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. 2017 Jan;59(Suppl 2):S220–S250.

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PMCID: PMC5324351

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Rare Case - Gerstmann's Syndrome

Col Siddharth Dixit

Classified Specialist Psychiatry Command Hospital Southern Command, Pune. Email Id: sid68sify@gmail.com.

Gerstmann's syndrome is a classic albeit controversial neurological syndrome. It is more in domain of neurologist than psychiatrist. We report a case of Gerstmann's syndrome with peripheral and central tuberculosis which presented in psychiatric setting baffling relatives and clinicians. Patient presented with acute onset of behavioral abnormalities and Standardized neuropsychological tests for intelligence, attention, memory, apraxia and language functions as well as tests for assessment of agraphia, acalculia, right - left disorientation, finger agnosia were performed. Individual exhibited all four symptoms of Gerstmann's syndrome viz finger agnosia, agraphia, right - left disorientation and dyscalculia, besides exhibiting nominal aphasia, alexia, constructional and ideational apraxia. Pure Gerstmann syndrome is a rarity and this case is an unusual presentation of neuro- tuberculosis still common in our clinical setting. In absence of localizing signs parietal lobe pathology can mimic psychiatric presentation.

Keywords: Gerstmann's Syndrome, behavioral abnormalities

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Pathways To Psychiatric Care In New Patients Attending Psychiatry Opd In Snmc, Bagalkot: A Case Series Study

Dr. Khushboo Dewani, Dr. Narayan R Mutalik

Department of Psychiatry, SNMC, Bagalkot, Karnataka. Email Id: khushboo.dewani@yahoo.in

Background: Neuropsychiatric disorders account for about 14 % of the global burden of disease. Many people living with mental disorders delay seeking psychiatric care from formal health facilities. This delay is because of various factors. Notably, the problem is not acknowledged, perceiving that treatment is not effective, believing that the problem will go away by itself, and desiring to deal with the problem without outside help. In addition, a lack of knowledge about psychiatric disorders remain major barrier to mental health care. Social, communal values and beliefs associate mental disorders to shame and fear thus influencing treatment seeking behavior and treatment outcomes. If disability is to be reduced, a bridging of the “treatment gap” must occur. An understanding of the way people seek care for mental disorders is increasingly recognized as important for planning mental health services, provision of appropriate training and referral from other sectors of health and social care.

Objectives: To determine prior care seeking pathways of new patients reporting to psychiatry OPD.

Materials And Methods: A semi-structured proforma was used to determine the socio-demographic details of new patients attending the psychiatric OPD in SNMC and HSK hospital. Pathway prior to care taking and treatment were determined. Statistical analysis using appropriate statistical tests were used.

Results: Awaited

Conclusion: To be drawn

Keywords: Pathways, Care, Psychiatry

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Are The Traditional Herbal Remedies – Frankenstein's Monster? Two Case Reports Of Barshasha Dependence

Dr. V. Venkatesh Raju, Dr. Aditya Somani, Dr. Aniruddha Basu, Dr. Debasish Bas

Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh. Email Id: venkateshraju2008@gmail.com

Background: Barshasha is an opium containing Unani preparation used widely for common cold, catarrh, cough, available as a thick paste in bottles of 60 g and 25 g that contain 1.67 g and 694 mg of opium respectively.

Objective: To present dependence of herbal medicines having opium or opium like psychoactive properties

Case description: 26 year old married male with anxious traits, started using tramadol at 16 years of age prescribed by doctor and later afeem in dependence pattern by 18 years of age. He started to use “barshasha” as a safe substitute. He would use one 60 g bottle of barshasha per day by mixing it with tea in dependence pattern and would also use 4-5 tablets of “kamini” another opium containing herbal ayurvedic product, which is prescribed for sexual weakness in traditional medicine. He finally presented due to problems related with heroin use.

22 year old unmarried male with dissocial personality traits, started taking afeem at age of 11years. Later out of curiosity started using bhuki, tramadol and codeine containing cough syrups in dependant pattern and also started using “barshasha”. At age of 21 started using heroin and finally presented due to socio-occupational dysfunction. Both cases had used “barshasha” in pattern suggestive of craving, withdrawal, tolerance, impaired control and significant socio-occupational dysfunction. They were treated with clonidine based regimen and started on naltrexone prophylaxis. Motivation enhancement, psycho-education and psycho-social intervention were also done.

Conclusion: These two cases illustrate the urgent need for regulations on herbal medications which are considered safe and innocuous which may later turn out to be Frankenstein's monster in the vulnerable individuals.

Keywords: Barshasha, Kamini, Dependence, Opioids

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Levetiracetam induced mania in an early adolescent male: Case Vignette and Discussion

Dr. Abhash Niraula, Dr. Nidhi Chauhan, Dr. Susanta Padhy

Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh. Email Id: abhashniraula@gmail.com

Objective: To present a case of an early adolescent male with idiopathic seizure disorder who developed mania induced by Levetiracetam.

Method: Case Report

Case Description: An early adolescent male studying in the 6th standard with easy temperament, with family history of alcohol dependence and depressive illness in father presented with an episode of generalized tonic clonic seizures at 13 years of age. MRI brain showed gliotic focus in left parieto-occipital region. EEG was normal. He was started on T. Levetiracetam 250 mg/day gradually increased to 1000 mg/day in the next 10 days. At 750 mg/day of Levetiracetam, family members noticed discrete change in patient's behaviour characterized by progressive irritability, increased energy and activity, decreased need for sleep, increased appetite, overtalkativeness, distractibility. He would voice of suicidal ideas 2-3 times a week in the latter part. This lasted for a month after which he was brought to us. The patient was admitted. Young Mania Rating Scale on admission was 19. NaranjoNomogram score was 7. Levetiracetam was gradually tapered off (125 mg/day) and T. Sodium Valproate started at 300mg/day increased upto 600 mg/day after Neurology Consultation. Subsequent to tapering and stopping of Levetiracetam over the next 8 days, his behavioural symptoms improved significantly. Young Mania Rating Scale at discharge was 5. The patient's seizures is well controlled with T. Sodium Valproate 600 mg/day with no re-emergence of behavioural symptoms post discharge.

Discussion: Levetiracetam is known to cause depression, psychosis, mania, suicide and other behavioural symptoms.

Conclusion: One should carefully monitor for behavioural symptoms in an individual treated with Levetiracetam

Key words: Levetiracetam, Mania, Behavioural problems

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Psychiatric burden in morbidly obese patients attending a Bariatric clinic in a tertiary care hospital in South India

Dr. Dheeraj Kattula, Dr. Stephen Amarjeet Jiwanmall, Dr. Nitin Kapoor, Dr. Mini Joseph, Dr. Thomas Paul, Dr. Simon Rajarathinam, Dr. Nihal Thomas, Dr. Vijay Abraham, Dr. Inian S

Christian Medical College, Vellore, Tamil Nadu, India. Email Id: askdheeraj@gmail.com

Introduction: The World Health Organization believes that the world is in grip of an epidemic of Obesity. In addition to physical problems, psychiatric comorbidies like depression etc are reported in the obese.

Aims: To estimate prevalence of psychiatric co-morbidity in obesity.

Methods: In a cross-sectional study we evaluated 60 morbidly obese adult patients attending a multidisciplinary bariatric clinic in a tertiary care hospital. We assessed them for past and present psychiatric disorders. We also looked at quality of life, perceived current stress and social support.

Results: The prevalence of psychiatric morbidity and its association with other variables like quality of life, current stress etc would be presented in the conference.

Keywords: Obesity, Bariatric clinic, stress

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Study of prevalence of Depressive features in Subclinical Hypothyroidism

Dr. Sunil Kochchar, Dr. Parag Dhobale

RDGMC, Ujjain. Email Id: sunil.kochar211@gmail.com

Background: Sometimes patients present to medicine opd with vague complaints. Depressive features are often under diagnosed in patients with medical co morbidities. In this study we tried to find depressive features in subclinical hypothyroidism patients.

Aims: To find out the prevalence of depressive features in subclinical hypothyroidism.

Method: Cross-sectional study.

Patients diagnosed with subclinical hypothyroidism, attending the medicine opd were interviewed, examined and enrolled in the study after taking written informed consent.

Result: The prevalence of depressive features in patients of clinical hypothyroidism was found to 42% in subclinical hypothyroidism group.

Conclusion: The prevalence seems to be much greater in patients of hypothyroidism as compared to euthyroid group.

Keywords: Depression, Hypothyroidism

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Cognitive Impairment in Bipolar Mood Disorders

Dr. Samhita Bhushan

Email Id: dr_samhita@hotmail.com

Case History: A 22yrs old girl was brought to our OPD by parents with complains of sadness, marked social withdrawal, psychomotor retardation and child like regression. A complete history and examination revealed a history of 6yrs with initial phase of hypomania followed by bipolar depression. Patient had a mania phase due to switch after taking antidepressant for one month. Patient developed cognitive regression after the onset of depressive phase lasting for 1 yr plus untill patient came for treatment. After complete investigation and evaluation patient was diagnosed as a case of Bipolar Mood disorder 1 currently in depression with cognitive impairment.

Result: After screening for organic causes the patient was started on Tablet Clozapine and Tablet Lithium. After gradually tapering the dose of Clozapine to 200mg a day along with lithium at 450mg twice a day patient started improving over the next 30 days.

Patient became euthymic with remarkable improvement in cognition.

Conclusion: Cognitive decline was present in patients suffering from bipolar disorders. Clozapine and Lithium can be effective in its management due to neuro modulator properties.

Keywords: Cognition, Bipolar mood disorders

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Development of Psychosis after Right Frontal Lobe Lesionectomy for Refractory Seizures

Dr. Bibin Thottam

St.Johns Medical College, Bengaluru. Email Id: bibinbt87@gmail.com

Introduction: It is estimated that percentage of active epilepsy in general population is 4-10 per 1000 and among which 20-40% would be having refractory epilepsy. Frontal lobe lesionectomy is one among the surgical procedures done for refractory seizures. Only few studies have been done regarding the outcome and prognosis of surgeries outside the temporal lobe. Though cognitive decline had been established in some patients who had undergone frontal lobe lesionectomy, only few cases were reported about major psychiatric symptoms after the same surgery.

Method: In this case report we describe a 39 year old male who presented with psychosis with depressive symptoms following right frontal parasagital lesionectomy for refractory frontal lobe epilepsy.

Case: This 39 year old male was a known case of refractory frontal lobe epilepsy and had undergone right frontal parasagital lesionectomy. 5 months later, he presented to the psychiatry OPD with 2 months history of visual and auditory hallucinations, delusion of guilt, apathy, social withdrawal, suicidal ideations and disturbed biological functions. Also noted to have a gradual decline in cognitive functions.

Conclusion: We hereby present a case who developed psychosis and cognitive decline following right frontal lobe parasagital lesionectomy in Indian setting. We hope this data would help in the management of refractory seizures in the future. This case study establishes major psychiatric symptoms as a probable outcome of frontal lobe lesionectomy and hence the benefit v/s risk has to be considered before planning frontal lobe lesionectomy.

Keywords: Refractory Seizures, Psychosis, Frontal Lobe

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Case Report Of Hysterical Belching

Dr. Arpit Jani, Dr. Chirag Kundalia Dr. Kalpesh Chandrani

P.D.U. Govt. Medical College, Rajkot-360001. Email Id: janiarpitm@gmail.com

Introduction: Conversion Disorder is a combined form of Hysteria and Somatization Disorder. Hysteria can show itself similar to neurological and organic disorder. The bodily sensation or functions are influenced by a disorder of mind. Physical and laboratory examinations persistently failed to show significant substantiating data about the patient's complaints. Excessive belching is often reported in patient with gastroesophageal reflux disease, a condition referred as ‘ Aerophagia’. Gastrointestinal complaints may be reported as somatoform disorder.

Case Report: A case report of 32 year old female Mrs. Y consulted OPD with chief complaints of belching since 3-4 months. Initially it was episodic in nature, lasting for variable period which spontaneously resolved. Episodes occurred while performing daily activities and resolved while sleeping, eating and speaking with people. There was no associated nausea, vomiting or pyrosis[heart burn]. Episodes increased with frequency which did not resolve with analgesics, antacids and antiemetics. Her symptoms worsened since last one week so she consulted us. On further interview she expressed about her father's cardiac condition diagnosed 5 months back, to whom she is emotionally attached. She was excessively worried about her father's paralytic attack 2 months back. Family history of psychogenic hiccup in cousin sister. On USG finding, there was sluggish esophageal movements with thin strip of air and collapsed esophagus.

Discussion And Conclusion: Conversion symptoms are associated with strong emotions. In the current case, on gastrointestinal evaluations, no problem was found. Identification of conflicts with the patients and correlating it with the symptoms would lead to significant improvement in the condition. There is a definite role of antianxiety medications, psychotherapy and hypnotherapy in resolution of conversion disorder.

Key Words: Conversion Disorder, Hysterical Belching.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Effect of ECT on symptoms of Idiopathic Parkinson's Disease: A Case Report

Dr. Swati Choudhary, Dr. Aditya Somani, Dr. Sandeep Grover

Department of Psychiatry, PGIMER, Chandigarh. Email Id: doc.swatich@gmail.com

Aim: To present the case of 62 years old male, with Idiopathic Parkinson's Disease (PD) who was managed with bilateral ECT for depressive symptoms, who also showed improvement in symptoms of PD with ECT.

Method (Case Description): A 62 year old male patient, who was diagnosed with PD 8 years prior to presentation, presented with an insidious onset depressive episode of 9 month duration. His episode was precipitated by worsening of PD symptoms, and symptoms were characterised by sadness of mood, agitation, excessive tiredness, anhedonia, reduced appetite, reduced sleep with early morning awakening, decreased self-esteem with further worsening of symptoms over the months with emergence of ideas of hopelessness, worthlessness, death wish, delusion of reference and infidelity. He was on a treatment of Levodopa 400mg/day, Carbidopa 100mg/day, Entacapone 800mg/day and Pramipexole 6mg/day for PD. Initially, he was managed for depression with Escitalopram 10mg/day and Quetiapine 50mg for 4-5 months without significant improvement in psychopathology. On exploration of past history, he was found to have suffered two similar episodes in the past. At the initial evaluation at our centre, he was found to have sadness of mood, excessive tiredness whole day, anhedonia, referential ideas, elementary hallucinations, ideas of hopelessness, worthlessness, death wish, marked sleep disturbances and poor oral intake. Neurological examination demonstrated coarse resting tremors and prominent rigidity of both upper and lower extremities, more on right side. His axial rigidity was prominent and also had bradykinesia. A diagnosis of PD with RDD, current episode severe with psychotic symptoms was considered. Initially, he was treated with Venlafaxine 112.5mg/day and Quetiapine 200mg/day. With no improvement in the psychopathology, he was planned for ECT. Patient received 8 effective ECTs along with same medications for PD. All ECTs were uneventful and there was significant reduction in symptoms of depression with reduction in Beck Depression Inventory Score from 29 to 6. Additionally, the symptoms of PD also reduced indicated by reduction in Hoehn and Yahr Scale score from 5 to 1.5 and UPDRS score from 61 to 20. Later he was continued on Venlafaxine 150 mg/day and Quetiapine 200mg/day and other antiparkinsonian medication, without any worsening of symptoms of depression and PD.

Conclusion: ECT also benefits symptoms of PD. Hence, it must be considered as an option in patients with medication resistant PD or those with severe comorbid psychiatric disorders.

Keywords: Parkinson, ECT, depression

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Post stroke depression and Vascular depression an overlap: A Case Study

Dr. Yogender Malik, Dr. Subho Chakrabarti

Department of Psychiatry, PGIMER, Chandigarh. Email Id: yogendermalik187gmail.com

Background: Post stroke depression (PSD) has been defined as depression occurring in the context of a clinically apparent stroke which usually develops soon after stroke; onset from few days to several months reported. Whereas Vascular depression (VAD) is considered to be a consequence of chronic ischemic, often subcortical lesions and refers to a late-onset depression (> 50 years), associated with risk factors & signs of cardiovascular risk. However, it had been seen that most often these two entities overlap and it is difficult to distinguish from one another.

Aim: To present the case of a 62 year-old man with a depressive episode following stroke & to discuss post-stroke & vascular depression.

Method (Case Description): A 62 year old male presented with an insidious onset of depressive symptoms 3-4 month after stroke. Exploration of history revealed that disability due to stroke resolved within 2-3 months but he started to have occasional sleep disturbances & easy fatigability. Additionally, he started to have sudden, frequent and brief spells of crying spells loudly, unpredictable & inconsolable, 5-10 times/day, lasting for 2-3 minutes; were not particularly associated with any worry or gloomy thoughts. He also had sadness of mood, anhedonia, excessive tiredness and lethargy, poor appetite, inability to work, restlessness, numbness in extremities, autonomic symptoms, low self-esteem, ideas of hopelessness and worthlessness and pessimism. These crying spells were far more frequent than could be explained by his sadness & became increasingly troublesome & socially impairing. He had no significant past medical history of any hypertension, coronary artery disease, diabetes mellitus etc. However, he had a history of tobacco dependence since last 40 years but had been abstinent after stroke. Routine investigations were within normal limit except for deranged lipid profile. MRI brain revealed (1) encephalomalacic changes in right frontal, insular cortex and right putamen involving the cortical and sub cortical fibers suggestive of old middle cerebral infarct and (2) Ischemic changes in B/L periventricular area involving small vessels. A diagnosis of PSD and VaD was considered. Management included treatment with Fluoxetine 30 mg/day and supportive sessions with which he had significant improvement over a period of 2 months. Other medications included aspirin 150 mg, atorvastin 20 mg and metoprolol 25 mg.

Conclusion: Both PSD and VaD have complex etiologies consisting of multiple biological and psychosocial factors. Current consensus is that these two entities are overlapping conditions in terms of epidemiology, clinical features, risk factors & underlying mechanisms. PSD is often viewed as a distinct subtype of VaD.

Keywords: Depression, Stroke

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Relation Of Cervical Spine Disease In Patients Of Scalp Dysesthesia.

Dr. Ranjan Bhattacharyya, Dr. Supriya Kumar Mondal, Dr. Barindranath Mallick, Dr. Utpal Roy, Dr. Madhab Kumar Mondal, Dr. Sumita Bhattacharyya

Murshidabad Medical College & Hospital. Email Id: Drrbcal@gmail.com

Background: Scalp dysesthesia is a common mode of presentation in rural West Bengal. The study aims at finding radiological correlation withbnimaging of cervical spine with the presenting symptoms. Introduction: most of these cutaneous pain symptoms are not attributed to any pathophysiology. The range of complaints vary widely from tingling, stinging to severe itching leading to scratch-itch cycle.

Methodology: the study used a cross-sectional, case control design with sample size n=40 with healthy volunteers (n=40) included for comparison. The opd patients were interviewed by principal investigator (psychiatrist) to find out any AXIS I disorder corroborated by another psychiatrist. The radiological finding had been carefully analyzed by two residents and verified by senior faculty from deptt of radiology.

Results: the loss of curvature is significantly high among patient group (p=0.011). Comparison of cervical vertebra of both patient and control group showed that, there is no significant difference between the patient and the control group. Reduction of inter-vertebral disc was found significantly high at the level of c4-5 (p= 0.033*) And c5-6(p= 0.012) In patient group in comparison to control group.

Conclusions: scalp dysesthesia does not seem to follow a dermatomal distribution given that the most common location in the present study was C5-C6. The symptoms of scalp dysesthesia may be related to chronic tension placed on the occip itofrontalis muscle and scalp aponeurosis (galea aponeurotica) secondary to underlying cervical spine disease, rather than psychiatric causes.

keywords: scalp dysesthesia; cervical curvature; dermatological conditions; psychiatric disorders; cutaneous syndrome.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Obsessive Compulsive Disorder Presenting With Compulsions To Urinate Frequently

Dr. Stephen Amarjeet Jiwanmall, Dr. Dheeraj Kattula

Christian Medical College, Vellore. Email Id: Stephenjiwanmall@yahoo.com

Obsessive compulsive disorder (OCD) is a common psychiatric disorder which is easily recognized. However, sometimes

Patients of OCD present in such an atypical presentation of symptoms and a pathway to care involving multiple specialities.

We report a case of a girl who had consulted several physicians and a urologist for frequent micturition, who was treated

As a case of ocd after clarifying the compulsive nature of her symptom. There was significant improvement in her

Condition following 8 weeks of treatment with 200 mg of sertraline and behaviour therapy.

Keywords: OCD, atypical presentation

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Views of parents of adolescents who received ECT

Dr. Natarajan V, Dr. Sandeep Grover

Department of Psychiatry, PGIMER, Chandigarh. Email Id: natarajanv1158@gmail.com

Background: Electroconvulsive therapy (ECT) is rarely used in children and adolescents. In the Mental Health Care Bill, it is proposed that use of ECT will be banned in children and adolescents.

Aim: To evaluate the experience of parents of adolescents who received ECT for their severe mental illness. Methodology: Using qualitative methods, parents of 3 children were interviewed by using a self-designed semi-structured interview after the completion of ECT course. The clinicians involved in the ECT procedure, i.e., seeking informed consent, administration of ECT and deciding about number of ECT were not aware about the study. All the interviews were recorded and the content was analysed and themes were generated.

Results: Parents of all the 3 adolescents expressed that their children were considered for ECT only after they had not responded to medication and were unmanageable. Prior to ECT the treating doctors did explain them about the ECT procedure and were not coerced to consent for ECT. Parents also expressed that they had dilemma prior to giving consent and were scared prior to first ECT. However, as the children's clinical condition improved, they felt that ECT was a good treatment. Two of the parents felt that ECT was delayed for their children and would not hesitate for consenting again, if required in future. When asked about the Government decision to ban the use of ECT in children and adolescents, the parents expressed that Government does not know what a caregiver goes through when their patients are acutely ill. They expressed that decision of administration of ECT must be left to the family and clinicians.

Conclusion: The decision to administer ECT is based on the clinical situation which should be best left to the family and clinicians. Rather than considering ban in the use of ECT, appropriate measures must be taken to avoid indiscriminate use of ECT in this age group.

Keywords: Adolescent, ECT

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Post encephalitic Kluver-Bucy syndrome mimicking Frontotemporal dementia - A case report

Dr. B. Sai Chaitanya Reddy, Dr. Subho Chakrabarti

Department of Psychiatry, PGIMER, Chandigarh. Email Id: Chaitanyareddy557@gmail.com

Background: Kluver-Bucy syndrome (KBS) was first noted in the humans with meningoencephalitis in 1975 by Marlowe et al. KBS can occur following a stroke or head injuries or encephalitis. In humans, the most common symptoms include placidity, hyperorality, dietary changes and prosopagnosia

Objective: To present a case of a 43 years old man who had post herpes simplex encephalitis developed significant change in the behavior and memory disturbances characterized by hyperphagia, hypersexuality, placidity, agnosia, hypermetamorphosis

Case description: A 43 year old male presented with significant behaviour problems post HSV encephalitis, characterized by forgetfulness especially related to recent memory, he could not identify the persons whom he met during this period, call them by some other names, he would demand food repeatedly, if denied becomes abusive and aggressive and hit family members, he would drink excess water, eat non edible things like talcum powder, soaps etc. He would demand for food when relatives visit to see him, would clap like a child when they agree and would cry when they refuse to bring, would snatch the food offered to his children, had inappropriate sexual behaviors like undressing in front of others, would try to examine the house hold articles for few minutes and keep them in mouth. He progressively worsened and started accusing that some people are trying to kill him but he didn’t name a person, would voice that he was able to see some people in black dress at the door, sitting beside him, threatening him and request his wife to sit beside him. He was already on oral hypoglycemic agents, BMI was >24 kg/m2 and he was started on valproate and aripiprazole. Hemogram, urine routine, liver and renal function tests, were normal. On neuroimaging marked changes predominantly involving bilateral frontal and median temporal lobes was found. MMSE Scale assessed severity of dementia and lobar function test predominantly showed involvement of frontal and temporal lobes. Additional diagnosis of Kluver-Bucy Syndrome was also considered.

Conclusion: Though clinical picture resembles the behavioural variant FTD and has high chance of labeling the individual a wrong diagnosis. This would effect the further management of the patient.

