case of a patient with IgG4 related disease, who developed an acute psychotic episode. This appeared to be independent of other contributing factors including the immunosuppressive medications. He achieved complete remission of psychotic symptoms with short term, low dose Risperidone.

Discussion: The neuropsychiatric manifestations of this recent syndrome are not fully known. We believe that psychotic symptoms could be a neuropsychiatric manifestation of IgG4 related disease. The possible contributions of immunosuppressive agents in the development of psychotic disorders will also be discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Use of SCALE model to enhance the mental illness recovery focus in a forensic setting

Leela Sivaprasad, Christina Tang¹

BSMHFT, Reaside clinic, Birmingham, United Kingdom, ¹SSSHFT, Hatherton centre, Stafford, United Kingdom.

E-mails: Leelas810@yahoo.co.uk, Leelas810@yahoo.co.uk

Keyword: Mental illness, recovery, forensic, SCALE model

Background: The value of a recovery focus within forensic services and settings particularly in terms of developing services ‘that inspire hope, meaning and purpose’, has been well outlined in recent years (Drennan & Alred, 2012). However, the issue of risk also needs to be considered and balanced alongside the drive for recovery (Barker, 2012).

We aimed to use and develop the SCALE model to enhance the recovery focus within our service.

A week long clinic wide launch was organised and deliveried across the 8 programmes. From a ‘mental illness and associated distress’ programme point of view, we focussed the goals on key issues often raised by patients-diagnosis, medication, legal status and issues, and leave/discharge. This was communicated in multiple venues and in different formats across the clinic and open to all patients to attend.

Although initial attendance and engagement posed some challenges, the initiative was met positively by patients and staff particularly due to greater transparency between patients and clinicians and its resonance with what patients were generally interested in with regards to their care.

Whilst the merit of this approach and it’s successful Introduction and adaptation to our service has been acknowledged, the ongoing challenges are in ensuring it becomes firmly embedded in our everyday practice, is delivered consistently across all areas, especially ‘mental illness and associated distress’ and is continuously adapted to the needs of our patients.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Experience of caregiving and coping strategies in caregivers of schizophrenia

Nimisha Doval, Anil Nischal, Manu Agarwal, Eesha Sharma

KGMU, India.

E-mails: ndkgmu13@gmail.com, an.kgmu@gmail.com, drmanuagarwal7@gmail.com, eesha.250@gmail.com

Keyword: Experience of caregiving, Coping strategy, schizophrenia, caregivers

Background: Until recently caregiving was mainly studied in terms of caregiver-burden. However, preliminary studies shed light on positive aspects of caregiving also. Caregiving can be a source of positive transformation in a person’s life. There is limited research on this area in India.

Aims: To assess the ‘experiences of caregiving’ and ‘coping strategies’ in caregivers of patients with schizophrenia. Secondarily, to study associations between these two variables.

Materials and Methods: A total of 102 caregivers of schizophrenia were recruited among the patients attending department of psychiatry in a medical college in north India. Socio-demographic profiles of patients and caregivers, and clinical histories of patients were collected. Caregivers were assessed on ‘Experience of Caregiving Inventory’ (ECI) and ‘COPE Inventory’ (COPE). Patients were assessed on Positive and Negative Syndrome Scale (PANSS).

Results: Among the negative experiences of caregiving, highest effects were seen on the domain ‘effects on family’. All the other domains had moderate scores, while stigma had the lowest. Among the positive caregiving experiences, ‘good aspects of relationship’ scored higher than ‘positive personal experiences’. Caregivers used a wide range of adaptive and maladaptive coping strategies. Only 3 of 15 – denial, substance use and humor – were being used minimally. There were statistically significant positive correlations between positive experiences of caregiving and adaptive coping strategies, and the negative experiences of caregiving and maladaptive coping strategies.

Conclusion: Caregivers of patients with schizophrenia reported both positive and negative experiences of caregiving. This finding is significant, given that the large body of work on ‘caregiver burden’ in schizophrenia connotes an essentially negative experience for caregivers. The correlation between the experiences of caregiving and coping strategies used by the caregivers suggest that the experiences are influenced not only by the illness characteristics but also by the coping methods employed. Thus, helping caregivers cope better might improve caregiving experience.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Self-reported quality of sleep among junior doctors

Saranya Dhanasekaran, Suresh Yadav¹

NIMHANS, Bangalore, India, ¹Lady Hardinge Medical College and Associated Hospitals, New Delhi, India.

E-mails: saranya296@gmail.com, suresh.yadav22@gmail.com

Keyword: Insomnia, quality of sleep, doctors

Background: Insomnia is an under recognised problem which could result in serious consequences especially among doctors such as day time sleepiness and impaired executive functioning.

Objective: The present study aimed to assess the self-reported quality of sleep among junior doctors.

Materials and Methods: A self-rated questionnaire to assesses sleep quality and disturbances over a 1-month time interval, adapted from the WHO worldwide project on sleep and health, was completed by hundred junior doctors between 23 to 34 years of age. The questionnaire had nine questions with five responses each (never, rarely, sometimes, frequently or always). Subjects who answered ‘frequently’ or ‘always’ to a question were considered to have sleep problems in that area. Those with substance dependence, medical illnesses known to affect sleep, doctors doing night shifts or preparing for exams at night were excluded.

Results: 34 % reported sleep problems in more than one area suggesting the need for detailed evaluation for insomnia. 13% had difficulty in falling asleep, 17 % took more than one hour to fall asleep, 8 % had more than three night time awakenings, 7 % took a long time to fall back asleep, 10 % woke up earlier than they intended to, 2 % drank alcohol/used sedatives to help them fall asleep, 17 % had difficulty arising in the morning, 18 % woke up feeling tired and 15 % felt sleep was adequate. None of the 34 subjects with sleep problems had themselves evaluated or treated.

Conclusion: There is a high prevalence of sleep problems among junior doctors. Effects of insomnia on professional decision making could be dire. Awareness and importance should be given to this subject in the medical curriculum.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Effect of adjuvant rTMS on childhood obsessive-compulsive disorder (OCD)

Suhasini Das, V. K. Sinha

Central Institute of Psychiatry, India.

E-mails: dassuhasini1908@gmail.com, dassuhasini1908@gmail.com

Keyword: rTMS, childhood OCD, adjuvant, treatment

Introduction: Childhood obsessive-compulsive disorder is a chronic disorder, often running a waning and waxing course. Despite advances in treatment, a large number of patients do not show much improvement. Repetitive transcranial magnetic stimulation (rTMS) has been shown efficacious in many psychiatric disorders, namely depression and auditory hallucinations, with conflicting reports in adult OCD. In our study, we wanted to assess its efficacy in childhood OCD.

Aims and Objections: To assess the efficacy of rTMS in obsessions and compulsions in childhood OCD.

Inclusion criteria: OCD cases < 18 years with mild to moderate depression.

Exclusion criteria: Any other co-morbid psychiatric disorder, neurological disease, ECT in the past 6 months.

Materials and Methods: Sample size: 20, Venue: K. S. Mani Centre of Cognitive Neurosciences, CIP, Sampling: Purposive, Scales: Childhood Yale Brown Obsessive-compulsive scale (CY-BOCS), Childhood depression inventory (CDI) and pediatric anxiety rating scale (PARS).

Procedure: 20 patients fulfilling inclusion and exclusion criteria were randomly alloted using random number generator to either ‘active’ (n = 10) or ‘sham’ rTMS (n = 10) and rated on CY-BOCS, CDI, PARS. They were given 10 sessions of low frequency (1Hz) rTMS over the supplementary motor area over 2 weeks. A second rating was done after 2 weeks and a final rating after 4 weeks to aseess the efficacy of rTMS.

Analysis and Results: To be presented at the time of presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychiatric co-morbidity in case of alcohol dependent patients admitted in a psychiatric hospital in eastern india

Ajay Halder, Avijit Chakraborty, Supreem Bose

institute of psychiatry, kolkata, India.

E-mails: halder.ajay@gmail.com, drabhijit2013@rediffmail.com, halder_ajay@yahoo.in

Keyword: Co-Morbidity, Alcohol Dependent, Psychiatric Hospital

Background: Psychiatric co-morbidities are very common particularly in alcohol dependent patients. They are very difficult to treat & prognosis is poor.

Objectives: To determine prevalence of psychiatric co-morbidities among alcohol dependent patients.

Materials and Methods: The study assessed the prevalence of psychiatric co-morbidities in 40 alcohol dependent patients admitted in Institute of Psychiatry, IPGME&R, Kolkata. A semi-structured proforma & DSM-IV-TR is used. Thereafter statistical analysis is done.

Results: The most common co-morbidities are depression (32. 5%), Bipolar Affective Disorder (20%), Anxiety disorder (17%), Personality disorder (4%), Schizophrenia (4%).

Conclusion: –62. 5% subjects substances uses for 10 or less years, 30% subjects are using 10-20 years, 7. 5% are using more than 20 years.

The majority of the subjects (70%) were dependent on alcohol for 5 years or less (25% 5-10 years, 5% >10 years).

17. 5% had legal problem, 82. 5% had no legal problem.

Unmarried patients are mostly belonging from low distance & started alcohol use early and most married patients are from high distance & started alcohol use lately(p <. 01).

All the patients are males in this study. The reason is that alcohol consumption by women is socially unacceptable till now and women may not avail treatment openly in a general hospital setting.

V-X std, married, hindu male of mean age group 25. 4 years of monthly family income Rs 1, 000-5, 000 are most vulnerable group of alcohol dependence with co-morbidities.

Though generalization is not valid as this is a psychiatric indoor based study, yet some definite trends have been found which are of research and clinical significance

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Major depressive disorder, chronic dissociative stupor, emotionally unstable personality disorder in a young woman: Exploration of the missing link.

Maha Prakash Sharma, Sujit Kumar Kar, Mamta Yadav, Shweta Singh

King George Medical University, Lucknow, U. P., India.

E-mails: mahaprakashsharma@gmail.com, drsujita@gmail.com, mamtaa.y@gmail.com, sscbhanu@gmail.com

Keyword: Major depressive disorder, chronic dissociative stupor, emotionally unstable personality disorder, Adverse childhood experiences

Background: Adverse childhood experiences have a significant impact on the mental wellbeing which depends on the severity, complexity, duration of the painful experience and the way it is dealt in the early life. The consequences can manifest in the form of some externalizing or internalizing behaviors. This single case study aims to highlight different adverse childhood experiences like — loss of parents, ill treatment by aunt, early marriage, teenage pregnancy, and physical abuse by alcoholic husband in a young woman which led to development of Major depressive disorder, dissociative stupor and emotionally unstable personality disorder. This case study also discusses the role of psycho-diagnostic assessments and issues related to management.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Study of relationship between event related potentials (P300 and CNV) in opioid dependence with and without self-harm

Ramling Rajappa Dhabale, C. R. J. Khess¹, S. K. Munda²

Central Institute of Psychiatry, India.

E-mail: jnramd@gmail.com

Keyword: Opioid dependence, self harm, P300, CNV

Background: Self-harm is any self-directed behavior that causes immediate destruction of body tissues. Several studies have found an association between self-harm and substance use, with opioid users topping the list. It has been found that those who engage in deliberate self-harm have deficits in focussing attention in goal-directed behaviors. We wanted to study relationship between cognitive markers of attention i. e. P300 and CNV in opioid users with and without self-harm.

Objectives: To study and compare P300 and CNV in opioid dependence with and without self harm and in normal controls.

Materials and Methods: Sample size: 30, Venue: K. S. Mani Centre for cognitive neurosciences, CIP, Sampling: Purposive, Scales: General Health questionnaire-12 (GHQ-12), Barrets’s Impulsive Scale-11 (BIS-11), Hamilton rating scale foe depression (HAM-D), self Harm Inventory (SHI), evoked potential measuring instrument.

Procedure: Patients in two groups opioid dependence with self-harm (n = 10), opioid dependence without self harm (n = 10) and 10 normal controls were included and above mentioned scales were applied. Event-related potentials (P300 and CNV) were measured using evoked potential measuring system.

Results and Conclusion: To be shared at the time of presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A study of disability in stable patients of schizophrenia

Maha Prakash Sharma, Anil Nischal, Bandna Gupta, Manu Agarwal, Sujit Kumar Kar

King George Medical University, Lucknow, U. P., India.

E-mails: mahaprakashsharma@gmail.com, an.kgmu@gmail.com, drbandna@yahoo.co.in, dr.manu777@yahoo.co.in, drsujita@gmail.com

Keyword: Schizophrenia, stable Patients, disability, IDEAS, cognition

Background: Schizophrenia is highly devastating among the mental illnesses. It is an established cause of disability and effects overall functioning of an individual. Disability arising out of schizophrenia is as disastrous as any physical disability. Difficulty in carrying out everyday life activities and social functioning is the prominent aspect of disability in schizophrenia.

Aims: Our aim was to assess disability in “stable patients” of schizophrenia and to study the association of socio-demographic and clinical variables of these patients with disability.

Patients and Methods: A total of 62 clinically stable patients of schizophrenia attending adult psychiatry OPD were assessed after excluding other psychiatric comorbidities on Mini International Neuropsychiatric Interview (M. I. N. I. ). Positive and Negative Syndrome Scale (PANSS) for psychopathology and Schizophrenia Cognition Rating Scale (SCoRS) for cognitive impairment were used. Disability was assessed on Indian Disability Evaluation & Assessment Scale (IDEAS).

Results: Disability was not correlated with any socio-demographic variable. Disability in undifferentiated schizophrenia was higher than paranoid schizophrenia. Disability (IDEAS-Global Score & IDEAS-Total Score) had significant correlation with psychopathology in all three domains of PANSS as well as the total PANSS score and the correlation was stronger with negative symptom scores than with positive symptom scores. The correlation between the general psychopathology scores and IDEAS-GS & TS was also significant. Disability (IDEAS-GS & IDEAS-TS) was strongly correlated with cognitive impairment. ‘Work’, ‘communication and understanding’, ‘Interpersonal relationship’ domains of IDEAS had strong correlation with cognitive impairment.

Conclusion: Nearly 25% of stable patients (on adequate treatment since at least last six months, did not require any increase in dose of antipsychotic medication over last three months) had certifiable disability. ‘Work’ domain of IDEAS was most affected followed by ‘communication and understanding’& ‘interpersonal relationship’.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Deliberate self-harm by multiple episodes of insertion of sewing needles into the forearm

Sudipta Ghosh, Pradeep Kumar Saha

Institute of Psychiatry, IPGMER, Kolkata, India.

E-mails: sudipta_dr@yahoo.co.in, pradeepnimhan@gmail.com

Keyword: Deliberate self-harm, intentional insertion of foreign objects, Cluster B personality

Background: Deliberate self-harm is common. It is usually by drug overdose or ingestion of other noxious substances, but self-harm by cutting or burning often comes to the attention of psychiatrist. In medical literature, phenomenon of intentional insertion of foreign objects inside the body is often found, though the incidence of having psychiatric pathology as a hypothesized etiology with this behavior is not clearly established yet. Such behavior is commonly found in incarcerated patients in prison and reformatories, though it is not entirely uncommon in normal population. Psychiatric diagnoses like psychosis, mood disorders, personality disorders, malingering are frequently associated with such behaviors either alone or in a conglomerated fashion. Such behavior with a clear psychopathology is rarely reported from India. We report a case involving multiple episodes of insertion of sewing needles into the forearm in 17 year old boy with cluster B personality. We discuss the management considerations and emphasize the importance of actively addressing the underlying psychiatric problems for all instances of deliberate self-harm.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Cannabis induced Koro: A case report

Pankaj Kanwar, Ramesh Kumar, Ravi Chand Sharma

Indira Gandhi Medical College, Shimla, H. P, India.

E-mails: kanwar.pankaj1@gmail.com, tzramesh@yahoo.com, dr.ravicsharma@gmail.com

Keyword: Cannabis, koro, culture-specific syndrome

Background: Koro is a culture-specific syndrome that refers to an episode of sudden and intense anxiety that the penis (or in females, the vulva and nipples) will recede into the body and possibly cause death. Koro in relation to consumption of cannabis is very rare, only a few cases have been reported so far.

Aim: To present a case of cannabis induced koro syndrome.

Case History (Material and methods): A 30 years old married male from Nepal presented with history of smoking four to five deep puffs of cannabis in the company of friends first time in his life. Cannabis smoking was followed after 5 minutes by episode of retraction of penis into abdominal cavity associated with shortness of breath, fearfulness, hot flashes, chills, headache and sensation of impending doom. For three months since patient had smoked cannabis, he was experiencing similar episodes daily which lasted 15-30 minutes. Patient had sought treatment from faith healers but did not improve.

Results: A diagnosis of cannabis induced koro was made and he was put on paroxetine 25mg/day and risperidone 1mg/day. Patient reported few days later as he experienced worsening of symptoms with these medications. He was shifted onto escitalopram 10 mg/day, olanzapine 5 mg/day and clonazepam 0. 75 mg/day. Patient started showing improvement after about two weeks. He became asymptomatic after about two months of treatment and remained so when he was seen on his last follow-up after four months of initiating treatment.

Conclusion: This case illustrates the de novo onset of koro and points toward the need for further research into the psychological and behavioral effects of cannabis.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychogenic blepharospasm: An interesting case report

Soumitra Das, Sathesh Vadasseril, Shaji C. V.¹, Roopchand P. S.¹, Prasant S. R.¹, Shyma M. M.¹

Dept. of Psychiatry, Govt. T. D. Medical College, Alappuzha, Kerala, India, ¹Dept. of Neurology, Govt. T. D. Medical College, Alappuzha, India.

soumitratdmc@gmail.com, drvsathesh@gmail.com, drshajicv@gmail.com, roopchandps@gmail.com, drprasanth2003@gmail.com, mm.shyma@gmail.com

Keyword: Psychogenic, Blepharospasm, Stress.

Background: Blepharospasm is an uncontrolled spasmodic contraction of orbicularis muscles of eye resulting in abnormal tic or twitch of eyes. It usually lasts for seconds to minutes but in severe cases eyes may be closed for hours. It may be benign essential or secondary due to a lesion in basal ganglia, pyramidal tract, trauma, local pathology in eyes or drug induced. It is an uncommon neurological disorder but often severely disabling. There is a female preponderance with mean age of onset as 56 years. Here we are presenting a case of psychogenic blepharospasm. 65 years old lady presented with history of episodic inability of opening eyes for last 6 months. She had repeated abrupt closure of eyes which used to persist for 1 hour. It made her socially and interpersonally disabled. Systemic and neurological causes were ruled out by detailed physical examinations and investigations including neuroimaging. Following poor response to oral medications she was injected with 7 units of Botox only in muscles of right eye. But within seconds she got relief from both eyes. On next session even with needle prick on one eye without any medicines and suggestions she opened her both eyes from tightly closed position. There are only few case reports about psychogenic blepharospasm in literature till date. As per literature stress cannot induce blepharospasm but it can exaggerate the severity of existing one. Here in our case though patient did not express any stressors but on regular follow relatives reported stress related to recently increased workload in house. From our case it depicts that true movement disorder is often difficult to distinguish from functional disorder. So evaluation and management of patient’s external and internal stress will be of immense help before conducting any invasive treatment.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Antipsychotic induced obsessive compulsive symptoms in schizophrenia- case series

Bhavuk Garg, Sumit Kumar Gupta

Institute of Human Behaviour and Allied Sciences, IHBAS, Delhi, India.

E-mails: bhavuk.garg@gmail.com, drsumit@aol.in

Keyword: OC symptoms, schizophrenia, antipsychotic induced

Background: Over the past 3 decades investigators have reported prevalence rates of clinically significant OC Symptoms in the schizophrenia population of 10%–52%. However, recent observations of the emergence of de novo OCD with atypical antipsychotic treatment of schizophrenia raise the possibility that some of these comorbid OCD cases were medication-induced. De novo emergence or exacerbation of obsessive-compulsive (OC) symptoms during treatment with clozapine, risperidone, olanzapine and quetiapine has been described in the literature.

We present a case series of patients with schizophrenia of varying clinical profile who developed OC symptoms after treatment with atypical antipsychotics.

The reported cases and the pathogenetic mechanism of development of OC symptoms will be reviewed and discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A Case of persistent delusional disorder: Role of culture revisited

Arghya Pal, Piyali Mandal, Arpit Parmar, Rajesh Sagar

All India Institute of Medical Sciences, New Delhi, India.

E-mails: drarghyamb@gmail.com, piyum2008@gmail.com, dr.arpitparmar@yahoo.in, rsagar29@gmail.com

Keyword: Delusion, culture, gas

Objectives: To demonstrate the dilemma caused by cultural issues in labelling psychopathology.

Methodology: We present a case of persistent delusional disorder in which ‘Gas’ was considered the primary invading entity to patient’s body. We discuss the implication of ‘Gas/air’ in Indian culture and the diagnostic dilemma it poses.

Results: A 45 year old diabetic lady with history of moderate depressive episode presented with an illness of 7 year duration, which started after laparoscopic tubal ligation surgery. After one week, patient started experiencing multiple bodily symptoms. She concluded that air inserted during surgery was causing all symptoms. She believed that air moved inside the vessels or bones. She consulted multiple physicians and underwent multiple investigations, which were normal. Inspite of reassurance, she still blamed test’s inability to detect air inside the body. Her belief was reinforced from reading materials in lay-press explanation by an Ayurvedic physician and also believers among her relatives.

Conclusions: ‘Air’ is considered as one of the five basic elements of Ayurvedas. The ‘vata’ dosha is composed of ‘air’ and any vitiation of air leads to vitiation of ‘vata’ which is believed to be associated with illnesses like flatulence, gout. However, the existing idea of air causing multiple somatic complaints mostly have been due to aberration and misreporting of the concepts of Ayurveda in lay-press. On one hand, the presence of cultural influence prevents us from labelling it as a bizarre belief, on the other hand we consider it a delusion rather than an overvalued idea due to the associated strong conviction. However, the cultural beliefs associated with the after effects is worth exploring.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

An open label study of augmentative repetitive transcranial magnetic stimulation for depression in non-responders to first line pharmacotherapy and psychotherapy

Varsha Dnyaneshwar Mahadik, Indla Ramasubba Reddy, Vishal Indla

VIMHANS hospitals Vijayawada, India.

