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 Table of Contents    
Year : 2018  |  Volume : 60  |  Issue : 5  |  Page : 124-168

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Date of Web Publication1-Feb-2018

How to cite this article:
. Posters. Indian J Psychiatry 2018;60, Suppl S4:124-68

How to cite this URL:
. Posters. Indian J Psychiatry [serial online] 2018 [cited 2022 Dec 4];60, Suppl S4:124-68. Available from:

A Cross-Sectional Study To Assess Anxiety And Depression In Parents Of Children With Intellectual Disability

Abhipsa Das, Prakhar Jain, Vinayak Pandhurang Kale

Junior resident(Second Year), Grant govt.medical college and sir JJ group of hospitals, Mumbai, Maharashtra. [email protected]

Introduction: Intellectual disability(ID) is a disability with limitations in intellectual functioning,adaptive behavior,social and practical skills.Their families experience repeated physical and emotional crises,also financial burden.India has a prevalence of 10.5/1000 in ID.Studies have shown association between parental distress and caretaking of children with ID but there is little data in developing countries concerning the impact of raising them.This study was conducted to assess the level of anxiety,depression or both anxiety and depression together among such parents.

Methodology: Study is being conducted at a tertiary care hospital after approval from the Institutional Research Committee.

Parents of children aged 2–18 years who were diagnosed with ID were assessed for depression and anxiety.

Diagnosis was made using The Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition.

Severity was assessed using -

  1. Hamilton Anxiety Rating Scale
  2. Hamilton Anxiety Rating Scale.

Pearson Chi Square test was used to evaluate associations.

Results: The final results will be analysed on completition of study.

Parents of 27 children have been evaluated so far.

89% of mothers had anxiety,depression or both anxiety and depression together as compared to fathers(77%).

35% mothers had anxiety,40% depression and 13% both.

42% fathers had anxiety,31% depression and 3% both.

Depression was highest among mothers of children with moderate ID(57%),anxiety was highest among mothers of children with profound ID(50%),and both anxiety and depression together were highest among mothers of children with profound ID(25%).

No association between father’s anxiety or depression and degree of ID in their children.

Conclusion: High rates of anxiety and depression were seen among parents of children with ID,especially mothers.Appropriate mental health screening is required for care givers of children with ID.The services provided for such children need to include interventions and support for caregivers.

Keywords: Intellectual disability, Depression, Anxiety

Trichotillomania in guise of rapunzel syndrome

Adi Pratyusha, Sushrut Patil, Datt, Praveen Khairkar, Monalisa kakumanu, Krishna chaitanya, Swapna pandurangi

PG student, Kamineni institute of medical sciences, Hyderabad, Telangana. [email protected]

Background: Trichotillomania (hair pulling disorder) is characterised by repetitive pulling of hair which is preceded by mounting of tension and followed by a sense of gratification after the hair is plucked. It has been included in ICD 10 under ‘Habit and impulse control disorders’ (F 63) whereas in DSM 5 under ‘OCD spectrum disorders’. It may be sometimes associated with trichophagia (ingestion of hair) resulting in Rapunzel syndrome (intestinal obstruction resulting from trichobezoar)

Case report: A 15yr old female patient presented to general surgery department with complaints of abdominal pain. On evaluation patient was diagnosed to have intestinal obstruction and trichobezoar was removed. She was referred to psychiatry department for behaviour exploration and further management. On interviewing, patient reported that she had a habit of plucking and eating her hair since she was 8yrs of age. Initially she would pluck whenever she was worried but however this habit gradually progressed over years. It causes immense distress to her but is unable to control this behaviour. She was diagnosed with trichotillomania using ICD 10 by a qualified psychiatrist. She was started on escitalopram 10mg and clonazepam 0.25mg and on follow up habit reversal behavioural therapy was initiated.

Results: Patient has been on regular follow up and reports improvement. Impulsive hair plucking behaviour has decreased and maintained on same treatment.

Conclusion: Trichotillomania with trichophagia is still an underestimated condition due to secretiveness and shame associated with the disorder. Diagnosis is missed because most of the cases masquerade as different diseases and the patients land up with dermatologists, physicians and surgeons but not psychiatrists. Hence adequate awareness regarding the illness and liaison consultation facilities go a long way in reducing the morbidity.

Keywords : trichotillomania, trichophagia, Rapunzel syndrome

Klingsor Syndrome : A Case Report from Central India

Aditi Patel, Pawan Rathi

Juniour Resident, Sri Aurobindo Medical College &P.G institute, Indore, Madhya Pradesh. [email protected]

Background: Klingsor syndrome or the act of genital self mutilation is a rare clinical entity associated with religious delusions. Such patients mostly present as surgical emergency before the psychiatric consultation is sought.

We report a case of 22yr old, unmarried male who in a fit of paranoia, inflicted the injury leading to the amputation of his penis and scrotum as a way to earn solace from God.

Keywords: Genital self mutilation, schizophrenia, Central India.

Psychological Distress in Wives of Patients’ with Alcohol Dependence and its Relation with Severity of Disorder and Patients Abusive Behaviour

Avina Gupta, Deepika Singh, Abhijeet faye, Rahul Tadke, Sushil Gawande, Sudhir Bhave, Vivek Kirpekar

Resident, NKP SIMS, Delhi, [email protected]

Background: Alcoholism, being a major public health problem, poses considerable burden for the society. Wives, being the most intimately related to their alcoholic spouses, suffer from significant psychological distress, created by the problems faced due to consumption of large amount of alcohol by them. Also; they are often exposed to high rates of domestic violence which further escalates the distress.

Objective: The study was undertaken to identify patterns of psychological distress amongst the wives of patients with alcohol dependence, assess the type of violence faced by them and find the association of their distress with patients’ violent behaviour & severity of alcohol consumption.

Materials and Method: 60 wives of patients with alcohol dependence were interviewed using semi structured proforma containing socio demographic profile and alcohol history of husband. Abusive behaviour faced by them was assessed using abusive behaviour inventory. Spouses of these wives were also interviewed using Severity of alcohol dependence questionnaire, to measure the severity of alcohol dependence.

Results: The average age of wives was 39.7 years. Psychological distress amongst them was found to have a prevalence of 80% with majority suffering from mild stress along with moderate degree of anxiety & depression.The mean score of scale for Severity of alcohol dependence was 25.18 indicating moderate degree of severity of alcohol dependence among the patients. Majority of wives suffered more of psychological abuse than physical abuse.

Conclusion: Significant psychological distress was found in those wives whose husbands had history of higher quantity of alcohol consumption, those who faced abusive behaviour from husband & those having shorter duration of marriage and lower age.

Keywords: Alcohol dependence, Psychological distress, Abusive behaviour

Binswanger’s Disease And Its Psychiatric And Behavioral Aspects

Ajinkya Ghogare, Ashish V. Saboo


Introduction: Binswanger’s disease is also known as subacute arteriosclerotic encephalopathy. It is characterized by diffuse demyelination of the subcortical white matter along with lacunar lesions in the basal ganglia and the brain stem. The damage is the result of the thickening and narrowing (atherosclerosis) of arteries that feed the subcortical areas of the brain.

The clinical features of Binswanger’s disease are highly variable and the psychiatric and behavioral manifestations have been less well described. Four cluster symptoms of the disease have been described –

Late onset paranoid psychosis

Confusional state


Behavioral syndrome of the frontal lobe type (apathy , irritability , and depression)

Objective: To report and discuss the rare and poorly understood case of Binswanger’s disease and its psychiatric and behavioral aspects.

Methodology: Clinical , psychiatric and radiological examination of subject and their correlation for management of patient.

Result: After detailed clinical and psychiatric examinations and correlation with MRI Brain findings subject was diagnosed as case of rare Binswanger’s disease

Conclusion: There is no specific course of treatment for BD. Treatment is symptomatic. People with depression or anxiety may require antidepressant medications such as the serotonin-specific reuptake inhibitors (SSRI) sertraline or citalopram. Atypical antipsychotic drugs, such as risperidone and olanzapine, can be useful in individuals with agitation and disruptive behavior. Recent drug trials with the drug memantine have shown improved cognition and stabilization of global functioning and behavior. The successful management of hypertension and diabetes can slow the progression of atherosclerosis, and subsequently slow the progress of BD. Because there is no cure, the best treatment is preventive, early in the adult years, by controlling risk factors such as hypertension, diabetes, and smoking.

Keywords: Binswanger’s Disease, demyelination, subacute arteriosclerotic encephalopathy

To study the Phenomenology of Autism Spectrum Disorder in Children and Adolescents using DBCL

Amar Deep Patel, Vivek Agarwal, Amit Arya, Manu Agarwal, Pawak Kumar Gupta

Senior Resident, King George Medical University, Lucknow, Uttar Pradesh. [email protected]

Background: Autism Spectrum Disorder is a neurodevelopmental disorder which is increasing across the globe that consists of group of disorder with onset in the developmental period. It includes social impairments, communication difficulties, and repetitive behaviors. ADI- R is a diagnostic tool and DBCL is screening tool used for ASD. Aim of this study were to study the Phenomenology of ASD in Children and Adolescents using DBCL.

Methodology: This is the cross sectional study to see the pattern of different sign and symptoms (Phenomenology) of Autism Spectrum Disorder using the tool DBCL (Brereton AV, et al., 2000). All old and new patients with Autism Spectrum Disorders in the age group of 4 to 16 year attending Child And Adolescent psychiatry OPD, Department of Psychiatry have been screened and included in the study.

Result: A total of 40 children were included and assessed. The most common symptom being in decreasing order were restricted interest, poor eye to eye contact, communication difficulties and repetitive behavior.

Conclusion: Restricted interest, poor eye to eye contact, communication difficulties and repetitive behavior were the common symptoms as assessed on DBCL in children and adolescents with ASD.

Keywords: ASD, DBCL

Awareness,emotional issues and attitude of parents towards children with Specific Learning Disabilties : A Retrospective Analysis

Amey Pusalkar, Alka Subramanyam, Ravindra Kamath

Junior resident, TNMC & BYL Nair Ch. Hospital, Thane, Maharashtra. [email protected]

Aims/Objectives: To assess awareness, emotional issues and self-esteem in children with Specific Learning Disabilities (SLD). To assess awareness, punitive attitude in parents of these children and correlate them.

Methodology: Retrospective data review was carried out from 500 standardized proforma used for assessing patients assessed during January 2009 to September 2017 The data from patients with age group 8 to 16 years who had been diagnosed to be having specific learning disability was taken with respect to the awareness of parent and the child, attitude of the child towards SLD, punitive attitude of the parent, self-esteem and emotional issues of the child due to SLD.

Results: Out of 500 children 35.4% were aware and 64.6% were not aware of SLD. 29% children had emotional issues like anxiety disorder (35%) and mild depression (65%). A statistical significance was found between awareness in children and emotional issues (p<0.001) using chi-square test. 37% of parents had punitive attitude towards their child’s disability and a correlation was found between emotional issues and punitive attitude of parents (p=0.023) using chi-square test. 45% parents were aware of SLD, 90% children had a negative attitude towards SLD and 34.8% had low self-esteem due to SLD.

Discussion : Study done in 2016 in Coimbatore found 14.2% children with SLD having depression and 23.8% anxiety while we found that 35% having anxiety disorder and 65% mild depression. Sahoo MK et al in 2015 found 30% children having emotional disturbances which coincides with our finding.


  1. Parents were found to be aware of SLD, whereas children were not.
  2. Of those children who were aware we found an association with emotional issues.
  3. Parental punitive measures correlated with symptom of anxiety and low self-esteem.
  4. Negative perception of SLD, correlated with low self-esteem.

Keywords: Specific learning disability, anxiety,depression

Comparison of total self-stigma between schizophrenia and alcohol dependence patients

Amey Joshi, Lipsy Modi, Imran Ali Shivji

PG student, jawaharlal nehru medical college, DMIMS(DU), Sawangi(meghe),Wardha, Maharashtra. [email protected]

Background: Self-stigma severely affects the people suffering from mental illnesses such as schizophrenia and alcohol dependence syndrome (ADS) and act as barrier to recovery process. Objectives: To determine the prevalence of self-stigma among schizophrenia and ADS patients; to compare the socio-demographic and clinical variables between schizophrenia and ADS patients with self-stigma; and to identify the risk factors.

Materials and Methods: A cross-sectional study was conducted on 100 patients, 50 patients with schizophrenia and 50 patients with ADS. A semi-structured data and Internalized Stigma of Mental Illness Scale (ISMIS) to measure self-stigma were administered.

Results: The prevalence of self-stigma was more in ADS (66%) than that in schizophrenia (50%). The stigma in schizophrenia was significantly associated with unmarried and divorced; education above 12th standard; those who belonged to joint family and urban region (P<0.05) while, in ADS it was associated with education above 12th standard (P<0.05). Only gender among the socio-demographic correlates was significantly different between schizophrenia and ADS patients with self stigma (P<0.05). The locality and education status were found to be strong predictors of stigma.

Conclusion: Self stigma is more prevalent in ADS as compared to schizophrenia and it is a significant problem in both. So, there is a need to take specific interventions to reduce the stigma and improve overall quality of life.

Key words: stigma, schizophrenia, alcohol dependence, mentally ill, risk factors.

Study of the pattern of stressors in Conversion Disorder among the patients attending Department of Psychiatry, RIMS

Amit Kumar Gupta, Th. Bihari Singh, N. Heramani Singh, R.K. Lenin Singh, S. Gojendra Singh

PG student, Psychiatry, Imphal, Manipur. [email protected]

Background: Conversion disorder is loss or alteration in sensory or voluntary function that cannot be fully explained by known patho-physiological mechanism. Psychological factor, such as conflicts or stress, are judged to be associated with the deficits. Objective: The aim of this study was to evaluate socio-demographic profile among all the patients of conversion disorder and associated stressors among all the patients of conversion disorder.

Method: 74 patients were diagnosed as Conversion disorder according to Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) were evaluated during October 2015 to September 2017. Hamilton Depression Rating Scale (HAM-D). Hamilton Anxiety scale (HAM-A) and Presumptive Stressful Life Event Scale (PSLES) were administered during the interview.

Results: In 74 cases we studied, majority of them were from the 18 to 29 years of age group. As for the immediate stressor it is found that it was present in 97% cases, broken engagement or love affair is most common type of immediate stressor. Life time stressor was present in 89% of cases. Excessive use of alcohol and financial problems are most common type of life time stressor. We found motor symptoms were the most common type of clinical presentation (58.4%). Amongst the motor symptoms, pseudo seizure was the most common presentation (29.7%). Conversion disorder with mixed motor and sensory deficit (multiple fainting spells) was found to be most common symptom (37.8%) present in this region.

Conclusion: Stressors like excessive alcohol drinking, financial problems, relationship problem in family are mainly responsible for Conversion disorder in this region and multiple fainting spells is most common symptom followed by pseudo-seizure.

Keywords: Conversion disorder, hysteria, stressor, pseudo-seizure

Stress and coping among elderly living in an ashram of Haridwar

Anindya Das, Apoorva Choudhary, Lakshay Tyagi

Associate Professor, AIIMS, Rishikesh, Rishikesh, Uttrakhand. [email protected]

Background: India’s population census suggests a growing number of elderly and raising old age dependency ratio (14.2% as in 2011). Whereas, research on the elderly in India are scanty with isolated community based studies and a few studies in old age homes. Thus we investigated the soci-demographic profile, patterns of stress and coping in a unique population of elderly living in an ashram of Haridwar.

Methodology: After a preliminary field survey it was found that only a single ashram with exclusive elderly population (age > 60yers) consented for the study. Consenting participants living for more than six months and without any acute illness or impairments (that interfered with cooperativeness and/or comprehension of the process) were included. Demographic profile (speciality designed performa), stress patterns in the last one year (Presumptive stressful life events scale), and coping strategies (Brief COPE) were studied.

Results: The results will discuss the profile of ashram residents, the pattern of life events experienced and its relationship, if any, with coping strategies.

Conclusion: Conclusion will be discussed in light of similar studies.

Keywords: elderly, stress, ashram, coping

Affect Regulation in Patients with Schizophrenia

Anil Sisodia, Sudhir Kumar, Sandhyarani Mohanty

Associate Professor, Institute of Mental Health and Hospital, Agra, UP. [email protected]

Patients with schizophrenia have deficits in emotional perception. The studies also suggest that these patients experience higher negative emotions than control. Suppression strategy for emotional regulation is implicated in reduced emotional expression in the patients. The suppression adversely affects the ability to identify emotions which could lead to maladaptive reappraisal of emotions. Emotion regulation accounts for the maintenance of optimal homeostatic arousal to facilitate goal oriented functioning.

Aim: The present study is designed to identify emotional regulation strategies in persons with schizophrenia.

Method: 30 patients with schizophrenia will be sampled from Institute of Mental Health and Hospital, Agra. Following tools will be administered (1) Positive and Negative Syndrome Scale (2) Positive and Negative Affect Scale (3) Affect Style Questionnaire (4) Emotion Regulation Questionnaire

Results: The data will be analyzed through correlation coefficients to understand the relationship in (1) Psychopathology and affect (2) Psychopathology and affective styles (3) Psychopathology and emotion regulation (4) Emotion regulation and positive/negative affect. Detailed results will be presented.

Keywords: Schizophrenia, affect regulation

Beliefs About Voices And Cognitive Insight In Schizophrenia

Sudhir Kumar, Anil Sisodia, Sandhyarani Mohanty

Associate Professor, Institute of Mental Health and Hospital, Agra, UP. [email protected]

Auditory hallucinations are a common phenomenon in patients with schizophrenia. Most of these patients have a belief that the source of these voices is external. According to the perspective of cognitive theory emotional and behavioral reactions to voices are determined by the meaning patients ascribe to the voices. The patients’ attitude towards voices would determine how they react to the voices and to what extent they feel the voices are disturbing.

Aim: The present study is designed to study the belief of schizophrenic patients about ‘auditory hallucinations’ and how these beliefs are associated with cognitive insight.

Material and Method: 30 patients with schizophrenia would be selected from Institute of Mental Health and Hospital, Agra. Beck’s Cognitive Insight Scale, Beliefs About Voices Questionnaire and Psychotic Symptoms Rating Scale would be administered on the patents.

Results: The detailed results will be presented and discussed.

Keywords: Schizophrenia,auditory hallucinations,cognitive insight

Disgust Propensity & Sensitivity and Emotion Regulation in Persons with Obsessive-Compulsive Disorder

Sudhir Kumar, Anil Sisodia, Sandhyarani Mohanty

Associate Professor, Institute of Mental Health and Hospital, Agra, UP. [email protected]

Background: Obsessive-Compulsive Disorder (OCD) is associated with heightened self-reported disgust. The changes in OCD symptoms across time result in reduced disgust propensity. However, this disgust in not characterized by abnormal physiological disgust response specifically electrodermal activity and facial electromyographic response. The intensity of obsessive belief is associated with a tendency to respond with disgust in the context of non-disgust context.

Aim: The present study was undertaken to understand how persons with OCD emotionally regulate their disgust.

Method: The study was carried out in the OPD of Institute of Mental Health and Hospital, Agra. The sample consisted of 40 patients with OCD. Disgust Propensity and Sensitivity Scale (Revised) and Emotion Regulation Questionnaire (ERQ) were administered. ERQ assesses two regulation strategies (a) Reappraisal and (b) Suppression. Disgust Propensity and Sensitivity Scale also has two dimensions (a) Disgust Propensity and (b) Disgust Sensitivity.