Keywords: Kluver-Bucy syndrome, HSV encephalitis

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

ECT in a patient with Severe Aortic Stenosis: A Case Report

Dr. Himanshu Singla, Dr. Sandeep Grover

Department of Psychiatry, PGIMER, Chandigarh Email Id: himanshu89_singla@yahoo.com

Aim: To present a case of 74 years old female, with severe aortic stenosis who was managed with bilateral ECT for her severe depression with psychotic symptoms.

Method (Case Description): A 74 year old female presented with insidious onset depression of 9 month duration, precipitated by psychosocial stressors. To start with, the symptoms were characterised by sadness of mood, loss of interest in previously pleasurable activities, easy fatigability pessimistic ideas about future, sleep and appetite disturbances. Over the months there was further worsening of symptoms with the emergence of ideas of hopelessness, decreased concentration, decreased self esteem, delusion of poverty and suicidal ideations. She was treated with Escitalopram (10-20mg) for 2-3 months and later with Sertraline (up to 150 mg) along with Quetiapine (50-100mg) for 4-6 weeks without significant improvement in psychopathology. While on sertraline and quetiapine she developed side effects in the form of bradykinesia, rigidity and tremors. At the initial evaluation at our centre, she was found to have sadness of mood, marked psychomotor retardation, delusion of poverty, suicidal ideations, marked sleep disturbances and poor oral intake. A diagnosis of severe depression with psychotic symptoms was considered. Initially, she was treated with Mirtazapine 7.5mg/day and ECT was planned. During the pre-ECT workup, her 2D-ECHO showed severe aortic stenosis with normal left ventricular systolic function. She was cleared for ECT under high cardiac risk. Patient received 9 ECTs without any complications. During the ECT procedures, Inj. Esmolol was given to alleviate hypertension/tachycardia and anticholinergics were avoided during induction. All ECTs were uneventful and there was significant reduction of HDRS score (26 to 5). Later she was continued on Mirtazapine 30mg/d without deterioration in symptoms thereafter.

Conclusion: ECT can be given in patients with severe aortic stenosis with proper evaluation and monitoring.

Keywords: Aortic stenosis, ECT, Depression

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Mindfulness for Mental Health

Dr. Swati Singh, Dr. Prerana Gupta, Dr. Swati singh

Teerthanker Mahaveer Medical College, Moradabad, U.P. Email Id: dr.swati5423@gmail.com

“An important part of mindfulness is reconnecting with our bodies and the sensations they experience. This means waking up to the sights, sounds, smells and tastes of the present moment.” That might be something as simple as the feel of a banister as we walk upstairs.

“It's about allowing ourselves to see the present moment clearly. When we do that, it can positively change the way we see ourselves and our lives.”

How mindfulness helps mental health?

Becoming more aware of the present moment can help us enjoy the world around us more and understand ourselves better.

When we become more aware of the present moment, we begin to experience a fresh things that we have been taking for granted.

“Mindfulness also allows us to become more aware of the stream of thoughts and feelings that we experience, and to see how we can become entangled in that stream in ways that are not helpful.

“Most of us have issues that we find hard to let go and mindfulness can help us deal with them more productively. We can ask: ‘Is trying to solve this by brooding about it helpful, or am I just getting caught up in my thoughts?’

“Awareness of this kind also helps us notice signs of stress or anxiety earlier and helps us deal with them better.”

How to be more mindful: Reminding yourself to take notice of your thoughts, feelings, body sensations and the world around you is the first step to mindfulness.

Mindfulness is recommended by the National Institute for Health and Care Excellence (NICE) as a way to prevent depression in people who have had three or more bouts of depression in the past.

How to be more mindful: Reminding yourself to take notice of your thoughts, feelings, body sensations and the world around you is the first step to mindfulness.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Frontal Lobe Tumor Presenting As Isolated Phantosmia - A Rare Case Report

Dr. Shweta Chauhan, Dr. Seema Singh Parmar, Dr. Shweta Chauhan

Department of Psychiatry, TeerthankerMahaveer Medical College & Research Centre, TeerthankerMahaveer University, Moradabad, Uttar Pradesh. Email Id: shwetachauhan29@gmail.com

A 40 year old male presented with episodes of olfactory hallucinations (specifically the smell of roses) for the past 20 days. He also complained of decreased sleep for the same duration. He gave the history of fever 1 month ago along with upper respiratory tract infection lasting for a week following which his hallucinations started. There was no history of traumatic brain injury or previous neurological or psychiatric illness. On examination, he showed no signs suggestive of substance abuse and his face was symmetrical. A cerebral contrast Magnetic Resonance Imaging was advised for the patient, which revealed an irregular cystic lesion in the right frontal lobe measuring 51mm × 46mm × 36mm causing a midline shift of 6mm to the left. On magnetic resonance (MR) spectroscopy reduced levels of N-acetyl aspartate (NAA) were seen along with markedly elevated Choline level leading to reversal of Hunter's angle.

Keywords: Phantosmia, Olfactory Hallucinations, Frontal Lobe Tumor, Magnetic Resonance Spectroscopy, Glioma.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Reasons Of Disciplinary Discharges From A Tertiary Care De-addiction Setting In India

Dr. Abhinav Tewari, Dr. Jawahar Singh, Dr. Namita Gautam, Dr. Yatan Pal Singh Balhara, Dr. Siddharth Sarkar

Department Of Psychiatry And NDDTC, All India Institute Of Medical Sciences, New Delhi, India - 110029. Email Id: Abhinavt27@gmail.com

Background: Disciplinary discharges from addiction treatment facilities contribute to a proportion of patients whose treatment is discontinued. This study aimed to find the proportion of patients discharged due to disciplinary reasons and to find the reasons of such disciplinary discharges.

Methods: This retrospective study was conducted using records of the patients admitted at the national drug dependence treatment centre (NDDTC), Ghaziabad. The proportion of patients admitted between 1st january 2014 and 31st december 2014 who were discharged due to disciplinary issues was computed. The reasons of disciplinary discharges, wherever available were categorized into various themes.

Results: During the study period, 44 out of 942 admitted patients (4.7% Of the sample) were discharged due to disciplinary reasons. The most common themes for disciplinary discharges were altercation with treatment providers in the ward, followed by altercations with other members of the ward and attempting to bring prohibited substances in the ward.

Conclusion: The findings suggest that efforts are required to understand the causes that lead to friction between patients with substance use disorders and others in the inpatient setting, and ensuring the safety of health-care providers.

Keywords: Addiction, Discharge, Disciplinary, India

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Profile Of Patients Presenting With Psychiatric Emergencies At A Tertiary Care Centre In India Over A One Year Period

Dr. Raman Deep Pattanayak Dr. Swarndeep Singh, Dr. Saurabh Kumar, Prof. Sk Khandelwal

Dept Of Psychiatry, A.I.I.M.S., New Delhi. Email Id: Drramandeep@gmail.com

Introduction: Psychiatric emergencies provide a unique settings with a high focus on acute care of emergency conditions, which require immediate attention and management. In order to develop and organize the services more effectively, it is important to assess the pattern of use and profile of patients visiting the emergency department who are in need of a psychiatric consultation. This report aims to add to only few existing reports from indian settings.

Methodology: A retrospective study was conducted for the patients who presented between January 2015-2016 at the All India Institute of Medical Sciences (AIIMS) And for whom a psychiatric consultation was sought in emergency. The emergency services at AIIMS. Are organized ‘on-call basis’ in emergency medicine department, whereby as and when required, calls are made to psychiatry ‘on-call’ doctor.

Findings: During this period of one year, a total of 720 patients were seen. The number of patients who were referred for psychiatric emergency consultation, most often, varied between three to five. The sociodemographic and clinical profile will be discussed, including the current complaints, immediate stressors, if any, provisional diagnosis and advice/treatment offered. Nearly 10% of the sample presented with deliberate self-harm attempts over this one year period (with a range of severity from low to high risk; and from parasuicidal to suicidal attempts). A triage of psychiatric emergencies has been conceptualized based on this sample with potential utility in future in terms of development of emergency services for psychiatry.

Conclusion: The profile of patients who are being referred to psychiatric emergency help in service organization and planning models of care. It is also important to add here that the kind of psychiatric emergency services available (E.G. A psychiatric emergency unit versus integrated with medical emergency services etc) may also determine the profile and pattern of conditions for which referrals are sought

Keywords: Emergency, Suicide

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

The Entire Spectrum Of Neuropsychiatric Manifestations In A Female Patient Preceding The Diagnosis Of Systemic Lupus Erythematosus By Two Decades: A Case Report

Dr. Sanjay Kumar Pattanayak, Dr. Mrinal Jha

V.I.M.H.A.N.S., New Delhi. Email Id: Drpattanayak@gmail.com

Introduction: Systemic lupus erythematosus (SLE) is associated with a range of neuro-psychiatric manifestations, but to the best of our knowledge, this is the first case report where obsessive compulsive disorder, persistent delusional disorder, schizophrenia and seizure disorder, all have possibly appeared as its neuro-psychiatric manifestations during the course of the illness. The case also gave us a unique and rare opportunity to report diverse presentations at different points of time.

Case presentation: a 45 year old, married female presented with history of one episode of GTCS at the age of 25years, which was treated for three years with sodium valproate. Later, she developed obsessive doubts of contamination, compulsive washing and checking alongwith blasphemous thoughts and religious rituals for two years which remitted completely with treatment. After two years of asymptomatic period, she developed delusion of infidelity with acting on behavior for the next five years, following which delusion of reference, persecution and auditory hallucinations appeared which she was treated with the diagnosis of schizophrenia. At the age of 44 years she had pulmonary effusion with another attack of gtcs with delirium for which she was hospitalized and after thorough investigation diagnosed as a case of SLE.

Conclusion: a full spectrum of neuropsychiatric manifestation can precede by many years in the same patient before the diagnosis of sle is made.

Key Words: Obsessive Compulsive Disorder, Schizophrenia, Seizures, Systemic Lupus Erthematosus.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Levitiracetam Associated Psychosis- A Case Report

Dr. Udit Kumar Panda, Prof. Neelmadhav Rath

Email Id: Uditpanda@gmail.com

Background: Levitiracetam Has Been Iincreasingly Preferred By Physician's For Treating Seizure Disorders In Both Adults And Children. Behavioural Side Effects Are Seen In About 37% Of Pediatric Patients On Levitiracetam Treatment.

Keywords: Levitiracetam, Psychosis

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Prevalence Of Depressive And Anxiety Disorders Among Residents Of Old Age Home For Women In Trichy District, Tamilnadu

Dr. Rahul Lalit Khemani, Dr. S Anandkumar, Dr. N Arunkumar, Dr. K Ramakrishnan, Dr. Mohd. Abrar

Email Id: Rkhemani2@gmail.com

Introduction: Aging is a normal biological phenomenon. Mental health problems amongst the geriatric group are much higher than other age groups as per various prevalence studies; depression and anxiety disorders being the most common. Studies done on geriatric population of old age homes have shown varied results and there have been no studies looking specifically into old age home for women.

Aims And Objectives: To study the prevalence of depressive and anxiety disorders among the residents of old age home for women.

Methodology: It was a descriptive cross sectional study done to assess the socio-demographic profile and pattern of physical and psychiatric morbidities of elderly residing in old age home for women. Consent was obtained from administrative body of the old age home. Semi structured socio demographic proforma and mini plus was used to collect data from 58 women residents who fulfilled the above criteria.

Results: Among the 58 residents interviewed, majority of them (79.2%) Were above 70years of age. Depression (18.9%) And dysthymia (18.9%) Were found to be the most common psychiatric disorder followed by anxiety disorder (5.2%) And double depression (3.4%). Two of the residents reported suicidal ideation (3.4%).

Conclusion: In our study, majority of the females were widowed and financially dependent as seen in other studies. The prevalence of psychiatric disorders was 46.4% Which is higher than the prevalence in general population and in equivalence to prevalence in female elderlies residing in other old age homes. Depression was found to be the most common mental disorder in consonance with most of the other studies.

Keywords: Depression, Anxiety, Old Age Home

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Cross Sectional Study On Quality Of Life Among Residents Of Old Age Home For Women

Dr. Mohd Abrar Ahmad Guroo

Email Id: Abrarguroo@gmail.com

Introduction: Aging is a biological phenomenon. The advancement in medical sciences has increased the life expectancy of individual by providing quality healthcare facilities. In india population of elderly people constitute 8.2% Of national population. It is estimated that elderly populations projected to raise to 12.4% By 2026. Old age homes are sheltered accommodation for older people without nursing or health care infrastructure. With the above estimated increase in number of older people and requiring help at old age homes, we require more knowledge about their life situation and what is needed to improve their quality of life.

Methodology: A descriptive cross sectional study was conducted to assess the socio demographic profile by semi structured questionnaire and quality of life by WHOQOL-BREF scale of elderly women residing in annai ashram, a old age home for women.

All inmates who gave oral consent were included in the study.

Severely ill, bed ridden, audio-visually impaired, mentally retarded elderly who could not answer were not included in the study.

Results: Mean of whoqol-bref general and physical score of total 58 inmates was 3.40(Sd:0.95) And 2.91(Sd:0.92). The mean score of physical, psychological, social and environmental domains were 56.14(Sd:11.80), 52.55(Sd:15.29), 58.72(Sd:18.85) And 79.93(Sd:44) respectively, where maximum score in environmental domain and minimum in psychological domain were observed. No statistical significance was observed when comparing the socio-demographic variables with mean scores of the domains; except there was higher physical domain score among literates and lower physical domain score among widowers with significance at 0.05 Level.

Conclusion: By improving the living arrangement and financial position, well being of old age would undergo change. Therefore in-depth studies through multidisciplinary assessment on issues like socioeconomic problems, morbidity pattern, quality of life and social security needs of the elderly should be done nationwide.

Keywords: QOL, Life expectancy, elderly

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Psychiatric Manifestations As Initial Presentation Of Frontal Glioma- 2 Case Reports

Dr. Ashitha M L, Dr. Roy Abraham Kallivayalil, Dr. Reji Thomas

Pushpagiri Institute Of Medical Sciences. Email Id: Ashithanair29@gmail.com

Background: Psychiatric symptoms may be the initial presentation of brain tumors in 18% of patients. It may present with multiple psychiatric symptoms such as depression, anxiety, mania, cognitive and personality changes and frank psychosis.

Case Reports: We present two cases of frontal glioma; one presenting as delusional disorder and another presenting as depressive disorder

Case Report 1: 62yr old female presenting with symptoms suggestive of delusional disorder. Patient was conscious oriented, mse revealing delusion of persecution and grandiosity. Neurological examination was normal and mmse score was 26/30. Neuroimaging revealed a well defined intra-axial solid cystic lesion in the left frontal lobe with solid areas showing restricted diffusion. Mr spectroscopy showed elevated choline peak suggestive of glioma. Bystanders opted for palliative care

Case Report 2: 52 Yr old male presenting with disinterest in daily activities, slowness in activities, lying down mostly, lack of energy and increased sleep suggestive of depressive episode. Mse showed reduced psychomotor activity and depressed mood with intact cognitive functions. Neurological examination was normal. Neuroimaging revealed a well defined intensely enhancing multilobulated intra-axial lesion in the right frontal lobe with extension to left and mass effects. Spectroscopy shows elevated choline peak suggestive of glioma. Patient underwent surgery and symptoms were resolved

Conclusion: Gliomas can be neurologically silent and present with psychiatric symptoms alone. Hence it is important to have an index suspicion of organic cause, especially with late onset and new onset psychiatric symptoms, atypical presentation and treatment resistant cases. Neuroimaging should be considered in such cases as early diagnosis and treatment is vital for the survival and quality of life in such patients.

Keywords: Frontal Glioma, delusional Disorder, Depression, neuroimaging

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

The Prevalence Of Internet Addiction Among The Students In A Western U.P. Medical College

Dr. Jitender Singh, Dr. Tarun Pal, Prof. Prakash Chandra

Saraswathi Institute Of Medical Sciences, Hapur (U.P.). Email Id: Dr.rktomar111@gmail.com

Introduction: Internet addiction is defined as mismanagement of internet use that causes mental, social and occupational problems. Thus, the assessment of prevalence of this disorder can lead to preventive measures and appropriate treatment to prevent its spread.

Methodology: In this cross-sectional study, prevalence of internet addiction disorder was assessed in Saraswathi Institue of Medical Sciences, Hapur (UP), India in 2015. Stratified random sample was used to select 192 students. Demographic data were recorded and internet addiction test (IAT) questionnaire was administrated.

Results: Out of 192 students participating in the study, 124 (64.58%) Were males and 68 (35.42%) Were female with a mean age of 21.05Β± 0.1 Years. Most of the students (42.4%) Were using the internet ‘under one hour’ and the lowest (4%) ‘more than six hours’. Mean test score of iat was 24.81 Β± 1.08 (Mild addiction). In terms of internet addiction, 69 (35.94%) Cases were normal users, 109 (56.77%) Had mild addiction, 12 (6.25%) Showed moderate addiction and 2 (1.04%) Were cases of severe addiction which are lower compared to previous studies.

Conclusion: The rate of internet addiction among students of Saraswathi Institute of Medical Sciences, Hapur (UP), India is lower than the previous reports. It is still necessary to curb the spread of this problem due to its complications.

Keywords: Prevalence, Internet Addiction, Saraswathi, Students

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Positive role of Media in Psychiatry- A case report

Dr. Aamirkhan Attaullakhan Pathan

Dept. Of Psychiatry, Medical College Baroda. Email Id: Pathan.aamir799@gmail.com

Media is a powerful tool, which can have both positive and negative influences on a stigmatized specialty like psychiatry. If used judiciously media can play an important role in psychiatry by creating awareness and thereby reducing stigma. It can also be helpful in highlighting difficulty in accessing psychiatric healthcare services.

Here we present a case of 35 years old married separated male from lower socio-economic status belonging to rural background having continuous psychiatric illness for 15 years whose life was revived after a local newspaper published an article on him. Local administration rushed to his help and was brought to government medical college, psychiatry unit for treatment purpose.

Fifteen years ago he had a history of acute onset of aggression, hallucination, delusion of persecution, poor self-care, sleep disturbance and running away from home. Initially he was taken to private psychiatrist where he was admitted for 15 days and received two ECTs. Patient was symptomatically better with treatment but they could not continue treatment due to financial constraint and lack of psychiatric services in their nearby area.

After one week of stopping treatment, patient started worsening. Due to his aggressive behaviour and tendency to runaway his family members kept him restrained using a chain outside their home in a temporary shade. His mother was the only person who would go near him, provide him food and change his clothes in which he used to pass urine and stool. Gradually patient stopped talking and would remain withdrawn.

Patient was diagnosed as suffering from schizophrenia and was started on antipsychotics. He is currently on treatment and comes regularly on follow up.

Had it not been for the efforts of proactive journalist who worked hard to get the story printed this patient would have been still in chains.

Keywords: Schizophrenia, Media, Psychiatry

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Clinical Presentation And Management Of Essential Tremors (ET) Preceding Onset Of Parkinson's Disease (PD) In The Course Of Bipolar Affective Disorder

Dr. Haobijam Asheema, Dr. Asheema

IHBAS, Delhi. Email Id: Asheemahaobijam@gmail.com

Essential tremors (ET) and Parkinson disease (PD) are the two most common movement disorders encountered. Although these are distinct clinical diagnosis, they have overlapping clinical features. A separate category of ET-PD syndrome have been proposed by researchers for the same. Additionally long standing bipolar disorder with subsequent psychotropic exposure complicates the presentation and poses difficulty in management in comorbid cases. We report a case of et preceding the onset of PD in the course of bipolar disorder; clinical presentaion and its management difficulties.

Keyword: Essential Tremors; Parkinson Disease; Bipolar Disorder.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

An Old Man Who Spitted Pearls- Case Report Of A Rare Delusion

Dr. Arti Tyagi, Dr. Supriya Agarwal, Prof. S.(Brig) Sudarsanan

Subharti Medical College, Meerut. Email Id: Artityagi009@gmail.com

As per Jasper, delusions are false judgments, they are held with extraordinary conviction and incomparable subjective certainty, they are impervious to other experience and to compelling counter argument, and their content is impossible. A number of fascinating delusions have been named assyndromes either of single delusion (e.g. Othello syndrome) or of cluster of delusions (e.g. Delusional mis-identification syndrome). Similarly, affected individuals with delusional disorder typically complain of infestation, deformity, personal ugliness, exaggerated sizes of body parts, foul body odor or halitosis. In our hospital we came across a unique case of delusional disorder with a rare content. Here, we present a unique case of 65 yrs old male having delusions of spitting pearls out of his mouth, rolling over of pearls in his tongue and under his skin, over his bed sheet and blanket. Our aim is to focus on variable presentations of a delusional disorder with a unique content and to broaden the themes of various delusions explained under delusional disorders especially in old age.

Keywords: Delusion, Syndrome, Old age

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Depression As A Presenting Feature Of Hashimotos Encephalopathy

Dr. Thalhath P, Dr. Roy Abraham Kallivayalil, Dr. Madhusudanan

Pushpagiri Institute Of Medical Sciences. Email Id: Thalhathpaloli@gmail.com

Objective: This case report highlights the importance of work up for an organic cause, when an elderly patient presents with depressive symptoms for the first time.

Case Report: A 66-year-old retired school teacher presented with amnesia for recent events, decreased interest in activities, decreased sleep and appetite for the last 2 years. She was on anti-depressants for the same. She had jerky movements of right upper and lower limbs for 1.5 Years. Three months prior to admission she showed psychomotor withdrawal and in 1 month she became bradykinetic and mute. She appeared withdrawn and apathetic with markedly reduced word output. She scored 11/30 on the mini “mental state examination (MMSE) She had marked rigidity of all four limbs, more on the right side. Focal myoclonic jerks was seen over the right upper lower limbs. Magnetic resonance imaging (MRI) of brain was normal.

Thyroid function tests revealed normal T3 (0.98 IU), T4 (14.8 IU), and thyroid-stimulating hormone (TSH) (3.09 IU). Anti-thyroid peroxidase (TPO) antibody titers were raised to 660 units (normal value being <20 units). In presence of anti-TPO antibodies, hashimotos encephalopathy was diagnosed. She received parenteral methylprednisolone followed by tapering doses of oral prednisolone. Within the initial 5 days of treatment, the patient showed significant improvement. She became more cooperative for examination, her speech improved dramatically and comprehension became better. She was last seen 3 months after the discharge, and her higher mental functions were almost normal, she was euthymic and extrapyramidal signs were absent. Repeat anti-tpo antibody titers were reduced (198 units, normal value <20 units).

Conclusion: This case throws light into the fact that a search for organicity should be made in an elderly person who presents with depressive symptoms for the first time.

Keywords: Hashimotos Encephalopathy, Depression

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Spasmodic Torticollis- An Unusual Presentation Of Conversion Disorder

Dr. Sharon Thomas, Dr. Roy Abraham Kallivayalil, Dr. Reji Thomas

Pushpagiri Institute Of Medical Sciences. Email Id: Sharon_091@yahoo.com

Introduction: Psychogenic dystonia is an unusual movement disorder caused by mental stress. Spasmodic dystonia as a presentation of conversion disorder is less commonly reported. We, hereby, report the case of a 40 year old lady, who presented with spasmodic torticollis, following mental stressors, and was diagnosed to have conversion disorder.

Case Report: A 40 year old lady, developed stereotyped, fixed, spasmodic deviation of the head with the chin twisted to right side, with head tremor from the, past 2 years. She was initially diagnosed to have spasmodic torticollis and was started on trihexyphenidyl and tetrabenazine, with improvement of symptoms over the next 2 weeks. She had recurrence of symptoms almost monthly and continued the same treatment for the next 2 years. She presented to us, 1 week back, with acute onset spasmodic deviation of the head with the chin twisted to right side. This episode was precipitated following an altercation with her mother- in -law. She also complained of palpitation and heaviness of chest. On examination, she was noticed to have tonic deviation of neck, with head tremor which was distractible and amenable to suggestions. Neck deviation was noted to shift sides. On reviewing the history it was found that she had no symptoms when she was staying with her husband abroad. All the events were precipitated when she had a mental stressor. Hence, she was diagnosed to have conversion disorder presenting as spasmodic torticollis. The drugs for dystonia were tapered and stopped and underwent several sessions of psychotherapy leading to complete resolution of symptoms.

Conclusion: This case highlights the importance of thorough psychological assessment in evaluating motor symptoms in the background of mental stressors.