E-mails: varsha.mahadik88@gmail.com, vishalindla@gmail.com

Keyword: rTMS, Depression

Objective: Lesion and neuroimaging studies suggest that left prefrontal lobe dysfunction is pathophysiologically linked to depression. Repetitive transcranial magnetic stimulation (rTMS) to prefrontal structures has a lateralized effect on mood in normal volunteers, and several preliminary studies suggest a beneficial effect of rTMS on depression. Our study aims to find if this beneficial effect can be increased if rTMS is administered concomitantly with pharmacotherapy and psychotherapy.

Description: Depression is a common condition. The population prevalence is around 17% and it affects both males and females. Psychotherapy in the form of CBT with pharmacotherapy like SSRI’s etc has long been the treatment of choice for Depression. We tried adding rTMS to the ongoing pharmacotherapy and psychotherapy to see if the response, remission and recovery was faster. The patients were given augmentative rTMS only after first line of drugs had failed to induce a response.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Success of comedy shows, does it correlate with the increased amount of stress in everyday lives

Jateen Ukrani, Indla Ramasubba Reddy¹, Vishal Indla²

VIMHANS hospitals Vijayawada, India,

E-mails: jateenukrani@yahoo.com, indlas1@rediffmail.com, vishalindla@gmail.com

Keyword: Stress, laughter, comedy

Objective: to study link between growth of comedy genre and stress.

Background: Laughter has both physical and psychological effects on health. Physical effects include boosting immunity and triggering release of endorphins which are natural stress-busters. These mediate the psychological effects of laughter that is they help feel relaxed, dissolve distressing emotions and one feels recharged. Humor also shifts perspective, allowing one to see situations in a more realistic, less threatening light. Laughter producing shows are gaining popularity in the main stream media.

Until the turn of the millennium, stress was considered a major problem only after a life crisis, but today it goes beyond a single-incident type of stress, such as you might experience following trauma, illness, home foreclosure, layoff, divorce, death of a loved one or other major life event. Day-to-day life used to be a lot different for most people. We had more time between events such as eating, sleeping, working, spending time with family and hobbies. We had time to unwind and recoup from stressful events. We could go on vacations without worrying about our E-mails piling up to the point we’d regret ever going.

So does this success and the evolution of the comedy genre signify the increasing amounts of stress in our lives ??

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

An unusual case of Recurrent Dissociative Fugue

Prabhleen Singh Jaggi, Harshavardhan Sampath, Samrat Singh Bhandari

Sikkim Manipal Institute of Medical Sciences, India.

Emails: z.prabhleen@gmail.com, drharsha79@yahoo.co.in, samrat.bhandari@yahoo.co.in

Keyword: Dissociative fugue, recurrent, abreaction

Background: Dissociative disorders are rarely reported diagnostic entities. They are one of the least understood yet rank among the most fascinating disorders in Psychiatry. The term ‘fugue’ has roots in the Latin ‘fuga’ which means flight. The predominant disturbance is a sudden, unexpected travel from one’s home or work place and amnesia for the ensuing events. The differential diagnosis includes other dissociative disorders, complex partial seizures, substance induced amnestic disorders, dementia, factitious disorders and malingering. The length of the fugue may last days, weeks or even several months. Recurrent dissociative fugue is the least reported of the dissociative disorders.

Here we present an unusual case of recurrent dissociative fugue in a 38 year old male serving as a constable in the paramilitary who was brought to our department for assessment following sudden unsanctioned absence from work, with no apparent memory of events that transpired during that time. The patient had regained his autobiographical memory after 3 days when he found that he had travelled afar and with difficulty returned home with the help of strangers. There is a history of similar episodes occurring thrice in his duty in the past 11 years.

Upon admission and serial interviews with the patient and after reviewing the service records a provisional diagnosis of dissociative fugue was made.

Physical examination was within normal limits. Mental State examination revealed low mood, ideas of hopelessness, passive death wish and apprehensions regarding how his illness is perceived by his commanding officers and peers.

Biochemical, imaging and electrophysiological investigations revealed no abnormalities. Projective tests and psychiatric rating scales were administered.

Chemical abreaction was performed for both diagnostic and therapeutic purposes after informed consent., during which the primary gain was revealed.

The case will be discussed in detail during the time of presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Family burden in primary caregivers of patient with schizophrenia, bipolar affective disorder and depressive disorder: a Comparative study from Eastern part of India

Amitava Das, Pradeep Kumar Saha, Sujit Sarkhel

Institute of Psychiatry, IPGMER, Kolkata, India.

E-mails: amitavadas16@gmail.com, pradeepnimhan@gmail.com, sujitsarkhel@gmail.com

Keyword: Caregivers, family burden, schizophrenia, bipolar disorder, depression, comparison.

Objectives: The extent of perceived burden for caregivers of patients with different types of major mental illnesses was not measured systematically. Current study was planned to examine and compare family burden in primary caregivers of patients with schizophrenia (‘S’), bipolar affective disorder (‘B’) and major depressive disorder (‘D’).

Materials and Methods: Thirty primary caregivers from each group (diagnosed by ICD 10 with duration of illness was at least six months) were recruited as a consecutive sample for this cross sectional study. Family burden was assessed using the Family Burden Interview Schedule (FBIS) of Pai and Kapur. Data was analyzed using the descriptive statistics, ANOVA followed by post hoc Bonferroni tests.

Results: There was a significant difference (p>0. 05) between the groups in all six domains of objective burden, total objective burden and subjective burden of FBIS. The extent of burden among caregivers of patients with schizophrenia and bipolar disorder was more than those of depression in domain of ‘financial’, ‘disruption of routine family activities’, ‘effect of physical health of others’, ‘effect of mental health of others’ and overall total objective burden scores. The pattern of burden among caregivers of schizophrenia and bipolar disorder is almost identical in most of the domains except for the domain of ‘disruption of family leisure’ and ‘disruption of family interactions’. In the domain of ‘disruption of family leisure’ burden was highest in schizophrenia followed by bipolar followed by depression group and in the domain of ‘disruption of family interactions’ schizophrenia group was leaded by bipolar and depression that were almost identical.

Conclusion: The present study has shown that caregivers of patients with schizophrenia and bipolar affective disorder experienced considerable high degree of family burden compared to depressive disorder, which has important implications for management of schizophrenia and bipolar affective disorder especially for developing country like India.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychiatric morbidity in spouses of patients with alcohol dependence

Amit Sethi, Priti Singh¹, Pratibha Gehlawat²

Pt B. D Sharma, University of Health Sciences, Rohtak, Haryana. 124001, India.

E-mails: sethiamit@gmail.com, bpreetirth@yahoo.co.in, hunt4prat_01@rediffmail.com

Keyword: Alcohol, dependence, spouses, psychiatric morbidity

Background: Alcohol contributes to family disruption, marital discord and psychopathology in the family. Spouses are more vulnerable than other family members and bear a significant burden.

Aim: To assess the psychiatric morbidity among spouses of patients of Alcohol dependence.

Materials and Methods: A cross-sectional study was conducted in the Department of Psychiatry and Drug de-addiction centre of Pt. BD Sharma UHS Rohtak. Spouses of 50 consecutive patients who were diagnosed as M&B Disorder due to Alcohol use formed the study group. The subjects were assessed for psychopathology using Clinical Interview Schedule-Revised (CIS-R).

Results: It was found that 54% of spouses suffered from Common Mental Disorders, out of which 30% showed significant Anxiety and 14% had significant Depression.

Results and implications will be discussed in the presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A rare case of multiple substance use with catatonia

Vijay Walia, Pratibha Gehlawat, Purushottam Jangid

Pt B. D Sharma, University of Health Sciences, Rohtak, Haryana. 124001, India.

E-mails: vijaywalia5014@gmail.com, hunt4prat_01@rediffmail.com, jangidp@gmail.com

Keyword: Catatonia, multiple substance use, hyperactive

Background: Catatonia is a movement disorder associated with various aetiologies. The main cause of catatonia includes almost always medical, neurological, or psychiatric illness. Little is known about catatonia associated Multiple substance use including volatile substances and cannabis.

Case report: We report a case of 16 year old male with multiple substance induced catatonia. In this case, the patient used to inhale whitener, quick fix and consumed cannabis (Bhang) for last one month. He presented to psychiatric OPD of Pt. B. D. Sharma, UHS, Rohtak with the complaints of agitation, irritability, hallucinatory behaviour and marked restlessness. He was diagnosed as hyperactive catatonia which in itself is not a common condition. He was recovered after 3 days of treatment with lorazepam (upto 8mg/day) and supportive measures.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Dissociative experience: difference between unipolar and bipolar depression, comparison with healthy

Seshadri Sekhar Chatterjee, Prathama Guha¹, Kaustav Chakraborty²

Department of Psychiatry. Medical College, Kolkata, India, ¹Department of Psychitry, NRS MEdical College, India, ²College of Medicine and J. N. M. Hospital, India.

E-mails: itismeseshadri@gmail.com, tcnpgc@gmail.com, kaustav.psy@gmail.com

Keyword: Depression, Bipolar disorder, Dissociation

Background: Unipolar and bipolar depressions differ strikingly in respect to neurobiology, course and management. But their apparent clinical similarity often leads to misdiagnosis resulting in chronicity of course and treatment failure. According to recent findings dissociative experience can differentiate between the two as more dissociative experience have been reported in bipolar depression patients. But there is no study done in India so far. In this study we have tried to assess the level of dissociation between unipolar and bipolar depression patients.

Materials and Methods: After ethical committee clearance 30 unipolar and 30 bipolar depression patients and 30 matched control participants were selected and assessed on the basis of a semi-structured socio-demographic and clinical proforma, Dissociative Experience Scale (DES) and Manic depressive questionnaire (MDQ). The three groups compared using appropriate statistical method.

Result and Discussion: Will be submitted during the study.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Risk of venous thromboembolism with antipsychotic drug treatment: A review and update

Ananya Mahapatra, Rishi Gupta, Ramandeep Pattanayak, Sudhir Kumar Khandelwal

All India Institute of Medical Sciences, New Delhi, India.

E-mails: nnyaa09@gmail.com, mailrishigupta@gmail.com, drramandeep@gmail.com, sudhir_aiims@yahoo.co.uk

Keyword: antipsychotic, deep vein thrombosis, thromboembolism

Background: With emerging evidence, antipsychotic drugs have been implicated in increasing the risk of venous thromboembolism. The exact nature of the association, however, remains to be elucidated. Given the serious nature of this adverse effect, it is important to review the current state of evidence regarding the risk and nature of association.

Objective: We aimed to review the emerging literature on antipsychotic drug exposure and venous thromboembolism.

Methodology: The electronic databases MEDLINE (via PUBMED) and EMBASE were searched using relevant keywords and MeSH terms (“venous thromboembolism” and “anti-psychotic drugs”) for the period between January 2000 and August 2014. A total of 266 results were obtained. The titles and abstracts of articles published in English were screened. Finally, 95 articles found relevant to the topic were selected for inclusion.

Results: Available studies indicate a strong association between second generation antipsychotics and venous thromboembolism, with maximum reports for clozapine. Amongst others, there are relatively more cases reported for Olanzapine, followed by Risperidone. However, there is a lack of conclusive evidence regarding statistically significant association in case-control studies. Amongst first generation antipsychotics, there is an increased risk with low-potency drugs compared to high-potency ones, although the strength of association was weak. Various hypotheses have been proposed for the underlying pathophysiology which include metabolic changes, enhanced platelet aggregation, increased levels of anti-phospholipid antibodies, hyperhomocysteinaemia. Hyperprolactinemia has emerged as another potentially important mechanism in mediating thrombogenesis. Risk has been shown to be more in younger subjects and within first few months of antipsychotic treatment.

Conclusion: Evidence suggests that antipsychotic drugs do increase the risk for venous thromboembolism. However more studies are required to explore the underlying risk factors. Treatment guidelines should emphasize on the need for careful monitoring in the susceptible or high risk group of patients.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Effectiveness of christ centered psychotherapy in different psychiatric conditions

Sandeep B, Paul Russell

Christian Medical College Vellore, India.

E-mails: sandeeppsychiatry@gmail.com, russell@cmcvellore.ac.in

Keyword: Christ Psychotherapy Religiosity Spirituality

Background: If spirituality is an inner relationship with the God who created you and me then that should lead us to greater mental health.

Objectives:

To assess the effectiveness of Christ Centered Psychotherapy(CCP) when given as an adjuvant to standard therapy in different psychiatric conditions
To determine factors associated with improvement in areas like duration and severity of symptoms after the intervention, the dosages and number of drugs needed to control symptoms, improvement in quality of life and coping skills and reduction in caregiver burden and all these parameters at 3 months’ follow up.

Methods: A naturalistic observational study is planned in which patients and care givers who are willing to undergo CCP after knowing the details about the same would be recruited. Baseline quality of life and spirituality would be assessed using WHO Quality Of Life Questionnaire and FACIT-Sp-12 (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being) respectively and the same would be measured immediately after the therapy and at 3 months’ follow up. CCP is a unique school of psychotherapy which comprises of series of sessions which has following characteristic features:

Rapport is established with the patient in an atmosphere of divine love of the Lord Jesus Christ as revealed in the Holy Bible.
The specific areas of problems are probed into in sufficient detail ensuring confidentiality.
It would be explained how God is most concerned in helping them in their troubled situation
They would be told about the forgiveness Jesus offers
Specific Bible quotations along with sufficient practical illustrations would be used to tackle the problems.

Results: This is an intervention proposed to be implemented. The results have to be measured as objectively as possible.

Conclusion: Spiritual interventions have been found to be useful to many patients with different psychiatric conditions in our day to day clinical practice. Here we are trying to prove it by sound scientific research.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Study on quality of life and psychopathology in parents of children with attention deficit hyperactivity disorder

Maidul Islam Sk, Sujit Sarkhel, Pradeep Kumar Saha

Institute of Psychiatry, IPGMER, Iop, Kolkata, India.

E-mails: mahi16feb@gmail.com, sujitsarkhel@gmail.com, pradeepnimhan@gmail.com

Keyword: ADHD, parents, psychopathology, quality of life

Aims and Objectives: The study was conducted to assess the Quality Of Life and Psychopathology in parents of children with Attention Deficit Hyperactivity Disorder.

Methods and Tools Used: Parents of children diagnosed with ADHD (According to DSM-lV-TR) were evaluated at one point for their Quality Of Life (using WHO-QOL-BREF) & for any psychopathology (using The MINI International Neuropsychiatric interview), and were compared with age – sex matched control group whose children were free from any chronic medical or psychiatric illness.

Result: Child ADHD was associated with increased rate of mood disorder in parents, specially Major Depressive Disorder and Dysthymia as compared to parents of healthy children. Child ADHD also adversely affected the Quality Of Life of their parents than parents of healthy children.

Conclusion: To conclude, it is not only child with ADHD who needs health care but also parents in order to prevent the adverse effect of parental ill health on the out come of ADHD child.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Temporal stability of obsession in obsessive compulsive disorder

Keshav Jee, Narendra Prathap Singh, Amardeep Kumar, Pramod Kumar Singh

Patna Medical College, India.

E-mails: drk.jee@gmail.com, Dearnpsingh@gmail.com, amardeep93@rediffmail.com, pkspostline@yahoo.com

Keyword: OCD temporal stability

Objectives: The aim of this study is to study the temporal stability of different types of individual obsessions in OCD patients.

Methods: A retrospective cross sectional study was done in the Psychiatry Outpatient Department of Patna Medical College, Patna. A total of 40 adult OCD patients were included in this study. Yale Brown Obsessive compulsive checklist (YBOCS) was administered to find out the different types of obsessions in past and present. Different clinical and socio demographic data were also assessed using appropriate information sheet to understand the possible factor associated with change in obsessive symptoms.

Results: Preliminary result analysis showed that 55% of the sample were female while 45% were male. The sample consisted of 52. 5% of patients from rural background while 47. 5% of patients were from urban background. 10% of the study population had episodic course while rest had continuous course. We found a precipitating factor in 32. 5% of the study population. Approximately one-third of the sample had family history of OCD. Past history of childhood abuse was found in 35% of the study population. Pure obsession was present in 7. 5% of the study population. Among obsession, we found most common obsessions as obsession of contamination (55%), religious obsession (30%), and aggressive obsession (10%). We noted change in nature of obsession in 62. 5% of our study population (between dimension, within dimension and symptoms added in course of time). This change occurred mostly in patients presenting with contamination obsession. Factors associated with change in obsessive symptoms will be presented in the conference.

Conclusion: The study highlights the need to understand the changing phenomenology of OCD in a subgroup of such patients to help us understand and manage this patient population effectively.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Adolescent and self injurious behaviours: A retrospective chart review

Pallavi Sinha^*1, Ajay Thangaraj², Amit Garg³, Deepak Kumar⁴

^1-3IHBAS, India,

E-mails: pallavisinha0102@gmail.com, atajayvz@gmail.com, drgargamit@yahoo.com, srivastav.deep@gmail.com

Keyword: self injurious behaviour, DSH, adolescents

Background: Self-injurious behaviours among adolescents are eliciting increased attention and concern around the world. It is used to describe different type of behaviours associated with varying levels of suicide intent and a variety of motives. Research indicates that self-injury tends to first occur during adolescence is associated with a range of psychiatric difficulties, serves multiple interpersonal and intrapersonal functions and is significantly associated with increased suicidality. The present study examines reasons for adolescent deliberate self-harm

Objectives: To study the clinical variables leading upto deliberate self harm in adolescents

Methodology: A retrospective chart review was done for a period of 2 years of all adolescents admitted in a neuropsychiatric tertiary care hospital with an attempt of deliberate self harm. File records were used to gather information on the proposed historical and clinical variables associated with deliberate self harm. Relevant statistical tools were used to analyse the data obtained.

Results: A total of 58 adolescents were admitted in a span of two years were admitted with an attempt of deliberate self harm. Majority were girls (64. 6%) in the age group of 15-19 years. 54. 8% of the adolescents had a past history of DSH. 5 adolescents had concurrent legal issues also. Remaining of the results will be discussed during the presentation.

Conclusion: DSH is common amongst the Indian youth, especially in females. Preventive programs should encourage young people to consult health professionals in stressful situations. Risk factors for DSH are many and varied and prevention programs should address these simultaneously, as well as educating young people on the use of mental health services.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Interferon-a double edged sword: A case report of psychosis

Deeksha Elwadhi, Aparna Das, Manushree Gupta

GB Pant Hospital, New delhi, India.

E-mail: elwadhideeksha@gmail.com, ad.mamc.1510@gmail.com, manushree@gmail.com

Keyword: Hepatitis C, interferon, neuropsychiatric sequelae

Introduction: Hepatitis C virus is one of the leading infective causes of liver cirrhosis, hepatocellular carcinoma and death worldwide. Interferon, a cytokine, has emerged as a major therapeutic option for chronic hepatitis C. Though there has been growing literature regarding the chronic neuropsychiatric effects of interferon alpha, like depression, anxiety and psychosis; its acute neuropsychiatric sequelae are lesser known. Less than 20% of the cases are seen within a week of interferon administration. Incidence of psychotic symptoms after interferon therapy is less than 1%.

Aim: To describe a case in which psychotic symptoms developed after a single dose of pegylated Interferon alpha2B.

Methodology: Detailed clinical & psychiatric assessment at tertiary care centre.

Results: A 30-year-old female diagnosed with hepatitis C, presented with a history of suspiciousness, irritability, restlessness, fearfulness and disturbed biological functions. Patient had delusion of persecution & reference and auditory hallucinations on MSE. The symptoms started following a single dose of Peg interferon alpha2B and Ribavarin. There was no antecedent psychiatric history, substance use disorder or any family history of psychiatric disorder. No abnormalities were detected in the patient’s hematological parameters, liver functions, electrolytes, BUN, serum ammonia levels, thyroid functions and NCCT head. No further injections of Interferon or Ribavirin were given but still the symptoms persisted for three weeks. All psychotic symptoms resolved within a week of starting Risperidone 2 mg.

Conclusion: Severe psychiatric manifestations represent the most important reason for the discontinuation of INF. Neurotoxicity seems to be mediated through neuroendocrine and neurotransmitter mechanisms, cytokines, and free radicals. There are no known cases of Ribavirin associated neuropsychiatric sequelae. This case highlights the emergence of abrupt psychotic symptoms with no antecedent predisposing factors after a single dose of Interferon and calls for further research in this direction

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Atypical Charles Bonnet syndrome “A case report”

Rohan Kalra, Narayan Mutalik

S. nijalingappa medical college, bagalkot, India.

E-mails: rohan_kalraji@yahoo.com, narayanmutalik@gmail.com

Keyword: Charles bonnet syndrome, sensory deprivation and visual

Introduction: Sensory deprivation is the deliberate reduction or removal of stimuli from one or more senses. Role of sensory deprivation in the etiology of hallucinations is often noted. Patients who became visually impaired often develop complex hallucinations with preserved cognitive status, called as Charles Bonnet Syndrome. We are hereby presenting a rare case of Atypical Charles-Bonnet syndrome without any co morbid psychiatric illness.

Case presentation:

History: 70 year old male, Mr X was a known case of left sided post-surgical Aphakia and haziness over right eye with B/L visual impairment since last 2 years. He presented with history of fearing by seeing animals, reptiles, insects and people who may come and take him away; precipitating after a road traffic accident. These symptoms started gradually after his complete loss of visual abilities. No significant past, family or personal history was noted.

On physical examination: His blood pressure was 160/90 mm of Hg.

There was no perception of light in both eyes. Right eye- Corneal opacity. Left eye- Increased intra ocular pressure with aphakia with optic atrophy.

No other positive findings.

On MSE: Patient was conscious and cooperative with good orientation. He had a euthymic affect, complex visual hallucinations and occasional auditory hallucinations. No other significant thought or cognitive abnormalities.

BPRS-36/126

HMSE-24/27 (2 items could not be done due to visual impairment).

HAM-D-6/68

Conclusion: The exact etiology of CBS is unknown. Visual hallucinations in a person can be the result of secretary phenomenon. The visual cortex had complex connections and it was believed that visual hallucinations result from increased neuronal activity or from a complex interaction related to the disappearance of the cortical inhibition. It was found that hallucinations in CBS correlate with cerebral activity in the ventral extra striate visual cortex.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Course of Transvestism A case report

Bhaskar Mara, Sreeraj V. S, Tejaswi T. P, Vinod Akkasali, Narayan Mutalik

S N Medical College, Bagalkot, India.