Results: The correlation between two dimensions of disgust scale and emotion regulation questionnaire revealed that both the dimensions of disgust scales are negatively associated with Reappraisal strategy and positively associated with Suppression strategy.

Conclusion: The persons with OCD use suppression strategy of emotion regulation for disgust propensity and sensitivity.

Implications: The suppression strategy does not help effectively to the patients to deal with the disgust. The reappraisal strategy has negative correlation and the prominence of reappraisal should be helpful to these patients in dealing with the disgust. Key Words: Disgust, Emotion Regulation, OCD.

Severity of OCD, Obsessional Beliefs and Self-Efficacy in Patients with Obsessive-Compulsive Disorder

Sudhir Kumar, Anil Sisodia, Sandhyarani Mohanty

Associate Professor, Institute of Mental Health and Hospital, Agra, UP. [email protected]

OCD is characterized by intrusive thoughts which lead to covert or overt acts in order to control the anxiety elicited by the unwanted thoughts. It is well recognized that the primary problem in this condition is not the presence of intrusive thoughts but the misinterpretation of these thoughts by the patients. The researchers have identified inflated sense of responsibility, perfectionism & certainty, and importance/control of thoughts as cognitive determinants in the development of OCD.

Aim: The present study was designed to assess whether obsessional beliefs are associated with severity of OCD and self-efficacy in patients having Obsessive-Compulsive Disorder.

Method: The study was conducted in Institute of Mental Health and Hospital, Agra. 40 patients with OCD constituted the study sample. Y-BOCS-II, Obsessional Beliefs Questionnaire and General Self-Efficacy Questionnaire were administered. The severity of Obsessions and Compulsions were rated separately on Y-BOCS. Obsessional Beliefs Questionnaire consists of three dimensions (a) Responsibility/Threat Estimation (b) Perfectionism/Certainty (c) Importance/Control of thoughts.

Results: The results revealed that obsessional belief of Responsibility/Threat estimation has a significant and negative correlation with self-efficacy scores. The other two dimensions Perfectionism/Certainty, and Importance/Control of thoughts are not associated with self-efficacy. Both the severity of obsession and severity of compulsion are negatively associated with self-efficacy. None of the dimension of obsessional belief questionnaire is associated with severity of compulsion. Two dimensions of obsessional beliefs, Responsibility/Threat Estimation and Importance/Control of thoughts, have significant positive correlation with severity of obsession. The dimension of Perfectionism/Certainty is not associated with severity of obsession.

Keywords: OCD, obsessional beliefs, Perfectionism

Haematological abnormalities among patients receiving Clozapine

Anish Shouan, Sandeep Grover, Subho Chakrabarti, Ajit Avasthi

Senior Resident, PGIMER, Chandigarh. [email protected]

Background: Clozapine is known to be associated with dreaded side effect of neutropenia. However, clozapine can also cause other haematological side effects. Other haematological side effects which have been noted with clozapine include thrombocytopenia, thrombocytosis, eosinophilia, and leukocytosis etc. Most of the data about other haematological side effects in patients receiving clozapine is limited to case reports, case series and occasional small sample size studies.

Aim of the Study: To evaluate the incidence of clozapine induced haematological side effects among patients receiving clozapine. Method: Data of 331 patients who were on clozapine for duration varying from 1 month to 22 years, with a mean duration of clozapine therapy being 52.96 (45.18) months were reviewed for haematological abnormalities.

Results: Majority of the patients were males (N=157; 56.8%), single (n=219; 66.2%), Hindu (n=242; 73.1%), residing in urban locality (n=223; 67.4%) and unemployed (n=289; 87.3%). Most of the patients (n=207; 93.7%) were diagnosed with psychotic disorders, mainly schizophrenia. These patients were receiving clozapine in the dose range of 12.5 mg – 600 mg/day, with a mean dose of 212.08 (102.43) mg/day at the time of review of their records. About one-sixth (N=55; 16%) of patients developed at least one incidence of eosinophilia (eosinophil count > 6%), and 8.2% (N=27) experienced one incidence of thrombocytopenia (platelet count < 1, 00,000 cmm3) and 7 patients developed at least one incidence of anaemia (haemoglobin level < 10 mg%) during the clozapine therapy. Only 2 patients developed neutropenia. Mean dose (mg/day) at which haematological side-effects occurred were as follows: 155.68 (100.23) mg/day for eosinophilia; 193.98 (148.93) mg/day for thrombocytopenia; 78.57 (22.49) mg/day for anaemia. All these abnormalities were observed in more than one serial haemogram. In a small proportion of patients, clozapine was discontinued due to the haematological abnormalities and other patients no other cause for these abnormalities could be ascertained and these abnormalities normalized on its own in subsequent follow-up.

Conclusion: Clozapine is associated with benign haematological abnormalities and most of these normalize with time.

Keywords: Clozapine, hematological abnormality, neutropenia

Anti-NMDA receptor encephalitis in psychiatry: two case reports

Anjukrishna G, Arun G

PG student, Jubilee Mission Medical College and Research Center Thrissur, Kerala. [email protected]

Introduction: Anti NMDAr encephalitis is a disease occurring when antibodies produced by the bodies on immune system attack NMDA receptors in the brain. Anti-NMDAr encephalitis, appears to be relatively common, particularly in comparison to similar autoimmune or paraneoplastic disorders

Methodology: Retrospective, hospital based study. 2 cases were studied. First case was a 14 yr female with, conversion reaction. Second case was 30 yr female, with psychotic symptoms.

Results: These cases after initial presentation, both cases developed altered mental status, CSF studies shows presence of anti NMDA receptor antibodies , confirmed diagnosis of anti-NMDA encephalitis. After diagnosis, treatment focused on immunotherapy, Corticosteroids and intravenous immunoglobulin (IVIg) or plasma exchange are recommending in managing the symptoms.

Conclusion: The classic presentation of NMDA encephalitis involves early symptoms like psychosis, personality change, memory loss etc. Days and weeks later patient develops autonomic instability requiring ICU care. This complex disorder requires sustained management and coordination of care between multiple medical specialties. The involvement of psychiatrist at many phases of disease suggests a familiarity with the syndrome to be essential particularly early on when appropriate diagnosis might help anticipate neurological decompensation.

Keywords: Anti-NMDA, encephalitis, IVIg corticosteroids

Protocol of a randomized controlled trial to test the efficacy of a novel internet-based intervention to treat depressive symptoms

Arka Ghosh, Rithwik J. Cherian, Surbhit Wagle, Parth Sharma, Braj Bhushan, Alok Bajpai, Nitin Gupta

PhD student, Indian Institute of Technology Kanpur, Kanpur, Uttar Pradesh. [email protected]

Background: Cognitive Behavioral Therapy (CBT) is an evidence-based therapeutic technique to treat depression. But its accessibility is limited by the dearth of trained therapists as well as the high cost and social stigma associated with visiting a therapist. Computerized CBT (CCBT), which involves delivering CBT automatically using a computer, is an emerging approach that could overcome these barriers.

We have developed a stand-alone, freely accessible internet-based tool, named TreadWill, for treating depressive symptoms. TreadWill is designed to be completed over a period of 6 weeks and educates the user about CBT through multimedia elements. To increase user engagement, it includes social networking features and personalizes based on the user’s dysfunctional profile.

Methods: We plan to conduct a 3-armed Randomized Controlled Trial to test the efficacy of TreadWill. We will randomly assign 600 participants (age: 16-35 years) to 3 arms (experimental, active control, wait-list) in a 1:1:1 ratio. The experimental group participants will have access to the full version of TreadWill. The active control group participants will have access to a limited, non-adaptive version with the same information but without the interactive features. The wait-listed participants will be put on a wait-list for a period of 6 weeks. The depressive symptom severity as measured by Patient Health Questionnaire-9 at baseline, post-treatment, and a 90 day follow-up will be used to assess the efficacy of the program. The total time spent by the users on the experimental version of the program compared to the active control will indicate the user engagement.

Results: A prototype version of TreadWill has been developed and internally tested, and a participant recruitment website is being developed.

Conclusion: Our study will provide new insights on the efficacy of CCBT in India and on factors affecting user engagement.

Keywords: CBT, CCBT, online, personalization, RCT.

Hematohidrosis: Case Reports

Asharul Hossain, Saswati Nath, Sayanti Ghosh, Md Haque Sabir Hannan, Arnab Pathak, Sumit Mukherjee, Tamosha Dhar

Post graduate trainee, R G Kar Medical College & Hospital, Kolkata, West Bengal. [email protected]

Hematohidrosis, also called blood sweat, is an extremely rare condition in which an individual sweats blood.True hematohidrosis occurs in bleeding disorders. It may occur in individuals suffering from extreme level of stress.

Around the sweat glands, there are multiple blood vessels in a net-like form, which constrict under influence of severe stress. As the anxiety passes, the blood vessels dilate to the point of rupture and blood enters into the sweat glands and comes out as droplets of blood mixed with sweat.

Here we report three cases

Case1: An eleven year old, Bengali, Muslim girl, residing in a rural area of West Bengal was brought by her elder brother to the Psychiatry department with the complaint of bleeding from intact skin of upper part of chest in several occasions since last one and half year.

Case2: A twelve year old, Bengali, Hindu girl, residing in a suburban area of West Bengal was brought by her parents to the Psychiatry department with the complaint of bleeding from intact skin of back of left ear on two occasions in last two months. She also had repeated episodes of stiffening of limbs with associated self-muttering for the same duration.

Case3: A fourteen year old, Bengali, Hindu girl, residing in suburban area of West Bengal presented with several occasion of bleeding from intact skin of both hands since 6 months. She also had repeated episodes of unresponsiveness and conduct disorder since childhood.

In all the cases necessary investigations like Benzidine test, Routine blood Investigation, platelet count, coagulation profile and skin biopsy were within normal limit.

Detail Psychiatric evaluation was done which revealed features of Acute Anxiety State.

All of them responded to propranolol 10mg twice daily and cognitive behaviour therapy.

Keywords: Hematohidrosis, stress, propronalol

“Differential diagnosis and severity of children presenting with repetitive behavior in a tertiary care hospital

SK Ashik Uzzaman, Saswati Nath, U.S.Mandal, Sumit Mukherjee

Post Graduate Trainee, R.G.Kar Medical College, KOLKATA, 67964 WBMC. [email protected]

Introduction: Repetitive behavior is a common symptom in children and is characterised by sameness, rigidity and repetitiveness. These stereotypic and repetitive behaviors seen in various psychiatric as well as neurological disorders. The aim of the study is to investigate distribution, patterns & severity of repetitive behaviors in different childhood disorders. Till today, the focus of almost all studies was on repetitive behavior on ASD & OCD. The purpose of this study is to bring all the children presenting with repetitive behavior under the same roof.

Materials & Methods: A Cross-sectional observational study, for the duration of 1 year, was performed on 72 Children (0-12yr) with repetitive behaviour attending the child guidance clinic, who had given consent. Children were screened by using CBCL and diagnosed as per ICD-10 DCR. Severity of repetitive behaviors was assessed using the RBS-R scale & score of different subscale of each disorder were compared. Statistical analysis done on SPSS version 20.

Results: Total 8 types of disorders were included in this study. Stereotyped behavior, Self-injurious behavior more in PDD than OCD, MR &TIC. Compulsive behavior more in OCD than PDD, TIC & MR. Ritualistic behavior, sameness behavior, restricted behavior and total score are more in OCD than tic disorder. Stereotyped behavior more in Tic disorder than OCD. Stereotyped behavior and self-injurious behavior more in MR than OCD.

Conclusions: This research contributes to the literature looking at domains or specific groups of repetitive behavior within children with PDD, OCD, TIC and other disorders. As per our knowledge this is the first study in India on repetitive behavior in different childhood disorders.

More generally, this research may contribute to improve screening and assessment procedures relating to the diagnosis in children presenting with repetitive behavior in opd set up.

Key words: Repetitive Behavior, Childhood disorders.

Can mother–infant bonding disorder be recognized by the members of the family?

Ashvini V, Bharadwaj B, Gopinath S, Jayalakshmi D

PG student, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, [email protected]

Background: Bonding disorders are disorders of mother-infant bonding seen in postpartum mothers. There may be a lack of positive feelings, anxiety in caring for, or expression of anger or rejection of the baby. These disorders often go unrecognised and have implications for the emotional and psychological development of the child. As part of an ongoing study to validate the Tamil translated version of the Postpartum Bonding Questionnaire (PBQ), we aimed to see if the maternal behaviour report by the family members, as rated on the Maternal Behaviour Rating Scale (MBRS), correlated with the presence or absence of bonding disorders.

Methodology: Hundred mothers attending the postpartum clinic in the department of Obstetrics and Gynecology of JIPMER were interviewed. Psychiatric illness was ruled out using the MINI screening instrument. The participants were interviewed using the Stafford Interview to assess mother-infant bonding. Two independent psychiatrists arrived at a consensus diagnosis of bonding disorder. The MBRS scale was applied to get the family member’s report of the mother’s behaviour. The MBRS makes an assessment of mother’s ability to care for the baby’s needs, affectionate behaviour, anger or anxiety towards baby and safety assessment.

Results: Hundred mother-infant dyads were studied. There were 98 mothers with two pairs of twins. The mother-infant bonding was unaffected in 84%. Mann Whitney U test was not statistically significant (p value = 0.564).

Conclusion: Sixteen percent of mothers had mother-infant bonding disorder. The MBRS scores based on family member’s report of maternal behaviour did not predict the presence of bonding disorder. Bonding disorders may have a predominantly subjective component which may need specific enquiry and cannot be detected merely by reports of maternal behaviour.

Keywords: Mother-infant bonding, anxiety, MBRS

Course and predictors of Recurrent depression in monozygotic twins – a case report

Ashvini V, Menon V, Gopinath S

PG student, Jawaharlal Institute of Postgraduate Medical Education and Research(JIPMER), Pondicherry, [email protected]

Background: Major depression is a psychiatric disorder which creates a huge burden on the patient causing socio-occupational dysfunction, and also alters the family dynamics. First degree relatives of the patient with major depression are at higher risk for depression, in which both genetic and environmental factors play significant role. How much each of these components contribute for the same, is still debatable.

Case: A 47 year old female, married for 30 years, was a monozygotic twin. The other twin was also married and both lived in separate places. She was premorbidly well adjusted and presented with 6 months history of depressive symptoms, with no psychotic, hypomanic, manic or other anxiety symptoms. Patient had the first episode of depression at the age of 32 and subsequently at 38, both when her twin sister had depressive episode, inspite of living in different environments. After that, due to multiple environmental stressors, she had further 3 depressive episodes, and the last episode was when she was on regular treatment, but her twin sister didn’t have further simultaneous episodes. The episodes were not precipitated by seasonal changes.

Discussion: Occurrence of depressive episodes in monozygotic twins despite living in different environments without simultaneous environmental stressors reiterates the upper hand of genetic factor. But when the presented patient had an episode, her twin was unaffected.

Conclusion: The recurrence of depressive episodes depend not only on shared genetic and environmental factors but also on epigenetic patterns. The co-occurrence in twins might be unidirectional due to factors like coping skills, severity of stressor and personality of each twin. The variation in the severity and course of the illness between the twins suggest that that genetic influence might not perpetuate throughout the life course of the twins, as expected, even when the individual enters another environment.

Keywords: MDD, recurrent depression, monozygotic twins

“Gratification disorder in early childhood: a rare presentation.”

Bhagyashree Garasia, Sushil Kherada, Kunjan Gupta, Suresh Gocher

Senior Resident, R.N.T. Medical College, Udaipur, Rajasthan. [email protected]

Introduction: Masturbatory activity in infants and young children is difficult to recognize because it often does not involve manual stimulation of the genitalia at all. It has variable clinical presentations in early childhood and failure to recognize these behaviors may result in unnecessary investigations and treatment. Masturbatory behaviour has been mistaken for epilepsy, abdominal pain, and paroxysmal dystonia or dyskinesia.

Case report: A 5 years old, female child, presented to psychiatry department OPD with the complaints of episodes of crossing over of both lower limbs along with episodes of rolling sideways. Each episode lasts for 1-2 minutes and these episodes occur 4-5 times in a day. These episodes occur only while the child is awake and not during sleep and after that child’s behaviour was normal according to parents. There is no history of loss of consciousness, frothing, incontinence or injury during episodes. There was no history of any abuse or medication intake. The child was admitted in psychiatry department under observation. Above mentioned episodes were witnessed during admission period with no other abnormal behaviour. By observation of episodes and after taking neurological referral in which complete neurological examination and radiological examination including NCCT Head, epilepsy was ruled out as differential diagnosis. Routine blood investigations also turned out to be normal. On the basis of above findings we made diagnosis of gratification disorder for which parents were reassured about child’s behaviour.

Conclusion: Gratification disorder is common in children, but could pose a diagnostic challenge in early childhood if the clinician is not aware of its possibility. There is little published data on gratification disorder (masturbation) in early childhood. This type of presentation is less reported elsewhere.

Keywords: Gratification disorder,Masturbatory behaviour,Epilepsy

To study predictors for withdrawal seizures in patients of alcohol withdrawal syndrome

Bhavneet K Ahuja, Sanjay Jain, Ajitabh Soni, Raghav Shah

PG student, SMS Medical college and hospital jaipur, Jaipur City, Rajasthan. [email protected]

Methodology: 100 patients were taken who presented in the deaddiction ward in alcohol withdrawal state. Comprehensive assessment of alcohol use with relevant blood investigations with revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale CIWA-Ar score for severity of alcohol withdrawal syndrome were applied. Patients were observed for withdrawal seizures after giving standard treatment regime. The patients were divided into 2 groups one with Withdrawal seizures and other without.

Results and Conclusion: Will be discussed at the time of presentation during the conference.

Key Words: Alcohol withdrawal syndrome, withdrawal seizures

Does Duration Of Pupillary Non-Reactivity To Light During Seizure Determine Clinical Response To Electro-Convulsive Therapy (Ect) In Schizophrenia?

Vani.P, Sayantanava Mitra, Sudhir Venkat, C.N.Naveenkumar, Shyam Sundar A., Jagadisha Thirthalli

Junior Resident, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka. [email protected]

Introduction: The autonomic arousal consequent to seizures results in the phenomenon of pupillary dilatation and non-reactivity to light. Combined cortical and sub-cortical regulation of autonomic activity makes it likely that pupillary dilatation and non-reactivity act as surrogate markers of ongoing seizure activity in deeper brain structures, particularly the hypothalamus.

Objectives: The present analysis is a part of a larger study and is aimed at evaluating pupillary non-reactivity (PNR) to light as a tool for predicting clinical outcome of ECTs in patients with schizophrenia, with a working hypothesis that degree of clinical improvement, PNR and motor/EEG seizure durations might be positively correlated.

Methods: This was a prospective observational study, involving consenting adult patients who were prescribed ECT (M=38/F=27;age=32.69+7.73years; Schizophrenia=60/Schizoaffective-disorder=5)following clinical decision. EEG/Motor seizures and hemodynamic functions were monitored, and PNR was assessed during the 2nd ECT session.Clinical parameters were assessedat baseline and after 6 sessions of ECT (thrice-weekly schedule) through BPRS and CGI scales.

Results: The mean of motor and EEG seizure durations during 2nd ECT session were 45.85+18.97 and 52.97+27.66 seconds,respectively. The mean pupillary inertia time to light was 57.31+28.52 seconds. All three variables had significant positive correlations with each other.However, no correlation emerged between relative clinical improvements and PNR/motor/EEG seizure durations; nor could we establish any correlation between the hemodynamic parametersand clinical improvement.