Key Words: Psychogenic Dystonia, Spasmodic Torticollis, Conversion

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Clozapine Induced Agranulocytosis And Use Of G-CSF

Dr. Chandan Singh, Dr. Nishant Vibash

CIP, Ranchi. Email Id: Drchandansingh02@gmail.com

Agranulocytosis has been one of the rare but serious side effects of clozapine which is sometimes life threatening in nature. Clozapine-induced agranulocytosis is reversible with the use of cytokines like granulocyte-colony stimulating factor (G-CSF). This is a case report of a middle aged patient who developed near-total absence of granulocytes during treatment with clozapine and was successfully treated with G-CSF

Index patient Mr A, a case of schizophrenia and tried on multiple antipsychotics (haloperidol, trifluperazine) in a span of 10 years at optimal doses and for adequate duration including depot medications and ECT. So subsequently in 2003, after baseline investigations, he was started on clozapine and gradually hiked to 300mg, upon which he was maintaining wel. He was again admitted because he was off medication and restarted with clozapine after baseline investigations. He was regularly supervised for clozapine side effects. Five weeks after admission i.e. On 16th february, 2016, the blood investigations showed decline in total leukocyte count (TLC) to 2020/cu.mm and neutrophil count to 404/cu.Mm. Considering the possibility of clozapine-induced agranulocytosis, clozapine was stopped, aripiprazole was started and blood counts were continuously monitored. Subsequently blood investigations were repeated on 17th february which showed further decline in tlc and neutrophil counts. A and reffed to rims, patient was investigated thoroughly with necessary investigations and expert monitoring done. He was treated with broad-spectrum antibiotics, anti-fungal agents and antipyretics. Blood count on 21st february, showed TLC count 600/cu.mm, neutrophil count 30/cu.mm. Considering the scenario as clozapine induced agranulocytosis, he was treated with granulocyte-colony stimulating factor (G-CSF) filgrastim (300 microgram, subcutaneous injection) every day for seven days. Granulocytes started to appear in the peripheral blood after 3 days of injection Filgrastim. His blood counts returned to normal levels in couple of weeks time.

Keywords: Clozapine, Agranulocytosis, G-CSF

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Genetic Association Study Of OPRM1 Gene With Alcohol And Opioid Dependence

Mrs. Tripti Grover, Mr Ranjan Gupta, Dr. Atul Ambekar, Prof. Arundhati Sharma

AIIMS. Email Id: Tripti.grover@gmail.com

Background: Drug dependence is a complex biopsychosocial disorder influenced by an interplay of genetic and environmental factors. Among other genetic factors, two polymorphisms in the mu1 opioid receptor gene (OPRM 1) rs1799971 (a118g) and rs1799972 (c17t) have been generating research interest. We aimed at identifying these polymorphisms in patients with alcohol dependence (AD) and opioid dependence (OD).

Methods: The study group comprised of 200 ad, 200 od recruited from NDDTC, AIIMS and 200 controls enrolled from the general population (all males). Subjects were interviewed using a pre-designed questionnaire after written informed consent 5 ml peripheral blood drawn for genetic analysis. Genomic DNA was isolated from peripheral blood was screened for presence of rs1799971 and rs1799972 polymorphisms by PCR-RFLP. The polymorphisms were visualized and scored on 3% agarose gel. Association with clinical parameters such as age at first use, quantity-frequency, assist score, and LFT(SGOT, SGPT) was analyzed using SPSS 16.0.

Results: In OPRM1 rs1799971 the genotype gg was found to be higher in OD patients (15%) in comparison to controls (11.5%) And the g allele was overrepresented in od patients (41.3%) in comparison to controls (33.5%) and AD subjects (37.3%). Thus, rs1799971 was found to be significantly associated with OD (p=0.046) and not with AD (p=0.416).

The cc genotype in rs1799972 was present in majority of the population studied and showed no significant difference between the cases and controls. The tt genotype was observed only in cases (OD 2%) and (AD 1%) and none in the controls. None of the polymorphisms showed association with any of the clinical parameters.

Conclusions: The findings suggest the possible association of 118g allele with opioid dependence in the indian male population.

Keywords: OPRM1, Alcohol Dependence, Opioid Dependence

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Psychogenic Aphonia In A Young Male - A Case Report

Dr. Pooja Nalinchandra Thakrar, Dr. Mahesh Suthar

Department Of Psychiatry, SSG Hospital, Baroda. Email Id: Poojathakrar44@gmail.com

Psychogenic aphonia formerly called hysterical aphonia or acute sudden voice loss and now a days additionally called functional neurological symptom disorder [subtype] or conversion aphonia is a rather rare disorder with a point prevalence of 0.4%. It appears about 8 times more frequently in females than in males. Conversion disorder is a manifestation of repression of unconscious intrapsychic conflict with conversion of anxiety into a physical symptom.

Case: - Here we present a case of 22 year old unmarried male from middle socio-economic status from an urban area. He was brought to the casualty department of SSG hospital in an unresponsive state. The patient had suffered from an episode of tightening of limbs followed by unresponsiveness for around 25-30 min. After regaining responsiveness, he was not able to speak. His MRI brain with contrast & MR angiography revealed no abnormality and on indirect laryngoscopy done by ENT surgeon, both vocal cords were found to be mobile.

On further elaboration, it was found that patient's marriage was planned with his girlfriend the day after he was admitted to hospital. The patient was in a relationship with another girl who was threatening to reveal their relationship to his fiance, if he didn’t marry her. Due to lack of assertiveness and weak ego strength, it was difficult to handle this unconscious conflict, which manifested as psychogenic aphonia.

During his 2 week stay in the psychiatry ward, he was treated with sertraline and clonazepam, and supportive psychotherapy. The patient became alright and started speaking.

Conversion disorder may have different signs and symptoms of non-organic origin, including vocal component. The occurrence of this type of aphonia in a young male patient is a rare event and should be kept in mind as a differential diagnosis.

Key Words: Psychogenic Aphonia, conversion Disorder

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Use Of Intravenous Ketamine In The Treatment Of Resistant Depression: A Case Report

Dr. Dhawal Patel, Dr. Lakhan Kataria, Dr. Parth Goyal

Department Of Psychiatry, Smt.B.K. Shah Medical College And Research Centre, Vadodara. Email Id: Dr.dhawal@yahoo.com

Introduction: Major depressive disorder (MDD) affects more than 350 million people globally, and is the leading cause of disability in the world. Treatment resistant depression (trd) presents as a key therapeutic challenge to physicians. Ketamine has shown promise in reducing the severity of depressive symptoms and acute suicidal ideas, in patients with trd.

Case Report: A 55-year-old female patient with treatment resistant depression was given intravenous ketamine, at the dose of 0.5 Mg/kg body weight, over 40 minutes, A total of 5 sessions were given to the patient, with a gap of 5 days between each session.

Results: The patient showed a marked response to intravenous ketamine treatment. After 5 sessions her Hamilton rating scale for depression (HAM-D) score dropped to 5 (pre-ketamine, HAM-D score was 22) and her hamilton rating scale for anxiety (HAM-A) score dropped to 2 (pre-ketamine, HAM-A score was 20). This improvement was sustained on 3 months follow-up (HAM-D score was 3 and ham-a score was 2)

Conclusions: Intravenous ketamine, is as a novel treatment option in ameliorating depressive symptoms in patients with TRD.

Key Words: MDD, TRD, Intravenous, Ketamine.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Factors Affecting Carbohydrate Deficient Transferrin (CDT) Levels In Alcohol Dependent Patients Attending An Addiction Medicine Facility In A Tertiary Psychiatry Centre In India

Dr. Venkata Lakshmi Narasimha Dr. Lekhnash Shukla, Dr. Priyamvada, Dr. Arun Kandaswamy, Dr. Prabhat Chand, Prof. Pratima Murthy, Prof. Vivek Benegal

Department Of Psychiatry, NIMHANS. Email Id: Narasimha.gvl.mbbs@gmail.com

Aims & Objectives: Factors affecting CDT level and other transferrin isoforms, in alcohol dependent patients.

Methodology: Blood samples of 100 patients visiting to the outpatient Department, centre for addiction medicine, NIMHANS, were collected. Their CDT and levels of transferrin isofroms were detected. The levels were correlated with age, gender, sex, body mass, smoking, frequency of alcohol use in last month, amount of last alcohol intake and time since last alcohol intake. Appropriate statistical analysis was done using SPSS (version 16.0)

Results: Factors like age, gender were not significantly associated with the CDT level. However, there was association between various asialo, monosialo and disalotransferrin to the total transferrin with the amount of alcohol intake and duration of last alcohol intake.

Conclusions: Elevated levels of CDT and the different isoform transferrin fractions would be an important biomarker both in terms of management and legal issues related to alcohol use. Further studies involving large sample size and comparing various genetic background are required.

Key Words: Alcohol, Carbohydrate Deficient Transferin, Isoforms

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Anxiety And Depression In Chronic Obstructive Pulmonary Disease Patients: A New Challenge To Treat

Dr. Baranwal Divyesh

Email Id: Divyesh2k5@gmail.com

Background: COPD is a multisystem, commonly preventable and treatable disease, characterized by persistent airflow limitation. It is a leading cause of morbidity and mortality worldwide. These patients also face the psychological consequences of COPD. Unfortunately, assessment of anxiety and depression are ignored in patients with COPD attending outdoor who hampered their quality of life.

Objectives: To assess the onset of anxiety and depression in COPD patients and to correlate their severity.

Material And Method: The study enrolled 50 diagnosed COPD patients. Spirometry was used for assessing the severity of COPD while depression and anxiety were evaluated by using Hamilton's anxiety depression scale (HADS).

Results: Patients suffered from mild, moderate and severe depression. The severity of both anxiety and depression was more with chronic and severe copd cases. Detailed results will be displayed at time of presentation.

Conclusion: COPD patients had significant prevalence of anxiety and depression, but they are hardly diagnosed and treated appropriately because of sparse published data to guide health-care professionals in the management of these co-morbid illnesses.

Key Words: Anxiety, Depression, Chronic Obstructive Pulmonary Disease.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Study Of Executive Dysfunction In Persons With Alcohol Dependence Syndrome

Dr. Harshit Hemant Salian, Dr. Girish Babu Nanjundappa, Prof. Abhay Matkar

NIMHANS. Email Id: Drharshit.nimhans@gmail.com

Background: Alcohol dependence syndrome is a chronic disorder resulting in disturbances of various cognitive function areas.

Aims: To determine the executive function deficits in persons with alcohol dependence syndrome.

Methods: Patients (30) with alcohol dependence syndrome admitted in psychiatry ward at SDM medical college were included in the study after taking informed consent. Voluntary healthy individuals (30) were included as controls. MINI 6 was used for clinical interview. Patients were evaluated using SADQ, CIWA-AR, trail making test-A and B, Stroop test, tower of hanoi, word list test, digit span test.

Results: Patients with alcohol dependence syndrome have more frontal lobe deficits in the form of executive function deficits compared to healthy controls. Patients with alcohol dependence syndrome had poorer performance in all the above mentioned tests.

Conclusions: Executive function deficits are more in patients with alcohol dependence syndrome compared to healthy controls. This may be the reason for maintenance of alcohol use in such individuals. These findings need to be kept in mind while focusing on interventions for patients with alcohol dependence syndrome. Interventions improving these deficits need to be planned for such patients.

Keywords: Alcohol, Executive Functions, Dependence.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Pattern And Severity Of Internet Use Among Medical Students- A Study From Northeast India

Dr. Rakesh Mohanty, Dr. Bhushan B Mhetre, Dr. Sana Yumnam, Prof. N. Heramani Singh

Email Id: Rmohanty.dr@gmail.com

Introduction: Internet was originally devised for information exchange and research purpose, but today it is an essential need of human life for social communication, education, research, health seeking, banking, business, shopping, administration, and entertainment. Internet addiction or pathological use of the internet usually refers to the phenomenon that an individual is unable to control his or her use of the internet which eventually causes ones marked distress and functional impairment in daily life. Students are particularly at risk because of their unique personal, social, academic and future needs. The study was designed to evaluate the pattern and prevalence of internet addiction among medical students in imphal.

Methodology: A cross sectional study was conducted in Regional Institute of Medical Sciences, Imphal. We assessed 207 medical students with the help of semi structured self-reported questionnaire consisting of questions related to pattern of internet use. We also applied Youngs internet addiction test to examine the severity of use. Data was analysed using SPSS version 21.

Results: We found that all of the participants were using internet more or less. Among the users, 2.9% were experiencing significant problem in their life and 20.8% of students were facing occasional or frequent problems because of internet use. Most of the participants were male, undergraduate students, unmarried and time of preference for internet use was night time between 9 pm to 12 midnight.

Conclusion: Most of the medical students use internet frequently. Efforts should always be taken for awareness about internet addiction and its consequences. We all know that the field of internet addiction research is in its infancy but that should not distract us or prevent us from taking what is an emerging problem seriously.

Key Words: Internet, Medical Students, Addiction.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Pattern Of Online Technology And Its Impact On Productivity At Workplace

Dr. Hemant Kumar Gupta, Dr Manoj Kr. Sharma

Email Id: Hemantgupta04@yahoo.com

Background: Internet use has affected the pattern of working style at the workplace. Recent years have seen an increased use of online activities (especially pornography/gaming) at the workplace. It has been shown to affect productivity at the workplace. There is a dearth of literature from the Indian context in this area.

Aim: This study was conducted to explore the pattern of pornography use& gaming at the workplace and its dysfunctions.

Setting and design: the present study was a cross-sectional prospective study.

Materials And Methods: The objective of the study was to assess the pattern of pornography use at the workplace.500 Employees having experience of internet use for more than a year of various government/private sector organizations in bengaluru were assessed using background data sheet, DSM 5 criteria, internet addiction test & pornography addiction screening instrument. Users who were unwilling to participate were excluded from the study.

Results: 7-9% reported preference for internet to work, meals, personal hygiene, sleep, and interaction with family members and effects on productivity. 3-4% have excessive use of pornography & game.

Conclusions: The present study has implications for evolving psychoeducational modules for the promotion of healthy use of technology.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Aripiprazole Plus Cognitive Therapy For Treatment Resistant Schizophrenia: A One-year Follow-up

Dr. Pankaj Sureka

Institute Of Medical Sciences. Email Id: Sureka1119@gmail.com

Treatment of clozapine resistant schizophrenia is markedly challenging. I am reporting the improvement of both positive symptoms and cognitive deficits in a patient treated with combination of aripiprazole and cognitive therapy (CT). His positive and negative syndrome scale (PANSS) score decreased from 70 to 40 within 1 year of the combination treatment.

Combination of aripiprazole and Cognitive Therapy might be an effective treatment modality in cases of resistant schizophrenia and this modality of treatment needs to be further explored.

Key Words: Clozapine Resistant Schizophrenia, Aripiprazole, Cognitive Therapy

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Ultra Rapid Cycling Bipolar Disorder And Its Management

Dr. Pallavi Rajhans, Dr. Nishanth K Narasimhamurthy, Dr. Ramandeep Pattanayak

AIIMS. Email Id: Pallavirajhans525@gmail.com

Introduction: Ultra-rapid cycling disorder is characterised by manic/hypomanic, mixed, or depressed episodes that occur every few days or weeks. DSM 5 TR includes rapid cycling but not ultra rapid cycling as a course specifier.

Case Report: We report the case of a 72-year-old male who presented with total duration of illness of eight years, abrupt in onset and episodic in course. The initial four years were characterised by 3-4 episodes per month of symptoms of elevated mood, overtalkativeness, over grooming, over familiarity and increased self-esteem lasting 6-7 days. There would also be an associated increase in appetite, decreased need for sleep and increase in tobacco use followed by patient returning to pre morbid self. From the past 4 years the patient started having episodes every alternate day with previous mentioned set of symptoms lasting one day and the other day having symptoms of feeling low and lethargic along with decreased appetite and substance use. An organicity work was planned for the patient and the CT scan head revealed lacunar infarcts in the right external capsule. MRI was planned for the patient and was subsequently started on valproate.

Discussion: The exact etiology of ultra rapid cycling disorder remains unclear. The onset of psychiatric symptoms occurring secondary to an underlying neurological problem presenting at a later age as in our case may help us widening our existing knowledge on ultradian cycling disorders.

Keywords: Ultra Rapid Cycling, Rapid Cycling, Ultradian

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Successful Management Of Lithium Induced Polyuria

Dr. Pallavi Rajhans Dr. Pooja Shakya, Dr. Namita Gautam, Dr. Ramandeep Pattanayak

Email Id: Pallavirajhans525@gmail.com

Introduction: Lithium therapy is often associated with polyuria leading to non-compliance of medications. Impairment in the urine concentrating capacity is seen in about 50% of patients receiving chronic lithium therapy. Amiloride though not considered to be the first line treatment has been used successfully in majority of the cases

Case Report: We report the case of a 24-year-old female who presented with lithium induced polyuria and polydipsia. The patient had history of recurrent depressive disorder with three moderate to severe depressive episodes in the past and was under our treatment and regular follow-up. She had been on lithium for the past two years. Patient was initially managed by restriction of water intake and other non-pharmacological measures which failed to provide relief. Investigations including urinary protein, creatinine and sodium potassium along with urine and serum osmolality were carried out. Considering the patient showing good response with lithium the decision of adding amiloride was taken and subsequently a reduction in dose of lithium was done. Weekly lithium level estimation and clinical monitoring for toxicity was done. Patient and family members were psychoeducated regarding the potential signs of toxicity and patient was managed accordingly

Discussion: Lithium interferes with cyclic adenosine monophosphate-dependent action of antidiuretic hormone on distal tubules and collecting-duct. Amiloride, is a potassium-sparing diuretic used for treatment of severe polyuria. It reduces the extracellular volume and glomerular filtration rate. Detailed clinical evaluation and laboratory tests are required to make a diagnosis and address the problem appropriately.

Keywords: Lithium, Polyuria, Polydipsia, Amiloride

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Case Report “ Dissociative Fugue” For 2 1/2 Years

Dr. Jigyansa Ipsita Pattnaik Dr. Snehanshu Dey, Dr. Anil Kumar Nayak, Prof. Neelmadhav Rath

SCB Medical College, Odisha, India. Email Id: Drjigyansaipsita@gmail.com

Introduction: Dissociative fugue is a rare, poorly understood and yet clinically one of the most fascinating disorders. Here, we describe a case of fugue in a 45-year-old male who was found on the streets after being reported missing for a period of 2 1/2 years.

Case Report: A 45 year old male, who was working at Kolkata, went missing suddenly without informing his family members. Despite extensive search, he was not found and after a period of 6 months, presumed to be dead and family pension was received.

But suddenly one fine day, after 2 1/2 years, he was found wandering on the streets in Jaipur & Odisha. He couldn’t recognize his family members initially, and was brought home by force. In a few days, he started identifying all his near and dear ones, and recalled his identity and could provide all details of his work and home. Even with much probing, he couldnt recall his whereabouts in the last two and half years. He could vaguely recall that he travelled by train to Mumbai in that period but couldnt elaborate it further. His family members brought him for evaluation and for certification of his mental fitness for rejoining his job.

All investigations and medicine consultation excluded any physical illness, however prior to the event he reported being stressed about his inability to pay his sons admission fees in time because of financial constraints.

Conclusion: Dissociative fugue is a rare clinical entity which can recur like any other dissociative disorder when the individual faces exceptional perceived stress. A dissociative fugue for 2 1/2 years is not yet reported in literature.

Keywords: Fugue, Dissociation

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Pellagra Induced Psychosis- A Rare Presentation

Dr. Disha Devang Parikh Prof. Pawar Alka V, Dr. Santre Manjeet S, Dr. Panse Smita N

Email Id: Disha_parikh007@yahoo.com

Introduction: Niacin (nicotinic acid) deficiency leads to pellagra characterised by diarrhoea, dermatitis, and dementia. Long standing deficiency is known to present with behavioural symptoms such as restlessness, agitation, irritability, insomnia, and rarely with psychotic features such as delusional thoughts and hallucinations.

Case: Mr. A, 35 year old married male presented with psychotic features in form of suspiciousness, delusional thoughts with persecutory content, hallucinations, agitated behaviour and decreased sleep since 1 month. On detailed evaluation, he reported of having generalized weakness, irritability and loss of appetite since 4 years. He also reported of developing skin lesions 3 months ago which were untreated. The patient did not have any cognitive impairment. After admission, he was initially started on low dose anti-psychotic medication. The diagnosis of pellagra was confirmed by dermatologist and he was started on injectable and oral high dose niacin supplements. The patient showed complete remission of psychosis within 1 week of treatment and hence his antipsychotic medication was discontinued. He was well maintained only on multivitamins over next 15 days. Complete remission of psychotic features was achieved on treatment of niacin deficiency. He was behaviourally asymptomatic at 1 and 3 month follow ups.

Conclusion: Niacin deficiency (pellagra) has an insidious onset and psychiatric symptoms appear rarely and late in the course when disease is allowed to progress. Psychiatrists need better training in the wide range of medical conditions that can present as neuropsychiatric disorders. There is a need to remain vigilant because often such patients are overlooked among psychiatric patients with no underlying physical illness.

Key Words: Pellagra, Niacin, Psychosis.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Steroid Induced Catatonia - A Case Report

Dr. Anil Kumar Nayak Prof. Neelmadhav Rath, Dr. Satyakam Mohapatra

Mental Health Institute, SCB Medical College, Odisha, India. Email Id: Dranil.nayak@gmail.com

Background: Catatonia though initially conceptualized as a subtype of schizophrenia, now recognized to occur not only with other psychiatric conditions but also with medical conditions and drug-induced and toxic states. These medical causes of catatonia account for between 20% to 30% of such cases. Literature search revealed very few articles written on catatonia due to steroids.

Aim And Objectives: Here we report a case of 23 years male with features of catatonia following use of prednisolone tablet and treated successfully.

Methods: Mr. B, a 23 years male brought by his father presented to the psychiatry OPD with symptoms of not obeying commands, remaining mute and aloof and also maintaining abnormal posture for hours since last 2 days though he was aggressive, suspicious, irrelevant and self-talkative at the onset i.e. 5 Days back. Detailed history from the informant revealed that Mr. B was taking tablet prednisolone 80 mg/day since 20 days prior to onset of illness to increase his weight as he newly joined in gymnasium a month back. On clinical examination he was stuporus and catatonia signs like posturing, negativism, waxy flexibility were present. All relevant investigations were done revealing no abnormality. He was started with injection Lorazepam slow IV 8 hrly and IV fluid with improvement in 3 days but antipsychotic was started owing to reappearance of psychotic symptoms and discharged after stabilization with antipsychotic medication. Now he is doing well and is under follow up.

Conclusion: This case report shows that corticosteroids may induce psychosis with catatonia which can successfully be treated with benzodiazepine and antipsychotic medication, but needs further exploration.

Keywords: Catatonia, Steroids, Benzodiazepine

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Substance Use Disorders In Incarcerated Population- Issues And Approach

Dr. Pallavi Rajhans Dr. Vaibhav Patil, Dr. Ravindra Rao

Email Id: Pallavirajhans525@gmail.com

Background: Substance use and incarceration form a vicious cycle. Globally, 10-48% of male and 30-60% of female prisoners are using or dependent on illicit drugs upon entry to prison. Crack users followed by heroin users appear to have the greatest odds of committing crime.

Aim: The review aimed to explore the epidemiology, various issues and possible approaches to address them in substance using incarcerated population.

Methods: Various drug reports and reviews were thoroughly studied which highlighted issues as well as proposed ways to deal with them. Data and information from reviews over past 5-10 years and recent drug reports were also reviewed to focus on current trends.

Results: Globally cannabis appeared to be the most common drug used followed by heroin among inmates. Overcrowding and abuse both physical as well as sexual abuse was highlighted in many studies and reports. High rates of acquiring infections as well as high rates of psychiatric morbidity were other general issues encountered. Certain specific issues included the knowledge and capacity to deal with this section of society and associated stigma. Access to preventive measures, cost of incarceration and post release overdosing and deaths were other challenges witnessed. Addressing these issues would require effective drug abuse management in prisons which would include co-operation, co-ordination and sensitization of the law enforcement personnel. Pharmacological as well as non-pharmacological management is important. The ultimate goal would be to integrate them in the society

Conclusion: High prevalence of substance use is seen in prisoners. Addressing their requirements would require tailoring of services to fit their needs

Keywords: Substance Use, Incarceration

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Cross Sectional Study Of Anxiety And Depression In Medical Professional In Medical College

Dr. Rishabh Pratap Singh Yadav Dr. Sagar Mudgal

Index Medical College Hospital And Research Center, Indore. Email Id: Dr.rishu1985@gmail.com

Introduction: Anxiety that affects almost 25% of population in India, is possibly the first stage. It is serious to handle depression if not addressed.