E-mail: bmara21@gmail.com,

Keyword: old age, dual-role transvestism, fetishistic transvestism, course

Introduction: Wearing of clothes of the opposite sex is transvestism. ICD-10 differentiates “Dual-role transvestism” from “Fetishistic transvestism”. The Later type is applied principally for those who obtain sexual excitement whereas in “Dual-role transvestism” individuals enjoy the experience of membership of the opposite sex without desire for permanent sex change or any sexual gratification.

Case presentation: We have come across with an interesting case of elderly male of age 75yrs brought by his wife complaining her husband of cross dressing. On detailed evaluation patient revealed its onset during adolescence, even before marriage. Initially he used to have sexual arousal followed by masturbation during cross dressing. After marriage, frequency of masturbatory activity during transvestic behaviour gradually reduced. He started preferring female role in stage plays in the form of Goddesses and enjoyed the dressing. In recent years, frequency of transvestic behaviour increased without any sexual gratification but just with an urge to makeup.

Conclusion: Literature is sparse regarding course of transvestism. In above case the non-linear progression of frequency and associated sexual excitation of transvestism is observed. The “Fetishistic transvestism” might transform to “Dual-role transvestism” over years. This case arise queries regarding the watershed line between the two types.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Extrapyramidal symptoms associated with aripiprazole-case series

Robbin Bose, Abu Backer, Sivaprakash Balasundaram, Sukanto Sarkar

Mahatma Gandhi Medical College and Research Institute, India.

E-mails: drrobin479@gmail.com, hifromabu@gmail.com, prakashb1685@gmail.com, sukanto_sarkar@yahoo.com

Keyword: Extrapyramidal symptoms, aripiprazole, atypicals

Objective: Aripiprazole is an atypical antipsychotic whose efficacy is due to its partial agonist activity at dopamine D1 receptors and serotonin 5HT1a receptors and antagonistic activity at 5HT2a receptors. Aripiprazole causes restlessness, insomnia, anxiety, akathisia, blurred vision etc but has an overall lower incidence of extrapyramidal symptoms (EPS) in comparison to many other drugs belonging to the atypical class. But this has been challenged by numerous recent reports that suggest it may be more likely to cause movement disorders than other atypical antipsychotics.

Methods: This is a case series of 6 patients seen during the previous year in an inpatient tertiary care centre in Pondicherry. Each had been administered Aripiprazole (doses ranging from 5 mg to 15 mg) for various indications. The patients were in the age group of 20-35 years and none had an organic mental disorder. Extrapyramidal symptoms were assessed using the validated Simson-Angus Scale (SAS).

Results: Each of the 6 patients developed significant extrapyramidal symptoms (SAS score of 6 to 11) on administration of Aripiprazole at doses within therapeutic range and had their medication changed or had to have an addition of anti-muscarinic drug. One patient developed it at 5 mg, while 3 patients developed it at 10 mg while 2 patients developed it at 15 mg. 4 patients were drug naïve while the other two were previously on treatment with other atypical antipsychotics which had been changed to Aripiprazole, following which they developed extrapyramidal symptoms.

Conclusion: Aripiprazole does seem to have a propensity to cause extrapyramidal symptoms. It also suggests that Aripiprazole be used with caution in those who have a high risk of developing extrapyramidal symptoms such as patients with a prior history of dystonia, parkinsonism or tardive dyskinesia.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Treating Gambling disorder (GD): a biofeedback based exposure therapy

Abhishek Ghosh, Lovee Dhawan, Debasish Basu

Post Graduate Institute of Medical Education And Research, India.

E-mails: ghoshabhishek12@gmail.com, drloveedhawan@gmail.com, db_sm2002@yahoo.com

Keyword: Gambling disorder, exposure therapy, biofeedback

Background: Psychosocial treatment for GD is analogous to that of the treatment for substance use disorders.

Objective: Aim of the paper is to discuss graded exposure therapy for a patient with gambling disorder.

Methods: SG, 43 years old married male who started to gamble in 1999 to compensate for the financial loss encountered in his family business. He gambled in an instant lottery. He had a net gain on the first day. He felt excited and anticipated to gamble once more. Then onwards, he started to bet almost daily. Initially he would gamble for the lure of gaining money but later just to reimburse his losses. He began to invest more and more money. Initially would borrow then even would have to embezzle from his friend’s shop. He would do make shift jobs only to earn money to gamble. He would report a constant preoccupation for arranging money, lottery numbers or about gambling experiences. Due to gambling he had significant interpersonal problem in the family. He was disowned by his father. However he continued to gamble. In March, 2014 his wife lodged a FIR alleging physical violence and SG was arrested. He was admitted in a deaddiction centre as he sought treatment. A biofeedback assisted exposure therapy was planned for GD. A hierarchy of gambling related cues (real and imaginary) was construed considering his ‘craving’ for the cues. Systematic and graded exposure was coupled with autogenic relaxation. Biofeedback was used for measurement and feedback of his level of arousal. Eight such sessions were conducted.

Results: At the end, he denied to have ‘craving’ even after exposure to cues. Subjective reporting was corroborated with the reading of biofeedback machine. He is abstinent form gambling till date.

Conclusion: Biofeedback aided exposure therapy could be effective in the treatment of gambling disorder.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Clinical profile of sexual dysfunction in alcohol dependent males

Nishanth Vemana, Samir Kumar Prahlad, P. S. V. N Sharma

Kasturba Medical College, India.

E-mails: Nishanth_vemana@yahoo.com, samirpsyche@yahoo.co.in, psvn.sharma@manipal.edu

Keyword: Clinical Profile of Alcohol Dependent males with sexual dysfunction

Background: Alcohol abuse can cause various forms of sexual dysfunction. Literature suggests that long term and high amount of alcohol consumption leads to sexual dysfunction. There is a need to ascertain the social and clinical parameters which can help us predict this. This study was undertaken with a view to augment our knowledge on this aspect.

Objectives: To find out the clinical profile of alcohol dependent males with sexual dysfunction.

Methods: Clearence from Institutional ethics committee was taken. 100 consecutive alcohol dependent males admitted in a tertiary care centre were assessed after written informed consent using alcohol intake database, MINI was done to rule out other psychiatric co-morbidities, severity of dependence was assessed using SAD-Q, sexual dysfunction was assessed using the IIEF questionnaire. The socio demographic and clinical data was then taken and a statistical analysis was done using SPSS 16. 0

Results and Conclusions: will be presented at the time of presentation

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Simple partial seizures presenting as migraine: A case report

Ruchika Rathee^*, Rahul Saha

Department of Psychiatry, PGIMER & Dr RML Hospital New Delhi, India.

E-mails: ratheeruchika@gmail.com, drrahul.saha19@gmail.com

Keyword: migraine, partial seizure, headache

Introduction: Migraine and epilepsy are episodic disorders that share many clinical features and underlying pathophysiological mechanisms. Glutamate is a critical mediator of the hyperexcitability in both focal seizures and migraine. In focal epilepsy, seizure generation and spread is mediated by synaptically released glutamate acting on AMPA receptors. Some antiepileptic drugs prevent the occurrence of migraine attacks, supporting the view that neuronal hyperexcitability is an initiating event.

Case: Simple partial seizures can often present a diagnostic challenge. We present the case of a 15 year old male child who presented to psychiatry OPD with complaints of headache since 1 year. The headache was described as sudden in onset, moderate to severe in intensity, localised to parieto-temporal lobe, associated with pain in epigastric region and nausea, aura before headache and photophobia lasting for around half to one hour during each episode. All investigations including serum electrolytes were within normal limits and the patient was started on Propanolol & Naproxen, keeping a diagnosis of migraine headache. However no response was noticed and an EEG was ordered which showed epileptiform discharges. The diagnosis was revised and simple partial seizures were treated with Sodium Valproate gradually taken upto 800mg. Patient showed significant response to antiepileptic treatment.

Conclusion: Insights into commonalities in the pathophysiology of epilepsy and migraine may suggest new treatment approaches for both conditions. This case report is being presented to highlight the unusual presentation of epilepsy presenting as migraine and the related literature.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Psychosis in a deaf-mute patient- diagnostic challenges: A case report

Aastha Sharma^*, Rahul Saha, Manohar Kant Srivastava

P. G. I. M. E. R. & Dr. R. M. L. Hospital, New Delhi, India.

E-mails: aastha.vinny@gmail.com, drrahul.saha19@gmail.com, manoharkant@yahoo.co.in

Keyword: Psychosis, Congenital Deafness, Diagnosis, Challenges

Introduction: The prevalence of psychotic disorders in deaf mute inpatients in the western population has been estimated to be 20-54%. There is paucity of literature about such presentation in the Indian scenario. Because of the difficulty in communication and disturbance in early skill attainment in life, the phenomenology of psychosis remains largely untapped in this population. We describe a patient with congenital deafness and psychosis and the challenges faced in the process.

Case: A 39yrs old Hindu unmarried male, belonging to MSES, presented in PGIMER, Dr R M L Hospital, New Delhi with symptoms characterized by withdrawn behavior, avolition, wandering aimlessly, laughing and crying for no apparent reason, fearfulness and hyper vigilant behavior, posturing, decreased sleep, decreased selfcare and poor oral intake from past 3. 5 years. The patient was prelingually deaf and mute since birth, communicating via gestures and sign language. On MSE, he was in a disheveled state in dirty attire and not making eye contact. Kirby’s method for examination of uncooperative patient showed blunted affect and there was no response to what was being said or done. Most of the communications were made by sign language with help from his family members. There was significant difficulty in making the diagnosis due to lack of proper communication. After repeated attempts by sign language, a diagnosis of “Other non organic psychotic disorders (ICD-10, F 28)” was made based on the history and the findings of sign language.

Conclusion: This case attempts to highlight the diagnostic difficulties in eliciting and understanding psychopathology in the deaf-mute population.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Panic attacks in a deaf-mute patient: Understanding the problem

Rahul Saha^*1, Aastha Sharma²

¹Department of Psychiatry, PGIMER, Dr RML Hospital, India.

E-mails: drrahul.saha19@gmail.com, aastha.vinny@gmail.com

Keyword: Panic attacks, congenital deaf mute, diagnostic challenges

Introduction: The prevalence of anxiety and depression in deaf mute population has been estimated to be more than normal hearers, though data is scarce. Deaf mute patients are vulnerable to mental health problems, yet have insufficient access to appropriate services. Difficulty in communication and poor understanding of symptoms remain a hurdle in the diagnostic process. We describe a patient with congenital deafness and sudden onset classic panic attacks.

Case: A 22yrs old Hindu unmarried female, belonging to MSES, presented in PGIMER, Dr R M L Hospital, New Delhi with sudden onset, multiple severe episodes of palpitations, breathlessness, anxiety, dryness of mouth, sweating, dizziness, restlessness with feeling of impending doom lasting 15-20 minutes, with no precipitating stressors since 6 years. No past or family history of psychiatric illnesswas present. The patient was prelingually deaf and mute since birth, communicating via gestures and sign language. She was otherwise a well-adjusted, cheerful and gregarious girl, with no evidence of inter-episodic free floating anxiety. Most of the communications were made by sign language with help from her family members. There was significant difficulty at first in making the diagnosis due to lack of proper communication. After repeated attempts by sign language, a diagnosis of “Panic disorder (ICD-10, F 41. 0)” was made based on the history and the findings of sign language.

Conclusion: This case attempts to highlight the diagnostic complication in eliciting psychopathology in the deaf-mute population. This report will also try to discuss various alternative methods of MSE, when language communication is very difficult and the importance of sign language in MSE.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Anti-nmda receptor encephalitis presenting as acute psychosis and catatonia

Ruchika Rathee^*1, Rahul Saha²

¹Department of Psychiatry, PGIMER & Dr RML Hospital New Delhi, India,

E-mails: drrahul.E-mails: ratheeruchika@gmail.com, saha19@gmail.com

Keyword: Encephalitis, catatonia, psychosis

Introduction: Anti-NMDA (N-methyl D-aspartate) receptor antibody encephalitis, also termed NMDA receptor antibody encephalitis, is an acute form of encephalitis which is potentially lethal but has high probability for recovery. It is caused by an autoimmune reaction primarily against the NR1 subunit of the NMDA receptor. Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a newly described form of encephalitis associated with prominent psychiatric symptoms at onset. Recognition of the symptom complex is the key to diagnosis.

Case: We present the case of a previously healthy 21 year old girl who developed rapidly fluctuating psychotic symptoms after a short febrile flu-like illness. She was admitted to a psychiatric facility in a state of rapidly worsening catatonic excitement. Her CT Brain was within normal limits. Within three days of admission she started having limb dyskinesias, fluctuating orientation and clenching of teeth. However EEG failed to reveal any features suggestive of epilepsy. CPK levels were done which were found to be raised and she was transferred to ICU for intensive care however serial CPK levels showed a downward trend. Subsequently anti NMDA receptor antibody tests revealed increased levels. She was managed symptomatically on sodium valproate in the intensive care unit and she recovered completely over a period of next two months.

Conclusion: This case report is being presented to highlight the need for psychiatrists to be aware of neurological conditions presenting in the psychiatric setup; especially due to the good prognosis associated with the condition with early identification and appropriate management. Psychiatrists should consider anti-NMDAR encephalitis in patients presenting with psychosis as well as dyskinesia, seizures, and/or catatonia, especially if there is no history of a psychiatric disorder.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Primary delusion in the backdrop of general lok sabha elections: A case report

Rahul Saha^*1, Aastha Sharma²

¹Department of Psychiatry, PGIMER, Dr RML Hospital, India.com, ²Department of Psychiatry, PGIMER, Dr RML Hospital, India, E-mails: drrahul.saha19@gmail, aastha.vinny@gmail.com

Keyword: Primary delusion, sudden delusional idea, schizophrenia, elections

Introduction: Primary delusions are defined as those delusions that cannot be understood as arising from a pre existing psychopathology. It is an interesting phenomenology which is rare and difficult to elicit in the clinical setting. We describe here a case with primary delusion heralding the onset of schizophrenia.

Case: 25 year old Hindu unmarried male, working in the banking sector presented to adult psychiatry OPD, Dr. RML hospital along with brother with no past or family history of psychiatric illness with chief complaints of suspiciousness, abnormal beliefs, hearing voices none else can hear, decreased sleep and agitation since 1 month. Exploration of history revealed that the illness started on the day of elections in the national capital in 10^th April 2014, when the patient had gotten into an argument with the polling officers at the local poll booth. After returning home, he started reporting to his family members that his activities and movements were being telecast live on various channels under the orders of Vice President of the rulling party. On MSE, affect was irritable. His thought showed sudden delusional idea, delusion of persecution & reference and thought broadcast. 2^nd and 3^rd person auditory hallucination was also elicited, which were of running commentary type. All his symptoms started from the sudden delusional idea and gradually other schizophrenic symptoms developed within next 2 weeks.

Conclusion: The indexed case is presented for its atypical phenomenology and fascinating occurrence in the backdrop of the great Indian Lok Sabha Elections.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Anxiety dreams and prodrome of psychosis: A case report

Aastha Sharma^*, Rahul Saha, Lokesh Shekhawat

P. G. I. M. E. R. & Dr. R. M. L. Hospital, New Delhi, India.

E-mails: aastha.vinny@gmail.com, saha19@gmail.com, drlokesh4@gmail.com

Keyword: Anxiety dreams, prodrome, psychosis

Background: Introduction: Prodrome is usually defined as the time between onset of unusual behaviour and frank psychotic symptoms. Anxiety, anergia, suspiciousness and sleep disturbances feature among prominent prodromal presentations. We describe here a case with anxiety dreams as the sole symptom in prodrome leading to a frank psychotic illness.

Case: A 26 year old Muslim housewife, belonging to nuclear family, LSES with family history of 1 episode psychosis in mother presented to adult psychiatry OPD, Dr. RMLH, Delhi with history of anxiety dreams and a premonition of something going wrong since 4 months, followed by an illness characterized by delusion of persecution and reference, decreased sleep, episodes of aggression and deterioration in functioning since 1 month. Patient attributed all of it to the dreams mirroring her reality. MSE revealed delusion of persecution, delusion of reference and blunt affect. A diagnosis of other non organic psychotic disorders (ICD-10, F28) was made. The case highlights the importance of anxiety dreams, as clinically most of these dreams are considered to be part of anxiety disorders. The indexed case highlights the progression of anxiety dreams to florid psychosis, and hence will help in recognizing similar cases in future and will help in proper management.

Conclusion: This interesting presentation highlights the importance of understanding the complex and varied presentation of prodromal psychosis in clinical settings, to aid in optimal management.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Exploration of various domains of Self esteem in children with ADHD: A Cross-sectional study

Pradeep Palaniappan^*1, Shekhar Seshadri², Satish Girimaji², Shoba Srinath²

¹PSG Institute of Medical Science & Research, India, ²National Institute of Mental Health And Neuro Sciences, India.

E-mails: docpradeep66@gmail.com, shekhar@nimhans.kar.nic.in, drgirimaji@gmail.com, shobasrinath@gmail.com

Keyword: ADHD, Self-esteem, Self-concept, Comorbidity

Background: Self-esteem is based on the ratio between perceived competence and the person’s aspirations in any one specific area of life. Though Low Self esteem(50%) was found in ADHD subjects, very few studies evaluating various domains of low self esteem exist.

Objectives: To study various domains of self esteem and factors associated with self esteem in children with ADHD.

Methods: 60 subjects aged 6 to 16 years who were diagnosed as ADHD based on DSM IV TR were recruited with informed consent, from NIMHANS Child and Adolescent Psychiatry clinic. Detailed interview of subjects and their respective parents were carried out using the Semi structured assessment schedule K- SADS – PL (for comorbidities), Conner’s ADHD severity index, Children Global assessment scale (CGAS) and Culture free self-esteem inventory.

Results: Recruited subjects were predominantly boys (86%), between 6- 9 years of age (66%), middle socio economic status (45%), and living in Nuclear family (77%). Score of Conner’s ADHD severity index was 14. 02 ± 4. 66 and CGAS was 44. 32 ± 10. 04. Parental conflicts were seen in 58% of the children with ADHD. 55 % of subjects had at least one comorbidity. Significant percentile of subjects had low self esteem in various domains, i. e; General (49%), Social (72%), Academic (80%), Parent (32%) and Global(68%). Presence of parental conflicts significantly affected academic (P = 0. 016), parental (P < 0. 001) and Global (P = 0. 03) domains, but not the others. Presence of comorbidity affected parental domain alone (P = 0. 005).

Conclusion: Factors that determine self esteem differentially influences various domains of self esteem in children with ADHD.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Study of Prevalence and factors associated with Treatment Non-Adherence in patients of Schizophrenia

Gandi Raga Sandhya^*, Gundugurti Prasad Rao, Venkateswara Reddy Reddam, Sri Ramya Vemulakonda

Asha Hospital, India.

E-mails: ragasandhya88@gmail.com, prasad40@gmail.com, venkyreddy97@gmail.com, sri.r.vem@gmail.com

Keyword: Schizophrenia, Non-adherence; ROMI; DAI

Background: Schizophrenia is a chronic severe disabling mental illness. Medication non-adherence is a major public health problem and it jeopardizes the treatment outcome. There are many factors contributing to non-adherence, whose identification has therapeutic and prognostic consequences.

Objectives: To determine the prevalence of non-adherence and major factors contributing to non-adherence in patients with schizophrenia.

Methods: 35 individuals with schizophrenia were selected on purposive sampling. Non-adherence level was calculated and they were assessed every month for the next three months in follow up visits for subjective reasons of medication non-adherence using the Rating of Medication Influence (ROMI) and Drug Attitude Inventory (DAI) scales.

Results: Non-adherence level was found to be 53. 1%. No statistical significance was found between socio-demographic profile and adherence. Reasons for non-adherence reported were no perceived daily benefit, negative relation with clinician, embarrassment or stigma over illness, medication currently unnecessary, and distressed by side effects.

Conclusion: Non-adherence was common in schizophrenia, and factors contributing to it ought to be addressed during follow-ups.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Oxcarbazepine and Quetiapine induced Stevens Johnson Syndrome: A Rare Case Report

Rajeev Ranjan^*, Sartaj Deepak, Rajesh Sagar

AIIMS, New Delhi, India.

E-mails: rajeevranjan5@yahoo.co.in, sartajdeepak@yahoo.com, rajeshsagar@rediffmail.com

Keyword: Oxcarbazepine, Quetiapine, Stevens-Johnson syndrome

Background: Stevens–Johnson syndrome (SJS) is a rare, severe and potentially life threatening illness. SJS is usually associated with several psychotropic drugs, commonly reported are carbamazepine, lamotrigine and valproic acid. According to a review of the literature, it appears that oxcarbazepine-induced SJS has rarely been reported. Here we report a rare case of oxcarbazepine-induced SJS exacerbated by Quetiapine.

Methods: A 32 year old woman with a psychiatric history of schizophrenia has been receiving quetiapine (300 to 600 mg/day) for last three year. Oxcarbazepine (600 mg/day) was added to the treatment following exacerbation of affective symptoms and after a week, the dose was raised to 900 mg/day. A few days later, she had developed a diffuse, erythematous full body rash and multiple maculopapular eruptions. The patient was hospitalized in the dermatology ward with diagnosis of Stevens Johnson syndrome. The skin pathology was consistent with SJS. Withdrawal of offending drugs and other common supportive measures were taken and patient was discharged after 3 weeks. No sequelae were found during 2 months of follow-up.

Results: Oxcarbazepine was the incriminated drug in this case, probably exacerbated by Quetiapine. The patients usually develop a hypersentivity reaction to this drug between 2 and 12 weeks after commencing treatment with it. Our patient had targetoid erythematous eruptions and mucosal involvement 10 days after starting oxcarbazepine treatment. During these 2 weeks, no other medicine was added except for Quetiapine which was continued for 3 years. Both the initial and titration doses were within recommended doses schedule. It has been reported that higher daily doses of drugs are associated with increased risk of SJS. However, there is no evidence about the relationship between oxcarbazepine dosage and SJS.

Conclusion: The present case report supports the clinical evidence that combination of Oxcarbazepine with Quetiapine increases the risk for this serious side effect.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Hyperthyroidism on long-term lithium carbonate therapy: A case report

Ananya Mahapatra^*, Mamta Sood

All India Institute of Medical Sciences, New Delhi, India.