Conclusion: Our findings show that PNR out-lives both motor and EEG seizures during ECT, indicating that the former might be a better marker of the cessation of actual seizure activity in deeper brain structures. However, we also found that improvement in clinical parameters did not correlate with PNR, suggesting that as long as a seizure is generalized for an adequate duration, the clinical improvements are similar.

Keywords: ECT; Pupil; Seizure; Schizophrenia

Severe Extrapyramidal Symptoms, a rare complication in Organophosphate Poisoning

Chaitanya Lata Singh, Smita Panse, Avinash Karde, Aditya Patil

Resident, BJGMC, Pune, Maharashtra. [email protected]

Introduction: Extrapyramidal Symptoms is a very rare complication of Organophosphate poisoning (OP Poisoning). Only 21 patients have been reported of which 6 are from India. Here is a case of extrapyramidal manifestation in intermediate phase of OP poisoning where use of amantadine lead to complete recovery.

Case summary: A 35 years old female from rural background was referred to tertiary care hospital with history of suicidal OP compound consumption after 1week of detoxification, for further management. Patient was admitted initially in emergency medicine ward for management of fever, raised blood pressure, rigidity in all 4 limbs, neck stiffness, difficulty in swallowing and inability to get up from bed. Her baseline lab investigations, USG abdomen, CT brain, MRI brain (plain) was within normal limits. Her CPK level was 425 IU/L ruling out NMS. She was started on symptomatic treatment with iv fluids, antibiotics, paracetamol, baclofen, Foley’s catheter and Ryle’s tube feeding but no improvement was perceived. Patient was transferred to psychiatry ward on Day-4 in view of catatonic features. She was given lorazepam challenge test followed by oral lorazepam 8mg/day but no improvement was perceived. Considering differential diagnosis of Extrapyramidal Symptoms, oral trihexyphenidyl 6mg/day was added but no improvement was seen. On Day 9 after review of literature, she was started on tablet amantadine 100mg/day (through RT) up titrated to 200mg/day on which complete recovery in neurological symptoms was seen by day 21 of admission. Before discharge she was started on quetiapine 50mg BD for mild psychotic symptoms and past history of 1 psychotic episode 2years back.

Conclusion: Favorable and rapid response to dopamine agonist, amantadine in such a severe case, stresses the need for early diagnosis and treatment to avoid severe neurological complication.

Keywords- OP poisoning, rare, extrapyramidal symptoms, amantadine.

Effects of ways of coping on psychological well-being of commercial sex workers (female)”

Joyita Chakrabarti, Mittu muthu Varghese, Daya Ram

Student, CIP, Ranchi, Jharkhand. [email protected]

Prostitution exists in India since time immemorial. Now it has become a thriving business in rural and urban setups and yet it has become a debatable issue. (Casciani and Dominic, 2009). In 2007, the Ministry of Women and Child Development reported the presence of over 3 million female sex workers in India, with 35.47 percent of them entering the trade before the age of 18 years (UNODC, 2007). Dandona et al. (2006) said that the majority of sex work in India is undercover due to unfavorable legal environment and discrimination against female sex workers.Twenty-three female sex workers in Hong Kong participated in in-depth interviews. In the results, it was found that the informants reported negative feelings in response to financial burden, clients’ demands, threats to physical health, and stigma. Some female sex workers showed their resilience by being able to rationalize their role, believe their ability to make a change in life, and stay optimistic. They adopted strategies including emotional regulation and acceptance of their responsibility and limits to cope with stressful life events (Yuen et. al, 2014).

The literatures about psychological well-being of female sex workers are very sparse. The incidents of sexually transmitted diseases are very high in this group of people. There are virtually no proper work has been done in the country to understand the psychological well-being of commercial sex workers.

Aim: To assess the effects of ways of coping on psychological well-being of commercial sex workers (female)”

Methods and Materials: 60 female commercial sex workers was recruited using using purposive sampling technique from Kalighat, Kolkata. Data was collected after obtaining the informed consent from the subjects. Each subject included in the study was evaluated for psychological well-being using psychological general well-being schedule (Harold Dupuy, 1977) and ways of coping was determined using ways of coping scale (Lazaras and Folkman). Data will be analysed using appropriate statistical tests and the results will be discussed during the presentation.

Keywords: coping, psychological well-being

Clozapine in Schizophrenia with Epilepsy

Chandramouli Roy, Jayanath B.P., Surendra Paliwal, Abhishek Kumar, Pranjal Dey, Varun S Mehta,

Junior Reseident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Introduction: Clozapine has been used in the management of treatment resistant schizophrenia. Its use has also indicated in patients having suicidal ideations and hostility. However, this resort could also result in some deleterious effects such as agranulocytosis, seizures and paralytic ileus.

Due to the probability of inducing seizures, the justification of Clozapine in patients with epilepsy and psychosis is restricted. We report one such case of successful trial of Clozapine in Schizophrenia with epilepsy.

Case Presentation: A 23 year old single Hindu male, a B. Tech student from sub urban Jharkhand reported with his mother with three attacks of involuntary jerky movements and loss of consciousness along bouts of aggressive behaviour, smiling and muttering to self, suspiciousness, sleep disturbances, and poor self-care for last 4 months. The symptoms had an insidious onset and were deteriorating in nature. The family history & past history was uneventful except for the presence of Hypertension and Diabetes Mellitus in the mother. The MSE revealed an uncooperative patient with poorly communicable affect, grandiose delusions and delusional perception. The patient was admitted and during the course of stay continued to remain aggressive and expressed suicidal intentions. After an initial trial of injectable psychotropics, the patient was started on tab. Clozapine due to its proven efficacy for aggression and suicidality. The patient was also on Tab. Sodium valproate for his seizures which were under control for the past 6 months at the time of admission. The patient continued his stay for two months during which there was improvement in his ward behaviour and psychotic symptoms. There were no seizure attacks during the stay while the dose of Tab. Clozapine was optimized to 300 mg/day along with Tab. Sodium Valproate 1200 mg/day.

Discussion: It would be done at the time of presentation.

Keywords: Clozapine, schizophrenia, epilepsy

To study neuropsychological functioning in euthymic Bipolar Affective Disorder patients, first degree relatives and healthy controls.

Vikash Chandra Mishra, Vikash Chandra Mishra, Parag Sharma, Dharmdeep singh rao

Junior resident, SMS Medical College Jaipur, Rajasthan. [email protected]

Background: Among the various endophenotypes, neurocognitive dysfunctions and Neurological soft signs (NSS) have received considerable attention as potential endophenotypic markers for bipolar disorder (BD) as these are seen in patients (during the euthymic phase) and in the first degree relatives

Objective: To study neuropsychological functioning in euthymic Bipolar Affective Disorder patients, first degree relatives and healthy controls.

Methodology: Sixty cases each of Bipolar Disorder patients in euthymic phase and their First degree relatives along with sixty age and sex matched healthy controls. these three groups were subjected to the neuropsychological assessment and then compared. Results and Conclusion: It will be discussed at the time of presentation.

Key Words: Euthymic patients; bipolar disorder; neuropsychological assessment.

Management of Specific Learning Disorder in India: Where do we stand?

Anamika Sahu, Rachna Bhargava, Rajesh Sagar, Manju Mehta

PhD Scholar, All India Institute of Medical Sciences, New Delhi, [email protected]

Background: Specific Learning disorder (SLD) is a neurodevelopmental condition that affects approximately 0.38%-15.2% Indian children, In Indian, very few focal intervention studies have been done to deal with learning problems of children with SLD. There is need to synthesis existing findings from varied setting and designs to understand potent management of SLD. Therefore, this review was done to evaluate the approaches and outcomes of interventions that used to manage learning problem of children with SLD.

Materials and Methods: To find appropriate studies, a thorough search of 25 years literature was conducted with electronic search engine databases e.g. PubMed, Educational Resources Information Clearinghouse (ERIC), PsycINFO and Google Scholar. Studies published in peer reviewed English language journals were included. Unpublished material and non-peer reviewed materials were not included as a part of this review.

Results: Finding of our study suggests that studies related to intervention for SLD are varied by their intervention approaches and outcomes. Researchers mainly used remedial training or cognitive training or both approaches to deal with children’s academic and cognitive problem. Intervention duration, number of sessions and session duration also varied from one study to another i.e. 1 month to one year intervention duration, sessions from 20-36 and session duration lasing from 20 minutes to 60 minutes. All intervention studies were conducted either at clinical setting or in school setting.

Conclusion: Remedial program and cognitive retraining approaches may improve the learning and cognitive skills of children with SLD. However, its effectiveness in all domains of academic area is limited.

Keywords: India, specific learning disorder, interventions

Dermatitis artifacta-A case report

Deepa N, S.Ananda Krishna Kumar T.Kumanan,

PG, Madurai Medical college, Madurai, Tamilnadu. [email protected]

Introduction: Dermatitis artifacta is a psychocutaneous disorder in which patient deliberately produces skin lesions to satisfy an unconscious psychological need. The skin lesions serve as powerful self expressive nonverbal messages and a cry for help. Dermatitis artifacta is more common in adolescent female.

Case Report: A 18 years old female presented to psychiatry department for skin lesions over her forearm, lower limb and right side of her neck which is sudden in onset with no history of trauma and all lesions were circumscribed and in reachable areas. The patient denied of inflicting lesions. They were said to be occurring frequently and the parents observed it to manifest spontaneously on full moon period healing without any treatment.

Family history: Alcohol dependence in father, frequent conflicts between parents regarding financial issues, and criticizing her skin colour.

General Examination: Patient shows lesions and multiple healed scars over reachable parts of the body.

MSE: Patient avoided eye contact, denied self infliction, and indifferent to skin lesions. She had low self esteem and several conflicts in interpersonal areas.

INVESTIGATIONS: Hb, TC, DC, ESR within normal limits.

Dermatology opinion: Dermatitis artifacta

Treatment: Supportive and Insight oriented therapy was given. Parents were counseled. On follow up skin lesions were found to have decreased.

Discussion: Initially, patient denied self inflicting behavior, indifferent to symptoms or how these lesions occurred but on subsequent interview she admitted. The underlying causes may be due to frustration about marriage, psychosocial stressors, and low self esteem. The unconscious desire may be to get attention and sympathy from her Parents. Whenever Patient is anxious or depressed, there is exacerbation of these skin lesions.

Conclusion: Dermatitis artifacta is a challenging condition. They can be helped by creating a therapeutic relationship, flexible and nonthreatening environment with psychosocial support.

Key Words: Dermatitis artifacta,lesions,inflicting

EEG Spectral Power as a Response Marker for add-on Memantine treatment in treatment of Alcohol Withdrawal Syndrome: A randomized, placebo controlled, double-blind, pilot trial

Dhruv Gupta, Shobit Garg, Sai Krishna Tikka, Sumit Khattri

PG- 2nd year, Shri Guru Ram Rai Institute of Medical And Health Sciences, Dehradun, Uttrakhand. [email protected]

Background: NMDA receptor antagonists have been found to be effective in treating alcohol withdrawal syndrome, in preclinical studies. However, only a few studies on the efficacy of NMDA receptor antagonists in humans have been reported. As NMDA receptor function has a vital role in the assembly of EEG oscillations, they might be used as response bio-markers.

Objectives: Primary: To investigated the effects of memantine, an NMDA receptor antagonist in alcohol withdrawal syndrome.

Secondary: To investigated the effects of memantine on depression and craving in alcohol withdrawal syndrome; also to study EEG spectral power as a response marker.

Material and Methods: The study was a prospective, randomized, placebo controlled, double-blind trial. Out of the 14 patients who completed the trial, so far, 08 patients were randomized to receive memantine add-on and 06 received placebo add-on. Severity of alcohol withdrawal was assessed by Revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-AR); craving was assessed using the Penn Alcohol Craving Scale (PACS); the Montgomery–Åsberg Depression Rating Scale (MADRS) and the Clinical Global Impression (CGI) Scale were used to assess depression and clinical improvement. Assessments were done at 0, 7th and 14th day. A resting state EEG was recorded at 0 and 14th day. Spectral power in five frequency bands- delta, theta, alpha, beta and gamma was measured across 8 brain regions.

Repeated measures ANOVA was used to analyse the primary and secondary outcome variables.

Results: Generally, none of the outcome measures showed sufficient power and effect sizes on the time by group analysis. We found no significant difference between memantine and placebo groups on the change of scores on withdrawal, craving, depression and overall clinical improvement over the course of 2 weeks. No differences were noted on EEG spectral power measures, as well.

Conclusions: This study fails to demonstrate whether or not add-on memantine is significantly superior in alleviating alcohol withdrawal compared to placebo. We also fail to provide evidence for whether this protocol has any effect on EEG oscillations.

Keywords: EEG, NMDA receptor antagonist, alcohol withdrawal syndrome

Geophagia- A Case Report

Dikshita Garg

PG student, D Y Patil Medical College and Hospital, Pune, Maharastra. [email protected]

Geophagia is defined as deliberate consumption of earth, soil, or clay

From a psychiatric point of view, geophagia has been classed as a form of pica—a term that comes from the Latin for magpie, a bird with indiscriminate eating habits. It is commonly associated with iron and zinc deficiency and is strongly associated with both family history and cultural factors. However, geophagia is often observed in the absence of hunger, and environmental and cultural contexts of the habit have been emphasized. Finally, geophagia is encountered in people with learning disability, particularly in the context of long-term institutionalization; in this regard, geophagia and other forms of pica are associated with a high rate of complications and substantial morbidity and mortality. We hereby report a case of a 25 years old woman with features suggestive of geophagia.. She preferred dry mud. She stated that the mud eating was preceded by an irresistible urge and simply that she enjoyed having mud. She did, however, note that once she began eating mud, she would have the need to eat more. Whenever she tried not eating mud she would feel the need to eat something hard and couldn’t control the urge to have mud and at times used to have apprehension. In order to control the apprehension she used to eat mud. Pt is also experiencing decreased appetite. Treatment includes the behavioral treatment of pica itself and the treatment of any underlying condition such as schizophrenia and iron deficiency. Eventually, when pica is diagnosed, no proven treatments exist. Although selective serotonin-reuptake inhibitors can be helpful in some cases, diagnosis and treatment must be individualized.

Keywords: Geophagia, pica, irresistible urge.

Association of Neutrophil/Lymphocyte Ratio in Patients with Depression and its Correlation with the Severity of Depression

Sanjay Jain, Paramjeet Singh

Resident doctor, SMS Medical College, Jaipur, Rajasthan. [email protected]

Background: Previous researches reveal that chronic inflammation is associated with depression. As a simple and cheap inflammatory biomarker, The neutrophil to lymphocyte ratio (NLR) has been investigated as a new biomarker for systemic inflammatory response in depression. The aim of the study is to investigate the relation of NLR with severity of depression in Indian setup.

Methodology: The study population consisted of 300 patients with depressive disorder according to DSM-V. Patients were evaluated with the Hamilton Rating Scale for Depression (HAM-D). The demographic, clinical data and blood samples were documented. Patients were classified into three groups according to their HAM-D score such as mild, moderate and severe depression.

Results: Patients with higher HAM-D score had significantly higher NLR levels compared to patients with lower HAM-D score. Correlation analysis revealed the neutrophil to lymphocyte ratio was positively correlated with the HAM-D depression index (r=0.390, p<0.001). In logistic regression analyses, NLR levels were an independent predictor of severe depression.

Conclusion: Higher HAM-D scores are associated with higher NLR levels in depressive patients and. A simple, cheap white blood cell count may give an idea about the severity of depression and NLR may be used as a new marker for depression.

Key Words: Depression, Lymphocyte, Neutrophil, Inflammatory.

Wilson’s Disease (Hepato-lenticular degeneration)

Ateeq Abu Baker Khan, Shriniwas B Chaudhari

Post Graduate Student, S. Nijalingappa Medical College, Bagalkot, Karnataka. [email protected]

Background: Wilson’s disease is a neuropsychiatric-autosomal recessive illness characterized by excessive accumulation of copper predominantly in liver and different parts of brain namely- basal ganglia, midbrain and pons.

Genetic defect is attributed to a membrane bound copper binding protein gene- ATP7B (on chromosome 13), which incorporates copper in ceruloplasmin. Impaired elimination of copper leads to its accumulation and resulting clinical features.

Patient can present with tremors, dystonia, rigidity, dysarthria, brisk reflexes and psychological and behavioural disturbances.

Neurological and psychiatric symptoms can occur at any point in the course of the disease.

We report a case of Wilson’s disease in a 26 year old female, presenting with psychiatric symptoms.

Case Summary: 26 year old female, with history of tremors, difficulty in walking and speaking since 10 years of age presented with complaints of feeling naked despite wearing clothes, sensation of touch when alone and disturbed sleep since 4 months.

Mental status examination revealed tactile hallucinations, ideas of reference, anxiety and dysphoric mood.

Neurological examination revealed tremors, rigidity in upper extremities, dysarthria, poor coordination and brisk deep tendon reflexes.

Ophthalmological examination revealed prominent  Kayser-Fleischer ring More Detailss in both eyes.

The patient had ceruloplasmin level of <0.08 g/L, serum copper level of 29.3 mcg/dl, liver function test revealed alkaline phosphatase levels of 144 U/L.

MRI brain reported focal areas of T2/FLAIR hyper-intensities involving bilateral thalami, midbrain and pons and mild cerebral atrophy significant for age.

Other investigations like renal function test, lipid profile and thyroid profile were found to be within normal limits.

Patient is currently on treatment with Penicillamine, Zinc Supplementation and Olanzapine. Psychoeducation was given to family members. Significant improvement has been observed with treatment.

Keywords: Dystonia, Dysarthria, Kayser-Fleischer ring, Ceruloplasmin

Delusional Parasitosis – A Case Report

Akanksha Gajbhiye, Ishan Choudhary, Suprakash Choudhury, Daniel Saldanha,

PG Student, Dr D Y Patil Medical College and Hospital, Pune, Maharashtra1 [email protected]


Delusional Parasitosis is an infrequent psychotic illness, where the patient has a false but firm belief that his body is infested with parasites. It is also known as Ekbom syndrome. Delusional parasitosis can be primary, secondary, or organic. Generally these patients initially consult non psychiatric specialities like physicians or dermatologists. It is usually difficult to convince them about consulting a psychiatrist. Presentation of delusional parasitosis varies among the patients, although it typically manifests as a crawling and pin-pricking sensation that is most commonly described as involving perceived parasites crawling upon or burrowing into the skin, sometimes accompanied by an actual physical sensation. Treatment primarily involves use of antipsychotics. It also involves management of primary psychological and medical condition in case of secondary or organic delusional parasitosis respectively. We hereby present a case of a 72 year old woman with features suggestive of delusional parasitosis. Patient was a known case of hypertension, came with chief complaints of a sensation of bugs/ insects crawling on her scalp and spreading to other parts of body since 2 years. On mental status examination, anxious affect, delusion of parasitosis, tactile hallucinations and impaired insight were noted. Patient was started on antipsychotic medication. Thereby concluding that skillfull handling of the case, empathy towards the patient, and careful history taking play a significant role in diagnosing and management of the condition.

Keywords: Delusional parasitosis, antipsychotics, Anxious affect

A Case Of HIV Presenting As Mania


Junior Resident, Institute of Mental Health, Chennai, Chennai, Tamilnadu. [email protected]

Introduction: The incidence of HIV infection causing mania disorder is 1% and is quite uncommon without opportunistic CNS infection.