Depression as per WHO is highest in India, being 36% which is reflected in the lancet study revealing highest prevalence of suicides in India (20% of the total suicides in the world).

The rate of suicidal deaths among doctors is 2-4 percent as against only about 1-2 percent among general population.

Objectives:

To assess the level of anxiety and depression among the doctors.
To compare the level of anxiety and depression among doctors based on factors such as clinician/non-clinician, academician etc.
To establish an association of anxiety and depression with work stress.

Material And Methodology:

Study Design: Cross Sectional Study

Study Population: All Doctors

Sample Size: 392

Study Method: Hospital Anxiety And Depression Scale (HADS)

Inclusion: All Volunteering Doctors

Exclusion:

Incorrect/incomplete Forms, Doctors already Antianxiety and Antidepressant Medication

Analysis: MS Excel 2007 and SPSS 20.0

Result: The over all prevalence of showed that 19.6% Doctors suffers from anxiety disorder,14.80% from depression and 3.8% had both the conditions existing simultaneously

Conclusion: The prevalence of anxiety and/or depression among doctors indicate the hidden stress in the profession which is not commonly being assessed.

The major reasons behind this stress may be:

Lack of opportunity to recreate
Over burdended schedule
Pressure of completion of syllabus
24 Hrs liability towards patients and the list is most likely to increase if assessed properly.

Key words: Anxiety, Depression, Medical professional

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Sexual Satisfaction Among Spouses Of Subjects With Substance Use Disorders

Dr. Sucheta Tiwari, Dr. Rashmi Prakash, Dr. Om Sai Ramesh

Lady Hardinge Medical College And Associated Hospitals. Email Id: Sucheta.tiwari@gmail.com

Background: Sexual dysfunction, reduction in libido, and poor sexual performance are commonly reported among subjects with substance use disorders. Partners of such patients often also suffer from mood and anxiety disorders. These factors may lead to poor sexual satisfaction among partners of people with substance use disorders.

Methods: This cross-sectional study was conducted on patients presenting to a drug de-addiction center in a tertiary care hospital and their partners.

Aim: The aim of this study was to assess the sexual satisfaction of partners of subjects with substance use disorders. The sexuality scale developed by Pramod Kumar was used for this study. Patients of ages <18 years or those not willing to give consent were excluded from the study.

Results: Will Be Discussed At The Time Of Presentation.

Keywords: Sexual Satisfaction, Substance Use Disorder

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Probability And Predictors Of First Treatment Contact For Mood And Anxiety Disorders In The Psychiatric Department Of A Tertiary Care Hospital

Dr. Sucheta Tiwari, Dr. Rashmi Prakash Dr. Shiv Prasad

Lady Hardinge Medical College And Associated Hospitals. Email Id: Sucheta.tiwari@gmail.com

Background: Mood and anxiety disorders are among the most prevalent psychiatric disorders in the community. Despite availability of highly efficacious treatment, most patients with anxiety disorders never access mental health services.

Methods: This cross-sectional study was conducted in the department of psychiatry of a tertiary care hospital, with the aim of assessing treatment seeking behavior among patients diagnosed with mood and anxiety disorders according to ICD 10 criteria. The instrument used for the same was treatment seeking behavior schedule by Chadda R et al., 2001. Patients of ages <18 years or those not willing to give consent were excluded from the study.

Results: Will be discussed at the time of presentation

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Case Of Cannabis Dependence And Demyelination

Dr. Ashish Pakhre, Dr. Shailesh Jha

Institute Of Human Behaviour And Allied Sciences. Email Id: Sjmc.ashish@gmail.com

Background: A 40 years old married male presented with h/o cannabis use for 15 - 20 years. He fulfilled the criteria for dependence. Patient also had difficulty in vision, and neurologic symptoms. MRI brain was done which was s/o demyelination in occipital region and frontal region.

Methodology: An extensive literature search was done to find out studies on association between long standing cannabis use and deleterious effects on neurons using Pubmed. Imaging studies, neurobiological and neuropsychological studies were reviewed.

Results: Review suggested that cannabis has been used in the treatment of many neurologic disorders including multiple sclerosis. It has been used to treat pain, spasticity, tremor, spasms, poor sleep quality, and bladder and bowel dysfunction, which among other symptoms, contribute significantly to the disability and impaired quality of life of many patients with multiple sclerosis. Few studies reported long term adverse effects of cannabis.

Conclusion: This case highlights the possibility of cannabis induced demyelination. It also demands further etiological research to rule out such association. There is paucity of literature on long term deleterious effects of cannabis on neurological system.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Presenile Dementia: A Case Of Hashimotos Encephalopathy

Dr. Desiree Saimbi, Dr. Rupali. p. shivalkar, Dr. Atmesh Kumar, Dr. Priyanka, Dr. Shashank, Dr. Saumya, Mrs Sanjeeda, Ms Atushi

Email Id: Dsaimbi@gmail.com

Background: Dementias are a heterogenous group of psychiatric disorders. Causes being infectious, metabolic, vascular, nutritional, autoimmune, trauma, tumour, degenerative.

Hashimotos encephalopathy is a rare neurological disorder with presumed autoimmune origin, characterised by high titres of antithyroid peroxidase antibodies. Occurring more in females in their fifth decade. Clinical findings are variable and non specific. Neuropsychiatric symptoms and signs include myoclonus, seizures, altered consciousness, ataxia, presenile dementia, psychosis, visual hallucinations, paranoid delusions, mania and depression.

Case Report: Mrs X, 56 years old widow, working in a government firm was apparently on treatment for OCD for the last 15 years. However for the last 6 months, she noticed herself turning forgetful, finding difficulty in recalling names and retaining recent events, misplacing her belongings, losing directions, difficulty in performing complicated daily tasks, handling money, leading to socio occupational impairment. She also reported increased repetitive thoughts about dirt leading to frequent bathing and washing. Family members noticed her turning frequently irritable, also turned suspicious, on few occasions. she would tell them of someone sitting beside her, who would vanish no sooner she turned. In last 2 months, abnormal jerky movements in limbs, and tremors in hands were noted for which she was hospitalized and investigated.

On examination tremors, myoclonic jerks, neck rigidity were noted. No KF rings. Cognitive examination revealed construction apraxia, agraphia and acalculia. Psychiatric evaluation revealed sad mood, obsessions and compulsion, visual hallucination and delusion of persecution. MMSE score 18, Y BOCS score 25.

Her blood investigation revealed following derangements, WBC 12000, anti TPO >1300, serum ammonia- 160.

Neuropsychological assessment (PGI BBD) score was 42. Cutoff being 20.

She responded with alacrity to methyprednisolone and continuation of fluoxetine.

Hence a zealous search for treatable causes of dementia in presenile age group is warranted, as significant treatment response is seen in this group.

Keywords: Dementia, Hashimoto's Encephalopathy, autoimmunity

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Socio-demographic Profile, Psychiatric Comorbidities, And Treatment Seeking Behavior Among Substance Abusers Attending A Drug De-addiction Centre

Dr. Sucheta Tiwari, Dr. Rashmi Prakash, Dr. Dinesh Kataria

Lady Hardinge Medical College And Associated Hospitals. Email Id: Sucheta.tiwari@gmail.com

Background: Presence of additional psychiatric comorbidity is associated with poor outcome in patients with substance use disorders. In addition, psychiatric facilities are usually not the first point of contact for seeking de-addiction services in the indian population.

Methods: This cross-sectional study was conducted on patients presenting to a drug de-addiction center in a tertiary care hospital. AIM: The aim of this study to explore the sociodemographic profiles, treatment seeking behaviour, as well as any psychiatric comorbidities among subjects with substance use disorders. Tools used in the study are a semistructured proforma including the Kuppuswamy scale, and the treatment seeking behavior schedule by Chadda R et al., 2001. Comorbid psychiatric diagnoses were made based on ICD 10 criteria. Patients of ages <18 years or those not consenting were excluded from the study.

Results: Will be discussed at the time of presentation

Keywords: Psychiatric Comorbidity, Treatment, Substance Abuse

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Childhood Trichotillomania With Atypical Treatment Response: A Case Report

Dr. Mrinmay Das, Dr. Amandeep Kaur

Govt. Medical College, Haldwani. Email Id: Mrinmaysmail@gmail.com

Trichotillomania once was considered as a rare disorder but now it is recognized as a psychiatric illness that is not as rare as previously thought. Standard treatment guideline of this disorder, especially for children is not available till the present date. In this report, a case of childhood trichotillomania, its various diagnostic possibilities and successful treatment with risperidone in a child has been described.

Key Words: Trichotillomania, Childhood Onset, Risperidone

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Curious Case Of Behaviour Addiction

Dr. Hemika Agrawal Dr. Manish Borasi, Dr. Hemika Agrawal, Dr. Abhilove Kamboj

Email Id: Hemikaagrawal1@gmail.com

Background: Evolution of a psychopathology from an inciting sexual abuse to impulsive sexual behaviour to impulsive compulsive sexual behaviour to addictive behaviour then to a psychotic illness.

Aim: To study the evolution of a psychotic illness in the case of behaviour addiction.

Case Report: A middle aged, unemployed, Hindu married male came to OPD of tertiary neuro-psychiatry centre with the complaints of insidious onset of behaviour change with no significant past, family, personal history or maladaptive premorbid traits. On exploration the history revealed that the patient had a history of childhood sexual abuse with history suggestive of excessive sexual behaviour which was both impulsive and compulsive type and persisting despite significant socio-occupational dysfunction for past 18 years, and history suggestive of infidelity beliefs against wife with associated acting out behaviour for past 5 months. Mental status examination suggestive of circumstantiality in thought form with delusion of infidelity and preoccupation with sexual thoughts in thought content with absent insight. He was diagnosed as having sexual addiction with persistent delusional disorder (subtype-infidelity). Patient was started on risperidone with regular monitoring for side effects being ensured. Patient showed improvement in both sexual behaviour and delusion of infidelity.

Conclusions: Excessive sexual addiction may lead to psychotic illness, and both respond well to antipsychotics.

Keywords: Sexual Addiction, Psychosis

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Personality And Behaviour Changes Due To Brain Tumour, Glioma - Case Report

Dr. Krunal Hitendrabhai Patel

PDU Medical College And Hospital, Rajkot. Email Id: Drkrunal2013@gmail.com

Introduction: Primary and metastatic brain tumours are frequently associated with secondary psychiatric and behavioural symptoms. These symptoms may include neurocognitive changes, changes in personality, perceptual abnormalities, disturbance of thought content and processes, anxiety and agitation, mood and affective changes. These symptoms often mimic the clinical features of primary psychiatric disorders.

Case Report: A 54 year old male patient Mr. A coming from low socio economic status was admitted in our ward on Jan 2016 with chief complaints of forgetfullness in day to day activities since 1 month, talking inappropriately, confusion, sleep disturbance, irritability and aggressive behavior, emotional lability, dysarthria, poor self-care, leaving home frequently without informing others since 10 days. Premorbidly, patient was working as taxi driver and had good interpersonal relationships. On MRI brain, findings were suggestive of well-defined mass lesion detected at left temporo-parietal region with internal thin septations and thick, nodular wall & mild surrounding oedema suggestive of high grade glioma.

Discussion And Conclussion: A wide variety of psychiatric and behavioural symptoms, often indistinguishable from those associated with primary psychiatric disorders, are associated with cerebral tumours in 47 to 94% of cases. The frequency of this association depends on the location of the tumour, with frontal, temporal and diencephalic neoplasms being most commonly associated with neuropsychiatric symptoms. In this case patients general condition and behavior gradually worsened over next few weeks and he passed away. It has been suggested that, in as many as 18 % of brain tumour patients, psychiatric and behavioural symptoms may have been the first indicator of a tumour.

Key Words: Personality Change, Behavioural Symptoms, Brain Tumour

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Gender Differences In Cognitive Dysfunction Among Bipolar Disorder Patients In Remisssion

Dr. Snehanshu Dey Dr. Jigyansa Ipsita Pattnaik Dr. Anil Kumar Nayak, Dr. Neelmadhav Rath

SCB Medical College, Cuttack Odisha, India. Email Id: Drsnehanshu@gmail.com

Introduction: Cognitive dysfunction is a significant phenomenological dimension in bipolar disorder (BD) particularly in the domains of verbal/learning and memory and executive function. There has been evidence of sexual dimorphism in normal brain structures and presence of sex-related differences in neuro-cognition in healthy participants and in schizophrenic patients. Not many studies are available in bipolar patients.

Aims And Objectives- This comparative study aimed to study the cognitive functioning of BD patients to detect any sex-related differences.

Materials & Methods: The study sample consisted of 72 adult patients (40 males, 32 females) diagnosed with bipolar affective disorder, currently in remission attending psychiatry OPD of SCB Medical College & Hospital over 6 months (Nov 2015- APR 2016), and assessed using following tools.

17-item Hamilton Depressive Scale
Young Mania Rating Scale
Wisconsins Card Sorting Test
The Digit Span Subtest Of The WAIS-R
DSSR (the Digit Symbol Subtest Of The Wais-r).

The results were obtained and tested for any gender differences and compared to age, sex, and education matched 50 controls.

Results: All patient groups showed impairment on executive functions, which were assessed using the WCST 128. A statistically significant difference was found only in the number of completed categories and perseverative errors.

There was a statistically significant sex-related difference in measures of short-term memory, attention, and working memory. Female patients performed significantly worse than male patients in the forward and backward digit span subtests of the WAIS-R (z = 2.95, P = 0.003, And z = 2.04, P = 0.042, Respectively).

Conclusions: Gender based differences among patients with bipolar disorder in the cognitive dimension do exist. Further research and exploration in this area is needed as it may have a great impact on the clinical expression of the patient, which can influence the diagnosis, prognosis and treatment guidelines.

Keywords: Cognition, Bipolar Disorder, Gender differences.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Aripiprazole Induced Weight Gain: A Case Report

Dr. Prashantkumar Mavjibhai Mahakal, Dr. Kalpesh Chandrani

P.D.U Medical College & Hospital, Rajkot. Email Id: Mahakalprashant5@gmail.com

Introduction: Weight gain induced by atypical antipsychotics is a well known side effect. Among this group of medications, aripiprazole has been reported to be weight neutral. We present here a case that contradicts this view.

Case Report: A 37 years old male patient of paranoid personality disorder was treated with tab. Olanzapine, cap. Fluoxetine and tab. Alprazolam daily for around 2.5 Months. Because of weight gain, tab. Olanzapine was down titrated and omitted within 15 days. After that, patient had self-omitted all the treatment for around 2 months. At that time, weight reduced by around 5 kg. The patient again came back for treatment, At that time tab. Aripiprazole 10 mg was given for around 6 months. While on Tab. Aripiprazole, patient had weight gain of around 11 kg. Then once again, patient had self-omitted all the treatment for around 1 month and his weight was reduced by around 5 kg.

Discussion And Conclusion: In this case, weight gain after aripiprazole use and weight reduction due to stoppage of its use, proved that weight gain was due to aripiprazole. This contradicts many clinical trials which suggested that aripiprazole does not cause much weight gain. So, this case highlights the importance of closely monitoring of weight of patient on aripiprazole.

Key Words: Aripiprazole, Weight Gain

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Comparative Study Of Neurological Soft Signs In Patients With Schizophrenia, Bipolar Disorder And Major Depression

Dr. Rekha Rani, Dr. Sanjay Jain, Dr. Richa Tripathi

Dept Of Psychiatry, A.I.I.M.S., New Delhi. Email Id: Drrekha088@gmail.com

Introduction: NSS are present in Schizophrenia, Bipolar disorder and other psychotic disorders. Therefore, it remains unclear if NSS are specific to schizophrenia or may occur at even higher rates in patients with other psychoses along the continuum of vulnerability

Method: It was a cross-sectional study conducted over a period of six months. The study included 90 consecutive patients in three equal groups and 30 healthy controls. The patients and controls were evaluated on Cambridge neurological inventory & Edinburgh handedness scale

Results: Prevalence of total NSS score, and sub scores (MI, SI and disinhibition) had been found significantly (statistically) higher in patients of schizophrenia (p value<0.05) than Bipolar group, depression and control group. There was no difference between Schizophrenia and bipolar patients in terms of NSS sub scores (MC, SI, disinhibition) and total NSS scores

Conclusion: Schizophrenia and bipolar disorder are similar in terms of NSS scores. The two groups showed excess of neurological soft signs than major depression patients and healthy controls. Major psychosis share common features and specificity of NSS expression has the potential to help the discrimination of schizophrenia and bipolar disorder from disorders less likely to have a neuro developmental component such as major depression.

Key Words-nss-neurological Soft Signs, Mc-motor Coordination, Si-sensory Integration.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Mood Disorder As An Early Presentation Of Epidermoid Of Quadrigeminal Cistern

Dr. Sujita Kumar Kar, Dr. Suyash Dwivedi, Prof. Awadesh K. Jaiswal

Lucknow. Email Id: Drsujita@gmail.com

Intracranial epidermoids are space-occupying lesions of rare variant. Though cerebro-pontine angle and parasellar region are common sites of occurrence, it has been reported in various other parts of the intra-cranial cavity. Headache and features of increased intracranial tension are the common clinical manifestation. Report of psychiatric symptoms as the initial presentation of epidermoid is not known in literature except a single case report, which describes mutism to be the manifestation of intracranial epidermoid. We present here the case of a young male who presented with long depressive episode persisting for three years with subsequent manic switch, which persisted for more than three years. An episode of unconsciousness warranted neuroimaging, which revealed a large epidermoid of the quadrigeminal cistern. Surgical resection of the epidermoid was done. Persisting mood symptoms had responded to mood stabilizer and antipsychotic treatment.

Keywords: Mood Disorder, ICSOL

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Moment Of Silence- A Rare Case Report

Dr. Sheethal Puttala, Dr. Ajit Mogalgiddi

Bhaskar Medical College. Email Id: Drsheethalraj89@gmail.com

Introduction: Absence seizures are characterised by brief loss and return of consciousness, generally followed by a period of lethargy (without post-ictal state). The most susceptible to this are children and the first episode occurs between 4-12 years old. It is very rare that someone older will experience their first absence seizures.

History: We present a case of 48 year old male patient, pastor by profession, who experienced sudden cessation of speech for nearly 5-10 seconds, usually while preaching in the church since 4 years. The symptoms were sudden in onset, initially once a month and progressed to to multiple episodes daily within 2 years. He also experienced sleep disturbance, difficulty in initiation and maintenance of sleep were present, accompanied by snoring and episodes of sudden shortness of breath which relieved on sitting. He was started on Armodafinil (Waklert) but he did not respond. Later he developed depressive symptoms and hence he was prescribed with Fluoxetine and carbamazepine (Tegretol). He responded very well no relapse during an observation of 5 months.

Keywords: Absence Seizures, CBZ

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Study Of Various Psychosocial Factors Associated With Opioid Use In Patients Attending Tertiary Care Hospital In Western Rajasthan

Dr. Vijay Kumar Saini, Prof. K. K. Verma, Dr. Harful Singh, Dr. Anant Kumar Rathi

Email Id: Vsaini344@gmail.com

Introduction: Opioid in various forms has been taken from ancient time in many parts of india. Various psychosocial and cultural factors are associated with its use. In our hospital, a large number of patients from various districts of Western Rajasthan attend OPD for substitution treatment. They admit different reasons behind starting opioid & continuing it. With this rationale, we planned a study to see these psychosocial factors associated with opioid abuse.

Methods And Materials: This was a single center, cross sectional study conducted at Department of Psychiatry, Sardar Patel Medical College, Bikaner, Rajasthan. 136 Subjects who were not taking any another substance other than opioid were recruited for study. Along with socio-demographic proforma, a semi-structured proforma of psychosocial factors which was validated by two psychiatrists had been applied to recruited subjects. Appropriate statistics was applied with IBM SPSS 22.0.

Results And Conclusions: Most of the subjects were males, married, illiterate, farmer and hailed from rural areas. There were one or more than one psychosocial factors for starting, continuing & quitting the opioid. Most common factor associated with starting opioid was to increase work capacity in agricultural work (n=46, 33.82%) followed by staying away from home for work (n=36, 26.47%) & Usage by another family members (n=34, 25%). Most common factors for continuing opioid were that it increases work capacity (n=61, 44.85%), long term use of opioids do not cause significant changes in behavior (n=33, 24.26%) & easy availability (n=32, 23.52%). Reasons for quitting were unavailability (n=58, 42.64%) followed by financial problems (n=33, 24.26%) & harmful effects on body (n=17, 12.5%). Other psychosocial factors were also reported for starting, continuing and quitting.

Knowledge About these factors may be beneficial in management of opioid users.

Key Words: Opioid, Psychosocial Factors, Western Rajasthan.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Oculogyric Crisis In Patients With Schizophrenia: A Case Series

Dr. Naresh Nebhinani

AIIMS, Jodhpur. Email Id: Drnaresh_pgi@yahoo.com

Background: Oculogyric crisis (OGC) is an acute dystonic reaction characterized by spasmodic deviations of the eyes, most commonly upward, occasionally lateral, downward, or oblique, lasting for a few minutes to several hours. Such reactions are commonly seen with the administration of typical antipsychotics and are considered rare with atypical antipsychotics.

Clinical Details: Here we report 3 cases of oculogyric crisis caused by antipsychotics.

Case 1-A 28 year old female diagnosed with schizophrenia, developed OGC on Haloperidol 15 mg/day in spite of an oral anticholinergic medication, which finally stabilized by switching to Quetiapine.

Case 2-A 25 year old male diagnosed with schizophrenia, develop OCG on Olanzapine 20 mg/day and not improved even after adding oral anticholinergic medication, which finally stabilized by switching to Clozapine.

Case 3-A 28 year old female diagnosed with schizoaffective disorder, develop ocg on haloperidol 15 mg/day in spite of an oral anticholinergic medication, which finally stabilized by switching to Olanzapine.

Conclusion: Oculogyric crisis is a potential side effect and generally responded to oral anticholinergics, but in some cases changing the antipsychotic might be the only possible option. Clinician needs to be aware of it, as early recognition is necessary to prevent major adverse outcomes.

Keywords: Oculogyric Crisis, OGC, Antipsychotics, Anticholinergics

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Complex Post-traumatic Stress Disorder In A Male Sexual Trauma Victim: A Case Report

Dr. Naresh Nebhinani

AIIMS Jodhpur. Email Id: Drnaresh_pgi@yahoo.com

Background: Though mainstream journals have published papers on complex PTSD, the category is not formally recognized in DSM 5 and ICD-10 diagnostic systems. Complex PTSD is a proposed diagnostic term for a set of symptoms resulting from repeated or prolonged traumas of a social and/or interpersonal nature in which there is an actual or perceived inability for the victim to escape. Person who experience chronic trauma often report some additional symptom alongside formal PTSD symptoms. Here we report a case of adolescent male with complex PTSD.

Clinical Detail: A 18 year old male child, brought by parents for treatment with complaints tracing back a year ago to a repeated and prolonged sexual abuse in form of sodomy, physical abuse in form of beating, and verbal abuse in form of threatening. Main complaints included mood swings, sleep disturbances, nightmares, explosive anger, and deliberate self harm, panic attacks, dissociative episodes and behavioral changes. He felt detached, shameful, guilty, stigmatized, helpless, and remains confined to home, stopped studying and even not performs everyday tasks. No psychic symptomatology was evident before the event to him. He was admitted, pharmacotherapy started in the form of SSRI and benzodiazepine along with non pharmacological management in the form of supportive sessions, addressing interpersonal difficulties and the specific symptoms by CBT. He maintained well from last 2 months.

Conclusion: Strengths in management of C-PTSD depends on making appropriate diagnosis based on concerted efforts by clinicians, comprehensive care, team work, sensitivity to age and sex, winning trust of the child and the care taker among others. This patient continues to respond well to treatment to date, bearing in mind that his age, presentation and personality within a dysfunctional family background did not offer good prognosis.