E-mails: nnyaa09@gmail.com, soodmamta@gmail.com

Keyword: lithium therapy, hyperthyroidism

Background: Treatment with lithium has been associated with a variety of thyroid function abnormalities. Although hypothyroidism is the most common manifestation, rarely hyperthyroidism following lithium use has also been reported with an incidence rate of approximately 2. 7 cases per 1000 person-years. Objectives: We report a case of gradually progressive euthyroid goitre followed by acute onset hyperthyroidism in a patient on long-term lithium therapy. Methodology: A 60 year old lady with bipolar affective disorder of 25 years duration was on 900 mg of lithium carbonate and 400 mg carbamazepine for the last 11 years and was maintaining well. Six years back, she developed a gradually progressive midline swelling in neck which was diagnosed to be goitre following a medicine consult but her thyroid function tests revealed no abnormality. Two months before presenting to our clinic, patient developed sweating, palpitations and weight loss despite increased appetite. Thyroid function tests revealed TSH-0. 04 µg/ml. She was diagnosed with hyperthyroidism in geriatric medicine OPD and referred to psychiatry for review. Endocrinology referral was sought and following investigations were advised. Titres of anti-thyroid peroxidase antibodies (29. 62 IU/L) and anti TSH-receptors antibodies (1. 1 IU/L) were within normal. limit. USG of thyroid showed heterogeneous echogenicity of bilateral lobes. 24-hr radioiodine uptake was 42%, suggestive of hyperthyroidism. Her serum lithium level was 0. 56 mmol/L. Results: Her symptoms improved after three months of treatment with anti-thyroid drug (carbimazole 10 mg/day). After three months her T4 level was 5. 84 µg/ml. and TSH-1. 36 U/ml. Patient continued to maintain euthymic status. Conclusions: Patients on long term therapy with lithium may rarely present with hyperthyroidism. Our patient presented with ethyroid goitre after 5 years of treatment with lithium followed by hyperthyroidism for last 2 months. The exact mechanisms of lithium induced changes in iodine metabolism remain unknown. Possible interactions of immune system and direct toxic effect of lithium in the development of hyperthyroidism remains to be elucidated.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Priapism with Risperidone use: A Case Report

Braja Kishore Giri^*, Satyakam Mohapatra, Neelmadhav Rath

Mental Health Institute, SCB Medical College, Cuttack, Odisha, India,

E-mails: drbkgirianurag@gmail.com, satyakgmu@gmail.com, satyakgmu@gmail.com

Keyword: Risperidone, priapism, antipsychotic

Background: Priapism is a rare sequelae of antipsychotics. It is considered as an urologic urgency

Aim and objectives: To report a case of a young man who developed priapism following treatment with 6 mg of risperidone.

Methods: Mr. A., 28-year-old Hindu male presented to the emergency room with a history of a persistent and painful penile erection from last 4 hours. It was sudden in onset while the patient was slept, and he awoke with a painful erection. The drug history revealed that the patient was taking 6 mg of risperidone per day from last 2 years as he was diagnosed to be a case of schizophrenia. A diagnosis of priapism was made, and the urology service was consulted. a shunt was placed between corpora cavernosa and corpora spongiosa to relieve his symptoms. His priapism resolved completely within a few hours with the shunt placement. His risperidone was stopped. He was started on amisulpride which has less a 1-adrenergic receptor blockade property. The patient was followed-up monthly and for last 6 months there was no complain suggestive of priapism and his psychotic symptoms are also controlled.

Conclusion: Risperidone is an established cause of priapism. Our patient, for unknown reasons, may have been more susceptible than most patients to the effects of risperidone that produced priapism. Patients with a history of priapism associated with antipsychotic treatment should be carefully educated and monitored for signs or symptoms of priapism when therapy with an antipsychotic is started.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Occurrence of life events in obsessive compulsive disorder and its impact on disease severity

Sandip Kumar Hazra^*, Sikha Mukhopadhyay, Sujit Sarkhel

Institute of Psychiatry, Kolkata, India.

E-mails: sandiphazra@rocketmail.com, sikhamukho54@gmail.com, sujitsarkhel@gmail.com

Keyword: Life Events, Obsessive Compulsive Disorder (OCD), occurrence, impact

Background: Existing research into the onset of obsessive-compulsive disorder (OCD) suggests the occurrence of potential life events as triggering factors; however studies are very few in number having methodological limitations and contradictory findings.

Objectives:

1)
To find out the frequency of life events in patients with OCD in comparison to their matched controls.
2)
To find out the impact of life events on the severity OCD.

Methods: Sixty patients, between ages 18 to 60 years, belonging to either sex, meeting the DSM-IV TR diagnostic criteria for OCD were selected for the study. Cases were rated with Yale Brown Obsessive Compulsive Scale (YBOCS), Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for Anxiety (HAM-A) and Presumptive Stressful Life Events Scale (PSLES) both for lifetime and past 1 year. A group of 60 normal controls were also rated on PSLES. Finally, both groups were compared in terms of life events.

Results: The frequency of life events, one year (t=5. 31, p=<. 001) and lifetime (t=11. 53, p<. 001), were significantly higher in patient group in comparison to controls. PSLES scores at both lifetime and one year showed significant correlation with YBOCS total scores. There was correlation between HAM-D and HAM-A scores with 1 year PSLES scores and between HAM-A and lifetime PSLES scores.

Conclusion: Life events were significantly more frequent in OCD patients both one year and lifetime, as compared to healthy controls. The severity of OC symptoms was directly proportional to the number of life events experienced in the last one year and lifetime.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Factitious disorder with psychological symptoms: illness as a whole or behavior as a part?

Kishore Dudani^*, Anil Tambi, Arvind Jinger

SMS Medical College, India.

E-mails: dudani_kishore@yahoo.co.in, dr.tambianil@gmail.com, drarvindjinger@yahoo.co.in

Keyword: Factitious Disorder FD, Borderline personality, Feigning

Background: Persons with Factitious disorder(FD) simulate illness, not for materialistic gain but for emotional care and attention that comes with assuming “sick-role”. The most commonly feigned physical complaints are infection, impaired wound healing, bleeding, rashes and neurological symptoms. Determination of feigned psychological symptoms can be difficult that may include depression, dissociation and bizarre behavior not improving on routine therapeutic measures.

FD usually begins in 2^nd-3^rd decade especially in single unmarried people with poor social support along with comorbidities of personality disorder, substance and mood disorder in many. Present case describes a young male patient with factitious psychological complaints of anxiety and sleep disturbances seeking repeated admissions, in background of borderline personality.

Mr. M has been presenting to our outpatient services for last 4 years. The chief complaints throughout were declining interest in studies or delegated household chores, impulsive and disobedient behavior towards family, and intermittent complaints of anxiety and restlessness. Past records revealed repeated voluntary admissions, multiple medications with changing diagnoses and insignificant improvement. Family dynamics comprised of prior disturbed interpersonal relationships. Personal history revealed truancy, substances use, stubborn behavior and poor academic performance during late adolescence. Lately for past 3-4 years impulsive behavior in form of suicidal threats, anxiety, heaviness in head and disturbed sleep were predominant complaints. MSE was lacking a corresponding affect and rather evidenced a disinterested attitude. Personality assessment was consistent with emotionally unstable impulsive type with normal intelligence. The repeated presentation of clinically vague symptoms, requests for admission and absence of external motive calls for the superseding diagnosis of FD on underlying Borderline personality.

There has been substantial evidence of factitious behavior existing almost universally along with borderline personality. Also the frequent occurrence in background of psychosocial issues calls for viewing FD with somatoform and conversion disorders, and malingering along a continuum of so-called “Abnormal illness behavior”.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Very low dose amitriptyline for clozapine-associated sialorrhea

Siddhartha Sinha^*, Jayati Simlai, Satya Kant Trivedi¹, Samir Kumar Prahraj²

Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS), Ranchi, Jharkhand, India, ¹PCMS, BHOPAL, India, ²Kasturba Medical College, Manipal, Karnataka, India,

E-mails: sidsin69@gmail.com, jayatisimlai@gmail.com, satyakanttrivedi@gmail.com, samirpsyche@yahoo.co.in

Keyword: Clozapine; Sialorrhea; Hypersalivation; Amitriptyline

Background: Clozapine is the antipsychotic of choice for resistant schizophrenia, but its widespread use is limited by adverse effects. Sialorrhea is a common and troublesome adverse effect seen with clozapine which leads to poor compliance. Several treatment strategies are advocated, no single treatment is considered superior. Amitriptyline, a tricyclic antidepressant, has been found to be useful for clozapine-associated sialorrhea at 87–100 mg.

Objective: To study the effect of very low dose amitriptyline (10 mg per day) in a patient with clozapine-associated sialorrhea.

Results: There was rapid and complete resolution of sialorrhea after three days without any emergent adverse effect.

Conclusion: Very low dose amitriptyline may be helpful in some patients with clozapine-associated sialorrhea.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Pseudo rabies: A rare case

Rohit Chandrakant Deshmukh^*, Anita Kashinath Nagargoje

Dr. PDMMC, India.

E-mail: rohitd902@gmail.com, aninagargoje@gmail.com

Keyword: Peudo rabies, delusion, rabid person, suicide.

Objectives:

1)
To report case of Pseudo rabies.
2)
To improvise the knowledge of mental health workers about rare cases in psychiatry.

Materials and Methods: A 27 years-old, single male has started thinking that he had contacted with rabies. This idea started becoming more and more firm and fixed almost of delusional severity. So that he would behave like a rabid person and would attack to other people by biting them. He would bite himself and also had made serious suicide attempts twice.

Result: Our patient had a dog bite by non rabid dog 7 - 8 years back which was painful and traumatizing to patient leading to his present thinking pattern. Even after receiving all preventive treatments for rabies and full explanation from physician he kept his belief of having contacted rabies.

Conclusion: We recommend that early intervention is necessary in all the patients suffering from traumatic experience like exposure to dog bite. Otherwise, the ideas like, having contacted to rabies may crop up and exacerbate to such an extent that it may lead to psychiatric emergency.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Anti-N-methyl-D-aspartate-Receptor autoimmune encephalitis with psychotic presentation: A diagnostic challenge

Anita Kashinath Nagargoje^*, Mukund Murke, Ashish Saboo

PDMMC, Amravati, India.

E-mail: aninagargoje@gmail.com, mukundmurke@yahoo.com

Keyword: Autoimmune encephalitis, Neuro-psychiatric symptoms, Psychosis, Seizure, Immunosuppresant.

Background: Title: Anti-N-methyl-D-aspartate-Receptor Autoimmune Encephalitis with psychoticpresentation: A Diagnostic Challenge

Background: Anti NMDA-R encephalitis is a very rare autoimmune disorder, often paraneoplastic in nature, presenting with complex neuro-psychiatric symptoms. Diagnosed serologically and often responsive to immunosuppressant treatment.

Objectives:

1.
To report a case of Anti NMDA-R Encephalitis presented in psychiatry department with neuropsychiatric symptoms.
2.
To educate psychiatrist on the challenges in diagnosis and management of this disorder.

Methods: A 25 year old married lady brought to hospital with altered behavior, hallucinations and delusions with history of first trimester abortion one month back. she was diagnosed as brief psychotic disorder and admitted under psychiatry. Next day when she had generalize tonic clonic seizures with autonomic disturbances, immediately shifted to ICU and investigated. CT& MRI Brain and blood investigations were normal. CT Abdomen-pelvis showed teratoma right overy. Then CSF send for NMDA-R antibodies. While awaiting reports she had facial twiches with perioral movements and later need mechanical ventilatory support. CSF was positive for NMDA-R antibodies but till then patient eventually died with respiratory failure.

Result: The case study highlights the importance of recognizing early common signs and symptoms which include hallucinations, seizures, altered mental status and movement disorders. Early diagnosis in above case could have better outcome. Thus, first presentation of psychosis should be screened for underlying neuropsychiatric fatal conditions like anti NMDA-R autoantibody encephalitis.

Conclusion: There is an increasing need for clinicians of different specialties, including psychiatrists, neurologists and intensivists to become familiar with this disorder and its potential complications.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Use of Sodium Valproate in BPSD in dementia and review of literature

Abhilove Kamboj^*, Om Prakash Jhirwal

IHBAS, India.

E-mails: abhilovekuk2@gmail.com, drjhirwalop@yahoo.co.in

Keyword: Sodium Valproate, BPSD, Dementia

Background: Management of BPSD (Behavioral and Psychological Symptoms of Dementia) has been a challenge for psychiatrists. Most of the evidence suggests limited benefit for sodium Valproate. We report use and response of sodium Valproate in difficult to treat BPSD.

Case report: Ms A, 65 years Hindu widow female presented to psychiatric unit of a tertiary care hospital, IHBAS. Patient presented with continuous illness of 3 years duration characterised by forgetfulness, inability to do her activities of daily living by herself with significant socio- occupational decline. For last 2 years patient started to have exacerbation characterized by irritability, agitation, aggressiveness with decreased sleep and appetite. She had around 2 such exacerbations. She also had 3 exacerbations characterised by withdrawn behaviour, sadness of mood, crying episodes, death wishes and decreased sleep and appetite. She had presented to us in similar state. Mental status examination confirmed the same. She is a known case of hypertension. She had no past or family history of psychiatric illness. HMSE score was 12, CDR = 1, EASI = 9, HAM-D = 17, CSDD = 20.

MRI revealed generalised atrophy of cerebrum and cerebellum. All routine investigations including TFT, serum vitamin B12 and folic acid were within normal limit.

Patient in past has been tried on several pharmacological agents namely sertraline 200 mg, mirtazapine 30 mg, Quetiapine 300mg on OPD basis. As patient was having behavioural problems mimicking mood symptoms, it was decided to start Sodium Valproate for the patient. Patient was started on combination of Donepezil 10 mg and Sodium Valproate 600 mg. After two months of pharmacotherapy, patient improved significantly and HAM-D score reduced to 8 and CSDD to 10. Patient is maintaining well till last follow up.

Conclusion: Sodium Valproate may be considered as one of the option for management of BPSD in dementia

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Improving the quality by reducing No-Show rates

Prashant Gajwani^*1

¹University of Texas at Houston, United States,

E-mail: pgajwani@hotmail.com

Keyword: Improving Quality of care by reducing no show rates

Background: Psychiatric care is often limited by patients missing their appointments. A lot of reserach has been done on improving compliance, but none on reducing no-show rates. It has been proven that non-compliance leads to reoccurance of mood episodes, worsening os psychosis, increase rates of hospitalization and poorer prognosis. The study conducted at University of Texas is the first of its type that explored reasons resulting in patients missing their appointments. after several operational steps, we were able to reduce no-show rates from baseline of 30% to 12%. reducing no-show rates would improve quality of care, medication compliance, improve morale of the faculty providers as well positively impact the financial health of the institution.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Expressed emotion in relatives of patients with schizophrenia, bipolar disorder and diabetes: A comparison

Ben Nasr Selma^*, Ben Rhomdane Asma, Amel Brahem, Souhail Ahmed Bannour, Bechir Ben Hadj Ali

Hospital, Tunisia.

E-mails: selmabennasr@yahoo.fr, benromdhaneasma@yahoo.fr

Keyword: Expressed emotion, relatives, schizophrenic and bipolar patients, diabetic patients

Background: The two aims of the study were to (1) investigate whether relatives of Schizophrenic and Bipolar patients differed from family members of Diabetic patients regarding to their Expressed Emotions (EE), and (2) whether EE subcategories (“Criticism” and “Emotional Over involvement”) of Schizophrenic and Bipolar relatives is related to relapse of patients.

Methods: Forty seven patients with schizophrenia, 36 patients with bipolar disorder (DSM-IV TR) and 30 patients with diabetes were included. All the patients are treated in the same hospital in Sousse.

The EE of key relatives was assessed with the Family Questionnaire (FQ) (20 items and two subcategories: “Criticism” and “Emotional Over involvement”)

The three groups of patients did not differ significantly regarding the duration of the disease.

Results were provided as descriptive statistics and the scores in the 3 groups were compared using ANOVA and Tukey tests.

Results: The three groups of relatives differ significantly regarding the two subcategories of the FQ.

The mean score of Criticism in Schizophrenic, Bipolar and diabetic relatives was respectively of 27, 74±6, 02, 23, 63±6, 08 and 19, 10±6, 47 (p<10^-3).

The mean score of Emotional Over involvement in the three groups was respectively of 31, 12±4, 71, 29, 47±6, 18 and 25, 16±6, 88 (p<10^-3).

Compared to Bipolar relatives the mean score of Criticism was higher in schizophrenic relatives (p=0, 009).

There was no statistical difference in mean scores of Emotional Over involvement between schizophrenic and bipolar relatives.

In schizophrenic and bipolar relatives, Criticism and Emotional Over involvement were higher when patients were in relapse phase.

We noticed a positive and significant correlation between the number of depressive episodes and the score of Emotional Over involvement in bipolar relatives.

Conclusion: In our study the mean scores of Criticism and Emotional Over involvement were higher in Schizophrenia and Bipolar relatives then Diabetic relatives. Those results mean that high expressed emotions are not specific of chronic diseases but they are mental disorders-specific.

High EE subcategories were related to relapse in both of schizophrenic and bipolar groups.

Emotional Over involvement of relatives was related to the number of depressive episodes in bipolar patients.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Acute onset psychoses in a healthy child: A rare case report

Mahesh Kamate, Jitendra Dilipkumar Mugali^*

Jawaharlal Nehru Medical College Belgaum, Karnataka, India.

E-mail: drmaheshkamate@gmail.com, drjitendramugali@gmail.com

Keyword: Acute psychosis, Nâ€‘Methylâ€‘Dâ€‘Aspartate receptor, auto immune encephalitis, behavioural disturbances

Background: Acute psychotic disorder in children is not very common. Most of the time acute psychosis in children are secondary to an organic cause. They mostly present with behavioural disturbances, hallucinations, delusions, muttering, variation in psychomotor activities and sleep disturbances. Diagnosis is usually suggested by clinical examination, CSF studies and neuroimaging in most of these cases. At times when these tests are normal, management becomes difficult. Anti- N-Methyl-D-Aspartate Receptor immune encephalitis (NMDRE) is a recently identified autoimmune disease which manifests mainly as acute onset psychoses with abnormal movements and seizures. In the early phase of the illness predominant symptoms constitute acute psychotic symptoms, behavioural disturbances. Investigations such as neuro-imaging, CBC and CSF analysis are normal in this entity. Diagnosis is usually based on CSF antibody testing. Hence many of these can present to a psychiatrist. It mainly occurs in young females who may have an underlying tumour (ovarian teratoma). But in children it occurs in the setting of an infection. If diagnosed early, initiation of immunotherapy and tumour removal (if present) may result in early and complete recovery. If therapy is delayed, the outcome may not be good. Since, investigations were normal, many times diagnosed as a pure functional disorder and treated. We here report a 12 years old girl who presented with episodes of aggressive behaviour, increased psychomotor activity, irritable, crying spells, elective mutism, muttering and visual hallucinations with seizures for 5 months. The diagnosis was missed for the first 5 months. After correct diagnosis and treatment with immunotherapy, patient improved. This case report highlights the need for better awareness of this disease among different specialties, i. e, psychiatry, general medicine, paediatrics and neurology. Also help for timely diagnosis and appropriate treatment of this treatable disease.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Diagnostic stability of ICD-10 Adjustment disorder - A retrospective two year follow up

Debanjan Mandal^*, Rajesh Gopalakrishnan, Anju Kuruvilla

CMC Vellore, India.

E-mail: debs05cnmc@gmail.com, sanju@cmcvellore.ac.in

Keyword: Adjustment disorder, Stress, Diagnostic stability, Retrospective study

Aim: To study the diagnostic stability of patients diagnosed with Adjustment disorder after two years of follow up.

Materials and Methods: Medical records of all adult patients who attended the Department of Psychiatry, Christian Medical College, Vellore, between January 1^st and June 30^th, 2012, diagnosed with Adjustment disorder, were reviewed at the end of two years to assess for the stability of diagnosis. Relevant socio-demographic and clinical details were collected.

Results: A total of 168 records were retrieved. The majority were lost to follow up within three months of index visit. Diagnostic stability and correlation with socio-demographic variables will be presented in detail.

Conclusion: The variable course and outcome of a diagnosis of adjustment disorder is well documented. It has been suggested that this diagnostic entity be removed from classificatory systems. However it is a useful category, as many patients present soon after the onset of illness, when the clinical features may not allow them to be categorized into any of the more classic disorders. The results of this study are consistent with existing literature highlighting its importance as a separate diagnostic category.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

High rate of epileptic seizure in patients abusing dextropropoxyphene

Naresh Nebhinani^*1, Debasish Basu², Surendra Kumar Mattoo²

¹AIIMS Jodhpur, India, ²PGIMER Chandigarh, India.

E-mails: drnaresh_pgi@yahoo.com, db_sm2002@yahoo.com, skmattoo@ymail.com

Keyword: Seizure, dextropropoxyphene, opioids

Background and Aim: Dextropropoxyphene (DPP), a weak opioid, is often abused as a psychoactive substance. Of late studies have reported seizures with DPP. The present research aimed to study the prevalence of epileptic seizure/s among inpatients with opioid dependence.

Methods: The study was conducted at a tertiary care deaddiction center recruiting consecutive patients with opioid dependence admitted from 1^st January, 2011 to 31^st December, 2011. Epileptic seizure was defined as per the International League Against Epilepsy guidelines.

Results: Out of 144 subjects, 35 (24. 3%) subjects had epileptic seizure/s in their lifetime. All were men, with a mean age of 29 years, had mean seizure duration of 4. 8 years and had up to 5 seizures in their life time. Majority had generalized seizures and one-third was receiving antiepileptic drugs. Three-fourth of the subjects had intoxication seizures, mainly with DPP (74%). Epileptic group was comparable to non-epileptic group for demographic and clinical variables including duration of dependence.

Discussion and Conclusion: One-fourth of substance dependent inpatients had epileptic seizure/s, mainly with dextropropoxyphene intoxication. Clinician’s awareness of this association has important implications for diagnosis and management of epileptic seizure in dextropropoxyphene dependent subjects.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Pathways of Care in patients with depressive disorders and Psychotic disorders: A comparative study

Naresh Nebhinani^*, Vrinda Pareek, Prerna Singh, Swapnil Tripathi

AIIMS Jodhpur, India.

E-mails: drnaresh_pgi@yahoo.com, vrindapareek96@gmail.com, nnebhinani@gmail.com, dr.tripathi1994@gmail.com

Keyword: Pathways of Care, depressive disorders, Psychotic disorders

Background: Though several studies have evaluated the pathways to care, but literature is really scarce from Northern-Western India.

Objective: To explore the pathways of care and first treatment contact in patients with depressive disorders or psychotic disorder attending a tertiary care hospital located in Northern-Western India.