Case history: A 17 year old girl presented in opd with symptoms of excessive talk,tall claims,grandiose delusion and irritable mood loss of appetite,cough on and off without expectoration for the past one month without significant family history and no similar episode in the past.She was a known case of HIV positive diagnosed at the age of three years and was on continuous followup for CD4+ Cells and was started on ART treatment five years back and her CD4+ was 600cells/ six months back.She was on irregular in ART medication for past four months.Her physical examination shows that she is oriented,has no meningeal irritation,no focal neurological deficit and lobar functions are normal.Baseline investigations were done which showed mild lymphocytosis and her X ray chest revealed patchy haziness in left upper lobe.She was started on second generation antipsychotics and mood stabilizers without significant improvement for about fifteen days.Chest physician opinion was obtained and She was started on cat 1 ATT.A review in ART showed her CD4+ count was 300 indicating a high viral load.CSF analysis revealed a normal glucose level,normal protein level and elevated lymphocytosis.MRI found to be normal. A diagnosis of AIDS induced mania was made she was started on CAT 1 ATT and ART medications are streamlined.Within fifteen days her mood symptoms improved.she attained complete remmision of symptoms and her CD4 count was 480cells/ after a month of followup.

Discussion: We considered other differential diagnosis like primary Bipolar affective disorder-mania and ruled out other opportunistic infections.

Conclusion: HIV presenting as depression is usually common at this age group whereas mania presenting at this age group without any focal neurological deficit and any opportunistic infection is a rare presentation.

Keywords: HIV,mania,mood disorder

Quality of life of OCD Patients

Dheerendra Pratap Singh, Priyanka Sharma, Prakash Chandra

Post graduate resident 2 nd year, saraswathi institute of medical sciences, Hapur, Uttar Pradesh. [email protected]

Introduction- OCD is a common and long lasting disorders leading socio-occupational impairment. It also have detrimental effect on the quality of life of OCD patients.

Aim & Objective- To asses the quality of life of OCD patients.

Methods- The current study was carried out in the psychiatry department of saraswathi institute of medical sciences hapur with Sample size of 50 OCD patients. After obtaining the consent from the patients they were evaluated on socio demographic proforma, YBOCS & WHOQLBREF. Data was then collected and was subjected to suitable statistical analysis.

Results- Detailed table and chart will be explained during presentation.

Conclusion- The study emphasized the holistic approach for the treatment of OCD patients by understanding the different deficits in the functioning and quality of life of patients, therby improving the outcome of illness.

Keywords- OCD, Quality of life.

Prevalence Study of Postpartum Depression and its Correlation with Socio-Demographic Variables at a Tertiary Care Hospital, KIMS, Huballi

Meghamala.S. Tavaragi, Raghavendra Patil, Mahesh Desai, Arunkumar.C

Karnataka Institute of Medical Sciences,Hubli, Karnataka. [email protected]

Introduction: Affective disorders occur commonly in postpartum period, ranging in severity from mild and transient ‘‘baby blues to postpartum depression(PPD) to postpartum psychosis.

Women with PPD are at high risk for recurrent depression.

Despite its serious consequences and amenity to treatment, PPD often remains unrecognized and end up with psychiatric disorders.


  1. To study the prevalence of Postpartum Depression among the patients who had delivered at KIMS, HUBLI.
  2. To find the association between Postpartum Depression and selected socio-demographic variables.

Methods And Methodology: 250 Women between 18 to35 years, who delivered at KIMS Hospital, Hubballi from January 1st 2017 to June 31st 2017 , willing to participate in the study were taken as sample.

Postpartum depression was assessed by using Edinburgh Postnatal Depression Scale(EPDS).

Severity of depression assessed by using Hamilton Depression Rating Scale (HAM-D).

EPDS AND HAM-D scales were applied on 3rd day of delivery and again on 6th week postpartum period

Results: Among 250 women 10.8% (27) women had postpartum depression.

Among 27 PPD women 5 had mild depression, 13 moderate depression, 7 severe depression and 2 had very severe depression.

Among 27 PPD women, 15 had delivered female babies, 5 male babies and there were 7 deaths(still births + ARDS deaths).

There is significant association between depression and number of female children(p<0.001*),number of pregnancies(p0.018*), female gender of present delivery(p0.01*), and also significant association between depression and husbands alcohol use(p0.007*), relation difficulties with in-laws(p<0.001*) and poor family support(p<0.001*).

Keywords: Postpartum depression, EPDS, Baby blues

Habit Reversal Training for Trichotillomania

Minny Jain, Om Prakash

MD Resident, IHBAS, Delhi. [email protected]

Background- Trichotillomania is characterized by the repeated urge to pull out hair, leading to noticeable hair loss, distress, and social or functional impairment. Most of the cases present initially to dermatologists with complaints of loss of hair and is often confused with other dermatological conditions like alopecia areata, tinea capitis, traction alopecia. It is a chronic condition and difficult to treat. No formal treatment algorithm is present for trichotillomania and no drug has been found to be universally effective.

Clinical Case: We present a case report of a 29 year-old single female diagnosed with trichotillomania, with complaints of recurrent hair pulling resulting in noticeable hair loss since the age of 18 years. She was treated with Habit Reversal Training over a period of 12 weeks and attained complete remission.

Ms. ES, a 29-year-old single female, a graduate banker belonging to a nuclear family of middle socioeconomic status was referred to the Psychiatry outpatient department by the dermatology clinic where she presented with complaint of alopecia. She gave history of recurrent pulling out of her hair resulting in noticeable hair loss since the age of 18 years. She used to develop an urge and a sense of tension immediately before pulling out the hair or when attempting to resist the behavior which got relieved on pulling out the hair. Hair pulling was only from the scalp, but never from any other site of the body. Due to the baldness arising due to her hair pulling, the patient started using a scarf which she would wear throughout the day. She developed decreased self-confidence due to her problems and started avoiding social gatherings. A diagnosis of Trichotillomania was made as per International Statistical Classification of Diseases and Related Health Problems, 10th Revision criteria.

Conclusion – This case highlights the efficacy of behavior therapy in trichotillomania

Keywords: Habit reversal, trichotillomania, behaviour therapy

Gilhari syndrome : A rare case

Rameez AK Shaikh, S.B. Deshmukh, Rohit Deshmukh .

PDMMC Amravati. Maharashtra. [email protected]

Introduction: Gilhari syndrome is characterized by patient complaining of small swelling on the body changing its position from time to time as if a gilhari (squirrel) is travelling in the body

Objectives: To report an interesting case of gilhari syndrome which had started with simple incidence and landed up in major psychiatric illness.

Case Report: A 24year-old, single male has started thinking that he had contacted with gilhari. This idea started becoming more and more firm and fixed almost of delusional severity. So that he would behave like a gilhari is moving beneath his skin. He would try to catch that squirrel, but every time he does that it would slip away. Squirrel sometimes would come around neck and he would feel like choking sensation and fear of death. Patient believed that Gilhari must be crushed to death or it will kill him. He also had made serious suicide attempts twice. We had started patient on benzodiapine which has reduced his anxiety. Mother has MDD, he is attention seeking, sensitive. No sick role, no secondary gain noted. Belief was firm, no insight, intact reality testing.

Discussion: Gilhari syndrome is condition which can be confused with, delusion disorder, PTSD, factitious disorder, Conversion disorder & Illness anxiety disorder. The belief that the Gilhari will rise in the back and after reaching in the neck will kill the person is so strong that the patient himself and/or the relatives produce him for crushing or killing the Gilhari in vital area which is very painful and may lead to serious consequences. He was having firm belief of squirrel moving under his skin, without any insight but reality testing and cognition were not affected

Keywords: Gilhari syndrome, delusional severity, psychoeducation, post traumatic stress disorder

Key Message : This condition usually is recognized and treated by the folk medicine of the culture(Rajasthan).The person should be given psycho education & informative talk about what may or may not be the consequences and intervention by psychiatrist should be advocated

Disulfiram induced psychosis: A summary of the published literature

Nileswar Das, Ananya Mahapatra, Siddharth Sarkar

Junior Resisdent, All India Institute of Medical Sciences, New Delhi. [email protected]

Introduction- Disulfiram has been reported to be associated with development of psychosis in selected cases. Although several reports have documented this association there is a relative dearth of research regarding this clinical phenomenon. We attempted to systematically review the published case reports of disulfiram induced psychosis in order to delineate its phenomenology as well as possible clinical correlates.

Methodology- A comprehensive review of published literature in English language journals with the search terms “disulfiram” AND “psychosis/psychotic disorder” yielded 17 cases (1960-2017) in total (for which full-text articles could be retrieved) which reported the onset of symptoms of psychosis after the initiation of pharmacotherapy with disulfiram.

Results- Majority of the patients were males (70%) with mean age of 32.5 years. The duration of treatment with disulfiram ranged from 3 days to a maximum period of 8 months. The dose of disulfiram used, ranged from 250 mg to 500 mg in majority of cases. Majority of the patients were however treated for 14-30 days with disulfiram. In all except one patient, the symptoms of psychosis subsided after withdrawal of disulfiram. The time duration after which the symptoms subsided ranged from 1-14 days, the mean time duration being 7.5 days. Family history of psychosis was reported in only 3 of the reported cases.

Conclusion- In a clinical setting, it is important to recognise disulfiram induced psychosis, distinguish it from independent psychosis and manage it by timely withdrawal of the offending drug. The role of disulfiram induced psychosis in the outcome of alcohol use disorder or development of schizophrenia and related disorders needs to be explored by rigorously conducted longitudinal studies.

Keywords- disulfiram, psychosis, psychopathology

Haloperidol, Divalproex Sodium And Priapism- A Case Report

Sagar Mudgal, Nikhil Nayar, Renu Pandey, M.K. Deshpande

P.G. Resident 2nd Year, Index Medical College, Indore, M.P. [email protected]

Priapism is a condition in which a penis remains erect for hours in the absence of stimulation or after stimulation has ended. It is a urological emergency that can cause serious complications. Several classes of medication are involved: antidepressants, antihypertensives, anticoagulants, alpha-blockers and some psychoactive substances. There have been few reported cases of priapism caused by antipsychotics and only one case report of that caused by sodium valproate. In our case a 26 year old male, known case of bipolar disorder presented with priapism after taking combination of haloperidol and sodium valproate. Our case highlights the need for physicians to be aware of the potential for this serious adverse effect, to select the appropriate molecule after careful history taking and the need for early intervention and appropriate treatment to prevent permanent impotence and other serious complications.

Keywords: Haloperidol, priapism, divalproex sodium

Case report: Unusual presentation of problematic pornography use with comorbid delusional disorder

Shailaja B, Suprakash Chaudhury, Archana Javadekar, (Brig) Daniel Saldanha

PG Student, Dr D Y Patil Medical College & Research Hospital, Pune, Maharashtra. [email protected]

Though the existence and clinical utility of the non-substance and behavioural addiction has been debated, with gambling disorder currently being the sole non substance disorder classified together with the substance use disorder in DSM-5, Problematic Pornography Use (PPU) is highly prevalent, especially among the young adult males. Here we present one such case of PPU. Mr. X, a 24yr old, unemployed, divorcee brought by his father with complaints of fearfulness, belief of being under threat without obvious reason, irritability, reduced social interaction and sleep disturbance of almost two-year duration. On interview he revealed that he had trouble controlling urge to watch pornography since the age of 14, he would spend almost 8-12 hours a day watching porn on the internet and would masturbate 8-9 times a day. He couldn’t have a conjugal married relation he faced divorce within a year of marriage, one of the reasons for divorce being his inability to perform sexual act. As the days passed he started believing that police have come to know about his excessive porn use and he would be arrested for the same. He believed that police have some tracking device which would trace him if he would watch porn content online because of which he stopped watching porn became fearful, suspicious and home bound. This case is unusual as the patient cut down his problematic pornography use without medical aid due to his own delusional psychopathology. For the comorbid delusional disorder, he was started on SGA and is on regular follow-up.

Deceptive Green

Surekha.S, G.Prasad Rao, Nakka Naga Rajitha, Kalasapati Lokesh Kumar

Post Graduate, Bhaskar Medical College, Hyderabad, Telangana. [email protected]

Wilson’s disease(WD) is a treatable autosomal recessive metabolic disorder which can cause a progressive neurological disease with psychiatric manifestations.Gradual deterioration of intellectual functions is one among them which is a very rare manifestation.

Introduction: WD resulting from a loss of function of an ATP7B,which involves a reduction in the transport of copper in the bile and its accumulation in the body, notably the brain.WD begins in the form of a hepatic, neurological, or psychiatric disease in at least 90% of the patients. The first manifestations are hepatic (40%), neurological (35%) or psychiatric (10%).

Case Report: A 11year old muslim boy from rural background was brought to paediatric out patient,whose parents noticed decreased academic performance and psychomotor activity.His initial investigations were found to be normal and was referred to a psychiatrist,patients school performance was normal till fourth class and there was a deterioration in academic performances since one year along with gradual decreased psychomotor activity.Routine and I.Q assessment was done which was below normal.Symptoms were sudden and progressive hence advised for MRI,which was suggestive of changes of WD;Ophthalmology consultation was taken and Kayser-Fleischer rings were visible in the cornea on slit lamp and was referred to a neurologist where he was diagnosed with WD and was treated further and improved symptomatically.

Discussion: Neuropsychological assessment is a valuable tool to evaluate the cognitive impairments in WD patients with or without neurological signs.Psychiatric symptoms are frequently encountered in WD.The recent resurgence of interest in neuropsychiatry has led to a more detailed consideration of the psychopathology associated with WD.WD characterized by disorders of affect, behavior and personality,Where as in our case,patient presented in contrary to the common psychiatric manifestations with WD which can only be diagnosed on detailed evaluation and specific investigations.

Key Words: Wilson’s disease, intellectual impairment, decreased psychomotor activity.

Neuroleptic Malignant Syndrome developing after 6 months of treatment initiation: A case report

Abhinav Pandey, Sanjay Gupta, Abhinav Pandey

Senior Resident, Ims Bhu Varanasi, Varanasi, Uttar Pradesh. [email protected]

Background and Aims: Neuroleptic Malignant syndrome is a potential lethal complication of psychotropic medication. Death is reported to be in around 5-20% of cases. Most of the cases develop this complication within one month of starting or change of medication. We report here a case who developed fever and was subsequently diagnosed with NMS, after remaining on stable doses of psychotropic medications, for nearly about 6 months.

Methods: Case report with brief review

Results: A 26 year female was diagnosed with paranoid schizophrenia six months back and was being treated with haloperidol 5mg and olanzapine 20mg. She was on stable doses of these medications. She presented with fever of 2 day duration and was admitted for further assessment and management. While being investigated patient’s condition further detoriated and within next 2 days she developed delirium. Her CPK level was found to be 1024 IU/L. Patient was shifted to ICU for further management.

Conclusions: Fever while on psychotropic medications should be carefully evaluated. NMS although a complication described to be developing early in the course of starting antipsychotic medications, can develop later as well.

Keywords: NMS, Psychotropic medications

Ascetic of Desire: Indian psychoanalyst writers depiction of Vatsayana

Amandeep Gill, GK Vankar, Nishant Ohr

Junior Resident, SAIMS, Indore, Madhya Pradesh. [email protected]

Introduction: ‘The Ascetic of desire’ is a novel by Sudhir Kakar, a psychoanalyst, that gives a startling psychological insight into the life and times of Vatsyayana, the author of Kama Sutra. The work Illuminates sexuality in all its expressions, recognizing various differences of class, culture, gender, race, and sexual orientation in an attempt to provide the essence of the Vatsayana’ s work.

Approach - A scientific review of literature of The Ascetic of Desire by Sudhir Kakar.

Findings and Discussion: The book spans over 18 chapters and 300 pages and tells the story of Vatsayana and his times through the ‘narrator’ who is under the tutelage of the great sage. Initially, a ‘novice’ in the matters of sex, portrayed through his interaction with prostitutes of Varanasi, the narrator embarks on a journey of sexual discovery under his master’s guidance. Vatsayana recounts his stories (which are not mere sexual escapades) from childhood through his youth, though laments at the end that not much work was done on ‘kama’ (desire) of old age.

Vatsayana’s work was not the first of its kind though it was unique in exploring women’s sexuality and treating the partners as parts of a single sexual unison. Through the book we see gradual change in the narrator regarding the acceptance of his sexual experiences and the resolution of guilt of having slept with his guru’s (Vatsayana) wife.

The Kama Sutra is a great ancient work, perhaps one of the most widely read treatise on sex ever written in history affirming a period when India was among the most culturally liberal societies as far as sex was concerned.

An interesting book from psycho-social perspective, it enables the reader to examine the history of sexual behavior and attitudes of ancient India in the light of modern psychoanalytical practice.

Keywords: Vatsayana, India, Sudhir Kakkar

A case for Metacognitive therapy in hypochondriacal delusions

Amit Kumar Sharma, Jayanath B P, Saurabh Jaiswal, Shraddha Choudhary, Varun Mehta, Surendra Paliwal, Madhumita Bhattacharya, Shatavisa Majumder

Junior Resident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Introduction: Body Dysmorphic Disorder (BDD) is characterised by a pre occupation with an imagined defect that causes clinically significant impairment in functioning. BDD is an under recognised chronic illness, wherein the affected individuals have a completely different metacognitive thought that they are unattractive, ugly, inferior and worthless. Metacognition is used to control the cognitive system which strengthen or suppress mental strategies and also increases monitoring process. In this case, we present a case in which Metacognitive therapy was used successfully to treat BDD.

Case Summary: A 25 year old single Hindu graduate male, from suburban Jharkhand with past history of febrile seizures reported with his mother having an illness duration of 5 yrs characterised by complaints of defect and shrinking of head, repetitive washing and undue orderliness. The mental status examination revealed the patient to be co-operative with anxious affect, obsessive doubts about contamination with compulsive washing, hypochondriacal delusions and grade I insight. The patient was admitted and was given a trial of T. Paroxetine 25 mg/day and T. Quetiapine 100mg/day initially which was followed by inadequate response to T. Pimozide 4mg/day, T. Aripiprazole 15mg/day in combination with Cap. fluoxetine 100mg/day & T. Buspirone 30mg/day. The patient continued to harbour the beliefs regarding the misshapen head and dreaded the consequences due to it. However, there was reduction in his preoccupation following the initiation of Metacognitive therapy. The medications were changed to T. Sertraline 200 mg/day & T. Amisulpride 200mg/day subsequently and the sessions were continued. The patient continues to maintain the improvement a month after discharge

Discussion: The case demonstrates the preliminary efficacy of metacognitive therapy in resistant somatic delusions.

Keywords: Body Dysmorphic Disorder, Metacognitive Therapy, Hypochondriacal delusions

Development of a Hindi instrument for self-assessment of ‘recovery’ in opioid dependence: A mixed methodology study at a de-addiction centre in a tertiary hospital in north India

Aniruddha Basu, S K Mattoo, Debasish Basu, Subodh BN, S K Sharma

DM Senior Resident, PGIMER, Chandigarh, [email protected]

Background: Long term studies have shown that prolonged abstinence is possible and ‘recovery’ is a reality in a smaller percentage of patients with opioid dependence (OD).

Objective: To apply an instrument developed out of qualitative approach on OD subjects for self-assessment of ‘recovery’.