Key Words: Complex, Male, Sodomy, CBT

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Kikuchi-Fujimoto Disease (KFD) Presenting As Treatment Resistant Mania

Dr. Soumyajit Sanyal

Institute Of Human Behaviour And Allied Sciences. Email Id: Sjsanyal@gmail.com

Background: Kikuchi disease, also called histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease is an uncommon, idiopathic, generally self-limited cause of lymphadenitis, commonly manifesting as cervical lymphadenopathy with systemic signs and symptoms resembling SLE or lymphoma. Autoimmune disorders are one of rare causes of treatment resistant mania.

Objective: To report a case of Kikuchi-Fujimoto disease presenting as treatment resistant mania.

Design: Case report.

Setting: Tertiary care neuropsychiatric hospital.

Methodology: Clinical description of a case of KFD and mania with investigations and treatment.

Results: After non response of 2 mood stabilizer and 2 antipsychotic combinations patient was thoroughly investigated and diagnosed with KFD from lymph node biopsy. Initiations of corticosteroids lead to rapid remission of symptoms of KFD and also the manic symptoms.

Conclusion: Psychiatric manifestations of KFD are extremely rare but neurological complications of autoimmune disorders in this case KFG may manifest as treatment resistance in various psychiatric disorders.

Keywords: KFD, Mania, Steroids

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Depression And Its Correlation With Socio-demographic Variables In Mothers Of Mentally Retarded Child

Dr. Gourav Chandravanshi, Dr. Krishan Kumar Sharma,

Prof. Mahendra Jain

Department Of Psychiatry, JLN Medical College, Ajmer. Email Id: Drgchandravanshi@gmail.com

Background: The birth of a disabled child in a family induces complex feelings in the family members. As mothers are the main care givers, they are most affected. Mothers often have needs during this time that are not addressed by professionals because of the exclusive focus on the child during the evaluation. This study was planned to find the prevalence of depression and its correlation with socio-demographic variables in the mothers of id children.

Objective: To find prevalence of depression and its correlation with various socio-demographic in mothers of id children.

Study Design: A cross-sectional study.

Materials And Methods: Mothers (n=60) of intellectually disabled children were included in the study. Objective data was collected in a special performa and mothers of these children were evaluated with Becks anxiety inventory and Becks depression inventory.

Results: The mean age of mothers was 32.5 years, who had received an average of 8 years of schooling. The prevalence of depression in mothers was 70%; it was more in mothers of female ID child, child with severe mental retardation and with higher levels of anxiety in the mother.

Conclusions: Prevalence of depression in mothers of ID children seems to be much greater than those reported from previous studies. However, they are not getting attention per se. They should be included in the protocol for management which may reduce psychological problems and enhance the psychological wellbeing of mothers.

Keywords: Depression, Mentally Retarded

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Study Of Psychiatric Comorbidities, Medical Conditions And Personality Disorders In Patients With Opioid Dependence

Dr. Amol Vijay Tayade, Dr. Nilam Behere, Dr. Shilpa Adarkar, Shubhangi Parkar

Email Id: Amstay92@gmail.com

Introduction: Opioid use has been occurring since ancient times and continues to be increasing in the present era. The ill effects seen due to the use of this illicit drug are alarming. There are various psychiatric comorbid disorders and personality disorders found in individuals with opioid dependence. Various psychiatric comorbid disorders may alter the consumption pattern of the drug itself or may be a result of its consumption. Also there are some medical conditions that occur along with it are debilitating.

Hence This study aims to assess various psychiatric disorders and personality disorders associated with opioid dependence. This study also evaluates associated medical conditions.

Methodology: The study was carried out in drug de-addiction centre of a tertiary care hospital in Mumbai after taking permission from institutional ethics committee. 85 Patients with opioid dependence were selected using the inclusion and exclusion criteria. The data was collected on a structured proforma and was analyzed.

Results: Past or present history of medical conditions was found in 51.5% Of the patients, thrombophlebitis being the most common (15%). 21% Of patients with opioid dependence were found to have comorbid psychiatric disorders at the time of evaluation, depression and anxiety disorders being most common amongst them. Past history of psychiatric disorders was identified in 36.5% of patients. 89% of patients had personality disorders out of which 68% had antisocial personality disorder. The findings are discussed in detail.

Conclusion: Majority of patients of opioid dependence have personality disorders. 21% Of patients have comorbid psychiatric disorders. These comorbidities warrant equal attention and treatment, of opioid dependence in general and relapse prevention in particular.

Keywords: Opioid, Personality Disorders, Psychiatric Comorbidities.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Child With Recurrent Abdominal Pain:a Cross Road Between Paediatrics, neurology And Psychiatry

Dr. Nakka Naga Rajitha, Prof. Sandeep Krishna Murthy Kosaraju

Bhaskar Medical College. Email Id: Ticksheethu@gmail.com

Introduction: Recurrent abdominal pain is a common problem among children. Many a times, inspite of a battery of diagnostic tests, the cause seems elusive. This can lead to these children being deemed to be suffering from psychogenic pain. Abdominal epilepsy is one such disease with a rare presentation which is easily treatable but rarely recognizable.

History: Here we present a case of 12 year old boy brought to paediatric outpatient clinic with complaints of abdominal pain since 4 months. His physical examination and a number of investigations were normal. He was thought to have functional pain and was referred to the child guidance clinic where he was examined by psychiatrist in detail and was advised an EEG to be done in order to investigate for epileptic phenomenon and it found to be abnormal indicating epilepsy. Child was treated accordingly and was found to be symptom free for past one year.

Keywords: Pain Abdomen, Epilepsy

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Rain Rain Go Away: A Case Report Of Lady With Ombrophobia

Dr. Niska Sinha, Dr. Rajesh Kumar, Dr. Krishna Kumar Singh

Email Id: Niskasinha@yahoo.com

Introduction: Ombrophobia or pluviophobia is the fear of rain seen more commonly in children, and early teenagers. The term ombrophobia originates from greek˜ombros meaning storm of rain and phobos meaning fear or aversion. Adults with this phobia have an irrational, persistent extreme fear of rain, trembling, palpitation, sweating, profuse breathing, chest pain, nausea, dizziness, fainting, feeling numb, worry that rain will deteriorate mental balance, heightened anxiety, panic attacks. They monitor weather forecasts, avoid outdoors during rainy days. Realization of fear being irrelevant is present in adults.

Ombrophobia can also be seen following any traumatic event experienced. Unfortunately, this phobia will worsen over time if it is not properly treated by either professional or self-help methods and other symptoms, like depression, may begin to appear. Treatment includes exposure therapy, group therapy or relaxation techniques.

Case presentation: Mrs. A 45 year old married Hindu female hailing from middle socioeconomic strata of rural Bihar presented to IGIMS OPD with classical symptoms of rain fear. The interesting findings were age of onset, its acute onset and varied clinical manifestations as several other associated phobias were found on further history and investigations which will be discussed in detail at time of presentation.

Summary: A detailed investigation and history is of utmost importance in psychiatry specially as psychopathology of every case is unique and aids a lot in treatment outcomes.

Keywords: Pluviophobia, Ombrophobia

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Galactorrhea Caused By Domperidone: A Rare Adverse Event Of A Common Drug

Dr. Kevin Pravinbhai Patel, Prof. Dr.Nimesh C. Parikh

Smt.NHL MMC. Email Id: Princekevin04@gmail.com

Introduction: Domperidone is a prokinetic drug used for treatment of vomiting, hiccups and prevention of nausea and vomiting caused by other drugs. It is D2 receptor antagonist with having mainly peripheral action and crossing blood brain barrier poorly. Its anti-dopaminergic action leads to galactorrhea in some rare case.

Method: We would like to report a case of domperidone induced galactorrhea in middle-aged female and discuss literature of about domperidone induced galactorrhea.

Discussion: Galactorrhea can be caused by numerous conditions of which some drugs can also cause it. Domperidone can rarely associated with galactorrhea. Dopamine and prolactin have reciprocal relationship. As domperidone causes D2 receptor antagonism, decrease in dopamine level leads to elevated prolactin level. Management of galactorrhea must be tailored according to its cause and in our case the patient responded well to drug discontinuation.

Conclusion: Galactorrhea is rare side effect caused by domperidone. Clinicians should be aware & watchful about such rare side effects of a common drug to avoid unnecessary worries to treat them immediately in patients already suffering from various illness.

Key Words: Domperidone, D2 Receptor, Prokinetic Drug, Galactorrhea, Side Effects.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Psychiatric Morbidity And Marital Satisfaction Among Spouses Of Men With Alcohol Dependence

Dr. Sarmistha Priyadarshani

Email Id: Priya.sarmistha@gmail.com

Background: Alcohol dependence has adverse health and social consequences; alcohol related problems primarily occur within the family context and maximum impact is felt on spouses, given the intimate nature of their relationship. Spouses play an important role in treatment programs related to alcohol. There is thus a need to study psychiatric morbidity and marital satisfaction in spouses of alcohol dependent patients in order to understand and address such issues.

Aims: The aim of this study was to assess the pattern of psychiatric morbidity, marital satisfaction in spouses of men with alcohol dependence syndrome and explore the association.

Materials And Methods: For psychiatric morbidity, 60 spouses of men with alcohol dependence syndrome were evaluated. Marital satisfaction was assessed using the marital satisfaction scale. Severity of alcohol dependence in the husbands and consequences of drinking was assessed using short alcohol dependence data and drinkers inventory of consequences respectively.

Results: More than half of the spouses (65%) had a psychiatric disorder. Primarily mood and anxiety disorder were present. Major depressive disorder was present in 43%. Psychiatric morbidity, marital dissatisfaction in spouses and higher adverse consequences of alcohol dependence in their husbands, were found to be significantly correlated with each other and their association was robust particularly when problems in the physical, interpersonal and intrapersonal domains were high.

Conclusion: Psychological distress and psychiatric morbidity in spouses of alcohol dependent men is high, with marital satisfaction being low. Addressing these issues will be beneficial as spouses are known to play an important role in the treatment of alcohol dependence syndrome.

Keywords: Marital Satisfaction, Psychiatric Morbidity, Spouses Of Men With Alcohol Dependence

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Cannabis Attributing To Chronic Mania: A Study Of Two Cases

Dr. Sujita Kumar Kar, Dr. Suyash Dwivedi, Dr. Adarsh Tripathi

Department Of Psychiatry, King George's Medical University, Lucknow, U.P. Email Id: Drsujita@gmail.com

Background: Manic episodes having chronic course are uncommonly seen. Chronic mania is defined as presence of manic symptoms for more than 2 years without remission. A number of studies show the role of cannabis use in causation of mania.

Materials And Method: We are presenting here two cases showing association of chronic mania and cannabis use disorder. Informed consent has been obtained from the patients. Our patients were adult males (40 years and 45 years old respectively) from lower socio-economic status. They had history of use of cannabis in the form of ganja for 15 years and 13 years respectively in dependence pattern. They also had increased talkativeness, increased irritability, disturbed sleep, increased physical restless, increased cheerfulness and grandiose delusions. The symptoms were persisting continuously with fluctuating severity for 6.5 years in the first patient and 12 years in the second. Both the patients also had history of use of tobacco in dependence pattern. The second patient also had history of alcohol use in dependence pattern, but was abstinent for nine years. None of them had past or family history of any psychiatric illness. Both the patients were investigated for various medical causes and were treated with mood stabilizer and antipsychotic drugs.

Results: All haematological investigations (routine hemogram, thyroid function test, VDRL) were within normal limits. CT scan of the both patients revealed diffuse cerebral atrophy. They were diagnosed with manic episode with dependence to cannabis and tobacco. They had shown significant improvement with above treatment and cessation of substance in a protected environment.

Conclusion: Cannabis use can have significant attribution towards development, prolongation as well as amplification of the severity of manic symptoms.

Keywords: Cannabis, Mania

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Study To Compare The Use Of Smartphones For Learning Among Postgraduate Medical Students And Interns Between An Urban Municipal Medical College And An Urban Private Medical College

Dr. Todkar Snehal Sanjiv, Dr. Henal Shah, Dr. Palsetia Delnaz Dara

Topiwala National Medical College, Mumbai. Email Id: Todkar.snehal1988@gmail.com

Introduction: Smartphones are being used for clinical guidelines, medical calculators, drug reference tools and other decision-support aids, textbooks, and literature search portal. Portability & userfriendliness of smart phones make it a popular tool for learning in medical students.

Hence the purpose of the study was 1)To compare the use of smart phone for learning among postgraduate medical students and interns between an urban municipal medical college and an urban private medical college.2)To assess the pattern of utilization of medical apps and academic use of smart phones among medical students.

Methodology: A descriptive cross-sectional study was conducted in postgraduate medical students and interns of TNMC, Mumbai(urban municipal medical college) & Dr DY Patil, kolhapur(urban private medical college). The questionnaire was constructed by the lead researcher and reviewed by an expert panel for content reliability and validity. The students were selected according to inclusion & exclusion criteria with written informed consent. Students were given a questionnaire in person and the responses were collected at the end of 7 days. Two reminders were given on 3rd and 5th day. This data was then analyzed.

Mean time among 4 groups(Intern and PG students from both colleges) was compared by anova test for smartphone use in learning and otherwise. Likert scale questions among 4 groups were compared by Kruskal-Wallis test(non parametric test.)

Results: TNMC Students were using smartphone as a learning tool (p value=0.003 Statistically significant) more as compared to DYP students. The number & frequency of utilization of medical apps used (including paid apps)was more for TNMC Students than DYP students. It was also observed that interns were using internet on smartphone for more hours/day(p value=0.000 Statistically significant) than PG students.

Conclusion: Smartphone is a useful learning tool for medical students in an urban municipal medical college than an urban private medical college.

Keywords: Smartphone, Learning, Medical Students.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Rare Case Of Kartagener's Syndrome With Psychosis

Dr. Prerna Balkrishen Khar, Dr. Swaroop Bhatankar, Dr. Manjeet Santre, Prof. Alka V Pawar

B.J. Govt Medical College, Pune. Email Id: Prernakhar@gmail.com

Introduction: Kartagener's syndrome is a rare genetic disorder of primary ciliary dyskinesis characterized by the triad of bronchiectasis, sinusitis, and situs inversus. The worldwide prevalence is 1/10000 to 1/50000. Only 5 cases have been reported worldwide of Kartagener's syndrome with psychosis out of which none have been reported in india.

Case: A 26 year old unmarried male presented with behavioral disturbances in the form of aggressive behavior, impaired self care and sleep disturbances. Informant gave history of muttering and gesticulating to self, irritability and suspiciousness for the last 4 years. On physical examination dextrocardia was observed. USG and HRCT done subsequently revealed situs inversus totalis and bronchiectasis respectively. Azoospermia was detected on semen analysis. There was also history of recurrent respiratory tract infections in childhood. In view of the above medicine and chest TB reference was taken and the patient was diagnosed with Kartagener's syndrome. He was treated with antipsychotics and benzodiazepines for his psychotic symptoms and sleep disturbances. Antibiotics and bronchodilators were prescribed for his respiratory infection. He showed significant improvement on antipsychotics which were continued after discharge. The patient continues to follow up on out-patient basis and is well maintained and working at present.

Conclusion: The biochemical lesion responsible for the presentation of Kartagener's syndrome also plays a role in the precipitation of psychosis or could be genetically linked to a locus contributing to increased risk of psychosis.

Key Words: Kartageners Syndrome, Psychosis, Genetic

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Studyof P Wave And Qt Dispersion In Patients With Obsessive Compulsive Disorder

Dr. G Madhavi, Dr. K. Shaguft Rahman, Dr. C. Shanthi

Email Id: Madhaviflowers@gmail.com

Background: Obsessive-compulsive disorder (OCD) is characterised by recurrent obsessions or compulsions that cause severe distress to the person. So the compulsive act which is carried out to reduce distress may often increases anxiety. Anxiety is also increased when a person resists carrying out a compulsion. It has been well established that autonomic nervous system is involved in anxiety states. Involvement of autonomic nervous system (ANS), causes increased risk of coronary artery disease and arrhythmias. P wave dispersion (difference between the maximum and the minimum p wave duration) predisposes to AF. Qt dispersion(QTD), defined as the inter lead QT variation is non-invasive measure of ventricular arrhythmia and of sudden cardiac death. In the present study P wave and QT dispersion in patients with ocd were studied.

Aims And Objectives:

1. To know P-wave and QT dispersion in OCD patients.

2. Relation between Y BOCS severity and p/qt dispersion

3. Relation to family h/o CAD and socio demographic profile.

materials And Methods: A total of 30 patients with ocd according to ICD 10 criteria were included in the study. Y-BOCS scale was used. In all these patients P wave and QT dispersion were calculated and compared with age and sex matched controls.

Inclusion Criteria:

1. Patients diagnosed to have OCD according to ICD 10.

2. Age between 18 and 60 yr.

Exclusion Criteria:

1. Patients with prior cardiac disease.

2. Patients with other systemic disorders

3. Patients with history of other psychiatric disorders and substance abuse.

4. Patients using drugs which interfere with P and QT intervals.

Results & Conclusions: Results and conclusions will be presented at the time of conference

Key Words: OCD, P Wave Dispersion, QT Dispersion.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Venlafaxine Induced Concomitant Fixed Drug Eruption, Acneiform Eruptions And Psoriasis In A Case Of Major Depressive Disorder

Dr. Pallavi Sinha, Dr. Amit Garg

Institute Of Human Behaviour And Allied Sciences. Email Id: Pallavisinha0102@gmail.com

Introduction: Adverse cutaneous reactions to antidepressants are diagnosed primarily on the basis of the patient's history. A clinician who is aware of these common and potentially serious adverse events will help avoid their continuation or recurrence. Dermatologic side effects have been reported in premarketing phase 3 trials along with few post marketing reports of severe cutaneous adverse reactions. We would like to report about the development of concomitant fixed drug eruption, acneiform eruptions and psoriasis in a depressed patient on treatment with venlafaxine. Case report a 32 year old married female was diagnosed as a case of major depressive disorder and was started on cap. Venlafaxine 75 mg/day with lorazepam tab 2 mg on sos basis (max 4 mg/day). After 7 days of initiation of venlafaxine she reported of itchy round red lesions, of approximate 2-3 cm diameter with burning sensation on both lower limbs with infrequent malaise and low-grade fever. Examination revealed clearing lesions with subtle hyper pigmentation on bilateral lower limbs in the area of lesions.

Discussion: It is very difficult to hypothesise a common cause of concomitant different skin lesions in index patient on venlafaxine. Fixed drug eruption and acneiform eruption could have resulted from either changes in an individual's levels of serotonin (both high and low levels of serotonin have been known to cause multiple skin problems, including rashes and twitching) or hypersensitivity reaction/allergic (anaphylactic) reaction to some inactive chemicals/constituents in the compound. Although the exact mechanism is unknown in psoriasis, recent research suggests a cell-mediated process that initiates both the active and quiescent lesions. It is important to identify drug-induced rash in the initial stages as they tend to resolve as soon as the the offending drug is discontinued and with supportive treatment. If under diagnosed or misdiagnosed, they can be severe enough to be life threatening.

Keywords: Venlafaxine, Psoriasis, MDD

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Shared Obsessive-compulsive Disorder In Twin Sisters: A Case Report

Dr. Dileep Kumar Verma, Dr. Chandan Singh

Central Institute Of Psychiatry, Kanke, Ranchi, India. Email Id: Dr.dileep09@gmail.com

Introduction: Shared obsessions and compulsions are a very rare disorder known to be represented by very few case reports in the literature. Knowledge about clinical features, treatments and prognosis in shared obsessive-compulsive disorder is limited to a few cases. New cases need to be reported in order to provide new information and experience about the shared disorder.

Materials And Method: We present a case report of two twin sisters of 28 year-old with similar obsessions and, compulsions. Illness started first in one sister followed by twin sister after 2 years with complaints of having excess concern about dirt and contamination and repetitive rituals with water like excess washing and bathing. Y-BOCS was applied to assess severity of symptoms. Both improved with pharmacological treatment with selective serotonin reuptake inhibitor and behavioral intervention.

Discussion: We highlight the uncommon phenomenon of shared or induced obsessive-compulsive disorder. We raise the question of broadening the concept of shared disorder so as to include shared OCD and perhaps other shared psychiatric syndromes. In the current psychiatric diagnostic nomenclature, (DSM V and ICD 10), there is no category for a shared OCD. Greater awareness about this entity among mental health professionals is needed

Conclusions: More controlled studies are required in order to better understand the psychopathology and mechanisms of shared or induced ocd and other non-psychotic shared disorders in psychiatry. We also believe there are important treatment implications of such an understanding.

Key Words: Obsessive Compulsive Disorder, Shared Obsessive Compulsive Disorder, Induced Obsessive Compulsive Disorder.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Study Examining Factors In Patients With Epilepsy That May Predispose To Interictal Psychopathology

Dr. Palak Talwar

Email Id: Palaktalwar@outlook.com

Purpose: To examine sociodemographic and illness factors that are associated with interictal psychopathology.

Method: This is a hospital based cross sectional study. Consecutive patients with epilepsy attending the outpatient department were included in this study. Sociodemographic data and illness-related variables in the patients were elicited using self-designed proforma and they were screened for interictal psychopathology using general health questionnaire after taking written informed consent. A total of 195 patients were screened using general health questionnaire and interview, of which 50 were found to have interictal psychopathology. A comparison of various sociodemographic and illness factors was done between the patients with epilepsy having interictal psychopathology and those without interictal psychopathology

Results: Data was analysed using SPSS 22.0. Chi-square test and t-test were used to compare nominal variables and continuous variables respectively. Patients with epilepsy having interictal psychopathology were associated with significantly lesser time since last attack (t=5.38; P=0.00), greater number of antiepileptic drugs used(t=2.133, P =0.35), presence of abnormal EEG (t =31.13, P=0.00), presence of nocturnal attacks (t =15.83, P=0.00), greater duration of seizure(t =10.06, P=0.007) and greater dose of phenytoin sodium(t=2.133, P =0.35). The two groups were similar across various socioeconomic factors and age of onset of illness, use of alcohol and other substances, presence of antecedent head injury, presence of comorbid illness, presence of family history of epilepsy and type & frequency of seizure

Conclusion: Polytherapy with antiepileptics, recent seizure & longer seizure duration and presence of abnormal EEG predispose people with epilepsy for interictal psychopathology. These may represent a population group that requires frequent screening. Cautious use of multiple drugs has been implicated

Keywords: Interictal Psychopathology, Epilepsy, Illness Factors

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Factitious Disorder-a Case Report

Dr. Santosh Kumar Kalla, Dr. R.rama Krishnam Raju, Dr. M. Vijaya Gopal

G.S.L. Medical College And General Hospital, Andhra Pradesh. Email Id: Drsantoshkalla@gmail.com

Factitious disorders are characterized by physical or psychological manifestations that are intentionally produced or feigned with no apparent external incentives in order to assume the sick role. These disorders are rarely reported or may be under-reported. It is thought to account for between 1 in 200 to 1 in 2,000 dermatological consultations. It is more common in women (male to female ratio of at least 1:3), with the highest frequency during adolescence and young adulthood. Here we report a case of 16 year male, presented with multiple wounds all over the body to the department of Dermatology, where he was diagnosed as a case of dermatitis artefacta and was referred to psychiatric unit in July 2016. Complaints were reported since 45 days, initially two in number over right thigh and gradually developed all over the body, but not on his back or other areas of the body inaccessible to the hand. Though he was not critically ill, he was abstinent from studies and had multiple visits to hospitals and faith healers. A provisional diagnosis of factitious disorder is made and was successfully managed with SSRIs and CBT. Case history and psychological interventions in detail will be presented at the time of poster presentation.

Key Words: Facticious Disorder, Dermatitis Artefacta, Ssris, Cbt.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Childhood Onset Schizophrenia- A Diagnostic Challenge

Dr. Prerna Balkrishen Khar, Dr. Swaroop Bhatankar, Dr. Manjeet Santre, Prof. Alka V Pawar

B.J.Govt. Medical College, Pune. Email Id: Prernakhar@gmail.com

Introduction: Childhood-onset schizophrenia (COS) is characterized by onset before the age of 13 years and has a prevalence of approximately 1 in 40,000. This is a severe form of the illness with gradual onset and poor outcome. The symptoms overlap with other disorders of childhood onset (eg. Autism spectrum disorder and attention-deficit hyperactivity disorder)and hence can present as a diagnostic challenge.