Methods: Sixty consecutive patients with diagnosis of depressive disorders or psychotic disorder (thirty in each group) were evaluated for their pathways of care and first treatment contact. This study is ongoing in our department with the target sample of 200 (100 in each group).

Results: Profile of pathways to care were similar in both the groups. The first treatment contact was a psychiatrist (government setup / private setup) in half of the patients, while it was physician in one-third of the patients. Nearly half of the patients visited faith healers at various points, though only minority of patients visited them as first contact. One-third of patients have visited AYUSH personnels at various treatment points.

Conclusions: First treatment contact with Psychiatrist was in half of the patients, but not in other half of the patients. It further delays in availing proper psychiatric treatment. It signifies the urgent need for mental health literacy as well as availability of mental health professionals in India.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Attitudes towards Psychotropics in patients with depressive disorders and Psychotic disorders: A comparative study

Naresh Nebhinani^*, Vrinda Pareek, Prerna Singh, Swapnil Tripathi

AIIMS Jodhpur, India.

E-mails: drnaresh_pgi@yahoo.com, vrindapareek96@gmail.com, nnebhinani@gmail.com, dr.tripathi1994@gmail.com

Keyword: Attitudes, Psychotropics, depressive disorders, Psychotic disorders

Background: Though several studies have evaluated the attitudes towads psychotropics in patients with psychiatric disorders, the literature is really scarce from Northern-Western India.

Objective: To explore the attitudes towads psychotropics in patients with depressive disorders or psychotic disorder attending a tertiary care hospital located in Northern-Western India.

Methods: Sixty consecutive patients with diagnosis of depressive disorders or psychotic disorder (thirty in each group) were evaluated for their attitudes towads psychotropics. This study is ongoing in our department with the target sample of 200 (100 in each group).

Results: Profile of pathways to care were similar in both the groups. Nearly two-third of patients considered psychotropics as most effective way to treat mental illness and to prevent relapse, with manageable side effects and benefits overweighing the risk. While on other side half to two-third of patients considered higher risk of dependecy, sedating and harmful side effects and opined for taking lesser than prescribed doses.

Conclusions: Though majority of patients had favorable attitude about efficacy of psychotropics, but they also had substantial misconceptions about side effects, and utility of taking lesser than prescribed doses. It signifies the urgent need for mental health literacy in India.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A Comparative study of Depressive and Cognitive Psychopathology in the Indian Elderly

Deepti Anujankunju Abraham^*1, Riddhi Ajit Desai²

¹Assistant Professor, SSIMS & RC, Davangere, Karnataka (Ex resident D. Y Patil Hospital & Research Institute, Navi Mumbai), India, ²Private Psychiatrist (Ex resident D. Y Patil Hospital & Research Institute, Navi Mumbai), India,

E-mails: drdeepabrah@gmail.com, desairiddhi@yahoo.co.in

Keyword: Geriatric, depression, cognition, loneliness

Background: Geriatric population and institutionalization of elderly is on the rise. Institutionalization imposes various physical, psychological and cognitive restrains of functioning in elderly.

Aims: To study and compare depressive and cognitive psychopathology in institutionalized and non-institutionalized Indian elderly.

Settings and Design: Study was cross-sectionally done over two years in 100 consenting elderlies, with 50 staying at registered old age homes, and 50 coming/referred to psychiatric department of a tertiary care teaching hospital

Material & Methods: Socio-demographic data was gathered with a self-designed questionnaire. Depressive psychopathology and loneliness was assessed with the Geriatric Depressive Scale (GDS) and Revised University of California, Los Angeles (UCLA) Loneliness scale respectively. Cognitive psychopathology was assessed with Montreal Cognitive Assessment (MoCA). Independence in activities of daily living assessed using Lawton activities of daily living scale (ADL). Data was analyzed in SPSS v 20, and statistical significance was established at P < 0. 05.

Results: Women were significantly more institutionalized (30 vs 20, χ² 6. 784, P < 0. 05). Prevalence of depression (56% vs. 16%, χ² 18. 783, P < 0. 001), loneliness (78% vs. 32%, χ² 21. 577, P < 0. 001), and cognitive psychopathology (78% vs. 42%, χ² 12. 042, P < 0. 001) was significantly more in the institutionalized group. Significant positive correlation between GDS and UCLA scores (r = 0. 785, P < 0. 001), ADL scores (r = 0. 517, P < 0. 001), and significant negative correlation between GDS and MoCA scores (r = 0. 437, P < 0. 001) was found in institutionalized groups. Non institutionalized group did not show significant correlation in the scores.

Conclusions: Depression, loneliness was observed in both groups but, cognitive decline was more in institutionalized group, with more impairment in activities of daily living as compared to non-institutionalized group. Home based elderly in family settings with more participation in activities of daily living were protected from this cognitive decline.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Alcohol use among males in the state of Uttarakhand

Anindya Das^*1

¹AIIMS Rishikesh, India,

E-mail: andydas@rediffmail.com

Keyword: Alcohol, Uttarakhand, prevalence, socio-economic determinants

Background: Alcohol use is an important risk factor for (both physical and mental) health outcome. Population level data pertaining to alcohol use has been collected in the last National Family Health Survey (NFHS) 3 (2005-06). It has been found that 39. 1 per cent of the population aged between 15-49 years drink alcohol.

For the following study data for Uttarakhand was extracted from the above survey with the aim of studying the degree and patterns of alcohol drinking in men. The study is restricted to the analysis of men between 15 to 49 years of age. It uses this dataset with the objectives to find the prevalence of alcohol use in groups by various socio-economic parameters of Uttarakhand. Further analysis is planned to be performed in a regression model to find the contribution of selected socio-economic parameters in predicting the chance of severe alcohol use (drinking ‘almost once a week’ or more).

The results of the study will be further discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Response of untargeted symptoms in psychiatric patients

Kishan Porandla, Preeti Gudlavallety^*, N D Sanjay Kumar

Prathima Institute Of Medical Science, India.

E-mail: prashanthihospital@gmail.com, aac.preeti@gmail.com, drsk2010@gmail.com

Keyword: Psychiatric disorders, untargeted symptoms, neuroimmunology

Introduction: Psychophysiologic or psychosomatic medicine is the field of psychiatry which deals with conditions that are frequently precipitated or exacerbated by emotional stress. Psychological distress of Psyhiatric patients can dysregulate neuroimmunological process which may worsen the co-morbid conditions like asthmatic attacks, increase sensitivity to allergens and flare up dermatological lesions in psoriasis and vitiligo.

Case Description: A series of four cases with different medical conditions developed psychiatric co-morbidities for which each of them consulted a private psychiatrist. A male patient suffering from psoriasis since 15 years also developed depression 2 years back and he claimed 75% reduction in the symptoms of psoriasis within two months of treatment with Tri Cyclic Antidepressant(TCA). Another male suffering from nasobronchial allergy for the past 10 years presented with symptoms of depression one year back and on taking TCA, the frequency of nasobronchial allergy which was once a month previously, completely subsided within a year. A female patient diagnosed as bronchial asthma 10 years back attended psychiatric clinic 5 years back with symptoms of schizophrenia and was put on resperidone. Later, it was found that there was 80% reduction in the usage of inhaler within a span of one year. A male patient with vitiligo since 3 years visited a psychiatrist 2 years back with symptoms of schizoaffective disorder. He claimed complete remission of the lesion within one year of starting the antipsychotic treatment.

Discussion: Stress due to psychiatric disorders activates the neuro-immuno-endocrine system leading to upregulation of stress hormones which in turn stimulate sympathetic nervous system thereby releasing catecholamines, neuropeptides and neuromediators. This system plays an important role in the treatment outcome.

Conclusion: Psychosomatic evaluation of components of a disease with due emphasis on interrelated pathophysiologies should be addressed for a holistic approach in alleviating the suffering due to the diseases and disorders.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Cycloserine induced acute psychosis in a young male with drug- resistant tuberculosis

Rajeev Ranjan^*, Sartaj Deepak, Saurabh Kumar, Rajesh Sagar

AIIMS, New Delhi, India.

E-mails: rajeevranjan5@yahoo.co.in, sartajdeepak@yahoo.com, saurabhksingh.singh@gmail.com, rajeshsagar@rediffmail.com

Keyword: Cycloserine, multidrug resistant tuberculosis (MDR-TB), psychosis

Background: Psychiatric manifestations present a major challenge in the treatment of patients with multidrug-resistant tuberculosis (MDR-TB). The incidence of depression, anxiety and psychosis during MDR-TB treatment with second line agent, particularly with cycloserine are reported. We report a 20-year-old male who developed polymorphic symptoms after addition of second line anti-tuberculosis treatment for his multidrug resistant tuberculosis.

Methods: A 20-year-old male, known case of disseminated tuberculosis with frontal lobe tubercular abscess on second line ATT (diagnosed as MDR-TB) including cycloserine (750 mg/day), levofloxacin (750 mg/day), clarithromycin (1gm/day) since 1 months, presented with one week history of anxiety symptoms, fearfulness, persecutory delusion, suicidal ideation, irritability, decreased energy and disturbed sleep. Patient also developed seizure during course of illness and was on valproate and levatoracetam. Since the patient was on several drugs with potential to cause acute psychotic reaction, we considered a provisional diagnosis of drug induced acute psychosis. The recommended intervention in such cases is discontinuation of the offending drug. However, it was decided to continue the antitubercular drugs as the patient had MDR-TB. He was simultaneously started on oral escitalopram 5 mg/day and later added olanzapine 2. 5 mg/day and the dosage was increased to 5mg/day within a week. Two weeks later, his sleep, appetite and interaction with others improved, and the delusions, fearfulness, anxiety decreased.

Results: We identified probably cycloserine as offending drug; and discuss the management and possible neurobiological mechanisms as etiological explanation and implications of psychosis caused by cycloserine.

Conclusion: Our case highlights the importance of awareness regarding psychiatric adverse events of antitubercular agents in MDR-TB patients and these can be treated with the addition of appropriate psychotropic drugs without discontinuation of the antitubercular regimen. Future needs include the development of new pharmacogenomic assays and surveillance mechanisms which will help in identification of patients at risk for these toxicities.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Efficacy of haloperidol vs levosulpiride injection in patients with acute psychosis: a randomized double-blind study

Sagar Lavania^*1, Samir Kumar Praharaj²

¹S N Medical College, India, ²KMC, Manipal, India,

E-mails: sagarlavania@rediffmail.com, samirpych@yahoo.co.in

Keyword: Haloperidol, levosulpiride, double blind

Aims: The aim of the study was to compare the efficacy of Haloperidol with Levosulpiride in patients with acute psychosis.

Background: Typical antipsychotics remain the first choice in treating acute psychotic symptoms, whereas atypical ones are considered alternatives. The side effect profile of typical antipsychotic restricts its use and search for a better antipsychotic which is safe & efficacious in patients with acute psychosis is needed.

Materials and Methods: This was a prospective, double-blind, parallel-group clinical study, involving 60 drug-naive acute psychotic patients. Patients were randomly assigned into two groups, ‘A’ and ‘B’, of 30 patients each, and received either intramuscular Haloperidol injection or Levosulpride injection, for initial 5 days. A blinded rater assessed the subjects using socio-demographic pro-forma, Brief Psychiatric Rating Scale (BPRS), Overt Agitation Severity Scale (OASS), Overt Aggression scale – Modified (OAS-M), Simpson Angus Scale (SAS) and Barnes Akathisia Rating Scale (BARS) at baseline and daily for next 5 days.

Result: Repeated measures ANOVA for BPRS scores showed significant effects of time (p<. 001, η²=0. 577), and a trend towards greater reduction in scores in Haloperidol group as shown by group × time interaction (p=. 076) with small effect size (η²=0. 046). For OASS, repeated measures ANOVA showed significant effects of time (p<. 001, η²=0. 431), but no group × time interaction. Repeated measures ANOVA for OAS-M scores showed significant effects of time (p<. 001, η²=0. 532), and greater reduction in scores in Haloperidol group as shown by group × time interaction (p=. 032) with small effect size (η²=0. 077). Higher rates of akathisia as well as extrapyramidal symptoms were noted in the Haloperidol group.

Conclusion: Haloperidol was found to be superior to Levosulpride injection for overt aggression, and possibly for psychotic symptoms.

Financial sponsorship-NIL

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Tardive dystonia in an adolescent girl treated with atypical antipsychotics

Anu Mary Mani^*, Shravanthi S, Manohari S. M

St. John’s Medical College, India.

E-mail: dr.anumani@gmail.com, drsravanti@yahoo.com, Smmanohari@yahoo.com

Keyword: Tardive dystonia, Aripiprazole, atypical antipsychotics

Background: Tardive dystonia (TDt) is a rare, persistent and delayed onset dystonia, associated with exposure to antipsychotics. The prevalence of TDt is 0. 5 to 21. 6% in patients who are treated with antipsychotics. Low risk of developing extra pyramidal symptoms have led to wide spread use of atypical antipsychotics in the recent past. Reporting 17 yr old girl a case of bipolar affective disorder who developed TDt when she was treated with 15 to 20mg of Aripiprazole for 1 year.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Perceived problems among psychiatrists towards using evidence based journal clubs (EBJC)

Parth Goyal^*1, Sandip Shah², Lakhan Kataria³, Nisarg Shah⁴

^1-4SBKS MI&RC Sumandeep Vidyapeeth, India,

E-mail: drparthgoyal@gmail.com, researchdirector@gmail.com, lakhankataria@gmail.com, molak.pleomorphic@gmail.com

Keyword: Evidence based journal clubs, KAP, critical appraisal

Background: An evidence based journal club (EBJC) is an interactive approach to make sense of evidence, in order to understand the real scientific applicability of articles published in journals. Thus it helps the doctors to practice evidence-based health care – which is the need of the hour.

Aims & Objectives: To understand the knowledge, attitude and practices towards evidence based health care practice (EBHCP).

Methods: Psychiatrists attending a Zone level CME with theme of Evidence Based psychiatry were given a 10-point questionnaire to assess these objectives. They needed to fill this after attending a session on “EBJC-Critical Appraisal of an Article” with role modeling.

Results: Of the 98 participating psychiatrists, 67 completed the forms.

Of them 55. 2 % were private practioners, 34. 3 % were academic and10. 4% were dual practioners.

90. 6% appreciated the need for EBJC, however just 21. 3% knew how to appraise it and most did not apply it. Main reasons for this was perception of being lengthy and time consuming (34. 3%), & lack of prior knowledge of biostatistics (23. 9%).

After attending the role modeling session, 80% were aware of the levels of evidence and 100% could correctly identify all the parts of EBJC. Also all the participants 1) agreed to update themselves and 2) volunteered for a one-day workshop on EBJC in psychiatry.

Conclusions: EBJC training is a very handy tool and arms the clinician with basic knowledge to practice evidence-based health care.

The problems faced in adopting EBHCP are the perceived lack of time to appraise an article and the lack of knowledge in biostatistics to interpret the results. However the willingness of clinicians to engage in evidence based workshops on EBHCP is a very promising step towards and can lead to large-scale adoption of this practice.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Presentation of Hurler syndrome in two biological siblings in a mental health clinic

Diwakar Sharma^*, Kabir Garg, Sujita Kumar Kar, Nimisha Doval

King George’s Medical University, India.

E-mail: diwakar.dr@gmail.com, kabirindian2007@gmail.com, drsujita@gmail.com, ndkgmu13@gmail.com

Keyword: Hurler syndrome, Mucopolysaccharidosis, intellectual disability

Background: Hurler syndrome, or Mucopolysaccharidosis type I (MPS I), is a rare genetic disorder that follows autosomal recessive pattern and results in the buildup of heparan sulfate and dermatan sulfate at cellular level due to a deficiency of alpha-L iduronidase enzyme in lysosomes. The overall incidence of Mucopolysaccaridosis type I is 0. 99-1. 99 per 100, 000 live births. Symptoms affect various organ systems and usually present during early childhood. Presentation to health care system revolves around various physical deformities as well as intellectual sub-normality. Recent research evidences are suggestive of the role of enzyme replacement in better cognitive outcome in patients with Hurler syndrome. In clinical practice, it is rare for a psychiatrist to come across such cases albeit cognitive disability in these children. Here, we highlight the medical and psychological findings of two affected siblings.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Atypical case of kleine levin syndrome

Prabhat Kumar Agrawal^*1

¹Department of psychiatry, Agartala govt medical college, India,

Email: prabhatbhalotia06@gmail.com

Keyword: Hypersomnia, decreased appetite, behaviour abnormality

Background: A 15 year old boy with duration of illness of 3 years, presented with syndrome onset after high grade fever, episodic course and spontaneous remission and normalcy in between episodes. Features of this episode was mainly hypersomnia with decreased appetite and behaviour abnormality mainly fearfullness and suspiciousness. Previous episodes were mainly have hypersomnia with irritability and hypersexuality. Patient responded well to lithium therapy.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Skilled yet lost? Challenges of international medical graduates in psychiatry: Australian perspective

Nagesh B Pai^*1, Vikas Garg²

¹Graduate School of Medicine, University of Wollongong, Wollongong Australia, ²Illawarra Shoalhaven Local Health District, Australia,

E-mail: nagesh@uow.edu.au, Vikas.Garg@Sesiahs.Health.Nsw.Gov.Au

Keyword: Australian Training, IMGs, education, workforce

Background: International medical graduates (IMGs) represent an increasing proportion of registrars in all Australian training programs. Psychiatry registrar Training programs have experienced significant increases in IMG enrolment in the recent years.

Objectives: This presentation is an experiential account of challenges of IMGs in Australasian setting.

Methods: Following recent training programs for IMGs and interactions with recently arrived IMGs the current review has been undertaken

Results: There is a compelling need to make curricular adjustments to enhance the transition for IMGs. Adjusting the psychosocial curriculum, through changes in orientation, contributes to a culture-centred approach to teaching. There has been significant efforts by RANZCP to identify both personal loss and cultural issues for IMGs in various stages of the registrar’s life cycle. Lifestyle changes and loss of self-esteem, country, and accessibility to family can be demoralizing for IMGs coping with the demands of their new role. Specific stages of the family life cycle can exert additional stresses for IMGs and their families. Understanding the specific challenges for IMGs during each life cycle stage can be instructive and helpful. RANZCP has introduced initiatives that encourage cultural pride and respect. Australian Clinical practice skills workshops, mentorship and coaching programs, reflection on treatment of IMGs demonstrates registrars’ appreciation of diversity and leads to a healthier, culturally rich learning environment for all involved in IMG education.

Conclusion: The IMGs are an essential component of our medical workforce, and RANZCP strategy is cognizant of past mistakes and has a clear focus of quality health care should be implemented to better integrate these doctors into the Australian community

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Epidemiological findings on psychiatric morbidity in a tertiary level hospital in northern India

Dhananjay Chaudhari¹, Shekhar Yadav², Prem Singh³, Ganesh Shanker⁴

¹G. S. V. M. Medical College, Kanpur (UP), India, ²Medical Officer, CGHS, Lucknow, India,

E-mail: georgiandc@gmail.com, drshekhar1511@gmail.com

Keyword: Epidemiology, psychiatric morbidity

Background: There is dearth in studies which could throw light on the epidemiological findings on prevalence of psychiatric illnesses in northern India. The present study is an attempt to provide and supplement the existing database related to this vital topic.

Subject: The present study is undertaken with the aim to study the diagnostic profile of patients attending the Out-Patient Department (OPD) of Department of Psychiatry at GSVM Medical College, Kanpur, that provides both outpatient and inpatient services to psychiatric patients residing in Kanpur and adjoining urban and rural areas.

Methodology: It is a retrospective study of all patients attending the Psychiatry OPD from October 2013 to September 2014. All the patients fulfilling the diagnostic criteria of ICD-10 for psychiatric disorderwill be included in the study.

Results: The details of diagnostic profile and clinical characteristics will be discussed in detail at the time of presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

YC2-Deppe (Youth Caring Community of Depression People) as a method to decrease the number of people who stress or depression and get stocks like prisoner in Indonesia

Eneng Elisnawati^*, Nana Nirmala

University of Indonesia, Indonesia.

E-mails: eneng.elisnawati@ui.ac.id, nirmala_nana83@yahoo.com

Keyword: YC2-Deppe (Youth caring community of depression people), stress, prevention, education

Background: Indonesia is a developing country that has the inhabitants of the world’s fourth largest. It is often causing no justice of welfare have been guaranteed by the government of Indonesia to Indonesian people. Moreover, the pressures on economic development and technology which is getting rapidly develops make a lot of the Indonesian people in poverty, suffering from hunger, low educated, even people get into stress that can lead into a depression. In fact, due to lack of the medicines’s cost and lack of knowledge from the family, cause many incidents of Indonesian people being stocks like a prisoner. The stigma of local residents also very influence to the decision of the family to do stocks like a prisoner or not to do it to members of their family who are subjected to stress. YC2-Deppe (Youth Caring Community of Depression People) created as an association for young people to assist the Government in stress prevention and stress education for the family which their family members have a risk factor to get a stress. The stress education will start from cause of stress until the right management of stress that can gived by the family. It can do by doing a health promotion and also directly going to the target areas which have been pointed by the Government. It is aim to reduce the prevalence of a person who is subjected to stress and depression in indonesia. Thus, the level of mental health of Indonesian people can be better, so that Indonesian people can be more contribute to build Indonesia.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Diphenoxylate dependence treated with Buprenorphine: A case report

Ritambhara Mehta^*, Saumitra Shankar Nemlekar

GMC, Surat, India.

E-mail: ritambharam@yahoo.com, saumitra121@yahoo.co.in

Keyword: Diphenoxylate dependence, buprenorphine, OST

Background: Diphenoxylate in combination with atropine, an over the counter anti-diarrhoeal medicine, is chemically an opioid agonist. It crosses the blood–brain barrier and therefore is potentially habit-forming and can generate significant tolerance if taken continuously for a protracted period. We present a case of diphenoxylate dependence which was managed with Sublingual Buprenorphine.

Case: Patient Mr. AJ, a 26 year married male migrated from Punjab for the main purpose of De-addiction, presented to OPD with complaints of oral use of 110 tablets of diphenoxylate since last 6 months. Patient had been using natural opioid formulation (boiled extracts of Opium fruit-Doda) since the last 5 years but due to migration and unavailability of raw opium plant products in Surat, as advised by experienced friends from Punjab, he started using diphenoxylate. The dose was calculated and increased to 110 tabs a day.