Methodology: This is a cross-sectional, descriptive study with both qualitative (grounded theory) and quantitative arms. In the qualitative arm consenting males with OD using illicit or prescription opioids were recruited through ‘purposive’ sampling. Initially in-depth interviews were conducted among patients, care-givers and treatment providers. By ‘open coding’ of the transcripts, 70 items were derived which helped in constructing a 5-point likert-type self-rated Hindi Instrument for Assessment of Recovery (HARI). In the quantitative arm HARI, Addiction Severity Index (ASI), Hindi Addiction Recovery Capital (ARC), WHO-Quality of Life – BREF Questionnaire (Hindi) were applied on 30 active users, 30 abstinent users and another 30 abstinent users on buprenorphine substitution(OST) for last 6 months. The initial factors extracted through exploratory factor analysis (EFA) were subjected to confirmatory factor analysis (CFA).

Results: EFA (varimax rotation) yielded a 40-item 5-point instrument. Six constructs - ‘holistic individual change’, ‘family and life functioning’, ‘future orientation’, ‘self-regulation’, ‘behavioural aspects of drug use’ and ‘psychological aspects of drug use’ were extracted. Internal consistency (Cronbach’s alpha>0.6), test-retest reliability (rho>0.5, p<0.01), and content and concurrent validity were acceptable. Convergent and divergent validity were established by comparing HARI with standardised instruments (positive correlation with ARC and WHOQoL BREF at p<0.01, negative correlation with ASI at p<0.01). CFA yielded a reasonable model fit [CMIN/DF=1.78(<2)]. HARI differentiated between OST and the ‘abstinent’ subjects (p<0.01).

Discussion and conclusion: After development, preliminary psychometric properties of HARI has been evaluated and clinical usefulness established. The construct validity needs improvement by applying HARI on a larger sample. HARI will be useful for monitoring ‘recovery oriented’ services.

Conflict of Interest: nil

Ethical Permission: Institute Ethics Committee

Clinical profile of patients attending child guidance clinic: a five year retrospective study from North India

Sidharth Arya, Sujata Sethi

Senior Resident, Institute of Mental Health, Rohtak, Haryana. [email protected]

Introduction : About 10-20% of children and adolescent are affected by mental health problems. Despite such high prevalence rates, mental health needs of this group remains neglected, especially in lower and middles income countries. To address this a number of initiatives have been taken in India. This study aims to highlight the clinical profile of patients attending a child guidance clinic (CGC) in North India over a period of five years.

Methods: Records of patients attending CGC in last five years from 2012-2016 were retrieved and relevant socio-demographic and clinical details were noted down. Frequency analysis was done using SPSS 19.

Results : A total of 2165 patients were registered over the five years. We were able to obtain data from 1706 records (79%). Majority were male (69%), between 5-15 years (77%), accompanied by either parent (83%), from rural background (55%), with ADHD being the most common diagnosis (2.1%). The trends shown point towards increasing attendance in the CGC over this period as well as increased consultation for ADHD

Keywords : mental health services, child guidance clinic, Attention deficit hyperkinetic disorder

Mental disorders in refugee and asylum seekers in India seeking treatment at outreach centres in Delhi

Avinash Shukla, Shivani Aggarwal, Ms Preeti

Senior Resident, Central Institute of Psychiatry, Rewa, Madhya Pradesh. [email protected]

Background: It is a known fact that that displaced population is at higher risk for development of various psychiatric disorders. India despite not being a signatory nation to the 1951 Refugee Convention and its 1967 Protocol has more than 200,000 refugees and asylum seekers. There is not much data from India examining different psychiatric disorders in refugee population in India.

Objective: To examine the frequency of different psychiatric disorders in refugee population in India and its socio-demographic correlations seeking treatment at the outreach centers.

Methodology: Review of case record files were done for all the patients who have been treated at two outreach centres providing mental health services to refugee population under the BOSCO UNHCR Refugee Assistance Programme. Socio-demographic and clinical variables were recorded. Diagnosis were recorded as per ICD 10 DCR.

Results: Results will be discussed in detail at time of presentation.

Conclusion: Will be discussed in detail at time of presentation.

Assessment of prevalence, diagnosis & management of Behavioral and Psychological Symptoms of Dementia (BPSD) in Indian clinical settings (AREST BPSD in India).

Keywords: Refugees and asylum seekers, sociodemographic correlations, mental health services

Assessment of prevalence, diagnosis & management of Behavioral and Psychological Symptoms of Dementia (BPSD) in Indian clinical settings (AREST BPSD in India)

Chetan Vispute, Nakul Vanjari, Swati Chavan, Chetan Patil, Urmi Ahire, Mangesh Kamle

Medical Advisor, Eisai Pharmaceutical India Pvt Ltd, Mumbai, Maharashatra. [email protected]

Introduction: Alzheimer’s disease(AD) is characterized by loss of cognitive & non-cognitive function. Non-cognitive symptoms include behavioral & psychological symptoms of dementia(BPSD) and neurological symptoms. Since the frequency of BPSD is highly variable, correct assessment of these symptoms may contribute to a better diagnosis and treatment, and could be a powerful tool to evaluate the efficacy of any therapy directed toward its improvement. This survey was designed to assess the prevalence and management of BPSD in Indian clinical settings. Methods: A questionnaire entered by 80 psychiatrists captured information regarding the prevalence of BPSD, and treatment approaches.

Results: Most common age group of AD patients was between 61–70 years as reported by 62(77.5%) of the psychiatrists. Most psychiatrists 51 (63.8%) reported that patients have AD of moderate stage at the time of diagnosis. Prevalence of BPSD was 60-70% reported by 62.5% psychiatrists. Noncognitive symptoms commonly observed were apathy agitation, anxiety depression, psychosis, irritability and delusion. Majority of the psychiatrists have reported using use of one or more drugs for management of BPSD symptoms. The use of acetylcholinesterase inhibitor(AChEI) is very high with most of 40(50.1%) psychiatrists having used it in more than 40% of the patients. Combination of AChEI+Memantine is widely used in more than 40% patients by almost 47 (58.9%) psychiatrists. Moreover 87.5% affirmed that combination of Donepezil+Memantine is an effective option in management of BPSD. Most common challenges in management of BPSD were disease awareness followed by appropriate diagnosis.

Conclusion: Prevalence of BPSD in this study was high. Focus on the early detection of BPSD and its management is important aspect of dementia care. Majority of psychiatrists reported the use of AChEI+Memantine in the treatment of BPSD and suggested that Donepezil+Memantine combination is an effective option in its management.

Key Words: Alzheimer’s disease, BPSD, acetylcholinesterase inhibitor, Memantine

Can Bornholm disease present with somatic ‘like’ symptoms ? : a case report

Gaurav Uppal, Sunil G Patil, Veda N S, Sanjay T Naik, Serena K

Junior Resident, MVJ MC and RH, Tq/Dt- hosakote,Bangalore, Karnataka. [email protected]

At least one third of all physical symptoms in the general population and in general medical-care settings are medically unexplained. Somatoform pain disorder is the most difficult to treat due to unexplainable locus of the pain. Bornholm disease is a viral illness which presents with episodic pleurisy and if often quite difficult to detect due to non specific chest pain symptoms. It becomes extremely difficult to detect them if both the illnesses present together. Present case describes a 55 year old woman, a known hypothyroid having on and off pain all in both upper and lower limbs which started after suffering a huge financial loss. After evaluation by orthopedics and neurologist and a psychiatrist, she was found to have degenerative changes in the spine, but her pain was out of proportion to the degeneration. On amytryptiline and pregabalin with psychosocial interventions, she showed marked improvement in her symptoms, till September 2017 , when she had shock like sensation in left lower chest in left side after throat pain and fever. CT chest showed minimal bilateral pleural effusion. Pulmonology and psychiatry evaluated patient in liaison, A diagnosis of Bornholm’s disease was made and a short course of steroids was given under antibiotic cover , to which she showed a marked improvement in chest painwith amitryptilline and pregabalin going on. Present case addresses the need for a thorough evaluation of the patients with somatic symptoms with multiple co morbidities. Sudden worsening of the symptoms in the absence of a stressors requires a thorough evaluation by the psychiatrists and treating physicians.

Abstract for Presentation @ ANCIPS 2018

Keywords: Chest pain, Liason, Bornholms disease, Somatic symptoms.

Sertraline induced cervical dystonia in patient of Obsessive Compulsive Disorder

Jamshed Ahmad, Abhijeet Srivastava, Sujit Kumar Kar

Senior Resident, King George Medical University, Lucknow, Uttar [email protected]

Selective serotonin reuptake inhibitors are the most common medication prescribed for Obsessive compulsive disorder, other anxiety and depressive disorders and generally considered to be well tolerated and safe. Among SSRIs, Escitalopram and Sertraline are known to be most safe and well tolerated. Rarely SSRIs have been found to be associated with drug induced  Parkinsonism More Details, dystonia and dyskinesia. We found 9 case reports attributing dystonia due to Sertraline. Here, we describe a young adult male with a diagnosis of Obsessive Compulsive Disorder who developed dystonia with sertraline in the absence of concurrent prescription of medications, which have potential action on the dopaminergic system. This case highlights the need for clinicians to be aware of this alarming acute adverse effect with sertraline, which is generally not considered as an offending agent for dystonia.

Keywords: Dystonia, selective serotonin reuptake inhibitors, sertraline

Seizure and intracranial calcification: Understanding about the window period of intervention

Jamshed Ahmad, Bandna Gupta, Sujit Kumar Kar

Senior Resident, King George Medical University, Lucknow, Uttar [email protected]

Intracranial calcification may result from disturbances in calcium metabolism. It often remains asymptomatic, but may present with symptoms like seizure, neurological deficits and peripheral signs of hypo or hypercalcemia. Correction of underlying metabolic disturbance before damage of neuronal tissue due to intracranial calcification may be useful in preventing irreversible neurological deficits. This window period may be the crucial period that needs through clinical evaluation and urgent intervention. We highlight the case of an adult female with seizure disorder, when evaluated for intracranial calcification, found to have disturbance of calcium metabolism. The management priorities were also discussed along with review of literature.

Keywords: Intracranial Calcification, Calcium Metabolism, Seizure

Acute Psychosis as rare early manifestation of Subacute sclerosing panencephalitis.

Jamshed Ahmad, Sujit Kumar Kar, Raj Rana

Senior Resident, King George Medical University, Lucknow, Uttar [email protected]

Background: Subacute Sclerosing Panencephalitis (SSPE) is a rare, late complication of measles infection. Illness generally starts with intellectual dysfunction, personality changes, myoclonus and epileptic seizures but in rare cases only psychiatric symptoms are initial presentation. However, mass immunization programme resulted in significant decline in the prevalence of measeles as well as its complications.

Materials and Method: We are presenting here a case, who initially presented with the symptoms of withdrawn behaviour, increased irritability, hallucinatory behaviour and reduced sleep. He was prescribed olanzapine (15mg/d) and he developed severe extrapyramidal side effects with olanzapine. The medication was stopped and anticholinergic medication was prescribed for treatment of extrapyamidal symptoms. After one month of these symptoms he developed myoclonic jerks, inability to walk, inability to speak, weakness in right upper and lower limbs. Measles immunization was not done during childhood period.

Results: All routine haematological investigations (routine hemogram, Liver function, Kidney function and electrolytes) were within normal limits. MRI Brain revealed area of hyperintensity on long TR images and hypointensity on T1 WI in Left Frontal Lobe. EEG revealed periodic complexes, serum & CSF IgG antibody for Measles virus were positive. He was diagnosed with SSPE.

Conclusion: High suspicion is needed to detect SSPE because of its atypical neuropsychiatric presentation. Detailed neurological evaluation is required to rule out organic conditions.

Keywords: A/c psychosis, SSPE, Measles, EPS

The role of probiotics in mental health: A review

Jawahar Singh, Arpit Parmar

SR, AIIMS, New Delhi. [email protected]

Introduction. The relationship between gut and brain has been proven for long. Emotional functioning and gut functioning have been interlinked. Recently, the role of probiotics in mental health has been gaining interest. Some literature suggests positive effects of probiotics on mood and other aspects of mental health. However, no systematic attempt has been made to review the existing evidence till date.

Aim. To review the existing randomized controlled trial assessing the effect of probiotics on various mental illnesses

Methods. Search was conducted using appropriate search terms including “probiotics” or “Psychobiotics” and “mental health”, “depression”, “depressive disorders”, “anxiety”, “anxiety disorders”, “mood disorders” and “randomized controlled trial” and various combinations of these search terms. PubMed and google scholar were primarily searched into. Cross-references were also looked into for additional studies. Only studies with randomized controlled in nature were included while open label trials, case series/reports and viewpoints/commentaries were excluded.

Results. The results showed that Psychobiotics has been studied in various mental illnesses such as depression, chronic fatigue syndrome, irritable bowel syndrome, smoking, autism and schizophrenia mainly. Although, the studies show positive impact of Psychobiotics in some of these conditions, the literature is still at large insufficient to provide a conclusive remarks of their role in mental illnesses.

Conclusion. Psychobiotics has shown a great promise in the treatment of some mental illnesses. More randomized controlled trials involving various mental illnesses patients are required. Development of specific forms of Psychobiotics will further help in management of mental illnesses.

Keywords: Probiotics, mental health, psychobiotics, depression

A study of knowledge and attitude towards sex and relation with disorders of sexual response cycle in females with dissociative conversion disorder (for Professor M. Murugappan Session II award)

Megha Agarwal, Kamal Kumar Verma, Anant Kumar Rathi, Girish Chandra Baniya

PG Student(3rd year), S.P. Medical College, Bikaner, [email protected]

Background- Females are commonly affected by various disorders in relation to sexual response cycle. Desire, arousal, and orgasm are the three principle stages of this cycle. Knowledge and attitude towards sex may also affect sexual functioning in females. Stress of sexual dysfunction affecting the sexual response cycle may be interrelated to conversion disorder.

  1. To assess knowledge and attitude towards sexuality and its relationship with disorders of sexual response cycle in cases and controls.
  2. To find the sexual functioning in various phases of sexual response cycle and identify disorders of sexual functioning in cases and controls.

Materials and method- This study was conducted at Department of Psychiatry, S.P. Medical College; Bikaner. 30 new, drug naive patients of dissociative conversion disorder (married females) formed the cases while 30 matched healthy relatives formed the controls. Both groups were assessed on the semi-structured sociodemographic proforma, SKAQ II and BISF-W scale.

Results - No significant difference was found between the mean scores of knowledge and attitude towards sex between the two groups. No significant relation was seen between knowledge and attitude and sexual dysfunction in both the groups. All domains of sexual functioning i.e. desire, arousal, frequency, receptivity, orgasm, satisfaction were more commonly affected in cases (p value < 0.05). Significantly higher number of cases had encountered difficulty in reaching orgasm(46.6%) and conflicts with the spouse(36.6%).

Conclusion – Higher prevalence of sexual dysfunction in the past one month may be a contributory factor for stress for the manifestations of conversion symptoms or it may be a result of conversion disorder. So every sexually active women having conversion disorder should be thoroughly interviewed for the presence of underlying and unreported sexual dysfunction.

Keywords- conversion disorder, sexual response cycle, SKAQ II- sex knowledge and attitude questionnaire, BISF-W- brief index of sexual functioning for women.

Aripiprazole induced neck dystonia and oculogyric crisis in a patient of OCD-A case report

Navratan Suthar, Naresh Nebhinani

Associate Professor, AIIMS, Jodhpur, Rajasthan. [email protected]

Background: Aripiprazole is the third generation atypical antipsychotic and a dopamine serotonin system stabilizer (DSS), which can be used as add on treatment for obsessive compulsive disorder (OCD). Generally it has a low propensity for extrapyramidal side effects, but few cases of aripiprazole induced acute dystonia were reported in literature. Here we present a case of aripiprazole induced neck dystonia and oculogyric crisis in a patient with OCD.

Case presentation: Mr. X, a 19 year old male, diagnosed as OCD, was treated initially with fluoxetine up to 80 mg, and later aripiprazole was added and hiked to 10 mg to achieve complete remission. On 5th day of aripiprazole 10 mg, he developed tightening of the neck muscles with backward & right sided deviation of head along with uprolling of the eye balls, which were associated with pain and anxiety and difficult to bring back to original position by the patient. It persisted for 5-10 minutes approximately, occurred 5-7 times in a day and resolved on its own. After evaluation he was diagnosed of having acute dystonia in the form of neck dystonia and oculogyric crisis. This was successfully treated with intramuscular promethazine and completely recovered after stopping of the aripiprazole. Naranjo’s causality assessment reveals probable association of aripiprazole with neck dystonia and oculogyric crisis.

Conclusions: This case outlines a significant side effect of aripiprazole, which a practitioner should be vigilant about before initiating the medication.

Keywords: Aripiprazole, Acute dystonia, Oculogyric crisis, OCD

Consultation Liaison Psychiatry. Experience from Nepal

Nirmal Lamichhane, Dev Kumar Thapa, Anil Subedi, Pujan Sharma Lamichhane, Basant Kumar Tamrakar,

HOD, Gandaki Medical College, Pokhara, Gandaki, Nepal. [email protected]

Background: Mental Health Service as a specialty in Nepal started only when the first Nepalese psychiatry started it in 1961 AD. Single manpower continued the services for almost two decades then couple of others joined. Obviously it was limited to the capital city till the 90s. In this backdrop consultation liaison psychiatry is overlooked matter in majority of the hospitals in Nepal. In fact many multi-specialty general hospitals are started and many are still run without psychiatry department or service.

Methodology: Consultation liaison psychiatry pattern was studied in tertiary care general hospital from 2007-2016.

After taking permission from the IRC and consent from the patients records of the consultation liaison psychiatry were kept in semi-structured performa with relevant variables. Analysis were done by using MS excel and SPSS tools.

Conclusion: This study reveals the fact that still psychiatry does not have wide acceptance as specialty. Consultation liaison services were sought mostly for cognitively and behaviorally disturbed patients while other cases takes long circle to reach the mental health services. We proudly recite “Health is a state of complete physical, mental and social wellbeing and not merely……..” while defining health but in practice it is obvious from this study that the identity and importance of psychiatry as essential component of health even amongst medical communities needs long struggle in developing country like Nepal.

Key Words: Consultation-liaison, Psychiatry, Nepal

Pesticide self poisoning: A study of suicidal intent, psychiatric morbidity and access to pesticides

Prakruthi.N, Jyothi K.S, Rakesh T.P

Senior resident, medical college, Thrissur, Kerala. [email protected]

Background: Suicide is a preventable mortality. Psychiatric disorders are known to increase the suicidal risk. Cross national analysis from WHO World Mental Health surveys by Nock et al found that after controlling psychiatric comorbidity, merely disorders characterized by anxiety and poor impulse-control were predictors in persons to act on suicidal thoughts. Poor impulse control can cause lower intensions of self-harm to become more lethal one, which also causes great impact on health sectors and families too. Use of pesticides for suicidal attempt in Asian countries in mainly attributed to its easy availability and less restrictions on its dispensing.

Methodology: A cross-sectional study of 101 cases with pesticide self-poisoning admitted in general medicine ward were interviewed after IRB clearance. Cases above 12 years of age were included and cases who cannot cooperate for interview were excluded from study. Materials : Beck’s suicidal intent scale ,ICD-10 clinical descriptions and diagnostic guidelines was used for psychiatric diagnosis, questions regarding access to pesticides were asked.

Results : Majority(45%) had low intent to commit suicide,38% medium and only 17% had high intent. About 35.4% cases had neurotic and stress related disorders(most commonly adjustment disorders)22.8% had alcohol dependence syndrome,20% had mood disorders (severe depression was most common),4% had personality disorder and less than 1% of the sample had independent psychotic disorder. Majority (61.4%) had easy accessibility to pesticides at home (unlocked) ,10.9% had availability in their fields and nearly 27.7% had brought from shop after planning for suicidal attempt(p<0.001).