Case: A 7 year old boy presented with hyperactive behavior, inattention, repetitive stereotypic hand movements and muttering and gesticulating to self of one and half year duration, that developed after an episode of high grade fever which was not associated with any focal neurological deficit. He was treated with antipsychotics, mood stabilizers and stimulants on out-patient basis; however not much significant improvement was perceived. He was hence admitted for diagnostic evaluation. An EEG done revealed generalized spike and wave pattern s/o generalized epilepsy. Aso titre was four times the normal range. MRI done did not reveal any abnormalities. A pediatric and neurophysician opinion was hence taken. A diagnosis of ADHD with co-morbid autism spectrum disorder was made and he was started on tab. Risperidone, tab. Valproate tob, and Atomoxetine. Since not much improvement was perceived, and the muttering, gesticulating and inattention persisted, the diagnosis was revised to childhood onset schizophrenia. He was started on tab. Clozapine over which improvement was seen. He continues to follow on OPD basis, is he attending school regularly and is he behaviorally stable

Conclusion: It is important to evaluate the cause of any psychosis in a child. A detailed history and examination, (including neurological), pertinent laboratory and imaging tests are important to rule out the various alternative differential diagnoses that also present with psychotic symptoms.

Key Words: Childhood Onset Schizophrenia

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Depersonalization Derealization In Prisoner

Dr. Disha Devang Parikh, Dr. Saurabh S Tople, Prof. Alka V Pawar, Dr. Manjeet S Santre

B.J.G.M.C. And Sassoon General Hospital. Email Id: Disha_parikh007@yahoo.com

Introduction: Depersonalization derealization syndrome involves unpleasant, chronic and disabling alteration in experience of self and environment. In addition to these classical features, patient may experience altered body sensation, anxiety, and depressive symptoms. Daydreaming and cognitive deprivation are potential triggering and maintenance factor for the syndrome

Case: A 30 year old unmarried male, mr. X, inmate of state central prison, was brought with complaints of sudden onset altered behavior with change in consciousness. On detailed examination it was found that he would engage in prolonged period of meditation that involved of continuous daydreaming. He also would not communicate much with any other inmates and would remain self-absorbed. He would also often chant mantras for several hours in the day. He gives a history of having feeling of unreality after such prolonged periods of chanting and meditation. He would also have disturbed body imagery in form of feeling of disembodiment and feels like detached observer. RIBT indicated that patient had difficulty in control and stress tolerance which might lead to affective dysregulation. It also indicated that under stressful situation, he is prone to have episodes where he gets detached from reality.

He was started on insight oriented psychotherapy in which links of his symptoms and daydreaming was done. He was advised to refrain from meditation or chanting.

Conclusion: Over a period of next 15 days in the ward, he did not experience such depersonalization derealization episode. He was also followed on opd basis after discharge. He did not report any such symptoms in prison after discharge over next two months.

Key Words: Depersonalization, Daydreaming, Prisoner

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Iatrogenic Opioid Use Disorder In A Young Woman: A Case Report With Unique Clinical Characteristics

Dr. Akriti Kamran Dr. Harshit Garg, Dr. Mohit Varshney, Dr. Alok Agrawal, Dr. Prabhu Dayal, Dr. Piyali Mandal, Dr. Atul Ambekar

All India Institute Of Medical Sciences. Email Id: Akritikamran@gmail.com

Introduction: Women represent a relatively uncommon but growing population of treatment-seeking opioid-users, particularly prescription opioids. We report a case of iatrogenic-onset prescription opiod use disorder, its consequences and successful (short-term) management in a young woman.

Case Report: A 27 year old married woman, presented with total duration of illness of 7 and 1/2 years with insidious onset, continuous course, characterized by multiple episodes of headache of migrainous nature, 4-5 episodes per day, relieved by injection pentazocine and promethazine. Pentazocine use was characterized by tolerance, use despite harm, and socio-occupational dysfunction. Examination revealed scarred veins on b/l upper and lower limbs and scars of healed abscesses on b/l deltoid region secondary to injection use. MSE had no remarkable findings except fair motivation (action phase) with internal locus of control. She was hospitalized and withdrawal symptoms were managed with sublingual buprenorphine, gradually tapered and stopped. There was significant improvement in headache with t. Topiramate (gradually increased to 50 mg). Non-pharmacological interventions were delivered in the form of psychoeducation regarding drug use, coping strategies for headache and sessions for relapse prevention. On follow up (2 weeks) she reports no opioid use.

Discussion: Data suggest that women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. Progression from substance use to dependence is quicker in women and they suffer more severe emotional and physical consequences, yet underutilize the treatment. In our case, headache and frequent use of prescription opioids progressed to harmful use of opioids (debatable diagnosis of dependence).

Conclusion: Her case demonstrates the need of a holistic approach for assessment and management of substance use disorders in women. Additionally application of diagnostic criteria for dependence in a case of iatrogenic use of opioids may be challenging.

Keywords: Opioid, Women

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Opiod Use In Females:A Case Report

Dr. Akriti Kamran, Dr. Harshit Garg, Dr. Atul Ambekar

All India Institute Of Medical Sciences. Email Id: Akritikamran@gmail.com

Introduction: Women represent a large and growing population of opioid users with a greater proportion abusing prescription opioids. Here we report a case of a female with prescription opiod use, its consequences and successful management.

Case Report: A 27 yrs old married female, mrs. U, presented with total duration of illness of 7 and 1/2 years of insidious onset, continuous course, characterized by multiple episodes of headache of migrainous nature, 4-5 episodes per day, relieved by injection pentazocine and promethazine with the injection use characterized by tolerance, use despite harm, with significant socio-occupational dysfunction. Examination revealed scarred veins present on b/l upper & lower limbs and scars of healed abscesses present on b/l deltoid region secondary to injection use, mse revealing fair motivation with internal locus of control. The patient was diagnosed as mental and behavioural syndrome due to opiod, harmful use (ICD-10), with migraine, with hypothyroidism. She was admitted and started on equivalent doses of buprenorphine to manage withdrawal symptoms, that was gradually tapered and stopped. To manage headache t.Topiramate was started at a dose of 25 mg, gradually increased to 50 mg on which there was significant improvement in headache. During ward stay non pharmacological interventions in form of psychoeducation regarding drug use, possible management stratergies along with sessions for relapse prevention were taken. Patient on follow up reported no opiod use.

Discussion: Data suggest that women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. In our case, headache and frequent use of prescription opiods progressed to harmful use of substance.

Conclusion: Her case demonstrates a successful management of opiod use in a female patient at a tertiary care centre.

Keywords: Opioids, Prescription Opioids, Female Gender

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Online Statistics And The Certification Of Disability Due To Mental Illness And Mental Retardation" What Can We Learn From Telangana And Andhra Pradesh?

Dr. Hareesh Angothu, Dr. Krishna Prasad M, Dr. Deepak Jayarajan, Dr. Siva Kumar T, Dr. Jagdisha Thirthalli, Dr. Aneel Raj

NIMHANS. Email Id: Hareesh.angothu@gmail.com

Introduction: As per the guidelines of persons with disabilities act 1995 appropriate medical boards constituted by different state government or by central government have the authority to assess and to issue such disability certificates. As of now as there is no central data registry about the certified persons with disability in india. Telangana and Andhra pradesh have initiated issuance of digital certificates using software called sadarem and started maintaining online statistics for persons with disabilities. Probably first of its kind in india, these both states are providing readily available statistics of persons with disabilities based on their type of disability, geographical location, sex, age etc.

Methodology: We have retrieved the online statistics of persons with disability due to mental illness and mental retardation from the respective state government maintained web sites and we have analyzed the data to understand about various socio demographic issues as per the data.

Results: 6935 persons were certified as having disability due to mental illness in Andhra Pradesh for a population of 4.93 Crores (about 14 persons per 1 lakh) in comparison with 27815 who were certified as having disability due to mental illness in telangana for a population of 3.52 Crores (about 79 persons per 1 lakh)

Conclusions: It provides finger tip statistics for administrators to plan for social reform measures and appropriate fund and resource allocation based on geography and types of disability. It provides an opportunity to compare the data between geographic pockets or between genders to analyze the differences if any are there and reasons for such differences. There should be a similar system of data base at india level by the ministry of social justice as early as possible and all the lessons from Andhra pradesh and Telangana experience should be used in formulating and implementing.

Keywords: Disability Act, Mental Retardation

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Depression In Diffuse Cutaneous Systemic Sclerosis: A Case Report

Dr. Meenakshi Jain, Dr. Rahul Valecha, Dr. Umar Mushir

Department Of Psychiatry, Index Medical College, Indore. Email Id: Meenakshijain2421@gmail.com

Introduction: Diffuse cutaneous systemic sclerosis (DCSSC) is a rare connective tissue disorder with unknown etiology and multi-organ involvement. Depression is a common, yet unfortunately under-diagnosed, psychiatric disorder associated with dcssc in a bi-directional relationship. On one hand, presence of arthralgia, fatigue, body image disturbance and resulting functional disability makes the patient vulnerable to depression. On the other hand, depression itself affects these patients via immunological dysregulation, altered social and behavioral processes, leading to poor compliance to treatments and hence, increased morbidity.

Case Description: A 25 year old female presented with nonhealing ulcer in both feet, fatigue, joint pain and excertional dyspnea. She was referred to psychiatry department with complaints of feelings of hopelessness and worthlessness, social withdrawal, irritability, loss of appetite and suicidal ideation. Patient was diagnosed with severe depressive episode without psychotic symptoms, as per ICD 10 diagnostic criteria. General examination revealed symmetrically distributed skin indurations, stiffening of fingers and hypertension. Investigations revealed hb = 8.5, Antinuclear autoantibody = positive, cxr = pulmonary fibrosis. She responded well to escitalopram 20 mg and psychotherapy. On her successive follow-up improved treatment adherence and better quality of life was documented.

Conclusion: Depression should be diagnosed early and treated appropriately in case of systemic sclerosis. Better global outcome of DCSSC requires a multidisciplinary management approach.

Keywords: Systemic Sclerosis, Depression, Escitalopram

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Treatment Refractory Essential Tremors Preceding Onset Of Parkinson Disease (PD) In The Course Of Bipolar Disorder: Therapeutic Challenge

Dr. Shailesh Jha, Dr. Pankaj Kumar, Dr. Siddharth Maheshwari

Department Of Neurology, IHBAS, Delhi. Email Id: Dr.shaileshk.jha@gmail.com

Essential tremors (et) and parkinson disease (pd) are the two most common movement disorders entity encountered. Although these are considered distinct but have overlapping clinical features. This relationship has been considered a separate category of ET-PD syndrome by the researchers. [99mTc]TRODAT-SPECT Scan is an appropriate method which can differentiate between pd versus et. Furthermore, the long standing bipolar disorder with subsequent psychotropic exposure complicates the presentation and management difficulty in such comorbid cases. We report a case of treatment refractory et preceding the onset of pd in the course of bipolar disorder and its management implications.

Keyword: Essential Tremors; Parkinson Disease; Bipolar Disorder; Treatment Refractory.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Metabolic Profile In Patients With Schizophrenia In North-western India: An Exploratory Study

Dr. Naresh Nebhinani, Dr. Navratan Suthar, Dr. Swapnil Tripathi, Dr. Priyanka Purohit

AIIMS Jodhpur. Email Id: Drnaresh_pgi@yahoo.com

Background & Aim: Very few studies have assessed metabolic profile in patients with schizophrenia in North-western india. The study was aimed to assess the metabolic profile in patients with schizophrenia.

Materials And Methods: By convenient sampling, 55 patients with schizophrenia were recruited from psychiatric outpatient clinic at aiims jodhpur and evaluated for the presence of metabolic abnormalities and metabolic syndrome (MS) using the modified national cholesterol education program adult treatment panel III NCEP ATP III criteria.

Results: 19 patients (34.5%) had MS and other 31 patients (56.45%) Had one or two metabolic abnormalities. Most common metabolic abnormalities were higher waist circumference (67%), followed by lower hdl (60%), and least common abnormality was raised blood pressure (14%). Nearly half of the patients (56%) were obese. Age, body mass index, obesity and being married were significantly associated with MS. MS was not associated with duration and severity of schizophrenia (PANSS score), attitude towards psychotropics (DAI-10 score), functionality (GAF score) and demographic variables. On logistic regression analysis, age, body mass index, obesity and being married were found significant predictors of MS.

Conclusion: One-third of the patients had ms and other half had one or two metabolic abnormalities. It calls for comprehensive physical and psychiatric care of the patients, with proper assessment, timely management and effective prevention of metabolic problems.

Key Words: Metabolic Syndrome, Metabolic Abnormalities, Schizophrenia, North-western India

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Levetiracetam-induced Acute Psychotic Episode- A Case Report

Dr. Prabhat Sharma, Dr. Rahul Valecha, Dr. Sudhir Mourya

Index Medical College Hospital And Research Centre, Indore. Email Id: Palu.diya.ps@gmail.com

Introduction: Levetiracetam(lev) is known to cause behavioural side effects ranging from anxiety to agitation and hostile behaviour. Even though psychotic symptoms were reported in initial trials, they are less common compared to behavioural symptoms.

Case Description: A 43-year old male with no past psychiatric history was admitted to our ward with a first episode of psychosis. He is k/c/o partial complex seizures since he was three years old. At initial evaluation, he was anxious, agitated, and was complaining of insects crawling all over his body and entering into his mouth, ears, and nose. He was distressed and was trying to pick these insects from his body. He said that he was able to see them and was asking to switch off the light to get rid of them. Medications on admission were lev 500mg orally twice daily, valproic acid 500mg orally twice daily. The patient denied any recent medication changes, but his wife said he was taking one extra tablet of lev from last one week. No h/o of substance abuse or any recent head trauma. Physical examination was normal. Based on history, physical examination, and diagnostic tests, a diagnosis of lev-induced psychosis was made. Lev was stopped and olanzapine 5mg orally was started. The patient recovered from his psychotic symptoms over next 48 hours and was discharged home.

Conclusion: This case report revealed that drug induced psychosis is one of the dose dependent side effect of lev. The early diagnosis by close clinical monitoring with regard to psychiatric adverse events and early treatment intervention is necessary.

Keyword- Levetiracetam, Psychosis, Partial Complex Seizures.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Ethambutol Induced Psychosis - A Case Report

Dr. Umar Mushir, Dr. Rahul Valecha, Dr. Meenakshi Jain

Department Of Psychiatry, Index Medical College, Indore. Email Id: Umar.mushir@gmail.com

Introduction: Most cases of ATT “associated psychoses were caused by isoniazide (INH), ethambutol (EMB)-induced psychosis being rare. The concomitant occurrence of INH and EMB induced psychosis in a single individual is extremely uncommon.

Case Description: A 47-year-old male, smoker, on ATT with isoniazide, rifampicin, ethambutol and pyrazinamide for pulmonary tuberculosis for last 4 weeks suddenly became restless with aimless, incongruous acts, and irrelevant talking, disorientation, and auditory hallucinations.. He had no past history of any mental illness. Vitals were stable with no neurological deficit.

Possibility of INH induced psychosis was considered as symptoms had temporal correlation with start of ATT hence isoniazide was stopped. After 2 weeks of stopping isoniazide, psychotic symptoms didn’t resolve. Psychosis was not severe and the patient did not pose a threat to himself and surroundings. He was admitted with round the clock monitoring. Finally, ethambutol was also stopped and att regimen changed to rifampicin, pyrazinamide and ofloxacin. Within a week the patient showed marked improvement in psychotic symptoms. After 3 weeks patient showed no signs of psychosis.

Conclusion: Most cases of att associated psychosis are caused by isoniazide. Ethambutol induced psychosis is rare. Isoniazide inhibits the activity of brain pyridoxal-5-phosphate (produced in the body from pyridoxine), which leads to a decrease in brain gamma-amino butyric acid and other synaptic transmitters, resulting in neurologic ill effects. Ethambutol is one of the most commonly used drugs in the treatment of tuberculosis. The main side effect is retrobulbar neuritis. Cns toxicity is not widely reported and psychosis secondary to it is very rare. Exact mechanism of ethambutol induced psychosis is not clear. The symptomatology of ethambutol induced psychosis is almost same as that of isoniazide.

Keywords: Psychosis, Ethambutol, Isoniazide

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Thyroid Dysfunction And Altered Lipid Metabolism In Elderly Depressed Women

Dr. Ram Kumar Solanki, Dr. Aditi Ranawat, Dr. Parag Sharma, Sawai Man Singh

Medical College, Jaipur. Email Id: Solanki_ramk@yahoo.co.in

Background: A majority of elderly women is accompanied with significant somatic and psychiatric symptomatology. A need was felt to examine whether a comorbidity of metabolic and psychiatric disorders occurs in this patient population or whether they occur independently.

Aim: To examine thyroid profile and lipid metabolism in elderly depressed women.

Method: A cross sectional, case-control study was planned. The experimental group consisted of elderly women with depressive disorder (ICD-10 criteria) (n=40), and was compared with a control group (n=30) without depressive disorder. Subjects were assessed through becks depressive self-rating inventory and their blood level of thyroid stimulating hormone (TSH) and lipid profile was assessed. Group comparison was done with chi square test and z test.

Result: Serum total cholesterol, triglyceride, TSH levels were significantly higher and hdl levels were significantly lower in the depressed group.

Conclusion: In elderly depressed women thyroid and lipid profile is significantly altered and needs clinical attention.

Keywords: Lipids, Thyroid Dysfunction, Depression

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Profile Of Patients Attending Emergency Psychiatric Services In RIMS Hospital

Dr. Ashutosh Dash, Prof. N. Heramani Singh, Dr. S. Gojendra Singh

Dept. Of Psychiatry R.I.M.S, Hospital, Impahl. Email Id: Ashutosh.dash9936@gmail.com

Background: A psychiatric emergency is any disturbance in thoughts, feelings, or actions for which immediate therapeutic intervention is necessary. There are studies showing wide range of concomitant medical disorders 7% to 63% in emergency presenting as psychiatric emergencies. So study of this pathway of care is utmost important.

Materials And Methods: A total of 709 consecutive patients were assessed in the emergency department of RIMS Hospital, Imphal. It was a cross sectional study for a period of 2 year. The patients were studied for socio-demographic variables, clinical profile and reason of referral. A semi-structured proforma was used to take socio-demogaphic variables and diagnoses were made according to ICD-10.

Results: This study showed that maximum number of psychiatric referrals belonged to the young age group of 21-30 years. Male were predominantly more than the females with a ratio of 2.12:1. Majority of the patients were from urban region, married, completed education up to secondary standard and jobless. The primary diagnoses in this study were substance use and related mental and behavioral disorder, anxiety and stress related disorder and mood disorder with 43.9%, 24% And 9% respectively.

Conclusion: Psychiatry as such, and emergency psychiatry in particular have been the neglected areas of medicine. The present study was an attempt to report data of the patients presenting in emergency department primarily with psychiatric problems which may help in planning and starting the emergency psychiatric services throughout the country.

Keywords: Psychiatry Emergency

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Case Of Anti Psychotic Induced Extra Pyramidal Symptoms In Organic Brain Lesion

Dr. Vaddi Rohit, Dr. Sameer K Praharaj

Kasturba Medical College, Manipal Karnataka. Email Id: Vaddirohit113@gmail.com

A 47 years old patient from MSES, currently bank employee reports of having anxiety and sad mood since last 3 years. Patient has been having difficulty in performing work as a cashier as he was having memory disturbances, he was noted giving cash to people again, misplacing the money. Patient was caught in one such act, since then patient started having fear, anxiety and palpitation. He developed sadness low self confidence decreased sleep and appetite. Patient was started on escitalopram 10 mg and clonazepam 0.5 Mg. Patient continued to have anxiety and depressive features. Later was started on t olanzapine 5mg 1 week after starting of medication patient started having tremors

Past Illness

Patient started having tremors at of 21 years of age. Patient was started on t proponalol 40 mg, had significant improvement of symptoms

Family history

4 spontaneous abortion in the elder siblings of the patient

Suicide in elder brother

Premobid personality-anxious avoidant type

Educational history. Graduate b com

Mse

Attention was aroused and sustained

Registration for address test was 2/5, 3 object test registration was normal. Recent recall of objects was 1 of 3 objects, was finding difficulty in remembering things which he eat for breakfast and dinner remote memory was intact

Mood sad

Affect depressed

Physical examination

Head circumference 60 centimetres, low set ears, 3.5 Centimetres gap between 1st and 2nd toe on the left leg and 2.5 Centimetres between 1st and 2nd toe.

Fine tremors, cog wheel rigidity, decreased blink rate and reduced arm swing.

After admission patient was started on trihexyphenidyl 2mg 1-0-0 for extra pyramidal symptoms. Little improvement of symptoms after 1 week of treatment. Patient continued to have tremors; cog wheel rigidity decreased. MRI was done. Further line of action will be presented in poster.

Keywords: Extra Pyramidal Symptoms, Organic Brain Lesion, OBL

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Study Of Prevalence Of Depression And Anxiety In Patients With Androgenetic Alopecia

Dr. Anisha. P. Landge Dr. Shubhangi Dere, Dr. Darpan Kaur, Dr. Sweta Roy, Prof. Rakesh Ghildiyal

Department Of Psychiatry, MGM Medical College, Navi Mumbai. Email Id: Dradl.1289@gmail.com

Introduction: Androgenic alopecia (AGA) is the most common form of hair loss in both men and women. Since hair is an essential part of an individual's self-image, the consequences of AGA are predominantly psychological. Several studies show that the negative self-perception of balding patients appears to be consistent between western and asian cultures.

Methodology: This was a cross-sectional, observational study conducted at psychiatry department, MGM medical college, navi Mumbai. Forty four consenting patients and fulfilling inclusion criteria (sample size calculated using open epi software) were included in study using simple random sampling. Patients were first assessed using the Ludwig scale for women and Hamilton-Norwood scale for men to determine the severity of AGA. Depression and anxiety symptoms were screened using the hamilton depression and anxiety rating scales (HAM-A and HAM-D).

Results: Data analysis was done using spss 17. Mean age of patients was 39.5 Years with majority (54.5%) Of the patients belonging to middle age group (31-45 years). Majority of the patients were females (52.3%), Graduated (36.4%), Having skilled jobs (52.3%), Married (81.8%), And belonged to middle class (52.3%). The maximum score attained was 37 and 44 on HAM-A and HAM-D respectively; minimum score of 10 with mean score of 19.5 And 22.2 And standard deviation of 7 and 9.6 On (HAM-A and HAM-D) respectively which signify mild-moderate anxiety and depressive symptoms in patients with androgenic alopecia. Statistical analysis did not reveal any significant association between the ham-a, ham-d scores with age of patients, duration and severity of their aga.

Conclusion: Co-morbid anxiety and depressive symptoms in AGA are common, however, they often go unrecognized. Liaison therapy with multidisciplinary approach between psychiatrists and dermatologists can help diagnose this morbidity earlier and help patients improve their psycho-dermatological disorders.

Keywords: Androgenic Alopecia, Depression, Anxiety, Psychiatric Morbidity

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Patterns Of Psychiatric Co-morbidities In Patients Of Chronic Retroviral Disease On Anti Retroviral Treatment- A Retrospective Data Based Analysis Study

Dr. Sweta Roy, Dr. Darpan Kaur, Dr. Shubhangi Dere, Dr. Anisha Landge

Department Of Psychiatry, MGM Medical College, Navi Mumbai. Email Id: Sweta2602@gmail.com

Back Ground: WHO data highlights that globally 36.7 million people were living with HIV. However, there is sparse literature on mental health research in HIV and AIDS from developing countries such as india.

Aims And Objectives: To study patterns of psychiatric co-morbidities and associated factors in patients of chronic retroviral disease on anti retroviral treatment.

Methods: This was a retrospective data analysis of patients with diagnosis of chronic retroviral disease on anti retroviral treatment referred to psychiatry opd services from 1/8/2015 to 1/8/2016. Institution ethics committee clearance was obtained and data was analyzed with spss 17. Variables such as demographic factors, comorbid substance abuse, psychiatric co-morbidity, source of referral, neurological and medical co-morbidity, psychopharmacological and psychotherapeutic intervention were analyzed.