On stopping the tablets, he developed intense pain in calf, perspiration, generalised weakness, tearfulness and feeling of congested nose, developing within 1 hour of his usual time of intake. Patient had difficulty in working and loss of sleep. At presentation his COWS score was 14 while SOWS score was 11. Patient was started on Buprenorphine + Naloxone 2mg and dose was titrated to 4 mg in form of BD dosages with monitoring of COWS score. Patient reported withdrawal features at BD dosages and sleep disturbance, so patient was shifted to OD dosage with a Clonazepam 0. 5 mg at night for sleep disturbance. After 5 days patient was stabilised on 4 mg at COWS 4 and SOWS 3.

Conclusion: There is an emerging trend of use of diphenoxylate as substitute for natural opioid due to its easy availability. Management of such patients with Buprenorphine is advisable due to its monitored prescription, ease of administration as well as known efficacy and safety in opioid dependence.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Knowledge and misperceptions of Attention Deficit Hyperactivity Disorder (ADHD) among primary school teachers of Vadodara district

Anupsinh Harendrasinh Chhasatia^*, Lakhan Rudabhai Kataria

SBKS MI & RC, Sumandeep Vidyapeeth, India.

E-mails: anup66tia@gmail.com, lakhankataria@gmail.com

Keyword: ADHD, KADDS (Knowledge of Attention Deficit Disorder), primary school teachers

Objective/Introduction: Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most commonly diagnosed psychiatric disorders of childhood. Teachers can play a key role in identifying and supporting students with ADHD. In order to fulfill this important role, it is imperative for teachers to have explicit knowledge about ADHD. Teachers are seen as one of the most valuable sources of information with regard to referral and diagnosis of ADHD. They also have the responsibility for creating an environment conducive to academic, social and emotional success for children with ADHD. However, since there is some doubt as to whether teachers have the appropriate knowledge of ADHD to fulfill this important role.

Aim: This study aimed at assessing the knowledge and misperceptions of ADHD of primary school teachers in Vadodara district.

Material & Methods: Total 491 schoolteachers participated in the study. The Knowledge of Attention Deficit Disorder Scale (KADDS) along with a demographic questionnaire was used as the survey instruments to collect data. Descriptive statistics and correlation test were used to analyze the data.

Results: Results indicated that teachers’ knowledge of ADHD was insufficient. Significant difference about knowledge was found between Urban & Rural (0. 00429); Gujarati & English medium school teachers (P = 0. 0013). Misperception was significantly higher (P = 0.05) in teachers teaching in primary standard compared to upper primary standard.

Conclusion: As the lack of knowledge was apparent from the study teacher’s training in the field of ADHD is required as they are the first person to come in direct contact with the children; for early intervention & better future of the children.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Study of children and adolescents seen at the child development & guidance clinic (CDGC) in tertiary care hospital

Ranjeet Singh Chaudhary, Jyoti Shetty, Nilesh Naphade, Leena Pandit

Bharati vidyapeeth Medical College, Pune, India.

E-mail: drranjeetchaudhary@gmail.com, shettyjyoti19@gmail.com

Keyword: Children and Adolescents, Child Development & Guidance Clinic (CDGC)

Background: Description: This is a Retrospective study of all children seen at the CDGC between September 2009 and August 2014.

The CDGC is a referral unit comprising of Department of Psychiatry and Department of Paediatrics with a team of Psychiatrists, Developmental Paediatrician, Psychologists, Special Educator, Paediatric Physiotherapists, Speech therapists offering diagnostic and interventional services. Training and Awareness Programmes are done on a regular basis. ln the Sarva Shikshan Abhyan a team of CDGC had undertaken training programmes all over Pune district for around 6500 teachers.

Objective and Rationale: To determine:

The profile of patients seen at the CDGC.
For further augmentation of services.

Design: Retrospective study of all cases at the CDGC at Bharati Hospital, Department of Psychiatry and Department of Paediatrics OPD between September 2009 and August 2014.

Eligibility: All patients seen and evaluated. No exclusions.

The most common referral was for Developmental delay (60%) including Cerebral Palsy (15%) and Mental Retardation, Scholastic backwardness (14%) and Attention Deficit Hyperactivity disorder (ADHD) (13%) formed a major part followed by Autism, Behavioral problems etc.

Psychoeducational assessments (DQ/IQ/ICIT/Curriculum psychotherapy based assessments) and Interventional services included physiotherapy, counselling, Behavioral therapy, speech therapy and pharmacological intervention were carried out.

Conclusion: 75% of the patients seen were direct referrals.

Augmentation of outreach programme needs to be done with establishment of parent support groups, CDGC - school liason, teachers awareness programme. In addition awareness programmes for medical professionals are also planned. Augmentation of services is planned by having specific liason person responsible for ensuring contact, assessment and follow up.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Tokophobia: A morbid fear of childbirth

Priyanka Yadav^*, Rajesh Sagar, N Manjunatha

All India Institute of Medical Sciences, India.

E-mail: drpriyanka2609@gmail.com, rsagar_29@yahoo.com, manjunatha.adc@gmail.com

Keyword: Tokophobia, fear of childbirth

Background: Pregnancy is a major life event in a woman’s life. Still some women may avoid it due to pathological fear of childbirth- Tokophobia. This fear can be primary in nulliparous women or secondary. We are presenting a case of a young married woman who was being treated as a case of depression for 2 years, who on further exploration turned out to be a case of secondary Tokophobia. Patient had a traumatic instrumental first delivery with perineal tears, post which she started experiencing disturbed sleep, sadness of mood, decreased interaction with family members, reduced appetite and some anxiety symptoms. Patient used to appear a little restless but could take care of her child. Patient started dreading childbirth but could not share with anyone considering sociocultural limitations. Patient started avoiding getting pregnant by using contraceptives and even avoided sexual activity sometimes. She also got a medical termination of pregnancy after an accidental delivery. After second such pregnancy patient worsened and came to AIIMS, wherein on detailed evaluation she reported her intense fear of childbirth and her avoidance of pregnancy due to that. She also expressed a strong preference for caesarean section in this pregnancy. She also reported difficulty in bonding with her baby after first delivery and her anticipated fears from this pregnancy. Patient also had moderate depressive features. With low dose Sertraline and psychotherapy addressing her fears patient started improving. Plan to involve her obstetrician for prenatal and antenatal education for holistic management has been done. Many females may have Tokophobia that may masquerade as anxiety, depression insomnia or post-traumatic stress disorder and thus remain untreated like in this case. A close liaison with obstetrics may help identify and alleviate distress of many women suffering from Tokophobia that is a multidisciplinary problem.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Marchiafava bignami disease treated with parenteral thiamine: A case report

Saumitra Shankar Nemlekar^*, Ritambhara Mehta, Kamlesh Dave, Nilima Shah

Government Medical College, India.

E-mails: saumitra121@yahoo.co.in, ritambharam@yahoo.com, drkamleshdave@gmail.com, itisnilima@gmail.com

Keyword: Marchiafava bignami disease, parenteral thiamine

Background: Marchiafava - Bignami disease is a known rare sequelae of chronic alcohol use. The clinical presentation however is markedly varied with no specific or pathognomonic clinical features. We present a case with Acute Stroke like presentation and its management with parenteral thiamine.

Case: Mr. MR, a 53 year old male with history of Alcohol (country liquor) use since 32 years was brought to hospital with acute onset of unresponsiveness after fall, unable to walk without support and not able to speak clearly. The patient was talking irrelevantly and was not oriented to time and place. The neurological examination revealed mild weakness involving left side of the body, non-reactive planters and exaggerated tendon reflexes on left side. Patient also had impaired joint position sense and fine touch involving lower extremities with swelling of both knee joints. The MMSE score was 12 at the time of admission.

Routine investigation revealed reduced platelets and raised ALT. The MRI revealed findings of bilateral hyper intense signal on T2W and FLAIR images. There was Hypo intense lesion on T1W images involving body, genu and splenium of corpus callosum. Subtle restriction diffusion noted. The features are suggestive of Marchiafava - Bignami Disease. Hyper intense signal on T2W and FLAIR images involving bilateral fronto-parietal subcortical region.

Patient was given IV fluids, Tab. lorazepam 2mg HS and IV Thiamine 500 mg/day. Patient had significant clinical improvement in 5 days and was discharged on request with MMSE score of 20.

Conclusion: There have been few guidelines for management of MBD and literature supports use of parenteral thiamine 500mg leading to remission of symptoms and symptomatic improvement. It is advisable to use parenteral thiamine in all cases as it overlaps management of other co-morbidities of nutritional deficiencies and Wernicke Korsakoff syndrome commonly seen in alcohol use disorders.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A case report of anorexia nervosa: Diagnostic difficulties in Indian scene

Diwakar Sharma^*, Sujita Kumar Kar, Manu Agarwal, Saurabh Kumar

King George’s Medical University, India.

E-mails: diwakar.dr@gmail.com, drsujita@gmail.com, drmanuagarwal7@gmail.com, skb.saurabh@gmail.com

Keyword: Anorexia Nervosa, eating disorder, medical complications, amenorrhea

Background: Traditionally and culturally, slimness had been not been encouraged in Non-western world. With the advancing globalization and unprecedented western influence, desire to seek ‘size –zero’ is becoming more and more common in countries such as ours.

An obvious manifestation of the same is seen in terms of epidemiology of Anorexia Nervosa. Recent trends are suggestive of an increasing occurrence of clinical and more importantly, subclinical cases in India. But presentation of such patients to mental health professionals is still negligible in comparison to their western counterparts. Studies state that Indian patients usually have atypical presentation, that is, without much distortion of self-image.

We came across one such interesting case of a 21 year old female with distortion of self-image, which is uncommon in Indian scene. Exhaustive medical evaluation and persistent diagnostic dilemma faced by the physicians before this psychiatric consultation is the focus of this presentation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Behavioral and neuro-developmental profile of children with Autism Spectrum Disorder in tertiary care center

Savita Sapra^*, Tanuja Kaushal

All India institute of medical sciences, India.

E-mails: saprasavita@yahoo.com, tanujakaushal19@gmail.com

Keyword: Autism spectrum disorder, Behavior, neuro-developmental profile

Background: The diagnosis of Autism spectrum disorder (ASD) has increased in recent years with studies estimating that at least 2 per 1000 children have ASD. It is a developmental disorder which affects broad areas of psychological and behavioral functioning. While upcoming researches are focusing more on etiological factors of ASD, the basic and most relevant areas of Behavior and neurodevelopment remain largely unexplored.

Objectives: The aim of this paper is to study behavior and neurodevelopmental profile of Children with ASD.

Methods: One hundred consecutive children with diagnosis of ASD within the age group of 3 to 12 years were assessed on DSM V, Child behavior checklist, Childhood autism rating scale and Developmental profile III.

Results: The mean age of sample was 4 years 5 months. There was predominance of males in the sample. Children were found to be having problems in relating to others, attending to a task and hyperactivity. Significant difficulties were observed in the domains of communication, socio-emotional and adaptive functioning.

Conclusion: Children with autism spectrum disorder (ASD) are more likely to behave in challenging manner due to multiple reasons. Understanding their behavioral and neurodevelopmental profile is a perquisite for planning and implementation of appropriate intervention.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Case report — Priapism: A rare side effect of antipsychotics

Kamlendra Kishor^*1

¹Department of Psychiatry, K. G. M. U. Lucknow, India,

E-mail: dockamlendra@gmail.com

Keyword: Case report

Backgound: Priapism is defined as prolonged and persistent erection of the penis without sexual stimulation. Priapism is a rare but important side effect of antipsychotic drugs which may evolve into a urological emergency. Drug induced priapism is associated with antidepressants, antipsychotics, antihypertensive medications, and accounts for approximately 15% to 41% of all cases, of which antipsychotics- induced priapism is most common. Most antipsychotic drugs are alpha-1 adrenergic antagonists, which is thought to be the principal mechanism involved in antipsychotic induced priapism.

Objective: To report a rare but an important adverse effect i. e. priapism due to most commonly used antipsychotics.

The Case: A 28 years old married male presented in OPD with psychotic symptoms for six months after assessment he was diagnosed as a case of paranoid schizophrenia. He was started on Risperidone which was gradually increased to 6mg/day. After a month he developed 3 episodes of priapism due to which his risperidone was stopped and he was shifted on Olanzapine but he again developed priapism on dose of 20 mg/day. Laboratory investigations did not reveal hyperprolactinemia or liver derangement and patient had no history of substance use. Patient was later shifted on Aripiprazole on which patient is showing response and had not developed any episode of priapism.

Conclusion: Treatment with antipsychotics with high alpha-1 blocking property can lead to the emergence of priapism, a rare but an emergency situation. Such patients may be missed in clinical practice may become non compliant to antipsychotics. Such condition also limits and poses challenge to psychiatrist while treating such patients. This case presents how a treatment regimen can be established balancing antipsychotic efficacy to acceptable side effects and offers guidance to psychiatrist regarding how antipsychotic-induced priapism may be resolved.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Re-challenge of Clozapine in a patient with history of leucopenia with Clozapine

Arnab Mukherjee^*, Rajesh Gopalakrishnan, Anju Kuruvilla

Christian Medical College, Vellore, India.

E-mails: arnabmukh11@gmail.com, rajeshgop@cmcvellore.ac.in, sanju@cmcvellore.ac.in

Keyword: Clozapine, agranulocytosis, leucopenia, side-effects, clozapine re-challenge, treatment resistant psychosis, schizophrenia, India

Background: Clozapine is generally reserved for patients with treatment resistant psychotic disorders. However its use is limited by its potential for rare but life threatening side effects like agranulocytosis. There are several reports where patients who have developed leucopenia or agranulocytosis due to Clozapine were re-challenged with clozapine.

Case report: A 27-year-old single male, with schizophrenia was commenced on Clozapine in view of treatment resistant psychosis. He developed leucopenia three weeks after starting Clozapine after which Clozapine was discontinued. Sequential trials (monotherapy and in combinations) of Amisulpride, Quetiapine and Risperidone did not benefit. Hence a re-challenge with Clozapine was considered in consultation with a haematologist. The frequency of monitoring white cell counts was increased to twice a week. He tolerated the re-challenge with significant reduction in psychotic symptoms and improvement in socio-occupational functioning.

Conclusion: Re-challenge with Clozapine is an option in patients with psychosis, with a past history of good response, and failure of alternate treatments. The common strategies used for rechallenge will be discussed.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Aggression directed towards emergency department

Nikita Dhaka^*1

¹S. N. Medical College, India,

E-mail: nikitadhaka08@gmail.com

Keyword: Violence towards emergency staff

Intoduction: Work place violence is one of the most complex and dangerous occupational hazard faced by health care professionals in today’s health care environment. The incidence of violence faced by workers in contact with people in distress is so common that it is often considered an inevitable part of the job and it adversely affects their efficacy. Health care workers are at forefront of this situation.

Aims and Objectives: To determine the scope and magnitude of patient and visitor aggression directed towards emergency staff and to determine effect of violence on health care workers.

Study and sample: A retrospective survey of 100 employees, working in Emergency department of teaching hospital of rajasthan, including doctors, nurses and ward boys.

Material and Methods: All subjects were subjected to a pre designed questionnaire, which has analyzed the definition of violence, number of episodes, risk factor, consequen of violence, copying and pretentive strategies for violence. The results were analyzed by Likerts scale.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A clinical study of substance use axis-1 psychiatric comorbidity among opioid dependent patients using injectable drugs.

Azhar Mahmood Farooqui^*1, Pronob Dalal², Amit Arya³

^1-3King George’s Medical University, India,

E-mails: azharmahmoodfarooqui@gmail.com, drpkdalal@rediffmail.com, amitarya.11kgmu@gmail.com

Keyword: Opioid dependence, comorbidity, injection drug users

Background: Literature shows that Opioid dependant IDU’s are found to abuse and have dependence of several other psychotropic substances. Globally most of the data come from the patient pool of various intervention programs (NSEP, OST and MMT) being running for such people. However Indian studies are still lacking in this area.

Aim: To assess other substance use disorder comorbidity in patients of opioid dependent injecting drug users (IDU’s).

Materials and Methods: All the patients already registered under the NSEP, Targeted Interventions, and NACO who are being referred for OST(Sublingual Buprenorphine) at Opioid Substitution Therapy Centre, Department of Psychiatry, KGMU Lucknow were screened on selection criteria, and those fulfilling the criteria were taken for the study. After taking informed consent a detailed evaluation was done for socio-demographic and clinical variables using semi-structured proforma. SCID-I was applied for diagnostic assessment of Opioid Dependence as well as to diagnose other substance use disorders. Diagnosis of opioid dependence and other substance use disorder was made according to DSM-IV-TR criteria Comparisons of Psychosocial factors assessed on Axis-IV of DSM-IV-TR and global functioning assessed by GAF of IDU’s with and without other substance use disorders was done.

Results: 58 out of 100 Opioid dependent IDU’s who were included in the study were found to have other substance use disorder comorbidity. Commonly found SUD’s among IDU’s were Cannabis abuse disorder (27. 63%), Alcohol abuse disorder (17. 11%), Sedatives and Hypnotics use disorder (21. 05%), cannabis dependence (03. 95%), Alcohol dependence (06. 58%), Sedatives and Hypnotics dependence (02. 63%).

Conclusion: Psychiatric comorbidity in opioid dependent injecting drug users is very high, other substance in particular. Number of comorbid diagnoses in a person may be high as four.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Persistent cavum septum pellucidum: Association with psychosis

Soumya Jhanda^*1, Sonali Sud², Susanta Padhy³

^1-3PGIMER, CHANDIGARH, India,

E-mail: soumyajhanda86@gmail.com, sonalisud@ymail.com, susanta.pgi30@yahoo.in

Keyword: Septum pellucidum; psychosis

Background: The cavum septum pellucidum (CSP) or persistence of space between the two leaflets of the septum pellucidum, reflects possible neurodevelopmental anomalies of midline structures. It has been associated with various psychiatric diagnoses like schizophrenia

Objective: To present a young male with persistent cavum septum pellucidum and psychosis

Methods (Case report): The index patient is a 17 year male. Birth history revealed mother to be diagnosed with hypothyroidism in preconception period, and was started with Thyroxin supplementation. No perinatal complications reported. Thyroid profile of the patient done at birth was normal. There was evidence of delay in motor, personal and social milestones. Detailed psychiatric history revealed that over the last 8-9 months there were gradual onset of symptoms of talking to self, laughing without reason, suspiciousness, fearfulness, visual hallucinations and impairment of academic performance because of which he dropped out of school. There was no history of similar symptoms in any family member. Mental status examination of the boy revealed decreased motor activity, scanty speech, at times irrelevant, constricted affect and occasional hallucinatory behaviour. A provisional diagnosis of Organic Psychosis was made and patient was started on oral antipsychotic (Tab Olanzapine 10 mg/day). Within 4 weeks, his parents reported improvement in social activities, decrease in hallucinatory behavior and reduction in fearfulness and suspiciousness.

Conclusion: Persistent Cavum Septum Pellucidum predisposes an individual to risk of psychosi.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Dual diagnosis in an inpatients general hospital psychiatry unit: A review

Khwaja Khayyam^*1, Jyoti Shetty², Nilesh Naphade³

^1-3BVDUMC, Bharati Hospital, India,

E-mail: khwajakhayyammbbs@gmail.com, shettyjyoti19@gmail.com, drnileshnaphade@gmail.com

Keyword: Alcohol dependence syndrome, Dual Diagnosis, Comorbidity, Substance abuse, Mood disorders, Antisocial personality disorder.

Introduction: Alcohol use is related to a wide range of physical, mental and social harms. It has long been noted that substance abuse has high degree of comorbidity. Comorbidity denotes the presence of a distinct clinical entity that has existed or may occur during the clinical course of a patient having the index disease. Alcoholics are three times more likely to have another psychiatric disorder. The psychiatric disorders that occur most frequently and that have been studied most in alcoholics are mood disorders (e. g. depression), anxiety disorders, and antisocial personality disorder (ASPD).

Aim: Assessment of psychiatric comorbidity in patients of alcohol dependence syndrome.

Materials and Methods: A retrospective review of all patients of alcohol dependence treated from July 2012 to June 2014 in psychiatry ward of BVDUMC Bharati Hospital, Pune will be done. A detailed evaluation of patients who have fulfilled the diagnostic criteria of alcohol dependence as per ICD-10 will be analysed. Detailed assessment of comorbid presentation in dual diagnosis patients

Results: It will be done by using appropriate tools and statistical analysis.

Discussion: The results will be applied to evaluate comorbidity, and discuss measures to treat, maintain abstinence and treatment compliance.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

PANDAS presenting in a young boy: A case report

Aakanksha Singh^*1, Santhosh Kumar T², Susanta Kumar Padhy³

^1-3PGIMER, Chandigarh, India,

E-mails:aakankshapgi@gmail.com, aakankshapgi@gmail.com, susanta.pgi30@yahoo.in

Keyword: Pandas, OCD, ADHD

Background: PANDAS (Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is characterised by presence of multiple neuropsychiatric disorders like OCD, ADHD, tic disorders, learning difficulty and hoarding. The aetiology is autoimmune mediated following infections with group — A beta-haemolytic streptococci. This condition is rarely reported in the literature.

Objective: To present the case of 8 years old boy with PANDAS presenting with multiple neuropsychiatric symptoms and discuss its management.

Methodology (Case description): A 9 year-old boy studying in 3^rd standard, belonging to a Sikh family of upper socio economic status and urban background presented with symptoms of acute onset from last one year. The symptoms comprised of hyperactivity, deterioration of handwriting, learning disability, hoarding and compulsive behaviour. He also had fluctuating motor tics including eye blinking and shoulder shrugging and vocal tics included throat clearing. Exploration of history revealed that he had multiple upper respiratory tract infections one year back and these were temporally related with onset of symptoms. Throat swab was positive for beta haemolytic streptococci. Serum antibodies were positive for CaM Kinase II activity, Dopamine receptor D1 and beta tubulin. Based on these findings he was diagnosed with PANDAS. Management involved treatment with Fluoxetine, Risperidone and Methylphenidate in required doses and behaviour therapy for learning disability. There was improvement in tics and hoarding but insignificant improvement in other domains. Response to I. V. Immunoglobulin administration is awaited.