Conclusion : Majority of suicidal attempt are of lower intent following stress ,which could become lethal on easy availability of unrestricted pesticides. Training regarding stress management and coping skills ,screening and treating depression and alcohol dependence can be a good strategies for prevention of suicide. Measures such as reducing toxicity of pesticides or adding emetics and controlled dispensing of pesticides have to be further researched for evidence on reducing pesticide poisoning.

Keywords: Pesticide, suicide, stress management, coping skills

A Case of Huntington’s Disease Presenting with Psychotic Features

Pritam Chandak

Consultant Psychiatrist & Trainee In Child And Adolescent Psychiatry,Nimhans, Nimhans, Nagpur, Maharashtra. [email protected]

Background: Huntington’s disease (HD) is a dominantly inherited, neurodegenerative disorder due to expansion of a polymorphic trinucleotide repeat in the short arm of chromosome 4. Clinical manifestations consist of a triad of choreic movements, cognitive decline and psychiatric syndromes starting in the fourth to fifth decade. Psychiatric manifestations vary and may precede motor and cognitive changes. Mood disorder, cognitive disturbances, anxiety disorders, and psychosis are the psychiatric comorbidities reported with HD. Personality changes and depression occur most commonly. Paranoid schizophrenia-like symptoms occur in 6% to 25% of cases.

Case report : We describe a 35 year-old woman with an 6 year long history of behavioral changes, multi-thematic delusions and auditory hallucinations. History and mental state examination were suggestive of paranoid schizophrenia. Neurological examination revealed discrete, involuntary movements affecting her arms and trunk. Genotyping detected an expanded allele (43 trinucleotide repeats). A three-generation-long family history of chorea and schizophrenia-like psychosis was found.

Conclusions: In clinical practice Huntington’s disease should not be neglected as differential diagnosis in middle aged patients with negative psychiatric history referring to psychiatrists for recent onset and rapidly progressing symptoms as behavior changes, anxiety, irritability, mood deflection, insomnia and poor response to treatment. In the case we reported, indeed, the symptoms necessary to diagnose a Huntington’s disease, as focal neurological deficits emerged only belatedly, at a final stage, while symptoms at onset appeared to be purely psychiatric. Psychiatric symptoms in HD are often amenable to treatment, and relief of these symptoms may provide significant improvement in quality of life.

Keywords: HD, chorea, schizophrenia like psychosis, trinucleotide repeats

Probable  Lewy body dementia More Details presenting as delirium in a 75 year-old patient

Rashmi Shukla, S.C.Tiwari, S.M.Tripathi

SENIOR RESIDENT, King George’s Medical University, KANPUR, Uttar Pradesh. [email protected]

Background: Distinction of “dementia with Lewy body “ (DLB) and delirium may be challenging in some cases, due to common clinical features such as fluctuations and hallucinations. Longer duration of cognitive changes usually supports diagnosis of DLB. We report the case of an elderly patient with probable DLB, presenting with acute confusional state, in order to draw attention to its diagnostic


Methodology: 75 years old man presented with inability to recognize family members, fluctuating consciousness, picking movements,visual hallucinations,urine incontinence for 15 days. History revealed onset of illness 4 years back with REM sleep behaviour disorder followed by fluctuating cognition and disturbed executive functioning. He also developed some depressive symptoms 6 months back and suspiciousness for last 1 month. Personal history revealed alcohol dependence for last 40 years. All investigations were normal except low sodium which was corrected still fluctuating cognition was persisting. CT scan showed diffuse cerebral atrophy. Neuropsychological assessment was done using LNNB which showed impaired Frontal lobe as well as temporal lobe functioning.

Results: After further observation and normalizing all biochemical parameters which can contribute to delirium, We excluded the differential diagnosis of alcohol induced amnestic disorder and behavioral variant of frontotemporal dementia and it was concluded that clinical presentation was consistent with a probable diagnosis of DLB. Patient was started on tab rivastigmine 1.5 mg and gradually increased up to 3 mg with slight improvement in cognition.

Conclusion: This case illustrates the complex and difficult diagnostic picture that can be associated with the clinical presentation of DLB. We should consider DLB as a potential possibility in the differential diagnosis of “delirium presentations,” especially in the elderly. This is an important consideration because neuroleptics, which are frequently used in the treatment of delirium, may exacerbate the parkinsonian and psychotic symptoms that often accompany DLB.

Keywords: Dementia with Lewy body, Delirium, Cognition

Electroconvulsive Therapy(ECT) Induced Mania – A Case Report

Raviraj Khadiya, Mahesh Suthar

PG Student, Medical College Vadodara, Mahisagar, Gujarat. [email protected]

Introduction: ECT is a non pharmacologic biological treatment which has been proven to be highly effective treatment option for Psychiatric disorder. ECT is known to cause certain side effects including cognitive dysfunction, cardio vascular problems and rare cases, Mania.

Case History: Here is a case of a 44 years old married female who presented to us with complaints of muttering to self, laughing without any reason, decreased communication, poor self care, insomnia, psychomotor retardation and persecutory delusion since 15 days. She was hospitalized with the preliminary diagnosis of “Brief psychotic disorder” according to DSM-5 criteria. She was not addicted to any substance. Routine laboratory investigations were within normal range. She was excessively worried about her son’s psychiatric illness (Schizophreniform disorder) for the past three months that was significant stressor for her. Her son was admitted in psychiatry ward for one month and her son’s illness was improved after given four ECT. So she was shifted earlier on ECT.

After one week she was shifted on ECT as there was no improvement on Trifluoperazine 10mg/day, Olanzapine 5mg/day and Diazepam 5mg/day. After second ECT, patient’s relative reported complaints of singing songs, being more talkative than usual, increased social interaction, decreased need for sleep and flight of ideas. Patient’s Young Mania Rating Scale was 27 indicated moderate severity of mania. It turned out to be turned out to be ECT induced Mania. After which she was started on Sodium valproate 1000mg/day, Olanzapine 10mg/day, Trifluoperazine 10mg/day and Diazepam 5mg/day.

Discussion: Psychiatrist should be alert to the substantial risk of mood switching when patient is being treated with ECT. Previously many cases reported about ‘ECT induced Mania’ were patient in depressive phase. It may be underlying bipolar illness come on surface after ECT.

Keywords: ECT, mania, mood- switching

Right Thalamic Infarct Presenting As Psychosis Like Symptoms : A Case Report

Rupali Rohatgi, Vrinda Saxena, Namita Ahuja, Ravi Gupta

Postgraduate Student, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand. [email protected]

Background: Psychosis is a neuropsychiatric condition caused by functional impairment of various regions in the brain. At times a strategically located stroke in the brain can produce such symptoms.

Case Description: A 50-year old male presented with sudden onset of symptoms characterized by irrelevant and excessive talks, decreased self care, agitated and disorganized behaviour for 2 weeks. Further history revealed that these symptoms were preceded by inability to understand anything, unsteady gait, right sided deviation of mouth and slurring of speech for a brief period of time. On examination and investigation patient was conscious, babbling continuously which appeared irrelevant to the context. Side shifting test showed impairment and perseveration. Clock drawing test showed neglect towards left side. MRI of brain showed infarct in right thalamus region.

Conclusion: A strategically placed thalamic infarct can produce signs suggestive of psychosis. Bedside tests such as side shifting and clock drawing test may help in finding out the aetiology.

Keywords: Psychosis, neuropsychiatic condition, clock drawing, thalamic infarct

Prevalence of stress and psychiatric diseases among Post Graduate Trainee doctors

Surjya Roy, Asim Kumar Mallick

PGT, Burdwan Medical College, Kolkata, West Bengal. [email protected]

Background: Stress is very much prevalent in various medical schools. This study was done to assess prevalence of stress and psychiatric disorders among Post Graduate Trainee doctors (PGT).

Methodology: Total number of PGT at Burdwan Medical College at a particular point of time in various clinical subjects were 170. All of them had been approached. Those who were available at the time of data collection and gave valid, informed consent was taken up as a sample. Socio demographic datasheets were filled up first. Study tools such as Kessler psychological distress scale questionnaire (K10 scale) was used to assess stress among PGT. Then clinical interview were conducted to assess prevalence of psychiatric disorders among them following ICD-10 DCR

Result: Mean score of stress was 18.63±4.41 (K10 scale), 33.3% PGT were stressed and 16.7% PGT had psychiatric illness. Among psychiatric diseases 4% had harmful use of tobacco, 4% mild depression, 1.6% panic disorder, 4.8% mixed anxiety depression, and 1.6% mixed obsessive thoughts, 0.8% harmful use of alcohol. Maximum stress was found among Anesthesia PGT. Stress was more among female PGT, and married PGT. Age and stress positively correlated. Stress and presence of psychiatric illness was highest among 3rd year PGT.

Conclusion: Early recognition of stress, psychiatric morbidity is very much needed among PGT for early Pharmacological and non pharmacological management.

Keywords: Stress, PGT, mixed- anxiety depression.

Trihexyphenidyl Dependence: A Case Report

Samant Darshi, R.K Bhandary

Junior Resident, KMC Manipal, Karnataka. [email protected]

Trihexyphenidyl (THP) is an anticolinergic agent. It is used for the symptomatic treatment of Parkinson’s disease in mono and combination therapy. It is also commonly used to treat extrapyramidal side effects occurring during treatment with antipsychotics. Reports have suggested THP use for recreational purpose indicating its abuse potential.

Case Report: 52 year old married Hindu male from MSES, premorbid difficult temperament. Onset of illness around 28 years of age, clinical picture marked by periods of hyperactivity, anger, agitation, violent behavior, muttering and smiling to self, auditory hallucinations and persecutory ideas, diagnosed as Paranoid Schizophrenia & Tobacco dependence syndrome. There were significant deficits in personal, occupational, functional and social domains resulting in admission to rehabilitation center.

Despite several trials of antipsychotics: typical and atypical and mood stabilizers with no significant improvement it was planned to tapper down THP, after which his symptoms significantly declined, as evidenced by improvement in his interactions with fellow residents, enhancement in his participation in activities of occupational and vocational therapy, he reported of improvement in positive symptoms and there were no additional fresh complaints.

On interviewing the informants and detailed discussion with the family it was found that the patient had been noted to consume trihexyphenidyl (THP) at home, almost around 5-8 tablets of THP each day. At the rehabilitation center it was noted that whenever the dose of THP was reduced the patient reported of restlessness and he would become agitated and would start asking for THP repeatedly.

Conclusion: What emerged as a major concern was whether the patient’s dependence on THP had a role to play in the enhancement of the hallucinations even though the patient was on antipsychotics. The frequent demanding of THP was an indication to suspect abuse or dependence which appeared to be linked to its hallucinogenic and euphoric effects.

Keywords: Triheyphenidyl, antipsychotics, Extrapyramidal symptoms, paranoid schizophrenia

Compulsive Staring, an Unsual form of OCD.

Sidda Reddy, Harish Kulkarni, Dip Bhadja

Junior Resident, JJM Medical College, Davangere, Karnataka. [email protected]

Background: OCD varies widely in presentation. Majority of patients present with both obsessions and compulsions while about 2% have predominantly compulsions only. Compulsion is an activity which is triggered by obsessions. Sometimes it is very difficult to unfurl obsessions into particular compulsions. Here is such a case of predominant compulsions.

Case Report: A 21 year old male patient presented with symptoms of repeatedly getting distracted from studying and had to keep staring at insignificant visual stimuli like pen marks, lines, books, windows etc. His attempt to shift-back attention to reading was unsuccessful as he was compelled to stare at these objects. This made him distressed as he knew looking at these was unnecessary and had failed resisting the urge. He was very anxious about this. He was fully aware of these staring and reported to be voluntary. He had good attention span in other activities apart from reading. He didn’t have any impulsions, hyperactivity, other mood symptoms, epilepsy. Patient had fleeting obsession (doubt) that he might miss something if he doesn’t stare at those things. This obsession was on reading related cues and was absent on environment related cues.

When compulsions are associated with obsessions diagnosis is easy. However when only compulsions are present then diagnosis will be challenging. After ruling out impulse controlled disorder, epilepsy, organic movement disorder diagnosis of OCD was made. On YBOCS he scored 34 on the first day, after total duration of 2 years of treatment patient was tapered off medications he scored zero on YBOCS. Literature is bereft of information on ‘staring’ as compulsion, even though YBOCS symptom checklist mentions it.

Conclusion: This unusual presentation posed a challenge for diagnosis and treatment. Case had predominant compulsions with occasional obsessions and staring as a compulsion needs clinical spotlight.

Key words: OCD, staring, predominant compulsions.

Non Catatonic Mutism as a Presenting Symptom in Schizophrenia

Aditi Singhal, Bharath D U, V. P. Kale

PG Student, GGMC Mumbai, Maharashtra. [email protected]

Introduction: Mutism is defined as the loss of faculty of speech due to functional or organic causes. It is typically associated with catatonic schizophrenia, but can occur in non catatonic schizophrenia patients. Case reports are appearing in developing nations but there is a lack of literature and studies on psychopathology or neurobiological basis of non catatonic mutism in schizophrenia.

Method: We describe a case of non-catatonic mutism of around 2year duration in schizophrenia which responded well to antipsychotics and discuss our case along with review of the recently reported cases in India.

Case description and discussion: 22 year old man brought with complaints of cessation of speech, irritable aggressive behaviour and hearing of voices inaudible to others since 2 years without any stressor. Although all his routine activities and self care were maintained ,he had stopped going to work. Patient says he stopped speaking because of the distressing command hallucinations which threatened him of dire consequences if he spoke to anyone (adaptive behaviour to psychotic symptoms). He was started on benzodiazepines and antipsychotics. Antipsychotics were given upto optimum doses and patient showed marked improvement.

All the recent case reports published on non catatonic schizophrenia are from India. All these cases had prolonged mutism and were resistant to conventional catatonia treatment but our patient started talking within a day after initiation of therapy.

Possible explanation of non catatonic mutism in schizophrenia can be

- primary psychotic phenomenon(poor response to catatonia treatment in case reports)

- extreme form of alogia

- adaptive behaviour to psychotic symptoms (our patient had rapid response to treatment)

Conclusion: Mutism in schizophrenia can be a symptom conundrum with varied response to treatment needing detailed evaluation for prompt treatment and better outcome.

Sub Specialty: Child and adolescent psychiatry

Keywords: Non catatonic mutism, schizophrenia, antipsychotics.

Domestic Violence and Role of Some Related Factors in Indian Urban Young Adults

T. Mitra., Kedar R. Banerjee, M. Das, J. Saha

Clinical Psychology, National Institute of Behavioural Sciences, Kollkata, West Bengal. [email protected]

Background: Domestic violence in form of physical aggression, emotional abuse, and sexual violence are becoming a serious problem in Indian urban life. In addition to physical injury, victims report greater psychological distress, suicidal thoughts, substance use and even indulgence in sexual promiscuous behaviour. This study examined several risk and protective factors for the domestic violence victimization among adolescents and young adults.

Methods: The subjects who visited the clinic at Kolkata during the period of 2010 to 2013. The resulting sample of participants (N = 180) included 142 women (78.89%) and 38 men (21.11%) with a mean age of 22.6 years (range 18–26 years). Questionnaires used for the purpose were serious violation, violence prevalence, Locus of Control, number of sibs, level of education and religiousness.

Results: Serious violation behaviors remained statistically significant in the multivariate model. Participants with an inner Locus of control were also significantly more likely to report those behaviours. Participants who have no sibs were more likely to report. Education level was not statistically significant. More religious people reported lesser violence.

Conclusion: Violence is a significant public health issue associated with serious issues for victims, families, and children witnessing family violence. The present study identified several risk factors associated with violence among a high-risk sample of young adults as serious violence-related behaviors, inner Locus of Control, use of intoxicating substance, and having less/no sibs emerged as significant predictors of violence. Collectively, these results suggest that interventions might focus on parental teaching about changing gender roles, causes of violence, anger, and stress reduction as one means to prevent domestic violence. Some possibilities include providing skills training for coping with stress, anger, and anxiety.

Keywords: Domestic violence, Indian Urban life, Young adults

Demonetization and psychiatric disorder: a series of three cases

Arun G, Anjukrishna G

PG student, Jubilee Mission Medical College and Research Center Thrissur, Kerala. [email protected]

Introduction: Demonetization, which occurred on 8th Nov. 2016 was an unexpected move, which came with negative and positive effects in the country. In the clinical services of Psychiatric Department of our medical college, we have come across three cases in which the illness manifestation was soon to the declaration of it. Their case records were picked up and information gathered. Only a period of three months were considered.

Methodology: Retrospective , chart based study. 3 cases were studied. First case was a 46 yr male with, was diagnosed to have Other Acute and Transient Psychotic Disorder with associated acute stress, treated with antipsychotics. Second case was a 27 year old male, with family history of psychiatric illness, diagnosed to have Mania and was treated with antipsychotics and mood stabilizer. Third case was a 31 yr male, with past history of Bipolar Disorder. He was diagnosed Bipolar affective disorder, current episode mania and was treated with antipsychotics and mood stabilizer.

Results: There were no cases with a diagnosis of non-psychotic diseases. The first patient was hailing the decision; the second was really affected negative and third had only an apprehension about it. It appears the strain due to stress is more important in the development of illness, rather than the meaning of it. All three patients were males. The psychosocial reasons explaining more men than women in hospital setting contrary to that in community may be still holding.

Conclusion: It is still a controversy whether the presenting complaint is because of psycho-social adversities or mental illness. There were only three cases in the series. However we propose during major psycho-social events in the society at large, practicing psychiatrist has to be in the look out of clinical presentations related to it.

Keywords: Demonetization, mania, young females

A Comparative Study of Cognitive Impairment in Unipolar and Bipolar Depression

Gaurav Dhanda, Mahendra Jain, Charan Singh Jilowa, Parth Singh Meena, Jitendra Arora, Sunil Moond

Resident, JLN Medical College Ajmer, Rajasthan. [email protected]

Context: While depression is known to involve a disturbance of mood, movement and cognition, its associated cognitive deficits are frequently viewed as simple secondary of the disorder.

Aim: To compare severity of the cognitive impairment in unipolar and bipolar depression.

Settings and Design: Cross-sectional, single assessment study conducted at a tertiary care centre.

Subjects and Methods: Participants was consist of depressed bipolar and unipolar patients taken from OPD, Participants included in study are who have fulfil the ICD 10 criteria for unipolar and bipolar deression(moderate to severe),age group between 18-50 years, literate enough to understand the nature of test to be taken,informed consent. Participants were individually administered sociodemographic proforma, trail A and B Test and stoop color test.. Standard descriptive statistics (mean, percentage) and independent sample t-test were applied.

Results: A total of 240 participants formed the study sample,with 60 patients of bipolar depression, 120 patients of unipolar depression and 60 are control group. Group comparison showed statistically significant difference between patients with BAD-UD(P=0.00),BAD- Control(p=0.00)and UD-Control(p=0.00) on trail B and stroop colour test both. There is more decline of executive functions and attention in BAD patients on trail B and stoop colour test as compared to other groups.

Conclusion: To conclude we found that executive function and attention of the unipolar depression group is significantly better than bipolar depression group.