Results: The study found that 14 patients of RVD on anti retroviral treatment had been referred for out patient psychiatric consultation over past 1 year. The overall rate of referral was low. Mean Age of sample was 47.8Yrs with sex profile being 50% male and 50%females. Majority of patients were from urban areas 57.1%. Most common neurological and medical co-morbidity were seizure and tuberculosis respectively. Psychiatric diagnosis analysis revealed that 60.5% Patients had depressive disorders, 21.4% Had psychosis (organic psychosis),7.1% had AIDS related dementia, 7.1% had personality disorders and 3.8 % Had manic episode. Maximum source of referrals were from Medicine department (21.4%) and NGO (20.8%). The most common prescribed drugs profile in the sample were escitalopram (5 mg to 20 mg), olanzapine (5 mg to 20 mg), donepezil (5 mg to 23.5 mg) and sodium valproate (500 mg to 1000 mg).

Conclusion: Consultation liaison psychiatry in arena of mental health and HIV are further needed with larger sample size and longitudinal models.

Key Words: Patterns Of Psychiatric Co-morbidities, Chronic Retroviral Disease, Antiretroviral Treatment

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Personality Correlates Of HIV Infection

Dr. Vinay Singh Chauhan, Prof. Brig(dr) S Sudarsanan, Prof. Col (dr) S Chaudhury, Dr. K Srivastava

AFMC, Pune. Email Id: Vinaychauhan2@gmail.com

Aims & Objectives: To study psychiatric morbidity in asymptomatic patients and to identify various determinants that affects the psychiatric morbidity and to assess their role

Materials And Methods: The study was undertaken at a large 1200-bedded tertiary care hospital. A case-control research design was used.

Cases: All asymptomatic HIV patients who were admitted to the hospital at the time of evaluation with appropriate inclusion and exclusion criteria. Controls: An equal number of age, education, sex, monthly income and occupation matched normal person were selected as controls.

Methodology: Following psychiatric scales were used to assess psychiatric morbidity: GHQ 12, HADS, MMSE, sensation seeking scale. The demographic characteristics of the group were compared by the chi square test. For comparing the scores on psychiatric rating scales the mann-whitney-u test was used.

Results: The subjects in two groups were matched in age, sex and education status. Risk factors for HIV in the present study were heterosexual promiscuity in 85% of the cases while multiple injections/tattooing (3%), transfusion of unscreened blood (25), health worker handling blood (1%) and in (9%) patient denied any high-risk behaviour. Asymptomatic HIV patients had statistically significant higher GHQ caseness & depression. Anxiety scores were higher in asymptomatic HIV patients. Sensation seeking trait was assessed under the four different characteristics. Thrill and adventure seeking, experience seeking and boredom susceptibility revealed statistically significant higher scores in asymptomatic HIV patients compared to HIV seronegative controls. However disinhibition scores did not reveal any statistically significant difference between two groups. The difference between the two groups for alcohol dependence syndrome was statistically significant

Conclusion: Psychiatric morbidity is higher in asymptomatic HIV patients as compared to HIV seronegative controls. High sensation seeking and substance abuse may play a vital role in engaging in high risk behaviour resulting in this dreaded illness.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Case Series Of Trichotillomania With Three Different Entity

Dr. Neha Rameshchandra Modi Dr. Pradhyuman Chaudhry, Dr. R.y. Mehta, Dr. K.r. Dave

Government Medical College, Surat. Email Id: Nrmsmile14@yahoo.com

Trichotillomania, a disorder characterized by chronic hair pulling that result in alopecia is an impulse control disorder. Trichotillomania affects 4% of the population.(P.N.Suresh et al 2012) Significant comorbidity(38.8%) is found between trichotillomania and different entities like schizophrenia, bipolar mood disorder or depressive disorders, Obsessive Compulsive Disorder, Borderline personality disorder.(Flessner et al2012, houghton et al 2016) While the most common age of onset is puberty, it can begin at any age but mainly reported in adolescents or young adult females.

We report three cases of trichotillomania with three different comorbid psychiatry disorders; schizophrenia, borderline personality disorder and Bipolar Mood Disorder.

Case 1: A 30 years old female patient with hearing of voices, persecutory ideas, fearfulness since last 12 years, developed urges of pulling scalp hair, waxing and waning along with psychotic features.

Case 2: An 18 years female patient with anger outbursts and self-harm behaviour, had adjustment problems with parents secondary to her relationship with a male which was not acceptable, developed urges of pulling scalp hair since 3 years.

Case 3: A 40 years old female patient presented with complaints of depressed mood without diurnal variation, feelings of worthlessness and hopelessness for 2 months along with scalp hair pulling behaviour. She had past history of manic and depressive episodes.

Discussion: In these cases, the description of hair pulling behavior is similar to that reported by patients with only trichotillomania. Further, patients denied any association between hair pulling and symptoms of comorbid disorder.

Current treatment strategies involve a multimodal approach. Patients of schizophrenia and borderline personality disorder had improvement after adding of ssris on atypical antipsychotics, while a patient of bipolar mood disorder had improvement in trichotillomania only with mood stabilizers.

Key Words: Trichotillomania, Psychiatric Comorbidities

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Multiple Brain Insults Attributing To Neuropsychiatric Manifestations In A Young Male

Dr. Sujita Kumar Kar, Dr. Abhijeet Shrivastava, Dr. Adarsh Tripathi, Dr. Sushanta Kumar Sahoo

King George's Medical University, Lucknow, U.P. Email Id: Drsujita@gmail.com

Background: Traumatic brain injury (TBI) can result into cognitive, emotional, behavioural and sensory- motor disturbances. These post-traumatic neuropsychiatric disturbances pose substantial challenges to clinicians in diagnosing, treating and rehabilitating such patients. The development of neurobehavioral sequelae after TBI is a multifactorial process which requires a multidisciplinary approach.

Aims And Objectives: In present case we aim to demonstrate the role of insult to brain (ischemic brain injury, seizure and traumatic cerebral bleed) in development of psychiatric disorder, in a 20 year old male.

Methodology: Patients history was evaluated in detail. After mental status examination, physical and systemic examination including detailed neurological examination, psychological testing, patient was diagnosed as a case of organic bipolar disorder. Rating scale (YMRS) was applied to assess symptoms severity. Side effects were closely monitored during hospital stay.

Results: In our patients behavioural changes correlated with ischemic brain injury. Initially attempted hanging resulting in comatose stage lasting for 24 hour could be causative factor for anoxic damage to brain followed by generation of depressive symptoms. A seizure episode caused resolution of depressive symptoms. Patient had manic symptoms for 3 months during which he had sustained traumatic brain injury (left frontal hematoma). It resulted in subsidence of manic symptoms on its own with re-emergence of manic symptoms as the hematoma reduced in next 2 weeks period.

Conclusion: Insult to brain could have impact on behavioral symptoms in various ways which depends upon the nature, site of the TBI and complex interaction between the psychiatric psychopathology and tbi that finally determines onset, course and outcome of neuropsychiatric presentation.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Prepartum Psychosis: A Case Report

Dr. Anu Hasmukh Patel, Dr Rajat Oswal

Medical College, Vadodara, Gujarat. Email Id: Anupatel311@gmail.com

Background: Reproductive events and processes affect physiological and psychological states concomitantly. Puerperal psychosis occurs in women during and within few weeks of pregnancy. Women with their first child birth, previous psychotic puerperal episodes, inherited serious psychiatric disturbances, caesarean section, female child, relationship problems are at a higher risk of developing puerperal psychosis.

Case: A 22 year old presented with first episode of hallucinations, disorganized behavior. Her symptoms started 3 days before the delivery and lasted till three weeks after delivery. She delivered a healthy female child. She was started on an atypical antipsychotic and was discharged on improvement after a week of hospitalization.

Conclusion: Prepartum psychosis doesn’t have a clear diagnosis in DSM 5. It is mentioned in brief psychotic disorder under the subtype of post partum onset which mentions during pregnancy and within 4 weeks of pregnancy. Prepartum and postpartum onset of psychosis presents different set of challenges for the treating psychiatrist. Post partum psychosis can be managed without much difficulty as side effects in infant can be monitored and dosage of drugs can be titrated as required with shifting from breast milk to top feed while prepartum psychosis needs special attention because one needs to be vigilant about labour or consider artificial induction of labour and passage of medication through placenta and its impact on the fetus.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Case Report On Psychopathology And Treatment Response In Schizophrenia

Dr. G J Vijay Mathews, Dr. M. Vijaya Lakshmi, Dr. R.V.R. Abhinaya

Andhra Medical College. Email Id: Dr.vijaymathews@gmail.com

Observation: A 30 year old female diagnosed as paranoid schizophrenia (ICD 10) of 4 years illness duration with probable precipitating factor being work and emotional stress at a gulf country where she worked as a maid. MSE showed paranoid & bizarre delusions, psychotic gender distress & 2nd person type auditory hallucinations which were treated with adequate doses of haloperidol for 6 weeks, later on with olanzapine plus electro convulsive therapy.. Poor response regarding bizarre delusions & psychotic gender distress was seen & so clozapine was initiated and later improvement was assessed. The dosage is yet to be titrated for further positive response and the case is being followed up.

Investigations: Routine blood investigations, mri brain, thyroid function tests were normal

Conclusion: Partial response is seen after initiating clozapine.

Keywords: Schizophrenia, Bizarre delusions

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Atypical Bipolar Vs Kleine-levin Syndrome

Dr. Mukku Shiva Shanker Reddy, Prof. S.k Chaturvedi, Dr. Harish Thippeswamy, Dr. Sanjib Sinha, Dr. Shivashanker Reddy

NIMHANS. Email Id: Shivakmc55@gmail.com

Background: Kleine-levin syndrome was first described by kleine and levin. Kleine-levin syndrome is characterized by episodes of hypersomnia along with cognitive changes, hyperphagia with compulsive eating, hypersexuality, or abnormal behavior (miglis & guilleminault, 2014). Sleep disturbances are common in mood disorders. In a study done to assess hypersomnia prevalence in 65 individuals with bipolar disorder and 19 individuals with major depressive disorde showed that78%of the BD group shown hypersomnia, whereas only 26% of individuals with MDD endorsed the same (detre et al., 1972). We present about a patient who presented with episodic hypersomnia.

Case history: a 58 year elderly gentleman working as accountant presented with illness of 40years duration characterized by excessive sleep initially once in year lasting 18 hours, progressed to 36 hours, now 60 hours. There is increase in frequency and duration of sleep gradually, more so in the last 1 year and also has hyposexuality. Premorbidly he was well adjusted. Patient's family history revealed bipolar illness in mother. Patient's personal history has shown nicotine use in dependence pattern and alcohol harmful use. He has hypertension since 8years. Treatment history shown that he was on tab. Lithium 400mg for 3 months, 10 months ago with moderate improvement. On physical examination his BMI-28.65 Kg/sqm, pulse rate-86 bpm, BP-130/80 mm of hg, MMSE score is 30 and CNS examination shown no focal deficits. Laboratory investigations -hb%- 14.5 gm/dl, FBS-99 mg/dl, TSH-2.65 IU/ml, vit. B12-136 pg/ml(low), folate-5.17 ng/ml, ANA- negative, RA-negative, urine drug screen is negative. MRI- brain-normal. Patient was diagnosed as atypical bipolar disorder versus Kleine-Levin syndrome. In the management patient was advised tab. Lithium SR 400mg, sleep hygiene measures, weight reduction.

Discussion &conclusion: the history of patient like mother having bipolar illness, he having alcohol harmful use started at young age, episodisity of the course and response to lithium made us

Keywords: Bipolar, Kleine-levin syndrome

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Brief Intervention In Substance Use: A Review

Dr. Preethy Kathiresan, Dr. Rachna Bhargava

Aiims, New Delhi. Email Id: Preethymmc@yahoo.co.in

Background: There is a growing trend of use of alcohol, tobacco and other illicit substances globally which can lead to increased risk of substance use related disorders. Brief intervention identifies current problems with substance use and motivates those at risk to change their substance use behavior. This can reduce the risks associated with substance use. The purpose of this poster is to review the available literature on brief intervention for substance use and its utility in indian context.

Material And Method: A review of literature was done using pubmed, google scholar. A total of 57 studies were reviewed including 9 studies from India.

Result: Substantial amount of evidence is available for alcohol followed by tobacco. Overall, the existing literature showed considerable heterogeneity in the brief intervention used in studies. Also there was no uniformity in the control groups used. Even with these limitations, brief intervention has been shown to be effective in alcohol use. Studies on brief intervention for other substances are scarce and the results are not conclusive. There are almost negligible studies on brief intervention from India. And the studies available are also mostly review of foreign articles. Also barriers in applying brief intervention in Indian context have been discussed.

Conclusion: Brief intervention should be implemented as part of general practice. Further research has to be done in India to determine the effectiveness of brief intervention among indian population using well designed randomized controlled trials and longitudinal studies.

Key Words: Substance Use Disorder, Brief Intervention

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Late-onset Obsessive-compulsive Disorder Without Evidence Of Any Organic Cause

Dr. Satyakam Mohapatra

Email Id: Satyakgmu@gmail.com

Introduction: Obsessive-compulsive disorder (OCD) is the fourth most prevalent psychiatric disorder, having an onset in the second and third decade of life. The mean age at onset of OCD is between 20 and 25 years and that only 15% of cases present after the age of 35. Late onset ocd is usually described in the context of organic etiology.

Methodology: We describe a case of a woman who developed OCD for the first time at the age of 58 years without any evidence of organic etiology and responded well to pharmacotherapy.

Results: A 58-year-old female patient presented with complaints of repetitive hand washing and cleaning, spending more time in bathing, fear of being contaminated with dirt and germs and decreased sleep for last 6 months. On mental status examination contamination type of obsession was elicited. Physical examination and laboratory investigations were within normal limits. Considering late onset of obsessive and compulsive symptoms non-contrast computerized tomography of the brain was done which revealed no abnormality. She was started on tablet fluvoxamine 100mg and tablet clonazepam 1mg per day. After 6 weeks of treatment her symptoms improved significantly.

Conclusion: While a great amount of attention has been paid to juvenile and adult-onset ocd, there is a dearth of studies on patients showing ocd for the first time at later stages of life. Previous reports suggest that in cases of ocd with delayed onset and absence of organicity may have fairly good response to treatment. Our patient also responded well to pharmacotherapy. We emphasize that as late onset ocd usually present with organic etiology, so every case should be investigated properly. But some cases may present without any organic etiology. So systematic research is required to understand whether late-onset is associated with unique clinical, genetic, neuropsychological and neurobiological correlates.

Keywords: OCD, Organicity, Late onset

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Clozapine Induced Hypertension: A Case Report

Dr. Peter Joseph Kinatingal

Email Id: Pjoekin@gmail.com

Clozapine is a second generation anti psychotic used in the management of treatment resistant schizophrenia. Though scientific reports are available, the development of hypertension as a side effect of clozapine remains relatively unrecognized.

An adolescent diagnosed as schizophrenia according to ICD 10, with inadequate response to adequate dose of 2 anti psychotics, developing hypertension at a dose of above 400mg/day of clozapine was observed in the inpatient setting of tertiary care center. Extensive and thorough examination and investigation including cardiac consultation revealed no other possible cause for hypertension, which reverted back to baseline once the dose of clozapine was reduced.

The blocking of renal d4 receptor, sympathetic hyperactivity, alpha 2 receptor inhibition are possible mechanism for clozapine induced hypertension.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Perceived And Internalized Stigma Among Substance Users: An Exploratory Study

Dr. Shreeya Gyawali Dr. Vinay Saini, Dr. Swarndeep Singh, Dr. Yatan Pal Singh Balhara, Dr. Siddharth Sarkar

Department Of Psychiatry And National Drug Dependence Treatment Centre, All India Institute Of Medical Sciences, New Delhi - 110029. Email Id: Shreeya.gyawali@gmail.com

Background and Aims: Substance use disorders are often associated with considerable degree of stigma. This study aimed to assess the relationship of perceived stigma towards substance use and the internalized stigma among substance users.

Methods: This observational study was conducted at the outpatient and inpatient of a tertiary care addiction treatment facility in india. Patients with substance use disorders were included, and demographic and clinical data were recorded. Perceived stigma was assessed using perceived stigma of substance abuse scale (PSAS), while internalized stigma was assessed using internalized stigma of mental illness scale (ISMI).

Results: A sample of 68 participants were included, 67 (98.5%) of whom were males. Opiates was the primary substance of abuse in the majority (n = 53, 77.9% Of sample). The mean PSAS score of the sample was 19.9 (Â±2.8), While the mean ISMI score was 3.04 (Â±0.33). Among the sub-scales of ISMI, the alienation score was the highest (mean score 3.30), Followed by social withdrawal (3.19), Discrimination experience (3.03), Stereotype endorsement (2.98) And stigma resistance (2.64). The perceived stigma scores did not have a significant correlation with the ISMI (r = -0.057, P = 0.645).

Conclusion: Stigma remains an important issue among patients with substance use disorders, though perceived stigma towards substance use seems to be independent of the internalized stigma. Further assessment is required to know how stigma influences the health-care seeking, and treatment outcomes, and how can such stigma be reduced.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Association Between Childhood Adversity And Metabolic Outcomes In Adults With Bipolar Affective Disorder

Dr. Mohit Saini, Dr. Th. Bihari Singh

Psychiatry RIMS, Imphal. Email Id: Msaini125@gmail.com

Introduction: Patients with bipolar disorders are often having co-morbidity with components of metabolic syndrome on the other hand childhood adversity has been hypothesized to be a common risk factor for both metabolic disturbances and bipolar disorder.

Methods And Materials: A Cross- sectional study was carried out in Department of Psychiatry, RIMS, Imphal. to examine the association between childhood adversity and metabolic outcomes in adults with bipolar affective disorder (BPAD). 73 Patients with lifetime diagnosis of BPAD were selected over one year period. International diabetes federation criteria were applied to measure metabolic syndrome (METS). Childhood adversity was measured using adverse childhood experience self-report questionnaire with categories of adversity pertaining to abuse, neglect, and family/household dysfunction. Chi square and fisher exact test was applied as tests of associations. For continuous variables student-t test or Mann Whitney test was applied depending on normality of distribution.

Results: One-fourth (24%) of the sample met criteria for mets. Childhood adversity was highly prevalent with 84% experiencing at least one category of childhood adversity. METS was found higher (p= 0.029) among subjects with childhood adversity of parental divorce / separation. Substance abuse in family was associated with a higher systolic blood pressure (o.R. = 2.659; 95% Ci= 1.186- 5.964; P = 0.017).

Conclusion: METS and BPAD typically emerges during adulthood, yet the risk of developing these is affected by social and economic factors in early life, such as childhood abuse, neglect and family dysfunctions. This study provides preliminary evidence linking childhood experience of parental divorce/separation and substance abuse in family to metabolic disturbances in adulthood.

Key Words: Childhood Adversity, Bipolar Disorder, Metabolic Syndrome.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Cyproheptadine And Dexamethasone Abuse In A Female With Generalized Anxiety Disorder And Tobacco Dependence- A Case Report

Dr. Deepak Krishna Ghormode Dr. Poonam Dhoke, Dr. Rekha Ratnani, Dr. Devendra Ratnani

Email Id: Gdkrishna@gmail.com

Background: Cyproheptadine is an antihistamine with additional anti-serotonergic and anticholinergic activity used mainly as appetite stimulant, in some allergic reactions and prophylaxis of migraine. Dexamethasone is a glucocorticoid used mainly for inflammatory and autoimmune conditions.

Aim: To present cyproheptadine and dexamethasone abuse in a female with generalized anxiety disorder and tobacco dependence

Methodology (case description): A 37 years old housewife educated upto x std, was referred for assessment of anxiety symptoms. On detailed exploration, she had symptoms since nearly 10 years suggestive of generalized anxiety disorder along with frequent panic attacks. She also revealed chewing tobacco almost daily since 10 years and since last five years, 5-6 times in a day with increased desire and would feel restless when could not get the substance. On further questioning, patient also reported taking tab cyproheptadine 4 mg and tab dexamethasone 0.5 Mg twice a day since nearly 8 years. Patient was suggested these tablets by her distant relative so as to look attractive and healthy as she appeared thin then. She continued these medications on her own initially for 4-5 months, once she tried to discontinue the medications but within the next day experienced sleep disturbance, restlessness, bodyaches and loose motions that reversed after continuing the tablets. Thereafter over the years she continued with the same doses and whenever she tried to discontinue, or could not get those, would have similar symptoms. She was treated on opd basis with paroxetine 12.5-25 mg/day and clonazepam 0.5 mg B.I.D. Gradually tapered off along with supportive psychotherapy.

Conclusion: Careful exploration of pattern of cyproheptadine and dexamthasone use may be essential as these are being commonly used and for various indications.

Keywords: Dexamethasone, GAD

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Lamotrigine In Idiopathic Hypersomnia: A Hypothesis From A Case Series

Dr. Sumit Kumar, Dr. Mercy Mohanty, Dr. Sandesh Pasumarthy, Dr. Sanjay Pani, Dr. Jayaprakash Russell Ravan, Prof. Prakash C Choudhary

Kalinga Institution Of Medical Sciences. Email Id: Sunn485@gmail.com

Background: Idiopathic hypersomnia is a clinical entity characterised by excessive sleepiness. This entity has been a neglected area in clinical practice. There is no FDA approved medication till date. Most often these subjects receive off label treatment as per the discretion of primary therapist.

Aims And Objectives: This observation study aims at use of lamotrigine as mono-therapy in patients with hypersomnia and to assess the effectiveness of lamotrigine as a first line intervention strategy.

Methods And Methodology: Twenty consecutive cases of hypersomnia attending a post graduate out- patient department of KIMS, Bhuvaneshwar were included in this study. Fourteen of the subjects were excluded due to presence of the primary psychiatric illness (like BPAD, atypical depression, Klein-Levin syndrome) and neurological disorder (like seizure disorder, post head injury sequel). Rest six subjects were given lamotrigine as monotherapy. The improvement was assessed after a period of 2 weeks in out patient clinics. Followed up after three months for assessing the sustainability of improvement

Results: 85% of these cases of idiopathic hypersomnia showed significant improvement in the symptoms of sleep as well as socio occupational functioning with long term stability.

Discussion: The possible hypothesis could be the action of lamotrigine on sleep cycle and on gaba-glutaminergic system. The polysomnographic study research shows lamotrigine increases in the sleep stability and reduces the phase shifts and neurotransmitter research shows glutaminergic inhibition at cortical projecton in ventral striatum, and stimulation of sigma receptors of gaba in these patients with sleep disorder

Conclusion: This case series will give an insight into the use of lamotrigine in idiopathic hypersomnic patient as a first line intervention and this also gives clinician stimulus to do future research in this clinical significant entity.

Keywords: Hypersomnia, Lamotrigine

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Study Of Prevalance Of Depresion In Patients With Vitiligo

Dr. Anurag Virendra Khapri, Dr. Ashish Saboo

Email Id: Anuragkhapri@gmail.com

Background/introduction: Vitiligo is an acquired depigmentation disorder affecting 1% to 4% of the population worldwide. The chronic nature of the disease, long-term treatment, and lack of uniform effective therapy are demoralizing for patients with vitiligo, leading to decreased self-image and depression. Course is progressive and the prognosis is unpredictable.

Methodology/Materials And Methods: This is a cross-sectional descriptive analytical study. Prevalence and severity of depression in vitiligo patients was studied by self-administered questionnaires distributed in dermatology departments in medical college. Modified beck depression inventory scale was the tool used in the questionnaire to study and classify depressive symptoms. A total of 52 vitiligo patients participated in our study, including 60% men and 40% women.

Results: According to the beck depression scale, 54.5% Were found to be depressed, most with mild depression. Depression was more prevalent in single patients, especially women in the first few years of the disease (p < .05). As shown by the findings of the study, there was a close relationship between dermatological diseases and psychological factors; thus, it is important to immediately diagnose concurrent psychological effects, especially those of depression and suicidal ideation. We found that there was a significant relationship between the prevalence rate of dermatological conditions and psychological effects; i.e. Depression (p=0.008) and suicidal ideation (p=0.001).

Conclusion: Age, sex, duration of disease, marital status, and educational level were significant factors that influenced severity and prevalence of depression. Assistance of a psychiatrist or psychologist is of crucial importance in taking care of vitiligo patients, especially in high-risk individuals.

Vitiligo, Depigmentation Disrorder, Depression

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Lady Who Gets Munchies In The Dark

Dr. P Krishna Chaitanya, Dr. Mona Lisa

Department Of Psychiatry, KIMS, Narketpally, Nalgonda. Email Id: Drkcpsych@gmail.com

Background: Night eating syndrome (NES) is described as a stress related eating disorder characterized by morning anorexia, evening hyperphagia and insomnia. Syndrome is described under other specified feeding or eating disorders in DSM V. In developed countries it is reported with a prevalence of 1% and commonly co-morbid with obesity.