Conclusion: The PANDAS subgroup has a distinct clinical presentation and an identifiable course of symptoms with a clear relationship between streptococcal infections and neuropsychiatric symptom onset and exacerbations. Some cases may need IV Ig or plasmapharesis for improvement. Additional studies are required to determine the role of immunomodulatory therapies and antibiotics prophylaxis for this group of patients.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Behavioral management of selective mutism in a young child

Vijaylaxmi M^*1, Soumya Jhanda², susanta kumar padhy³

¹PGIMER, Chandigarh, India, India,

E-mail: drvijayalakshmi1987@gmail.com, soumyajhanda86@gmail.com, susanta.pgi30@yahoo.in

Keyword: Selective mutism, behavior therapy, child

Objective: To present a 11 years male child with Selective mutism and Social anxiety disorder successfully managed with behaviour therapy. Also, we will discuss various behavioural strategies for the management of selective mutism.

Case description: The index child had normal developmental milestones without any ante-/peri-/post natal complications, above average intelligence without any evidence of separation anxiety/school refusal/poor academic performance. However, since early childhood, he would remain uncomfortable in social situations and public places. He would cry continuously till the time he would be taken back home. In the school, he did not speak even a single word since the day one. He would make gestures and write on a piece of paper to communicate with friends and teacher. He would not answer in oral exams although he scores best marks in written exams. He would not speak to outsiders but would communicate well verbally with family members. Child was started on Fluoxetine 20 mg/day, propranolol 10 mg/day. Detailed behavioural analysis, Benson Henry relaxation technique, systematic desensitisation & graded exposure therapy, sliding-in technique, positive reinforcement with tokens were the components of behavioural management. Mother, teacher and psychiatric nurse acted as co-therapists. Appreciable change in verbal communication at school was noticed after six weeks of intensive therapy. Faulty communication pattern of mother was dealt with. Interactive active play with his younger brother was encouraged.

Conclusion: Selective mutism is often underrecognised and inadequately treated. Individual tailor-made behaviour therapy should be considered rather than heavily relying on pharmacotherapy. The treatment should be instituted early.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Pediatric case of medically unexplained bleeding: Probably munchausen syndrome by proxy

Preeti Pansari^*1, Praveen Das², Vijaya Raman³, S M Manohari⁴

¹NIMHANS, ^2-4St Johns Medical College, India,

E-mails: preeti_pansari@yahoo.com, praveendas07@yahoo.co.in, vijaya.raman12@gmail.com, smmanohari@yahoo.com

Keyword: Pediatric, Medically Unexplained Bleeding, Munchausen Syndrome by Proxy, Dissociative Disorder, Factitious, Bleeding Orifices

Case Report: Münchausen syndrome by proxy is fabricating symptom and signs of an illness in a child by an adult, usually the mother. The victims are usually children of less than 6 years of age. It is a serious form of child abuse and it poses a great challenge to the diagnosticians. Bleeding is one of the commonest forms of factitious symptom. However, not many cases have been observed on bleeding from multiple orifices in paediatric age group. Here, we present a case of a four year old girl who has visited multiple hospitals right from the age of four months, undergoing surgery’s to identify the source of atraumatic bleeding from multiple orifices resulting in vain. A myriad of investigation done by the paediatric teams over four years proved no etiology. A diagnosis of medically unexplained bleeding was made.

The details of this case and what led to the diagnosis of Münchausen Syndrome by Proxy will be discussed in this paper.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Hashimoto’s encephalopathy: A report of two cases

Sydney Moirangthem^*1, Sabina Rao²

^1-2National Institute Of Mental Health and Neuro Sciences (NIMHANS). Hosur Road. Bangalore - 560029, India,

E-mail: sydmoir2006@yahoo.com, sabinarao@yahoo.com

Keyword: Hashimoto’s encephalopathy, Steroid responsive psychosis

Background: Hashimoto’s Encephalopathy (Steroid Responsive Encephalopathy Associated with Thyroiditis) is a type of autoimmune encephalitis.

Patients of HE typically present with serious, debilitating symptoms that may include: concentration and memory problems, personality changes, speech difficulties (usually transient), tremors, muscle jerking (myoclonus), impaired coordination and balance (ataxia), headaches, disorientation, seizures or seizure-like events, partial paralysis (generally on the right side), sleep abnormalities, which may include hypersomnolence, status epilepticus (20% cases), psychosis, coma. The condition tends to follow a relapsing and remitting course, although long-term remission has been reported in some cases. Left untreated, HE can – in some cases – lead to coma or even death, particularly in pediatric patients where status epilepticus is not uncommon.

We present two cases of HE who presented to us at different point of time. The first case was a 23 years old male misdiagnosed as schizophrenia & the second case, a 32years old female presenting with delusion of doubles in a medical OPD. Both cases were treated with steroids & antipsychotics along with the thyroid hormone supplements & they recovered completely.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Title- Hyper IgE syndrome associated with dissociative disorder: A case report

Swapnajeet Sahoo¹, Soumya Jhanda^*2, susanta kumar padhy³

^1-3PGIMER, Chandigarh, India, India,

E-mails: swapnajeet.same@gmail.com, soumyajhanda1987@gmail.com, drsusanta_padhy2001@yahoo.co.in

Keyword: Hyper IgE syndrome, dissociative disorder, neurobiology

Background: Hyper-IgE syndromes (HIES) are primary immunodeficiency disorders characterized by recurrent skin infections, recurrent pneumonia and increased serum IgE levels. Currently, there is evidence for neurobiology of dissociation and has gained poularity. HIES has possible association with autism and mental retardation via chromosome 4. However, no such association has been reported with other psychiatric disorders.

Objective: To present a case of a 13 years old male child with Hyper IgE syndrome who presented with dissociative convulsions. Possible underlying common biological mechanism for both the conditions is discussed.

Methodology (Case Report): A 13 year old male child, diagnosed as Hyper IgE syndrome since the 3 years of age following repeated episodes of furuncles and serum IgE levels >=2000. Since then, he was on Cloxacillin prophylaxis, had 3 admissions, father became overprotective and had witnessed death of two seriously sick children of his age suffering from chronic illness. Since Oct 2013, episodes of unresponsiveness for 10-15 mins with increasing frequency and duration without any h/o of frothing, tongue bite, tonic-clonic movements of limbs and urinary/faecal incontinence or disorientation. He stopped going to school but play at home. EEG, MRI and other necessary investigations were normal. Symptoms further worsened following fathers diagnosis of myocardial infarction. The child was managed with supportive psychotherapy, relaxation exercises and play therapy, art therapy, and activity scheduling along with environmental manipulation. Hyper IgE syndrome was graded as mild possibly heading towards spontaneous resolution. Antibiotic prophylaxis for hyper IgE syndrome was stopped. The child improved after a period of 20 days.

Conclusion: Dissociation can be a common pathway of escaping from unavoidable stress due to a chronic medical illness. It remains to be explored the link between HIES and neurobiology of dissociation.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Factors influencing the acceptance of yoga-based intervention in somatoform disorders

Roshan F Sutar^*1, Geetha Desai², Shivarama Varambally³, B N Gangadhar⁴

^1-4NIMHANS, India,

E-mail: roshidoc@yahoo.co.in, desaigeetha@gmail.com, drvarambally@gmail.com, kalyanybg@yahoo.com

Introduction: Somatoform disorders are routinely encountered both in psychiatric and primary health care settings. They are difficult to diagnose in first consultation and quite difficult to treat as well. Pharmacological treatment options are very limited and very few have demonstrated efficacy. Hence, Complementary and Alternative Medicine (CAM) therapies are widely used in somatoform disorders. Yoga therapy is one of the most accepted CAM treatments worldwide, and has been proven effective in the management of Depression, Anxiety and Schizophrenia. Evidence for yoga-based interventions in somatoform disorders is very limited. This study looked at acceptance of a specific yoga module as treatment in patients with somatoform disorders.

Objective: To study the feasibility and the factors influencing the acceptance of yoga therapy in patients with somatoform disorders.

Materials and Methods: In an open non-randomized study at NIMHANS, patients with somatoform disorder were screened for acceptance of yoga therapy for their illness. Of the 212 patients screened, 177 patients met the inclusion criteria for the study among which 100 were females and 77 were males. Among 177 individuals, 105 refused to take part in the study due to various reasons. The primary reasons for non- participation was identified using semi-structured interview and analyzed using frequency distribution. The influence of various demographic and clinical parameters was analyzed using bivariate analysis and binary logistic regression.

Results: Nearly two-thirds (66%) of patients eligible for yoga did not consent for the study. The primary reasons for refusal were 1) distance between hospital and residence, 2) inability to come daily for yoga sessions due to work and 3) preference for medications. The predictors of yoga acceptability were studied in terms of consent given for yoga therapy. Binary logistic regression was used to analyse the results. It was found that males were 3 times more likely to give consent than female. Also it was found that if individual agrees to receive the yoga therapy is 20 times likely to give consent than subjects who are not agreed. No patient refused citing the research nature of the intervention as a reason.

Conclusion: Factors such as the need for daily training under supervision, distance from specialized yoga center and longer period of training are the most important barriers that prevent women from receiving yoga therapy in spite of good acceptability factor. Home based yoga practices may break the barriers to yoga therapy in this population, particularly for women. Yoga seems to be an acceptable treatment option in patients with somatoform disorders. Yoga programs for this population must look at flexible models/schedules of yoga therapy that are patient-friendly and home based to overcome barriers.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Childhood maltreatment and recurrent dysphagia

Soumya Jhanda^*1, Swapnajeet Sahoo², Shubh Mohan Singh³

^1-3PGIMER, CHANDIGARH, India,

E-mails: soumyajhanda86@gmail.com, swapnajit.same@gmail.com, shubhmohan@gmail.com

Keyword: Child maltreatment; recurrent dysphagia.

Background: Psychogenic dysphagia is a rare swallowing condition that is not well understood with no structural cause or organic disease. A thorough swallowing evaluation is necessary in a patient with suspected psychogenic dysphagia. A multidisciplinary approach is required to make this diagnosis

Aim: To present a boy with childhood maltreatment developing recurrent dysphagia in adolescence

Methods (Case report): The index patient is a 14 year old male. His father used to consume alcohol, and since childhood would verbally and physically abuse him. He would hit him e. g. with a stick or would push him forcefully against the wall with force. Patient sustained multiple bruises due to this and would remain scared of the father. No history of fractures. He gradually appeared to be a shy and an introvert child. In mid 2012, patient’s uncle died to whom he was attached. Thereafter, started to have difficulty in swallowing both liquids and solids. He started to have hiccups after each bite of food and then after few minutes he would regurgitate food items; which he denies doing voluntarily. The expulsion of food mixed with saliva would occur from upper part of throat where he would complain of feeling of discomfort. Mostly the expelled materials would be food items just swallowed. ENT examination was normal. Gastroenterology opinion was taken. Upper GI Endoscopy and Barium swallow were normal. Esophaegeal Manometry revealed initially high pressures in Upper and lower esophageal sphincters. After patient was advised to relax for 5 min by deep breathing, the pressures returned to normal, and the contractions appeared in the esophagus.

Conclusion: Childhood neglect, abuse and traumatic experiences can later lead to unexplained symptoms and ‘psychosomatic’ disorders

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Kabuki syndrome presenting as intellectual disability

Khagendra Kafle^*1, Nidhi Chauhan², Susanta kumar Padhy³

^1-3PGIMER, Chandigarh, India,

E-mails: khagendrakafle@gmail.com, dr.nidhichauhan@gmail.com, susanta.pgi30@yahoo.in

Keyword: Kabuki syndrome, mental retardation, intellectual disability

Objective: Kabuki syndrome (KS) is a rare genetic disorder first diagnosed in 1981 and present with unique facial characteristics, mental retardation, health problems and socio-emotional delays that are often mistaken for other diagnostic problems. We will give a brief review of KS highlighting its signs and symptoms.

Case Description: A fifteen-year-old male child, weighing 29 kg with height 126 kg presented to child psychiatry clinic of a tertiary care hospital for evaluation of subnormal intelligence. History from the child’s parents revealed that he was born out of full term vaginal delivery, weighed 2. 5 kg and cried immediately after birth. He had recurrent ear infection after age of 2 months and there was developmental delay in all aspects. During childhood and early adolescence he was calm and quiet child, and had poor academic performance. On examination, he had a short stature, had a typical facies characterized by long palprebral fissures, broad and depressed nasal bridge and low set ears. IQ was 59. Elder brother had been diagnosed as profound mental retardation with behavioral problems but there were no typical physical features as in our patients.

Conclusion: Kabuki syndrome as an entity should be considered as a differential diagnosis of a child presenting with intellectual impairment. Factors related to differential diagnoses should be identified to aid primary care and mental health clinicians in better understanding this unique syndrome.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A case of schizophrenia presenting as gender identity disorder

Abhishek Pratap Singh^*1, Padma Angmo²

^1-2Institute Of Human Behaviour And Allied Sciences, Delhi, India,

Emails: dr.aps1983@gmail.com

Keyword: Schizophrenia, gender identity disorder

Objective: Literature review suggests delusions of gender change and transsexualism could be a rare manifestation of schizophrenia. To avoid diagnostic confusion, one must understand the relationship between such sexual manifestations and schizophrenia as it has implications for management and prognosis. We are hereby presenting a unique case report of gender identity disorder as a rare manifestation of schizophrenia.

Materials and Methods: A 24 year old, Muslim male presented with insidious onset illness of one year duration characterised by spending more time in eunuch community, feminine demeanour (grooming and walking like women, keeping long hairs, covering head with Dupatta, shaving eyebrows, applying lots of cosmetics). Over next few months, he was noticed to have irritability, reduced interaction, social withdrawal, muttering to self, abusive behaviour, disturbed biological functions and marked socio occupational decline. There was no past or family history of psychiatric or medical illness. No history of any endocrinopathy or use of hormonal medications was apparent. Physical examination was normal including age appropriate external genitalia and normal secondary sexual characteristics. Patient was guarded on mental status examination and did not reveal any explanation for his behaviour; no delusion/hallucination/hallucinatory behaviour/depressive cognition/gender dysphoria could be elicited. Provisional diagnosis of schizophrenia was made and patient was given an empirical trial of risperidone upto 6 mg. Over a period of 2 months, patient attained complete remission including resuming his pre morbid gender role. Patient continued to maintain well over next 2 months follow up. However, the dilemma of getting explanation of the transient changed in gender identity yet remains unresolved.

Result & Conclusion: Since change in gender identity could be seen as epiphenomenon of other psychiatric illnesses including schizophrenia. So, process of making diagnosis should be rigorous as it has implications for management.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Clozapine induced dose dependent neutropenia

Abhishek Pratap Singh^*1, Praveen Tripathi², Manoj Kumar³

^1-3Institute Of Human Behaviour And Allied Sciences, Delhi, India,

E-mails: dr.aps1983@gmail.com, tripathipraveenucms@yahoo.co.in, drmanoj_k73@rediffmail.com

Keyword: Clozapine, schizophrenia, neutropenia

Objective: Literature review suggests 2. 7% of patients treated with clozapine develop neutropenia. Of these, half do so within the first 18 weeks & three-quarters by the end of first year but the risk is not dose-related. We present a rare case of childhood onset schizophrenia having, clear dose dependent clozapine induced neutropenia.

Materials and Methods: Young adult male of 22 years, known case of childhood onset schizophrenia of 10 years duration presented to a tertiary care neuropsychiatry centre. Patient had symptoms characterised by disorganised behaviour, suspiciousness, self muttering, violent aggressive behaviour and on and off catatonic symptoms. No past or family history of psychiatric illness or medical illness including any blood dyscrasias was evident. Physical examination and routine investigations were normal. After inpatient hospitalisation, patient was given adequate trial of haloperidol, risperidone and modified electroconvulsive therapy with minimal improvement. In view of treatment resistance, patient was started on Clozapine. After 2 weeks at 150 mg dose, patient started to show improvement but developed fall in neutrophil counts (TLC 3920, ANC 1530). It was associated with fever of 2 days duration with no localising signs of infection & normal concerned laboratory investigations. Clozapine was withheld and after two weeks of afebrile state & normal blood counts, after high risk consent, patient was re-challenged with clozapine with gradual dose escalation & twice weekly counts monitoring. This time at minimal dosage of 75 mg only, patient developed decrease in leucocyte count. So, further dose could not be increased and was continued on 50 mg clozapine augmented with 600 mg Lithium. Any Subsequent attempts even for minimal dose escalation were corroborated with decrease in neutrophil counts.

Result & Conclusion: Clozapine induced leucopenia is an idiosyncratic drug reaction with unclear mechanisms. Index case opens the channel for further research in this regard.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Delirium: Nicotine withdrawal as a rare etiology: Case report

Pravesh Gautam^*1, Prerna Kukreti², Amit Garg³

^1-3institute of human behaviour and allied sciences, India,

E-mail: drpravesh03@gmail.com, dearfrien@gmail.com, dr.amitg80@gmail.com

Keyword: Nicotine withdrawal, delirium

Objective: Delirium is frequent amongst hospitalized patients especially with medical illnesses and alcohol use. However, delirium with possible etiology of nicotine withdrawal is a rare entity. So far only nine case reports and three case series, that too all in background of critical medical illnesses have been reported. We report a rare case of nicotine withdrawal delirium without any other medical comorbidity.

Methodology: Young adult male with history suggestive of cannabis and nicotine dependence of ten years duration and multiple episodes of cannabis induced psychosis. Patient presented with acute onset behavioral disturbances of 2 months duration characterized by delusion of persecution & auditory hallucination. He was admitted in dual diagnosis ward in view of marked aggression and was started on haloperidol. On second day of admission, patient developed hyperactive delirium. Patient’s physical examination, complete hematological, metabolic profile, chest X-ray and ultrasound abdomen all were unremarkable. Patient’s oral intake was adequate and no other contributory risk factors were apparent for delirium. Patient reported craving and a 4 mg nicotine lozenge was given, leading to improvement of delirium within few hours without any other intervention. Patient was continued on NRT with complete clearing of sensorium within 24 hours.

Result & Conclusion: The case study warrants keeping nicotine withdrawal too as an under-recognized cause of delirium and suggests that in hospitalized heavy smokers who develop delirium with agitation, a simple trial with a nicotine replacement therapy can offer a dramatic therapeutic response.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Autoimmune encephalitis masquerading as psychosis: Diagnostic & therapeutic challenge

Prerna Kukreti^*1, Amit Garg², Lomesh Bhid³

^1-3institute of human behaviour and allied sciences, India,

E-mails:dearfrien@gmail.com, dr.amitg80@gmail.com, dearfrien@gmail.com

Keyword: Autoimmune encephalitis, neuropsychiatry manifestation

Objectives: Autoimmune encephalitis usually have neuropsychiatric symptoms but are often misdiagnosed as functional psychosis and leads to management difficulty. We report a case of Anti-NMDAR encephalitis masquerading as psychosis.

Methodology: A young girl was referred to psychiatry emergency by medicine department in view of abrupt onset two weeks behaviour suggestive of marked aggression, visual and auditory hallucinations. There was no history of head injury, seizure, loss of consciousness, fever. There was no history of recent travel, animal bite or any substance use or drug intake. One week prior, she had one episode of right focal seizure involving hand. Physical examination was unremarkable. Comprehensive hematological / metabolic panel, urine drug screen, and contrast MRI brain were normal. CSF analysis was negative for HSV & showed just lymphocytic pleocytosis. Work up for rheumatologic process and thyroid disorders was unremarkable. There was no epileptiform activity on EEG. No neoplasm was identified on CT of the chest, abdomen, or pelvis. Serum and CSF were sent for NMDA receptor (NMDAR) antibodies and came positive. She was treated with a 5-day course of IV prednisolone followed by oral prednisolone with low dose haloperidol for behavioural management of aggression. Patient showed significant improvement over one week with near complete improvement in a month.

Result and Conclusion: Anti-NMDAR encephalitis is an Immunological disorder common in young adult women, commonly associated with ovarian teratoma. It usually has a prodrome followed by a psychotic phase, comorbid seizures and hyperkinesis are too common. Chances of it being misdiagnosed as psychosis are quite common.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Musical hallucinations as the only silent presentation of stroke: diagnostic quandary

Prerna Kukreti^*1, Om Prakash²

^1-2institute of human behaviour and allied sciences, India,

E-mails: dearfrien@gmail.com, op.ihbas@gmail.com

Keyword: Musical hallucination, stroke

Objective: Musical hallucinations (MH) are disturbing phenomenon that occurs in 2% of individuals with significant hearing loss. There is generally no psychotic elaboration of the origin or meaning of MH. The impact on the client can be benign or quite disturbing. The nature of the underlying pathophysiology and neuroanatomy is unknown. We report a unique case of sudden onset musical hallucinations as the only presenting symptom of stroke.

Methods: A middle age adult male of 47 years age with no past or family history of psychiatric illness was referred by an otolaryngologist in view of abrupt onset musical hallucinations of one week duration. There was no prior history of substance use or any other medication intake or hearing difficulty. Physical and mental status examination was normal with complete insight into symptoms, MMSE score was 30/30. Preliminary radiological investigation of MRI brain, routine biochemical investigations and urine drug screen was non contributory. Pure tone audiometry was normal. Behavioural intervention and distraction was advised by the audiologist for next two weeks with no improvement. PET scan showed pontineâ€‘cochlear nucleus lacunar infarcts.

Result and Conclusions: Sudden onset musical hallucination can be a rare manifestation of cerebrovascular accidents that affect portions of the auditory system, including the cochlear nucleus. Information regarding the impact of cochlear nucleus damage on the possible release of musical hallucination, management and response status of the patient on follow up will be presented.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Intellectual quotient in ultra high risk of psychotis subjects: A comparative study

Selma Ben Nasr¹, Asma Ben Romdhane², Amel Brahem³, Asma Ben Dhia⁴, Souhail Ahmed Bannour^*5, Bechir Ben Hadj Ali⁶

^1-6CHU Farhat Hached, Tunisia,

E-mails: selmabennasr@yahoo.fr, asmabrchaouch@yahoo.fr, braham.amel@yahoo.fr, souhailb_tn@yahoo.fr

Keyword: IQ - Ulta High Risk - psychosis

Introduction: Cognitive deficits including lower intelligence quotient (IQ) are considered a core element of psychotic disorders. That would be present even before the emergence of psychosis symptoms at the ultra high risk of psychosis (UHR)

The aim was to compare the IQ of UHR subjects (+) with those of healthy controls (TS), subjects seeking treatment but who are not prodromal psychosis (UHR (-)) and subjects with a first episode of psychosis (PEP)

Materials and Methods: This is a descriptive and comparative study conducted in the Department of Psychiatry of the University Hospital Farhat Hached Sousse for a period of two years from July 2010 to July 2012. A total of 71 subjects were recruited and divided into four groups: A group of UHR subjects (+): n = 27; A group of UHR subjects (-): n = 12; A group of patients with PEP: n = 14 and a group of healthy control subjects: n = 18

The identification of UHR subjects (+) was made using the CAARMS (The Comprehensive Assessment of At Risk Mental States). The study of IQ is made by testing the Raven Progressive Matrices, “Matrices standard progressive” PM38.