Keywords: Cognitive impairment, executive function, unipolar depression

Hoarding Behaviour In Residual Schizophrenia

Amal Shareef, Anupama M

Junior Resident, JJM Medical College, Davangere, Karnataka. [email protected]

Background : OC symptoms are common in schizophrenia especially during acute phase. However they are less common in residual phase. Common Obsessive Compulsive symptoms in Schizophrenia include ritualistic touching , repeated behaviors of washing , violent images. But, hoarding has been less described in Schizophrenia.

Case Report : Mr. S , a B.Ed graduate with history of Schizophrenia since 20 years of age. He has no positive symptoms for last few years and currently has predominant negative symptoms. Patient has a strange repetitive behavior of visiting different OPDs of different departments in the general hospital and collecting different medications. He specifically visits Psychiatry OPD more often and requests different doctors (consultants , PGs , interns) to prescribe him T. Risperidone, THP (Trihexyphenidyl) and Inj. Diclofenac. These medications he collects for free from the pharmacy and hoards them at home.

Details of his illness and abnormal behavior will be discussed.

Conclusion : This hoarding behavior with other negative symptoms posed great difficulty in management.

Keywords : OCD ,Hoarding , schizophrenia

Analysis of Sibling Relations in Children with Attention Deficit Hyperactivity Disorder

Ajita S. Nayak, Kumar Hemant Saurabh, Shubhangi R. Parkar, Hrishikesh B. Nachane

2nd Year PG Student (MD Psychiatry), Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra. [email protected]

Introduction: Sibling relationships are often among an individual’s longest lasting relationships. Siblings affect each other’s development by being source of help, emotional support and companionship. Children with ADHD could be at higher risk of poor sibling relation because of their impaired interactions due to attention deficit. These affected sibling relationships could also lead to non-compliance and family conflicts. Hence this study was undertaken.

Aims and Objectives: To study the quality of sibling relationship in children with ADHD and to compare it with normal controls

Methodology: The present study was conducted at a child guidance clinic of a tertiary hospital after taking ethical clearance. 30 children diagnosed to have ADHD and 30 normal controls between the ages of 5 to 12 years, who had at least 1 live sibling; were recruited for the study. The parent rated version of the sibling relationship questionnaire (SRQ) was used to assess the quality of sibling relations in the 4 broad domains of warmth/closeness, relative status/power, rivalry and conflict and several other subdomains. Unpaired student t test was used to compare the scores on the SRQ between the 2 groups.

Results and Conclusion: Our study showed lower levels of warmth in the ADHD group (p < 0.05) as compared to the controls. The other 3 domains showed no significant difference. When the subdomains were analyzed, we found higher levels of affection, prosocial behavior and competition in the control group (p < 0.05). Maternal partiality was seen less with children with ADHD (p < 0.05).

Our study concludes that sibling relations of children with ADHD are significantly strained as compared to normal children. Early identification and intervention should be carried out to improve the outcome in ADHD children.

Keywords: Sibling relation, children, attention deficit hyperactivity disorder

Study of neurological soft signs in new onset schizophrenia

Jitender Arora, Mahendra Jain, Charan Singh, Parth Singh, Gaurav Dhanda

PG Student, JLN Medical College Ajmer, Rajasthan. [email protected]

Objective: The aim of this study was to assess the neurological soft signs in clinically symptom free first episode schizophrenia patients and healthy controls.

Methodology: This was a cross sectional study conducted at JLN Medical College Ajmer. Study sample consists of 50 clinically symptom free schizophrenic patients and 50 healthy controls. Inclusion and exclusion criteria were met. Diagnosis was confirmed by two psychiatrists and ICD10 criteria were met. Both the groups were assessed on NES(NEUROLOGICAL EVALUATION SCALE).The schizophrenic patients were also assessed on BPRS scale.

Results: Study shows that schizophrenic patients scored significantly higher in all the subscales of NES that is Sensory Integration, Motor Coordination, Sequencing of Complex Motor Acts, Primitive Reflex.

Conclusion: Neurological soft signs are present in schizophrenia. They are present even during symptom free period and they are not due to effects of active illness. Therefore it is concluded that neurological soft signs represent a trait like abnormality in schizophrenia.

Keywords: Schizophrenia, neurological soft signs, neurological evaluation scale

Hypothyroidism and Psychiatric Syndromes

Jovanjeet Singh, Sudarshan C.Y., Shamshad Begum

Junior Resident, JJM Medical College, Davangere, Karnataka. [email protected]

Background: Neuropsychiatric manifestations like mood disorders, anxiety disorders and psychosis accompany primary hypothyroidism. Psychosis typically emerges years or months after the onset of physical symptoms. Disorders of thought occur in patients with either clinical or subclinical hypothyroidism, suggesting that psychosis may be unrelated to the absolute degree of thyroid hormone deficit. Recognition of comorbid psychopathology is essential for comprehensive care of the patient and better quality of life. Indian research in this area has focused more on mood disorders than psychotic illness. In this background present study is planned to comprehensively assess psychiatric morbidity in patients having hypothyroidism.

Materials and Methods: 50 patients of both genders aged between 18-60 years having comorbid hypothyroidism and psychiatric syndrome formed the sample. Sociodemographic details, information about hypothyroidism were recorded. Psychiatric morbidity was evaluated using Mini International Neuropsychiatric Interview Plus

Results: Females constituted 66% of the sample. The mean age of patients was 39.7 years. 62 % of the sample had Non- psychotic illness of which MDD constituted 51%. Among Psychotic illness ,47% had MDD with psychotic features,21% had mania and 32% had Schizophrenia. When detection of hypothyroidism preceded psychiatric illness, non- psychotic illnesses were detected earlier than psychotic illness. When detection of psychiatric disorders preceded hypothyroidism , hypothyroidism was detected earlier in non psychotic illness than psychotic illness. However these differences did not reach statistical significance.

Conclusions-Psychiatric syndromes and hypothyroidism are closely related. Even though mood disorders contribute mainly for psychiatric morbidity, even psychotic disorders do occur commonly. The Routine screening of one condition when another is present can be useful for comprehensive care of patients.

Keywords – Hypothyroidism, psychiatric morbidity

A study of female sexual dysfunction among the drug naive depressed patient

Mahendra Kumar Sharma, Ram Kumar Solanki, Kuldeep Yadav, Vikash Chandra Mishra, Ravi Kumar Gupta

PG Student, SMS Medical College Jaipur, Rajasthan. [email protected]

Background: Sexual dysfunction is highly prevalent among women as per available literature. In Indian population only few studies are available related to above subject.

Aim: To stdy the phenomenology of sexual dysfunction and related factors among newly diagnosed depressed patients.

Design: A cross-sectional, prospective study conducted at the department of psychiatry SMS Medical college and attached Hospitals Jaipur.

Materials and Methods: 50 consecutive cases diagnosed as per ICD-10 and fulfilling the inclusion and exclusion criteria were recruited after written informed consent. All the subjects were assessed for severity of depression by Hamilton Depression Rating Scale (HAMD - 17 item ) The sexual dysfunction was assessed by female sexual functioning index (FSFI) and Arizona Sexual Experience Scale (ASEX) female version. Socio-demographic characteristic of all the subjects were recorded. 50 matched control group were also assessed on similar lines.

Results: The study showed that female sexual dysfunction was significantly high in experimental group as compared to control as assessed with both FSFI and ASEX-F.

Conclusion: All depressed female coming to OPD for treatment should also be assessed for sexual dysfunction.

Keywords: Sexual dysfunction, depression, ASEX, HAM D 17

Long term neuropsychiatric disorders of earthquake exposure

Jai Singh Yadav, Adya shanker srivastava, Samiksha kaur

Associate professor, IMS, BHU, Varanasi, uttar pradesh. [email protected]

Background: An earthquake resulting from the releases of energy from the lithosphere of earth, this energy produces seismic waves. These waves travels through the earth, interior and can be recorded by seismometer. The strength, size and magnitude of the earthquake are measured using Richter scale. High intense earthquake is associated with neuropsychiatric disorders such as anxiety, mood disorders, sleep problems, post traumatic stress disorders and dizziness. Though limbic area, a part vestibular control is responsible for emotion and psychological response; equilibrium dysfunction can also occur through psychological stress such as anxiety. The earliest earthquake jerk on 2016-01-04 (Richter scale 6.8) shaken the northeast India, Bihar, Uttar Pradesh, Bengal, Haryana Nepal and Himanchal Pradesh. We found that the many patients visited the psychiatric OPD with complaints of various neupsychiatric problems as similar as symptoms occur during earthquake.

Purpose of study: To find out pattern of earthquake anxiety and vertigo after long time exposure of high intense earthquake jerk and their treatment outcome

Methodology: We have included five patients those have attended psychiatric OPD for their various psychiatric complaints along with neurological problems like vertigo or headache. All patients exposed to high intense earth jerks in the past on 2016-01-04.The treatment response after two week were rated using HAM A, and DARS.

Result: We found that all patients have various neuropsychiatric disorders like dizziness, anxiety, death anxiety, headache; these symptoms exaggerated during development of emotional anxiety. The treatment response rate with benzodiazepine and SSRI within 2 week of treatment, were 61.21% on HAM-A and 65.96% on Death Anxiety Rating Scale. with anti anxiety and antidepressant drugs within 2 weeks duration of treatment.

Conclusion: We found the series of patients those experienced jerk of earthquake complaints various neuropsychiatric problems like anxiety, Vertigo, death feelings, depression, insomnia and headache.

Key Words: SSRI -selective serotonin reuptake inhibitors, HAM-A- Hamilton Anxiety Rating scale, DARS-Death Anxiety Rating Scale.

Prevalence of Sexism and Sexual Harassment and their Association with Current Depressive and Anxiety Symptoms in Undergraduate Medical Students – A Descriptive Cross-Sectional Study

Jayashree Iyer

Student, Jawaharlal Nehru Medical College, Belgaum, Karnataka. [email protected]

Background: Little is known about the prevalence of sexism and sexual harassment among the college going youth of India and how these affect their mental health. The aims and objectives were to find out prevalence of sexism and sexual harassment among undergraduate medical students recently (past 3 months) and in their lifetime and find out their association between current depressive and anxiety symptoms.

Methods: A cross sectional survey was done involving 1st and 2nd year MBBS students, in the classroom, using 3 questionnaires. One to assess history of experience to sexism, another to assess history of experience of sexual harassment and the PHQ-SADS scale to assess mental health.

Results: A total of 225 students were included. The prevalence of lifetime sexism (72.66% v/s 63.91%; p=0.0091) and lifetime and recent sexual harassment (p<0.0001 for recent, p=0.0303 for lifetime) were found to be higher in women than men, although the prevalence in men was also considerable. The average severity scores were higher in women (p=0.0168 for lifetime sexism; p=0.0008 and p<0.0001 for lifetime and recent sexual harassment respectively). The PHQ-SADS scores were significantly higher in those who had a history of experience of sexism and sexual harassment than those who did not (p=0.0016 and p=0.0052 for PHQ-9 in recent and lifetime sexism; p<0.0001 and p=0.001 for PHQ-9 in recent and lifetime sexual harassment respectively; p=0.0084 for GAD-7 in recent sexism; p=0.0150 and p=0.0014 for GAD-7 in recent and lifetime sexual harassment respectively).

Conclusion: It was found that there is high prevalence of history of sexism and sexual harassment among college students. These experiences affect the mental health of individuals, increasing their risk of developing depression and anxiety disorders.

Keywords: Sexism, sexual harassment, mental health

Parallel evolution of complex traits between Vocal learning birds and Humans

Kamaldeep Sadh, Sanjeev Jain, Muralidharan Kesavan, Urvakhsh Mehta, Shivashankar N

Junior Resident, National Institute of Mental Health and Neurosciences, Banglore, Karnataka. [email protected]

Background - Vocal learning is the ability to learn to produce vocalizations by imitating a model.The neural correlates of it being a corticostriatal loop and direct connection between cortical areas and brainstem vocal motor and respiratory nuclei for phonation. Also, functional brain regions specialized for vocal learning in both have found to have similar specialized expression of genes (a specific glutamate receptor, gene encoding for parvalbumin). As the genetic and anatomical studies have found an analogous brain regions for song and speech between birds and humans, we have looked over this association between the behavioral, neuroanatomical and molecular convergence for the vocal-learning trait with the phenomenology of auditory hallucinations provided by the patients.

Methodology – Our study included 20 subjects diagnosed to have Severe Mental Illnesses and currently experiencing auditory hallucinations as part of their syndromal presentation and phenomenology was assessed in multiple domains.

Results- We found that 7 patients reported hearing Non-verbal hallucinations out of which 3 reported hearing birds speaking to them or them understanding the language of birds. They reported “I hear voice of pigeons calling me to come down”, “ I used to hear voices of birds talking to me saying- sambhu acha hai”, “I used to hear bird’s voice in her native language saying -hum mahadev hain, humari beti sabse achi hai”. She also reported that she used to talk to the birds and once, when she would ask them whether they like rains or not, the birds would tell they like it.

Conclusion- This study provides an insight into the fact that complex traits (vocal learning) has limited ways of evolution and hence, opens a way to look into other traits like these and getting a better understanding of evolution of these complex traits and linking them with current presentations of various psychiatric morbidities.

Keywords: Birds, auditory hallucinations, evolution

Study of risk factors associated with suicide attempt in patients with bipolar I disorder

Karthick Subramanian, Vikas Menon, Vigneshvar Chandrasekaran

Senior Resident, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, [email protected]

Background: Suicide is the leading contributor for mortality in bipolar disorder. A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries are rare. The present study aimed to identify the risk factors associated with suicidal attempts in bipolar I disorder (BD-I).

Methods: Patients with BD-I currently in clinical remission (N=102) were included in the study. The socio-demographic details and the clinical data were collected using a semi-structured proforma. The psychiatric diagnoses were confirmed using the Mini International Neuropsychiatric Interview (MINI 7.0). The Presumptive Stressful Life Events Scale (PSLES), Coping Strategies Inventory-Short Form (CSI-SF), and Buss-Perry Aggression Questionnaire (BPAQ) were used to assess the patient’s stress scores, coping skills, and aggression, respectively. Binary logistic regression analysis was performed to identify the predictors for lifetime suicide attempt.

Results: One hundred and two patients (Males=49, females=53) with BD-I were included for the study. Thirty seven subjects (36.3%) had a history of suicide attempt. On binary logistic regression analysis, the odds ratios (OR) for predicting a suicide attempt were highest for positive family history of suicide (OR 11.45, 95% Confidence Interval (CI):1.15-114.40, p=0.038), followed by presence of psychiatric co-morbidity (OR 3.24, 95% CI:1.13-9.32,p=0.029), lower scores on problem focused disengagement (OR 0.71, 95% CI: 0.56-0.90,p=0.005), and increased verbal aggression as per BPAQ (OR 1.11, 95% CI: 1.00-1.24).

Discussion: The study sample reflected the high incidence of suicidal behaviours in patients with BD-I. The findings reiterate that genetic loading, psychiatric comorbidities and poor coping strategies can significantly worsen the suicide risk.

Conclusions: Clinicians should exert caution while evaluating BD-I patients with a family history of suicide, multiple psychiatric diagnoses, poor coping skills, and verbal abusiveness.

Keywords: Suicide, Coping skills, family history

Stickler Syndrome with Unspecified Non Organic Psychosis

Uma Maheswari Kiruthika, Aravindhan, Poornachandrika

Junior Resident 1st Year Postgraduate, Institute of Mental Health,Chennai, Tamilnadu. [email protected]

Introduction: Stickler syndrome is a group of hereditary genetic conditions with features including distinctive facial appearance, visual disturbance, hearing defects, cleft palate etc. A co occurrence of psychosis features in a patient with stickler syndrome is very unusual. Here we present one such case.

Case History: A 38 year old female presented with complaints of talking to self, suspiciousness, referential ideas for past ten years with complaints of denial of her husband’s death(which happened one month before), belief that her husband is alive and in hiding for the past one month duration. On evaluation she was found to have flattened midfacial features, skull deformities (?oxycephaly), operated cleft lip and palate, with brachydactyly. Her ophthalmic examination revealed early onset lens opacification and high myopia. On ENT examination she was found to have mixed deafness. Her MRI showed Microcephaly. All these features suggested a syndromic diagnosis. She was diagnosed as Stickler Syndrome variant with Unspecified Non Organic Psychosis. She was treated with optimal dose of antipsychotic and benzodiazepine and improvement noted.

Discussion: The association between Stickler Syndrome - a genetic condition caused by Collagen gene mutation and Psychiatric disorders have been studied. It showed that most cases were associated with specific learning disabilities. Other syndromes with similar features were ruled out.

Conclusion: The usual psychiatric co morbidity of Stickler Syndrome is Specific Learning Disability. The occurrence of psychosis in a case of Stickler syndrome has been very rarely documented. Further studies to analyse genetic relationship between both conditions and a careful screening of all cases will help in better treatment outcome.

Keywords: Stickler Syndrome, Psychosis, Genetic Conditons

Comparison of Socio Demographic Variables and Treatment Outcome of Patients Suffering from Alcohol Dependence Syndrome Treated at a Tertiary Care Psychiatry Hospital , A Decade Apart

Kshipra Naik, Roshan Kanekar

Junior Resident, Institute of Psychiatry and Human Behaviour, Bambolim, Goa. [email protected]

Introduction: The magnitude of alcohol abuse in Goa continues to be on the rise. As a result, presentation of alcohol dependence in patients visiting a tertiary psychiatry care hospital is not uncommon. Paradoxically various factors are implicated in overlooking the issue of alcohol dependence. One of the factors being the belief that these patients do not respond much to treatment.

Hence this study attempts to compare the treatment outcomes of patients visiting Institute of Psychiatry and Human Behaviour (IPHB), diagnosed to be suffering from alcohol dependence, a decade apart.

Methodology: A retrospective comparative study done in IPHB, a tertiary psychiatry hospital, Goa. The two population samples considered are patients who came in the year 2005-2006 and those who came in 2015-2016. Each sample constituted hospital records of the first 100 consecutive patients visiting the OPD for the first time and diagnosed as alcohol dependence syndrome. Files were scrutinized for psychiatrist note, opinions and reports. Findings of follow up after 3, 6,9,12 months were noted. Patients were divided into 3 categories: full remission, partial remission and relapse.

Results: Results a decade apart will be compared in terms of socio demographic variables and treatment outcome of the patients. Currently under analysis.

Implications: The notion that alcohol dependence does not have any good treatment outcome and that it is a self created illness is held strongly. However the beneficial effects and positive treatment outcomes need an equal emphasis. This study will help shed light on the stand of treatment outcomes now and then.

Keywords: Alcohol dependence, tertiary care, socio demographic variables

A Rare Case report of Adult abdominal Migraine

Ankush Sharma, Abhay Jain

Medical College, Ujjain, Madhya Pradesh. [email protected]com

Objective: To report the rare case of a 36-year-old young male with signs and symptoms of abdominal migraine followed by self induce vomiting.

Case Summary: A 36 year old young male presented with episodic, severe, poorly localised abdominal pain lasting for 1-2 days, mostly relieved by vomiting which also led the patient to self induce vomiting up to 30-40 times in a day to get relief. Patient had a history of several previous admissions with similar symptoms and extensive gastro-intestinal work-up in which findings were normal and consistently inconclusive. He had no family history of migraine headaches. A diagnose of abdominal migraine was made and prophylactic therapy with Divalproex Sodium 1gm once a day relieved the symptoms.