Case Report: A 25 year old female was brought to psychiatric out-patient department with complaints of abnormal eating behavior and disturbed sleep on an average of 5-6 times per week. Patient says she was suffering from these problems since 5-6 years which initially started by skipping breakfast and eating more in evening hours due to her busy college schedule. Patient was evaluated using night eating questionnaire (NEQ) and HAM-D with showed a score of 31 and 13 respectively. She was diagnosed based on DSM 5 by a qualified psychiatrist. Patient was started on ssri and on follow ups CBT was also given.

Results: Patient is on regular follow up with the department and after 4 months of starting treatment with SSRI and CBT, the patients nocturnal awakenings had fallen to an average of 2 per week. The NEQ and HAM-D scores also significantly reduced to 25 and 12 respectively. There was also reduction of weight with BMI of 26.

Conclusion: The increased attention to NES within the past decade has prompted several modifications to its core diagnostic criteria, better understanding of its etiology and effective treatment strategies. Although rare among general hospital setting in developing countries, a need to identify the syndrome and applying effective strategies to treat would be worthy.

Keywords: Night Eating Syndrome, Other Specified Or Eating Disorders, Night Eating Questionnaire.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Major Depressive Disorder In Case Of Spino-cerebellar Ataxia

Dr. Ruchira Pravinkumar Trivedi, Prof. Dr. N C Parikh, Dr. N D Shah

Email Id: Ruchira_trivedi@yahoo.com

Back Ground: The patients with spino-cerebellar ataxia (SCA) tend to exhibit depressive symptoms. A study of patients with degenerative cerebellar diseases showed a high prevalence of all mood disorders (68%) including MDD (35.5 %). However, the pathology of depressive symptoms associated with SCA is controversial and remains to be elucidated.

Case Report: We report a case of 42yr old female, diagnosed with SCA at 38 years of age. She had a positive family history in her mother and maternal uncles. She developed depressive symptoms during the course of SCA. She fulfilled the criteria for major depressive disorder according to DSM V. Her HAM-D score was 34. At the time of presentation. She was treated with selective serotonin reuptake inhibitor and responded well to the treatment with decrease in HAM-D to 14.

Discussion: MDD in patients of SCA could be due to either reactive stress caused by disorder or due to central dysfunction caused by degenerative changes in brain. In our case as patient responded well to the treatment, we believe that depression may have been caused by an abnormality of reversible neural transmission including serotonin transmission due to central dysfunction, and it is unlikely that the depressive symptoms are reactive to stress. We found similar findings in one study of Japan, having case reports of 2 patients, one having MDD and developed SCA later and another patient having SCA, who developed MDD later, both treated with ssris and responded well to treatment.

Conclusion: Although cerebellar degeneration is irreversible in SCA patients, our case suggests that MDD in SCA may be reversible and treatable using antidepressants such as SSRIs with few adverse events. Therefore, it is important for neurologist to detect MDD in SCA patients early and consult psychiatrist.

Keywords: SCA, MDD, SSRI

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

PANDAS - With Tics A Case Report

Dr. Vundi Manasa Ram, Dr. S. Kiran Kuma, r Dr. s. radha Rani

Department Of Psychiatry, Andhra Medical College, Visakhapatnam. Email Id: Manasarammay8@gmail.com

PANDAS, also labeled as PANS, is a pediatric autoimmune neuro-psychiatric disorder due to streptococcal infection. Although it affects 1 in 1000 children, cases reported in Indian context are relatively few because of lack of awareness about the syndrome amongst clinicians. We report here a case of an 11 years old girl from a rural area presenting to us with an acute onset of repetitive involuntary movements and vocalizations following a febrile illness with sore throat 1 month prior. Investigations confirmed raised aso(anti steptolysin ‘o’) titers. A diagnosis of PANDAS was made and treatment was started. The patient responded to treatment and gained symptomatic relief. Timely intervention and high index of suspicion towards a pediatric febrile illness can help to reduce the morbidity associated with this neuro-psychiatric disorder.

Key words: PANDAS, Tics.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Clinical Study To Assess Pattern Of Cognitive Deficits And Its Corelation To Severity Of Depression

Dr. Karnik Kishore

Email Id: Imkarnik@yahoo.co.in

Objective: This Study Aimed At Assessing The Pattern Of Cognitive Deficits In Patients Suffering From Depression And To Study The Corelation Between Cognitive Domains Affected And Severity Of Depression.

Hypothesis:

There is no cognitive dysfunction in depression.
There is no significant correlation between cognitive dysfunction and severity of depression.

Method: A total of 40 patients with depression diagnosed according to ICD 10 research diagnostic criteria and 40 healthy controls were included. PGI battery of brain dysfunction (PGI PDD), frontal assessement battery and Hamilton depression rating scale (HAM D) was adminstered and analysis was done using chi" square test, unpaired t test and pearsons correlation.

Results: The study revealed significant differences in the dysfunction scores between the study and control population. Dysfunction in the various cognitive domains like memory, executive function, reasoning and problem solving, motor speed, diminished intellectual capacity in patients of depressive disorder were found. In the study group more than 80% of patients had cognitive dysfunction and a positive correlation was found between dysfunction and HAM D scores.

Conclusion: Depression is associated with significant disturbance in cognitive functioning and the cognitive dysfunction increases with increase in the severity of depression.

Key Words: Depression, cognition, Dysfunction, Correlation.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Gender Dysphoria In Children With Disorders Of Sex Development- Clinical Challenges In Indian Setting- A Case Series

Dr. Tess Maria Rajan Dr. Gopinath S, Dr. Jai Ganesh S Thamizh, Dr. Preeti K, Dr. Bibekanand Jindal, Dr. Subahani Shaik

Department Of Psychiatry, JIPMER. Email Id: Tesmaria_89@yahoo.co.in

Introduction: Disorders of sex development (DSD) are congenital conditions which presents at birth as ambiguous genitalia or later in puberty as atypical secondary sexual characteristics. In developing countries like india where the resources for diagnosis of the condition is lacking, the chances of the gender being misdiagnosed at birth is not rare. The development of gender dysphoria in children with DSD is common and this is reflected in the revised definition of gender dysphoria in DSM V. Also when the real gender of the child, when revealed at a later date poses a significant psychological impact on the child and the family.

Case Summary: Here we discuss two cases- first a child with karyotype 46, XY with 5α-Reductase deficiency (5-ARD) born with ambiguous genitalia and raised up as a girl. Second, a child with karyotype 46, XX with partial androgen insensitivity syndrome (PAIS) who was raised up as a boy. This child had a sibling with the same diagnosis who was raised as a female.

The real gender was revealed after the diagnosis of the underlying condition when the first child was 6 years old and the second child 8 years old.

Outcome: The first child who was brought up as female, when told about her real gender was rather happy and expressed that all throughout he wanted to be a boy. The parents too were happy about it.

The second child who was brought up as a male, showed significant distress when he got to know about his female identity and expressed his wish to continue as a male.

Conclusion: These two cases bring to light the higher chances of occurrence of gender dysphoria in children with DSD which leads to significant psychological distress, and also highlight the importance of screening for other psychiatric comorbidities in them.

Keywords: Gender Dysphoria, DSD, PAIS, 5α-Reductase deficiency (5-ARD)

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Medical Students’ Attitude Towards Suicide Prevention In North-western India

Dr. Naresh Nebhinani, Mrs Mamta

AIIMS, Jodhpur. Email Id: Drnaresh_pgi@yahoo.com

Background & Objectives: Medical students are future physicians and their attitudes towards suicide attempters may impact upon the quality of care. This study was aimed to assess medical students attitudes toward suicide prevention.

Methods: Cross-sectional study was conducted in AIIMS jodhpur. 243 Medical students (first, second and final year mbbs) were recruited through total enumeration method. Attitude towards suicide prevention scale was administered.

Results: Nearly half of students opined lack of suicidal communication by suicide attempters in case of serious suicide intent and minority of students considered unemployment and poverty being major obstacles in effective suicide prevention. Nearly half of the students were comfortable in suicide risk assessment. Majority of the students acknowledged their role for suicide prevention. Half of the students opined significant effect of suicide prevention measures. Majority of students had positive attitude towards working with suicidal patients. One-third of students had previous exposure of managing any suicidal patient and attending suicide prevention programs.

Conclusions: Majority of the medical students had positive attitude towards working with suicidal patients. Medical curriculum should incorporate regular programs on assessment, and management of suicidal patients.

Key Words: Medical Students, Doctors, Attitudes, Self-harm, Suicide, Suicide Prevention

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

A Study On Olanzapine Induced Weight Gain Among Patients Of Schizophrenia In Relation To Age And Gender

Dr. Shiladitya Mukherjee, Dr. Rama Krishnam Raju, Dr. Anupam Das

GSL Medical College And General Hospital. Email Id: Shiladityamukherjee621@gmail.com

Background: The introduction of atypical antipsychotics was a big step forward in the treatment of schizophrenia and other psychoses. However they are liable to cause weight gain and further put the patient at risk of metabolic disorders.

Aim: To evaluate weight gain associated with the use of olanzapine, in relation to age and gender, in patients of schizophrenia.

Methods: One hundred patients fulfilling the ICD-10 criteria for schizophrenia, were included in this study to evaluate weight gain as an adverse effect of treatment with olanzapine in relation to age, gender, dose and body mass index (BMI). Sociodemographic data and baseline weight along with height (to calculate the BMI) were recorded before the initiation of treatment. The patients were administered a flexible dose of olanzapine (15 mg) as monotherapy. Pregnant patients, smokers, patients with history of endocrine disorders, CVS disease and chronic alcoholics were excluded from the study. The increase in weight as a neuroleptic side-effect of olanzapine was recorded and analysed in relation to age, gender, dose and bmi.

Results: Of the patients receiving olanzapine, 66.6% had a weight gain of 5 kg over a period of 4 weeks. The weight gain was not related to the dose of the drug or BMI. The increase in weight was significantly related to age of 45 Years and female sex, indicating that women of 45 Years of age are more prone to gain weight with olanzapine therapy in comparison with women <45 years and men of any age group.

Conclusion: The potential for weight gain associated with the use of olanzapine is high in females more than 45 years of age. The potential of olanzapine to cause long-term complications will need further study.

Keywords: Weight Gain, Olanzapine, Body Mass Index, Age, Gender

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Recurrent Psychotic Symptoms In A Patient With Basal Ganglia Calcification: A Case Report

Dr. Deepak Krishna Ghormode, Dr. Amit Biswas, Dr. Jolly Mathew, Dr. Poonam Dhoke

Email Id: Gdkrishna@gmail.com

Aim: To present a case with recurrence of psychotic symptoms after successful treatment of the initial episode later detected to be having bilateral basal ganglia calcification.

Methodology (case description): Mrs. A, 41 year old separated female who was premorbidly well adjusted, had family history of psychosis, presented with an abrupt onset illness, characterized by auditory hallucinations of commanding type, irritability, delusion of grandiose identity and ability. In view of the acute onset of psychosis a non- contrast computerized tomography (ncct) of head was done which showed calcification of bilateral basal ganglia. Other investigations were found to be normal. Further exploration of history revealed that she had an episode of similar symptoms about 2 years back, was treated with risperidone upto 4mg/day following which the symptoms completely resolved within next two months, with whole episode lasting for 6 months, the risperidone was continued for about 16-18 months and gradually tapered off and stopped two months back. A diagnostic possibility of schizophrenia versus organic psychosis was considered. In view of the past response, she was managed with risperidone upto 4 mg/day with which she showed complete improvement over the next 6 weeks.

Conclusion: basal ganglia calcification is associated with psychotic illnesses and patients presenting with psychosis may be screened for basal ganglia calcification, based on presence of atypical clinical features. Also it highlights the importance of continuation of treatment to avoid risk of relapse if organic cause is evident.

Keywords: Basal Ganglia, CT

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Complicated Opioid Withdrawal - Case Report

Dr. Nimish Gupta, Dr. Vivek Kumar, Dr. Supriya Agarwal

Subharti Medical College, Meerut. Email Id: Drnimishgupta0910@gmail.com

Although, anecdotal case reports are being published describing complicated opioid withdrawal e.g. Seizure and delirium but various international classification system and standard textbooks do not mention about the complicated withdrawal like with alcohol. Interestingly, these complications reported from specific form of the opioid and specific geographical region. The case in this report presented with complicated opioid withdrawal like picture which was later found to be due to organicity. Hence, we report this case here to discuss various possibilities to be explored while dealing with the case of complicated opioid withdrawal.

Keywords: Opioid, Complicated Withdrawal, Seizure, Delirium

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Depression And It's Correlates In Patients With Diabetes Mellitus Attending Secondary Care Centre Of North India

Dr. Jyoti Gupta, RPGMC, Tanda

Email Id: Drjyotigupta2017@gmail.com

Introduction: People with diabetes mellitus (DM) are at a greater risk of depression than those without DM. Depression in diabetes is mostly under-detected, under-diagnosed, and under-treated.

The aim of the study was to know the presence of depression in patients with DM and examine interrelationship between socio-demographic, anthropometric, clinical profile and quality of life variables with depression in patients with DM. There is scarcity of such data from secondary care settings of north india.

Materials And Methods: This cross-sectional study was conducted in a secondary care hospital of North India from september 2014 to july 2015. Socio-demographic, anthropometric and clinical data of DM patients attending medicine OPD or those admitted in the ward of the hospital were collected after due informed consent. Patients were applied quality of life instrument for indian diabetes patients (QOLID) and patient health questionnaire-9 (PHQ 9). Data were reported as the mean â± sd or percentages. Bivariate analysis was done using pearson product-moment correlation. All statistical analyses were carried out using statistical package for social sciences (SSPS) (version 17.0, Usa).

Results: Out of 83 patients included, 31 (37.3 %) Were found to have depression [8.4% Minor, 16.9% Moderate, 12 % definite major depression]. Total quality of life score and its all 8 domains showed significant negative correlation with PHQ score. Quality of life score also showed significant negative correlation with duration of diabetes mellitus. Higher HbA1C levels predicted poorer quality of life and risk of depression.

Conclusion: Depression is highly prevalent in patients with Diabetes mellitus and leads to poorer quality of life. Poor glycaemic control predicts low quality of life and higher risk of depression.

Key Words: Diabetes, Depression, Quality Of Life

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Role Of Metacognition In Generalized Anxiety Disorder: A Study From A Tertiary Care Psychiatric Centre In Northern India

Dr. Jyoti Dubey, Dr. Shweta Singh, Prof. P. k Dalal, Dr. Adarsh Tripathi, Dr. Manu Agarwal, Dr. Sujit. K Kar

King George Medical University Lucknow, U.P.226010. Email Id: Jyotidubey070@gmail.com

Background And Objective: The importance of metacognition in GAD has been implicated in recent models of psychological disorder given by well and their treatment. Involvement of the metacognitions as the vulnerability factors in predicting development and maintenance of various psychological disorders including GAD. This study aimed to investigate the role of metacognition in patient with gad in comparison to healthy controls.

Methodology: This study was a cross- sectional study on 25 subjects of GAD of equal age, sex, education matched controls. Purposive sampling method was used. Semi-structured performa was used for socio demographic details for both groups and subjects were assessed on standard progressive matrices (SPM), MINI international neuropsychiatric interview (MINI), general health questionnaire (GHQ) and metacognition questionnaire (MCQ). We have conducted chi-square test and t-test to determine the significant difference between metacognition of the GAD patient to the healthy controls.

Results: Study revealed that the metacognition of the GAD was significantly different from the healthy controls on all sub domains of mcq i.e. positive belief about worry, negative beliefs about uncontrollability of thoughts and danger (uncontrollability and danger), beliefs about cognitive confidence (cognitive competence), general negative beliefs (including themes of weakness, superstition, punishment and responsibility) and cognitive self-consciousness.

Conclusion: Finding of the study corroborate with the metacognitive models. GAD patients have higher dysfunctional metacognition then the healthy controls.

Key Words: Metacognition, Generalized Anxiety Disorder, anxiety

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

“Induced Delusional Disorder” A Case Report

Dr. Ramananda Kishore Kavi, Dr K Sarada, Dr T S N Raju, Dr S Radharani

Department Of Psychiatry, Andhra Medical College, Visakhapatnam. Email Id: Krk.nanda@gmail.com

Induced delusional disorder is a rare disorder which is characterized by the transfer of delusions from one person to another. Both persons are closely associated for a long time and typically live together in relative social isolation.

A 26-year-old female and her 45-year-old mother were brought by their brother with the help of police personnel to outpatient department for evaluation and treatment. On examination the patient had fixed, false belief that she is being plotted against and is being poisoned by her father for 5 years. These symptoms are the same as the delusions of her mother, who was symptomatic for the last 15 years. Patient was diagnosed with induced delusional disorder. Patient was started on olanzapine and psychotherapy was also started. Later both mother and daughter were placed in separate wards and after two months of treatment, symptoms started improving.

Induced delusional disorder is a chronic disorder and long term treatment may be required. Atypical antipsychotic olanzapine along with psychotherapy and separation from the primary case (her mother) is shown to be effective.

Keywords: Induced Delusional Disorder, Shared Psychotic Disorder, Folie ΰ deux, Double Insanity, Olanzapine.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Clozapine Induced Leucocytosis

Dr. Muhammed Rajees M, Prof. Praveen Lal, Dr. Neethi Valsan

Jubilee Mission Medical College Thrissur. Email Id: Drmrajees@gmail.com

Clozapine, an atypical antipsychotic is considered as the antipsychotic of choice for treatment resistant schizophrenia. Clozapine was the first neuroleptic identified without motor side effects and it has consistently demonstrated advantages in a variety of clinical situations. Yet its use is still in controlled line or as a second line treatment due to its side effect profile. It has many hematological side effects in which agranulocytosis is the most important and fatal. Leucocytosis, defined as a leukocyte count greater than 11,000 cells per mm3, associated with clozapine treatment has received less attention in the literature. We are reporting a case of clozapine induced leucocytosis. Our patient 27 year old male presented with persistent delusions and hallucinations four years duration. He was on treatment with typical and atypical antipsychotics. But there was no improvement. So we considered him as a case of refractory schizophrenia and started him on clozapine after initial hematological work up. On gradual increasing of the dose it was found that his WBC count also increased. When the WBC count reached 15000,cells/mm3 we did a medical consultation and investigation including blood and urine culture and chest x ray and ultra sound abdomen. Patient was afebrile and there was no symptoms or signs of any infection. We took it as a case of clozapine induced leucocytosis and continued hiking the dose and reached 600mg. His count went on to 19360 and after that started to come down gradually and reached within normal limit. The mechanism and risk factors of clozapine-induced leukocytosis are unknown. It has been hypothesized that clozapine stimulates the release of certain cytokines including TNF IL 2, IL 6 and G-CSF. These cytokines inhibit the apoptosis by up-regulation of anti-apoptotic proteins, and induce differentiation and maturation of myeloid cells to granulocytes which cause an increase in number of leukocytes.

Keywords: Clozapine, Antipsychotics

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Self Reported Suicidal Behavior Amongst College Students In Urban Setting

Dr. Ashish Hasmukh Patel, Dr. Ritambhara Mehta, Dr. Kamlesh Dave, Dr. Pradhyuman Chaudhary

Government Medical College, Surat. Email Id: Drashishptel@gmail.com

Aims And Objectives: To evaluate knowledge and attitudes towards suicide and suicidality behavior amongst college students

Introduction: Suicide is presently the second leading cause of death for the 15-19 year old and the third leading cause of death among adolescent of 15-24 years age in the world, as well it is on the rise. Suicidal behaviors are common and problematic among young populations, and attitudes held towards such behavior are likely to impact the frequency of its occurrence.

AIM: This study is aimed at measuring attitudes and knowledge towards suicide, and suicidality behavior amongst college students in urban setting.

Method: A cross sectional study of 175 medical, physiotherapy and nursing college students, was performed using semi-structured questionnaire for attitudes, knowledge and behavior including suicide opinion questionnaire (SOQ) and suicidality behavior section of MINI. after written informed consent. Attitudes and knowledge questionnaire is divided into 5 domains of acceptability, perceived Factual Knowledge, Social disintegration, Personal defect and emotional perturbation.

Result & Conclusions: Males show stronger attitudes as compared to females that suicide note reveals anger towards world (p=0.017), Suicide is an act of self-punishment (p=0.045), People who commit suicide have a weak personality structure(p=0.004). Whereas females show stronger attitudes that people with incurable disease should be allowed to commit suicide(p=0.042). Nursing students more strongly believe that suicide is a sanctioned behavior (p=0.000). Physiotherapy and undergraduate medical students more strongly believe in social disintegration (p=0.003) And personal defect (p=0.00) Respectively as the reasons for suicide.

Keywords: Suicide, College Students, Attitude And Knowledge Towards Suicide, Suicidality Behavior

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Recurrent psychotic symptoms in a patient with Basal Ganglia Calcification: a case report

Dr. Deepak Ghormode, Dr. Amit Biswas, Dr. Jolly Mathew, Dr. Poonam Dhoke

Email Id: gdkrishna@gmail.com

Aim: To present a case with recurrence of psychotic symptoms after successful treatment of the initial episode later detected to be having bilateral basal ganglia calcification.

Methodology (Case description): Mrs A, 41 year old separated female who was premorbidly well adjusted, had family history of psychosis, presented with an abrupt onset illness, characterized by auditory hallucinations of commanding type, irritability, delusion of grandiose identity and ability. In view of the acute onset of psychosis a Non- contrast computerized tomography (NCCT) of head was done which showed calcification of bilateral Basal Ganglia. Other investigations were found to be normal. Further exploration of history revealed that she had an episode of similar symptoms about 2 years back, was treated with risperidone upto 4mg/day following which the symptoms completely resolved within next two months, with whole episode lasting for 6 months, the risperidone was continued for about 16-18 months and gradually tapered off and stopped two months back. A diagnostic possibility of Schizophrenia versus organic psychosis was considered. In view of the past response, she was managed with Risperidone upto 4 mg/day with which she showed complete improvement over the next 6 weeks.

Conclusion: Basal ganglia calcification is associated with psychotic illnesses and patients presenting with psychosis may be screened for basal ganglia calcification, based on presence of atypical clinical features. Also it highlights the importance of continuation of treatment to avoid risk of relapse if organic cause is evident.

Indian J Psychiatry. 2017 Jan;59(Suppl 2):S220–S250.

Successful treatment of a 100 year old bipolar patient with risperidone: Indian experience

Anita Sharma, Om Prakash

Institute of Human Behaviour & allied Sciences (IHBAS), Dilshad Garden, New Delhi 110095 India. Email Id: mailto:drjhirwalop@yahoo.co.in

Objective: To present a case of successful treatment of drug-naive bipolar affective disorder patient of 100 year of age with risperidone.

Method: A 100-year-old female presented to us with history of ten days duration with symptoms of euphoric mood, increased psychomotor activity and disruption in functioning. She had history of multiple episodes of mania and depressive illnesses since last 70 years. It is noteworthy to mention that she had not received any treatment in past. These episodes used to occur once in 5 to 8 years. There was no history of any medical illness and substance abuse/dependence. There was no associated history of any loss of consciousness, forgetfulness, head injury, or urinary / fecal incontinence. Her mini-mental status examination revealed a score of 25/30. Her detailed systemic examination and investigations were all normal. Magnetic resonance imaging of the brain and electroencephalography were normal. A diagnosis of bipolar affective disorder current episode manic without psychotic features was made and the patient was started on risperidone 1 mg along with lorazepam 1 mg per day. Risperidone was increased to 2 mg over a period of next few days. The patient showed improvement in her symptoms over a period of next 10 days. She has been followed up in the outpatient department for the next three months and has been maintaining well on risperidone 2 mg.

Result and discussion: Our case report of first of its kind presents the successful treatment of manic episode of bipolar affective disorder with risperidone in elderly patient of 100 years. The expert consensus guidelines recommend risperidone as the preferred (first-line) atypical antipsychotic agent for the treatment of bipolar disorder in the elderly. There are no controlled studies of risperidone for bipolar disorder in the elderly. Controlled studies with larger sample size are required to further investigate the use of risperidone in the elderly bipolar patients.

Keywords: Risperidone, Bipolar affective disorders, Elderly.

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