Result: The majority of subjects UHR (+) (77. 8%) had a lower average IQ. compared with healthy controls (44. 44% <25th percentile IQ), UHR subjects (+) had a lower IQ (77. 8%) (p = 0. 02).

However, we found no difference in IQ levels between subjects UHR (+) and patients with a PEP (77. 8% against 100% had an IQ <25th percentile).

Conclusion: In our study the UHR subjects + present impaired IQ but this alteration would be less important than the subjects with PEP This suggests a degradation of IQ from the prodromal phase. These markers could contribute to a better identification of UHR subjects (+) and could be markers of psychotic transition

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Innovative delivery of specialist management of depression in primary care

Lee Kissane¹, Richard Tranter², Miss Carys Hogan³

¹ Keio University Department of Health Policy and Management Kawai Clinic, ²Nelson Marlborough District Health Board Mental Health CPG, ³Betsi Cadwaladr University Health Board

E-mails: lak10016@yahoo.co.uk, carys.hogan@wales.nhs.uk

Aims: The poster describes a development pathway to deliver specialist expertise in optimizing depression care to primary health care settings.

Content: A specialist nurse delivered system of assessment and monitoring of treatment outcomes, with reporting back to GPs, was initially developed as part of a Wales NISCHR Clinical Research Fellowship. This system has now been implemented within a secure annonymised web-based platform linking GPs with patients, shifting time-consuming assessments outside of the clinic setting and delivering detailed monitoring of treatment response.

Relevance: Depression is a leading cause of disability. Only a third of patients achieve remission with first line treatments. Optimizing treatment can double remission rates and half indirect costs of depression.

Outcomes: Pilot results from the nurse specialist delivered service demonstrated significant improvements in standardized outcome measures for depression and achieved the predicted additional one third of patients, previously resistant to at least two iterations of treatment, achieving remission.

Discussion: It is possible to deliver specialist care of depression in primary care settings through innovative systems and technologies, doubling the number of patients achieving remission, realizing enormous savings in indirect costs of the illness and achieving significant gains in public health. The web-based system allows this service to be extended throughout health systems. It also reduces assessment burden on time-constrained clinics, and allows benchmarking and auditing of clinical outcomes in depression against national standards.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Evaluation of psychoses of the elderly- is it difficult?

Rachna D, Kritika S, Aneek S, Kushagra V, Madhav G, Deepika V, Saldanha D

Department of Psychiatry Dr D Y Patil Medical College, Pimpri, Pune 411018,

Email: d_saldanha@rediffmail.com

Background: When elderly patients present with features of acute psychosis without any past history of significant psychiatric illness, the possibility of an organic pathology should always be considered. We present two elderly persons presenting with prominent psychotic symptoms in clear consciousness to medical emergency. The cases are discussed in view of multiple etiological possibilities.

“Case 1: A 68 years old male presented with acute onset of severe agitation, extreme fearfulness on seeing his reflection in mirror or glass screens and refusal of food and water of a day’s duration preceded by low grade fever and head ache of 5 days (untreated). History revealed class -1 dog bite (unprovoked stray dog bite) six months prior with no post exposure anti rabies vaccinations. On l examination patient was afebrile, conscious, and oriented, pulse of 110/minute and BP 160/110 mmHg. Systemic examination revealed plantars extensor. MSE showed increased psychomotor activity, ideas of reference and visual hallucinations. Impaired insight and judgment”. MMSE showed a score of 26/30. Necessary precautions for possibility of rabies were taken. With parenteral haloperidol 5mg patient was sedated. Neurologist suggested a possibility of HSV encephalitis. MRI Brain revealed multiple vascular infarcts, demyelinating patches secondary to vascular/toxic/inflammatory suggesting a possible diagnosis of rabies (Fig 1& 2). A Contrast MRI brain after 48 hours revealed multiple lacunar infarcts and demyelinating plaques in various stages of evolution. Virological studies could not be carried out. Patient was treated with haloperidol 5mg intramuscular once daily for 2 days and Injection acyclovir 500 mg intravenously thrice daily for 5 days as advised by neurophysician. Examination on day 3 of treatment showed normal mental status, a MMSE of 28/30. 2 weeks after discharge the patient had remained asymptomatic.

Case. 2: “A 61/F came with complaints of hearing of voices, seeing dead people, suspicious that people are talking about her. When she had gone to her nephew’s marriage, she started seeing the dead first wife of her husband who threatened her as a result she was sleepless for 15 days. She had one episode of seizure a day prior to admission. On G/E she was afebrile, P-92/min regular, B. P. =100/70 mm of hg. S/E revealed no abnormality. All investigations including M. R. I and EEG were WNL. She was started on antipsychotics tab Quitiapine 50 m. g b. d, but her condition deteriorated on 3^rd day of her admission. Antipsychotics were with held and she was shifted to MICU and was empirically started on antibiotics & antimalarials. MRI showed hyper dense lesions in bilateral hippocampus and para hippocampus areas suggestive of limbic encephalitis. All investigations were WNL. A search for primary by PET scan was negative. She was started with steroids considering autoimmune aetiology of LE. She improved with steroids. Antipsychotics were restarted for persistent visual and auditory hallucination & delusions. On subsequent follow up after one month she remained asymptomatic.

Conclusion: Purpose of discussing these cases is to highlight the difficulties that we face in diagnosing the actual causes that help in treating the patient timely and thereby reduce their suffering.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Behavioral problems in patients with intellectual disability: A study of 2 cases

Aneek S, Madhav G, Kushagra V, Ishan C, Saldanha D, Bhattacharya L

Department of Psychiatry, Dr D Y Patil Medical College Pimpri, Pune 411018.

E-mail: d_saldanha@rediffmail.com

Brain insult from a variety of causes in early infancy can result in retarded growth of cerebrum. Abnormalities in behaviour are most often the early signs of cerebral damage as seen in the two cases presented here.

Case 1: A 9 year old male known case of Seizure disorder since 2. 5 years of age presented with weakness of right hand and difficulty in speaking. Since 5 years of age he required assistance for self-care, has impaired attention, over activity and decreased sleep Milestones were achieved till age of 2. 5 yrs and delayed thereafter. Gen exam revealed microcephaly (41cm), Rt. Upper limb paresis. (Motor power grade 2/5). MSE: Cooperates with difficulty, restless, agitated, Impaired speech, Unable to convey mood and thoughts, Attention arousable but ill sustained. MRI showed evidence of gross white matter loss cystic encephalomalacia with gliosis and Wallerian degeneration. EEG: Excessive focal slowing sharp spike wave multifocal epileptiform activity. IQ of 45. He was treated with Tab Risperidone (0. 5mg)h. s Tab sodium valproate (150 mg ) b. d. and Skills training, family counseling. Follow up of the patient showed slight improvement.

Case 2: 17 years old male was brought by parents with complaints of abnormal behavior (biting others and self), agitated, aggressive and disinhibited behavior. Difficulty in understanding basic tasks and things; needs assistance in performing daily activities, decreased sleep since childhood Full term normal delivery ; no H/O birth asphyxia, milestones normal till age of 1. 5 years, suffered from high fever (Encephalitis) at age of 1. 5 years ; thereafter milestones delayed. Physical examination: Bite marks present on both arms and hands. IQ of 43 MSE: Agitated, speech difficult to comprehend. Often biting his right shoulder, aggressive towards the examiner and relatives, inappropriate affect. MRI: - Encephalomalactic changes in bilateral periventricular white matter, corona radiata, with hyper intensity in periventricular white matter and thinning of corpus callosum. EEG: No abnormality. Managed with Tab haloperidol (1. 5mg) b. d. and behavioral program.

Discussion: These two cases of moderate degree of intellectual disability with normal development till a cerebral insult caused delay in developmental milestones is a occurrence that can be regarded as a final stage of a number of different disease processes that will be discussed in the light of available literature.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Difficult to treat: Enuresis with ADHD and Tic disorder

Deepika V, Aneek S, Saurabh K, Jyotsna V, Bhattacharya L, Saldanha D.

E-mail. d_saldanha@rediffmail.com

Background: Enuresis is an elimination disorder which is difficult to manage in the young children. When it is associated with ADHD and Tic disorder it becomes all the more difficult to treat effectively. The following case illustrates the problem.

“7 years old male child was brought by parents with complaints of difficulty in paying attention to routine tasks, fighting with siblings and children in school, losing things, destroying/damaging things at home, cannot sit at one place since 4 years. The child has facial grimacing & blinking of eyes repeatedly since 2 years. He also passes urine at night in bed almost 3 to 4 times in a week. All routine including urine analysis were WNL. EEG showed no abnormality. USG Abdomen and pelvis were normal. MRI was normal. Patient was treated with Tab Atomoxetine 10 mg HS & then increased to 15 mg. Tab Imipramine 25 mg HS. Opinion of Neurologist was taken for tic disorder and was advised Tab Revocon 25mg (Tetrabenazine) ½ tab in the morning & ½ tab at night. Emotional support, bladder training techniques was explained to the parents. Patient showed good results on follow up”

Discussion: Very little empirical information regarding the course and outcome of Tic disorders in ADHD exists as on date. However the onset of Tic disorders are generally seen in children and most studies on Tic disorder in ADHD have been reported in adult ADHD. Presence of Enuresis in ADHD complicates the treatment profile. It is necessary to rule out organic causes for the presence of Enuresis and Tic disorder and also basal ganglia dysfunction.

Conclusion: The case highlights the rarity of its association with three major problems in the childhood.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Escitalopram induced severe hyponatremia: A case report

Parmar Arpit, Mandal Piyali, Tripathi Manjari, Sagar Rajesh

E-mail: dr.arpitparmar@yahoo.in

Keywords: SSRIs, Escitalopram, Hyponatremia

Objectives: Selective serotonin reuptake inhibitors (SSRIs) are among most preferred medications for various indications. There are multiple case reports of hyponatremia developing after use of SSRIs especially fluoxetine, sertraline, paroxetine. Mechanism involved for such adverse effect includes SIADH. Although few case reports suggests an association of hyponatremia with escitalopram, most of them have other confounding factors like multiple comorbidities and use of other drugs causing hyponatremia. We present a unique case in this regard.

Methods: A 50 year old male, known hypertensive for 12 years (normotensive on Telmisertan 80 mg and acetyl salicylate 150 mg for previous 2 years), without other comorbidity presented with a history of panic attacks for which he was prescribed escitalopram 10 mg. He took it for almost 2 years. After 1 year of stopping escitalopram, he again started experiencing panic attacks for which he started Escitalopram 10 mg. On 3^rd day, patient had excessive vomiting followed by altered sensorium. His investigations were suggestive of severe hyponatremia (serum Na 94 mEq/L), hypokalemia, hypochloridemia with low spot urinary sodium (43 mEq/L) with increased beta activity on EEG and normal MRI. A diagnosis of metabolic (hyponatremic) encephalopathy and SIADH was entertained. Escitalopram was discontinued and serum sodium was raised upto 132 mEq/L and urinary spot sodium normalized (84 mEq/L) within 5 days.

Results: This is an unique case in which hyponatremia developed in a middle aged male with relative absence confounders like comorbidity and drugs known to cause hyponatremia. The rapidity of development of hyponatremia is also remarkable.

Conclusion: This case suggests a strong association of escitalopram and severe hyponatremia and also highlights the need for regular sodium monitoring and further research.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

A study of executive functions of divers

Surg Capt Sunil Goyal, Dr Nikita Shah, Surg R Admiral VSSR Ryali, Ms Jyoti Rathod

INHS Asvini, Mumbai,

E-mail: dr_sgoyal@yahoo.co.in

Keywords: Executive function, Divers

Background: Existent literature suggests that due to a variety of reasons, such as the detrimental effects of breathing gas, barotraumas, decompression sickness and arterial gas embolism, diving causes long term cognitive impairment, including impaired executive functioning. However, the jury is still out on the presence and extent of impairment of executive functions as a result of diving and the study was done to test whether there were such deficits in divers. Further, the deficits were correlated with the years of diving.

Methods: In this cross- sectional study, carried out in a tertiary care hospital of the Indian Navy, 46 divers, with no physical or psychiatric co-morbidities were administered Wisconsin Card Sorting Test to assess their executive functions. Their performance was compared to that of 46 healthy matched controls (non-diving sailors). Their performance was also correlated to the years of diving.

Results: The study found that the divers performed worse than controls in executive function. However, interestingly, the total years of diving correlated with improvement in executive function.

Conclusions: While executive function appears poorer in the divers as compared to the control, the within divers correlation of executive function found an improvement in functioning with an increase in years of diving. This effect could be due to improved diving technique in the more senior divers which may lead to lesser insults to the brain. Another explanation for this finding is the ability of the brain to compensate for a decline in function. One could conjecture that plasticity, i. e. the ability of the brain to modify its organization and ultimately its function, may be one of the possibilities to account for this surprising improvement in executive function that is seen, as brain injury is known to give rise to an impetus for affecting plasticity.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Delusional parasitosis[scalp] with depression: A case report

Ramya Shruthi D, Sindhur, Shivananda Manohar, T. S. S. Rao, Rajesh Raman

Department of Psychiatry, JSS Medical College and Hospital, Mysore, Karnataka.

E-mail: shruthidudyala@gmail.com

Background: Delusional Parasitosis is a condition in which patients have a fixed belief that they have been infested with parasites. G. Thibiérge first described the condition in 1890s and called the syndrome Acarophobia. Other terms used in the literature are parasitophobia, entomophobia, monosymptomatic hypochondriacal psychosis, and Ekbom syndrome. The term Delusional Parasitosis was introduced by Wilson & Miller in 1946.

Case Report: Mrs. V, aged 42 yrs, married, high school teacher, coming from middle socioeconomic status presented with a complaint that she is infested by insects on her scalp following the application of hair dye. Acting on this belief, she started pulling her hair telling that she is removing insects and she collected brittle hairs claiming that they are insects. She was wearing a wig on her scalp to hide those insects which she thought could cause her embarrassment in public. She had also stopped going to school and taking classes since she felt that people were staring at her scalp to see the insects. She had also tonsured her scalp to get rid of those insects. She had initially consulted a dermatologist and was prescribed ketaconazole shampoo for 2 weeks, for which she did not respond. Patient also harboured suicidal ideas for which she was referred to a psychiatrist. After a detailed evaluation of her symptoms, she was prescribed T. Risperidone 3mg, T. Trihexyphenidyl 2mg, T. Escitalopram 10 mg. She responded to these medication at the end of 2 weeks and has been maintaining well even after tapering the medication.

Discussion: Delusional Parasitosis can be divided into three subgroups: 1. Predominantly hypochondriacal traits – patient is convinced that they have an incurable physical illness. It is referred to as hypochondriacal delusion of parasitosis or simply DP. 2. Paranoid delusions without hypochondriacal traits - They tend to fight against parasites, which impair their existence. This is referred as delusions of infestation. 3. Both hypochondriacal as well as paranoid delusions. They are referred to as hypochondriacal delusions of infestation.

Treatment: Delusional parasitosis patients rarely consult a psychiatrist in Indian setting. Successful treatment depends on: 1. Carefully collecting the patient’s history. 2. To rule out other systemic or dermatological infections. 3. Understanding the impact of the condition on their daily activities. 4. Gaining the patient’s confidence. 5. Appropriate and adequate medication.

Indian J Psychiatry. 2015 Jan;57(Suppl 1):S113–S159.

Antipsychotic induced hyperammonemia: A case report

Najla Eiman, Tharunkrishnan, Shivananda Manohar, Rajesh Raman, TSS Rao

JSS Medical College, JSS University, Mysore, Karnataka,

E-mail: najem2911@gmail.com

Urea is the major disposal form of amino groups derived from amino acids. The first step in the urea cycle involves the enzyme Carbomyl phosphate synthetase-1 which is also the rate limiting enzyme for the cycle. N-Acetylglutamate is an essential activator of CPS-1 enzyme. The first case of Valproate induced hyperammonemia was reported by Coulter and Allen in 1980. The prevalence of asymptomatic Hyperammonemia in patients receiving Valproic acid is around 51. 2%.

Case History: Mrs. X, a 50 year old married woman from a rural background presented with history of delusions of infidelity, delusions of persecution since one year and presence of manic symptoms for one month. She was diagnosed as a case of Schizoaffective disorder and started on Sodium Valproate 500 mg bid, Risperidone 4 mg od and THP 2 mg od. She returned for follow up two months later when Sodium Valproate was discontinued and the patient was maintained on Resperidone 4 mg od, THP 2 mg and Zuclopenthixol depot preparation. She presented two weeks later with 5 days history of vomiting, decreased appetite, generalized weakness and tremors. Serum Ammonia levels were assessed and were found to be 95. 4 mcmol/L. The patient was treated on an in-patient basis with antipsychotics being withheld and was started on IV fluids and Lactulose 15ml tid. Clinical improvement was seen in two days with her ammonia levels dropping to 16. 9 mcmol/L.

Discussion: The mechanism for Valproate induced hyperammonemia is by the inactivation of N-acetylglutamate. which is an allosteric activator of CPS-1 enzyme. There has been less evidence for Risperidone induced Hyperammonemia and the probable mechanism being inhibition of albumin binding of Valproate which increases the serum valproate levels. The mechanisms of independent Risperidone induced hyperammonemia need to be further explored.

Clinical Presentation of Hyperammonemia: The patient usually presents with acute onset of impaired consciousness and lethargy, focal neurological signs or symptoms, and increased seizure frequency. In milder cases the symptoms include asterixis, vomiting, perseveration, aggression, ataxia, and eventually coma and death. Identification of Hyperammonemic encephalopathy poses a challenge in Psychiatry as the changing Mental Status Examination may be mistaken for improvement or deterioration of psychiatric symptoms.

Management: Psychotropic drugs should be withheld. Administration of Lactulose, Neomycin and supplementation with L-carnitine has been found to be beneficial.

Future Directions for Research:

Identifying risk factors for development of Hyperammonemia.
Potential interactions of Sodium Valproate with other Antipsychotics.
Educating physicians in diagnosing Hyperammonemic encephalopathy.
Long term effects of undetected Hyperammonemia on cognitive functions.

PERMALINK

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Levosulpride induced parkinsonism

A study of psychiatric Co-morbidity in alcohol dependence syndrome

Psychosocial, psychiatric and clinical implications of diabetic foot ulceration: A prospective analysis

Impaired mu wave suppression as a trait marker in schizophrenia

Electroconvulsive therapy in a child suffering from acute and transient psychotic disorder with catatonic features

Antidepressant withdrawal induced mania: A case report

Critical appraisal of the narcotic drugs and psychotropic substances (amendment) act, 2014

Prevalence and associated risk factors of social anxiety in medical students

Child psychiatric disorders in DSM-5

A case of OCD with externally imposed ambivalence

A Case of PTSD successfully managed with pharmacological and psychotherapeutic interventions

Duloxetine induced myoclonic jerks: A case report

Aripipraziole induced torsion dystonia in a neuroleptic naive patient

Mirtazepine unmasking underlying restless leg syndrome:

Depression literacy among the first year graduate students of a university

Disulfiram-induced neuropathy: A case report

Emotion Awareness and Regulation in Persons with Chronic Schizophrenia

Hysterical mutism: A case report

Treating somatic delusion with paroxetine: A case report

Anti-NMDA receptor encephalitis presenting as catatonia: A case report

Gender difference in lipid profile in first episode mania

Social cognition in Individuals at clinical high risk for psychosis: an Indian Study

Neurodevelopmental hypothesis of schizophrenia: From a gamma perspective

Effect of MRI-guided transcranial magnetic stimulation of right inferior parietal lobule on schneiderian first rank symptoms in schizophrenia

The relevance of avoidant/restrictive food intake disorder; the new DSM-5 diagnosis: A review

Unusual physical outcome of a sign of mental illness

Conversion disorder: Still a fertile ground for clinical error? A case of heidenhain variant CJD.

Topiramate for olanzapine-induced weight gain: A systematic review and meta-analysis

Very low dose amitriptyline for clozapine-associated sialorrhea

Ekbom’s syndrome and pontine infarct: A case report

Effect of gallic acid on antioxidative enzymes activities in depression

Acute dystonia associated with Sertraline: A case report and review of the literature

Fahr’s Syndrome with pseudopseudohypoparathyroidism: A case report

Sociodemographic profile of women substance dependents in swami vivekanand DDTC, amritsar

A case of Craniopharyngioma: Atypical presentation with psychiatric manifestations

Self esteem and social anxiety in Patients of acne vulgaris

Study of domestic violence in female patients of schizophrenia

Study of differential expression of impulsivity in bipolar mania and depression

Pentazocine dependence in sickle cell anaemia: A case report

Revisiting the case of Phineas gage-diagnosis & management; dilemma

Technology addiction among subject seeking ayurvedic treatment

Knee-buckling (Negative Myoclonus) associated with Clozapine: Is there a dose-response relationship?

Comparison study of nicotine dependence among patients of schizophrenia, BPAD with mania and general population.

Influence of empathy on quality of life in advanced cancer patients

Prevalence and risk factors of depression and anxiety in patients of Diabetes Mellitus in a tertiary care centre

Obsessive compulsive disorder: Onset at 78 years of age “A case report”

Aripiprazole induced skin rash: A case report

Quality of life in patients with breast cancer receiving post-operative radiotherapy

Factors affecting non-compliance among psychiatric patients in the regional institute of medical sciences, imphal.

Kleine-levin syndrome (KLS)-experience of ten cases

Sexual function in women in rural Tamil Nadu: Disease, dysfunction, distress and norms

Autoimmune encephalitis presenting with behavioral changes, seizures, dystonia and regression in a pediatric patient A case report

Disulfiram induced psychosis A case report

A study of depressed non diabetic post menopausal women. Is there any association of fasting plasma glucose and LH levels ?

Medical students attitude towards suicide attempters: An exploratory study

Psychosis in a patient with Immunoglobulin G4 (IgG4) related disease

Use of SCALE model to enhance the mental illness recovery focus in a forensic setting

Experience of caregiving and coping strategies in caregivers of schizophrenia

Self-reported quality of sleep among junior doctors