Discussion: Abdominal Migraine with adult onset is a very rare condition, with less than 40 cases reported till 2016. The symptoms mimic GI pathologies and even with multiple psychiatric consultations, the diagnosis mostly remains elusive. This case additionally had no positive family history of Migraine Headaches. Patient responded to standard prophylactic migraine therapy, after suffering for more than 8 years with this condition.

Conclusion: Abdominal migraine should be considered a possible source of severe abdominal pain followed by self induce vomiting when accompanied by a complete gastrointestinal workup with normal results and no family history of migraine. Prophylactic use of Divalproex sodium is helpful if abdominal migraine is the likely source of pain.

Keywords: Episodic, abdominal pain, abdominal migraine

Study of Aggression and Associated Factors Among Patients Presenting to a Psychiatric Hospital

Raghavendra Kumar K, Ashish Srivastava, Preethi V Reddy, Maria Yvonne D’silva Pereira

Post Doctoral Fellow, National Institute of Mental Health and Neurosciences(NIMHANS), Bangalore, Karnataka. [email protected]

Background: Approximately ten per cent of the adult population suffers from some form of mental illness – ranging from depression to schizophrenia. It is important to restate that most mentally ill individuals are not violent. However they are more vulnerable than are mentally healthy individuals, to acting aggressively when stressed, especially if they have endured early, severe, on-going maltreatment. There have been several studies, from the west, looking into these factors and how they can be prevented but very few Indian studies. This study aims to find association between the incidences of aggression with the modes of admission, and factors pertaining to patients and hospital.

Methodology: The study was conducted in a tertiary care psychiatry hospital. Outpatient and In-patients were included in the study. 200 consecutive incidences of aggression were recorded over a period of 1year. Staff Observation Aggression Scale- Revised (SOAS-R) was applied for rating the episode of aggression. Factors studied were compared with the SOAS-R score, after calculating the basic frequencies, for statistically significant association using chi-square test.

Results: Significant association existed between the SOAS-R scores and modes of admission, compliance, total duration of illness, bed occupancy. Commonest diagnosis was Organic Mental Disorders 13%. Irritability was the commonest psychopathology, 33%. Past history of violence 69.5%, self- harm in the present or past were 47.5%, family history of psychiatric illness 48% of the sample.

Conclusion: Aggression in psychiatrically ill patients is multifactorial, and associated with a host of heterogeneous attributes. Routine, mandatory screening of the categories of patients with high prevalence of aggression, before admission, will ensure necessary steps to pre-empt and reduce the risk of untoward consequences.

Keywords: Aggression, Psychiatric hospital, associated factors

Depression and quality of life in patients with Pemphigus

Megha Ashok Maghade, Abhijeet Faye, Deepika Singh, Sushil Gawande, Rahul Tadke, Sudhir Bhave, Vivek Kirpekar

PG Student, NKP Salve Institute of Medical Sciences & Research Centre Nagpur, Nagpur, Maharashatra. [email protected]

Background: Pemphigus is a chronic, relapsing autoimmune blistering disorder requiring long term treatment and frequent hospitalization. Severe skin and mucosal involvement in these patients is associated with psychological distress, leading to depression. Visible skin lesions can reduce self-esteem and affect patient’s quality of life. This study aims to assess presence of depression and effects on quality of life in these patients. Correlation between them was also analyzed.

Materials and Methods: A cross-sectional single interview study was carried out on 100 consecutively selected patients with Pemphigus attending dermatology out patient department in tertiary care hospital. Assessment was done with semi-structured proforma, Becks depression inventory (BDI) and quality of life measure -Skindex 16. Data was analyzed statistically.

Results: Mean age of the participants was 32yrs, 65% were females, majority were married, employed and from rural background. 22% satisfied the DSM V (Diagnostic and Statistical Manual for Mental disorders) criteria for major depressive disorder. Assessment using BDI in these patients for severity of depression showed mild depression in 12%, moderate depression in 7% and severe depression in 3%. Patients having longer duration of illness and history of frequent hospitalisation were found to have significantly high scores on subscale for depressive symptoms. Quality of life assessment using Skindex-16 scale among these patients showed that they experienced more severe emotional and symptomatic effects due to skin disease compared to functional effects especially during relapse. Those who had poor quality of life showed significantly high scores on subscale for depressive symptoms.

Conclusion: More than 20% patients of Pemphigus had diagnosable depression with significant effects on quality of life. Regular screening for depression is important in pemphigus patients as it will help in planning early intervention in them.

Keywords: Pemphigus; depression; quality of life.

Delusion of Pregnancy –An unusual case Report

Avisha Mahla, Rajat M.Oswal

Second year Resident doctor, Medical College,Baroda, Vadodara, Gujarat. [email protected]

Introduction: Delusion of pregnancy (DP) is defined as the belief of being pregnant despite factual evidence to the contrary. DP is a somatic type of delusional disorder classified within Schizophrenia spectrum and other Psychotic disorders according to DSM-5.

Case History: This is an unusual case of 62 years old married menopausal female who was referred to Psychiatry department with complaints of belief of being pregnant since 1986, cough and vomitting. She believes that her vomitting is due to her pregnancy. She believes that she was pregnant in 1986 when she underwent tubectomy. Due to sutures of tubectomy the child is not getting delivered but is in a healthy state as she can regularly feel its movements.

She has continuous illness of 17-18 years with marked irritability and delusions of being pregnant & infidelity. She is performing all her daily chores properly. She is able to maintain her self-care. Sleep and appetite are also normal.

She was started on Risperidone 2mg and her irritability has reduced and her interaction with family has improved.

Discussion: In this patient we noted delusion of pregnancy without any other psychotic features which favours the diagnosis of Delusional disorder according to DSM-5. What is unusual is that she believes that she is pregnant since 1986 and was actively menstruating until 2000 after which she had menopause.

Keywords: Delusion of pregnancy, somatic type, Risperidone

Rapidly progressive dementia in a case of progressive multifocal leucoencephalopathy with HIV

Partha Pratim Daimary, Soumitra Das, Seshadri Sekhar Chatterjee

MD Trainee, Psychiatry, NIMHANS. [email protected]

Dementia is either gradually, step ladder or rapidly progressive neuro-degenerative disorder. Alzheimer is the most common cause for gradually progressive dementia, whereas Prion Disease, STDs- HIV and Syphilis are the main causes of rapidly progressive dementia. HIV Dementia Complex is one of the primary manifestation of advanced stage of neurodegeneration. But, with the advent of newer treatments, the improvement rate is rising. Here, we are presenting a case, who presented with severe dementia, history of TB & weight loss. At the time of admission his HMSE was 17/31 and within weeks it sank to 13/31. Reportedly his wife was also taking treatment for TB & lost weight significantly. The history raised suspicion of immunodeficiency and upon careful history taking and evaluation of physical and bio-chemical parameters he was found to be HIV Positive. His MRI showed Peri-ventricular white matter changes, predominately involving the ior part and also involving the brain stem. Also, one ring enhancing lesion was noted in left temporal region, suggestive of tuberculoma (PMLC). Later, upon suggestion, his wife underwent HIV test and showed to be HIV positive, as well. Soon, treatment was initiated and within months, the person, who couldn’t find his own home, could re-join job. The case is interesting as it was early onset dementia which was rapidly progressive and not matching the characteristic of Alzheimer’s or FTD which are common in day to day practices. This case emphasises the point that we should be vigilant when handling a case with atypical presentation of Dementia.

Key words: Dementia, HIV, PMLC, Rapidly Progressive

Ketamine therapy and its efficacy in treatment of depression

Suprio Mandal, Vinod Kumar Sinha, Nishant Goyal, Nirmalya Mukherjee

Junior resident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Background: Major depressive disorder is one of the most debilitating condition prevalent worldwide. Ketamine is NMDA receptor antagonist having rapid action on depressive symptoms.

Objectives: Ketamine at subanesthetic doses have effect on different symptoms in depressive disorders. Here we will examine the effects of subanesthetic dose of ketamine on various psychopathology variables in terms of depressive symptoms, anxiety symptoms, and illness severity comprehensively in terms of immediate effect and delayed effect after repeated doses of injection on male patients of severe depression.

Methodology: A open label study of 20 patients (19 completed the study) of male sex, with a diagnosis severe depression, having no previous history of psychotic disorder, head injury, organic disorder, substance use and drug free for 4 weeks, having no cardiological problem were admitted in patient, assessments were done at baseline then injection ketamine hydrochloride was given at dose of 0.5mg/kg intravenous bolus, assessments were done at 1 hour of first dose, total 6 doses were given in similar pattern over two weeks. After two weeks final assessment was done.

Results: There is significant lowering of HAM-D, HAM-A and CGI-severity of illness from baseline to two weeks. Whereas change in scores at first hour is significant for HAM-D and HAM-A. Adverse effects seen are mild and transient and subsided within one hour of ketamine injection.

Conclusion: Ketamine has robust and rapid effect on depressive and anxiety symptoms as well as this improvement is sustained with repeated dosing after two weeks and there is overall decrease in illness severity with repeated dosing and it is also well tolerated in dose of 0.5mg/kg given intravenous bolus.

Key words: Ketamine hydrochloride, depression, NMDA

Electroconvulsive therapy for musical obsessions

Manish Pardeshi, Jayanath B P, Varun Mehta, Nizamuddin Parvez, Abhishek Kumar, Surendra Paliwa

Junior Resident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Introduction: Musical obsessions are miscellaneous obsessions explained as repeated, intrusion of musical sounds/tune or songs in the mind which are anxiety provoking and difficult to suppress. Studies have shown short term efficacy of ECT in small subgroup of resistant OCD. Here we will discuss the effect of electroconvulsive therapy in musical obsessions in a case of resistant obsessive compulsive disorder.

Case Summary: A 28 year old single, unemployed Christian belonging to low socioeconomic family of sub urban Jharkhand presented with complains of repetitive songs and tunes being played in his mind which were intrusive, distressing and difficult to get rid of; fear of contamination and repetitive acts of washing and checking for the past 14 years. He was admitted in the hospital and mental status examination revealed a tensed manner of relating, decreased motor activity, dysphoric affect, musical obsessions, obsessive thoughts about dirt & contamination and compulsive acts of hand washing, impaired social and personal judgement and Grade 3 insight. Patient had received failed trials of SSRIs i.e. T. Escitalopram (60mg), T. Sertraline (100mg), T. Fluoxetine (50mg), T. Fluvoxamine (300mg); TCAs i.e. T. Clomipramine (200mg); and Anxiolytic i.e. T. Buspirone (15mg). Considering inadequate response, Modified ECT was started every alternate day and the obsession score on Y-BOCS scale reduced from 15 to 6 and compulsion score reduced from 10 to 0. Currently, patient is maintaining well on Maintenance ECT once in a month along with Tab. Escitalopram (60mg), Tab. Clomipramine (200mg).

Discussion: The case reiterates the importance of maintenance electroconvulsive therapy in a subset of patients having resistant obsessions & compulsions

Keywords: Electroconvulsive therapy, musical obsession, Resistant OCD

Conversion Disorder with Aphonia and Deafness or Malingering a Diagnostic Dilemma

Meenakshi jain, samir desai

Postgraduate resident, IMCHRC, Indore, Madhya pradesh. [email protected]

Conversion disorder originally referred to as hysteria, conversion reaction or dissociative reaction is a psychiatric disorder characterized by sudden onset of pseudoneurological symptoms or deficits that affect either voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors. It is rare to find an acute onset of combination of sensory and motor deficit symptoms in a male patient.

Case – 17 year old, Hindu, unmarried, male Mr Lalit (name changed) presented to medicine department with complains of one episode of severe chest pain 3 days back, followed by bilateral hearing loss and inability to speak since 3 days. Patient was a known case of sickle cell anemia and was on tab hydroxyurea 500 mg OD for the same. Detailed history and physical examination revealed no other abnormality. Consultation from ENT department revealed absence of any structural anomaly. Hemogram, LFT, KFT, CT scan brain were normal. 2 days later patient was referred to psychiatry department. Detailed interview was suggestive of conversion disorder (psychogenic aphonia with psychogenic deafness). Management plan included, Pentothal assisted interview, tab diazepam 5 mg BD and supportive psychotherapy. 2 days later relatives requested discharge as they wanted to visit a faith healer and left against medical advice. On successive follow-up to medicine department for sickle cell anemia, patient reported that he discontinued the medication after discharge and recovered spontaneously after 15 days.

Key word = conversion disorder, psychogenic aphonia, psychogenic deafness, hysteria

A Study on Prevalence of Internet Addiction in Medical Students and its Relationship with Personality Traits

Medikonda Meena Kumari, Somasundara Babu

PG, Asram Medical College, Eluru, Andhrapradesh. [email protected]

Objective: To assess the prevalence of internet addiction and its relationship with the personality traits in undergraduate medical students.

Materials and Methods: The present study employed a descriptive, correlative method and the sample comprised 100 undergraduate medical students of Asram Medical College, Eluru. The tools used are Internet Addiction test (IAT) designed and developed by Young and NEO-Five Factor Inventory (NEO-FFI) questionnaires.

Results: Results indicated that 88% of medical students are addicted to internet, and internet addiction is significantly correlated with neuroticism.

Conclusion: The study demonstrated that there is high prevalence of internet addiction in medical students, so to prevent internet addiction in adolescents we should take measures like teaching and counselling them regarding the pathological effects of internet addiction and also personality screening to be done during the start of undergraduation to identify the risk personalities and to counsel them from being addicted.

Keywords: Personality traits, internet addiction, medical students.

Lennaux-Gastaut Syndrome Presenting with Symptoms of ADHD- A Case Report

Mrunmayee Pradhan

PGT, SCB Medical College, Cuttack, Odisha. [email protected]

Background: Lennox-Gastaut syndrome is a form of severe epilepsy that begins in childhood. It is characterized by multiple types of seizures and intellectual disability. People with Lennox-Gastaut syndrome begin having frequent seizures in early childhood, usually between ages 3 and 5.The association of attention deficit hyperactivity disorder can cause significant impact on the social life of affected individuals and their families. Clinical studies suggest that 30-40% of people with epilepsy also have ADHD.

Aim and Objective: to present the case of a patient of Lennox- Gastaut syndrome who presented with attention deficit and hyperactive symptoms.

Material and Methods: A 7 year old male child presented with the chief complaint of restlessness, moving around the house , fidgety behavior, episodes of self-injurious behavior. He was stubborn towards parents. the symptoms of 2 yrs duration with insidious onset and continuous course.The academic performance was poor and patient remained inattentive during studies. On ADHD checklist, he was found to have moderate level of hyperactivity. On medical evaluation and past treatment records, patient was found to be a diagnosed case of Lennox- Gastaut syndrome. the seizures started at the age of 1.5 years. the episodes gradually increased in frequency and severity. Patient was prescribed methylphenidate and the antiepileptics were continued as advised. After 3 to 4 follow ups, in a span of 7 months, the hyperactive symptoms subsided.

Conclusion: ADHD is often under diagnosed in children. Its comorbidity with epilepsy is an add-on burden. So, early diagnosis and treatment is very important for prevention of long-term effects. As children diagnosed with ADHD often have significant difficulties in adolescence regardless of treatment, so early detection, diagnosis and treatment is very important for prevention of long-term adverse effects of ADHD

Key words: Attention; Deficit; Hyperactivity

Childhood onset Schizophrenia (Very Early Onset Schizophrenia)-A Rare Case Report

Muthamilselvi. C, Meena, Shanthi Nambi

Postgraduate in psychiatry, Institute of mental health, Chennai, Tamil nadu. [email protected]

Introduction: Childhood onset schizophrenia is very rare and virulent form of schizophrenia , recognised as neuro developmental disorder. Schizoprenia with onset prior to the age 13 is referred to as very early onset or childhood onset schizophrenia. Frequency of childhood onset schizophrenia is reported to be less than one in about 40,000 children.

Case History: A 15yr old female child discontinued 9th std presented with complaints of fearfulness and suspiciousness that people at school are talking about her and watching her through the camera for 3yrs, refusal to go to school and poor selfcare for 1 yr, with her complaints increased for the past 8 months. She had permissive, over protective parenting, with significant family h/o mental illness in the paternal grandmother, ocd features in the father, expressed emotions in the mother, disturbed communication styles in maternal uncle. On MSE, she had persecutory and referential delusions and perplexed affect. She was diagnosed as childhood onset schizophrenia. Her bmi was 37.7 and investigations- T3,T4,TSH within normal limits. MRI brain- normal study. She was started on T.Risperidone and then on T. Aripiprazole. As she did not respond even with maximum dose, she was put on clozapine and arpiprazole combination after which she achieved significant improvement and she is on regular follow up now.

Conclusion: The diagnosis of childhood onset schizophrenia is continuous with the adolescents and adults. Young age, insidious onset, chronic course are predictors of poor prognosis. Hence early detection, adequate Psychosocial, pharmacological intervention and family education is necessary.

Keywords: Childhood onset, schizophrenia, psychosocial intervention

Amisulpride induced acute dystonia-A case report

Navratan Suthar, Brajesh Mahawer, Naresh Nebhinani

Senior Resident, Aiims Jodhpur, Jodhpur, Rajasthan. [email protected]

Background: Amisulpride, is a second-generation (atypical) antipsychotic. At higher doses, amisulpride antagonizes postsynaptic D(2) and D(3) receptors, preferentially in the limbic system, thereby reducing dopaminergic transmission, which is responsible for extrapyramidal side effects (EPS). Generally amisulpride has a low propensity for EPS, but few cases of were reported in literature. Here we present a case of amisulpride induced acute dystonia.

Case presentation: Mr. X, a 20 year old male, diagnosed as “Depression with psychotic features”, was put on escitalopram 20 mg, and amisulpride 100 mg/day, which was increased to 400 mg/day in the next 4 weeks. On 5th day of amisulpride 400 mg, he developed tightening and rigidity of the neck and limbs, with slurring of speech and salivation. It persisted for 20-30 minutes approximately, so he consulted at emergency, diagnosed as acute dystonia, was successfully treated with intramuscular promethazine 50 mg and recovered completely after stopping of the amisulpride. Naranjo’s causality assessment reveals probable association of amisulpride induced acute dystonia. Presently patient is symptoms free, euthymic on fluoxetine 40 mg and quetiapine 200 mg without recurrence of dystonia.

Conclusions: This case outlines a significant side effect of amisulpride, which a practitioner should be vigilant about before initiating the medication.

Keywords: Amisulpride, EPS, Acute dystonia

Galactorrhea with antidepressants-A case series

Navratan Suthar, Vrinda Pareek, Naresh Nebhinani

Senior Resident, AIIMS Jodhpur, Rajasthan. [email protected]

Background: Galactorrhea is a rare but distressing adverse effects experienced commonly with antipsychotics. It was also reported with antidepressants in the medical literature, but less commonly with SSRI (Selective Serotonin Reuptake Inhibitors). Here we present series of 3 cases, which have developed galactorrhoea with combination of antidepressants.

Case details: Here first case developed galactorrhoea with hyperprolactenemia, initially with combination of fluoxetine 40 mg and escitalopram 20 mg (PRL-1854 ng/ml), and later with the combination of fluoxetine 40 mg and amitriptyline 25 mg (PRL-333 ng/ml).

In second case, galactorrhoea was developed initially with the combination of SSRI & SNRI (venlafexine 150 mg, fluoxetine 20 mg) with hyperprolactenemia (PRL>200 ng/ml), and later with dosulepin 225 mg with hyperprolactenemia (PRL-170 ng/ml).

In third case, galactorrhoea was developed with the combination of 2 SSRIs (escitalopram 20 mg/day and sertraline 50 mg/day with hyperprolactenemia (PRL-164.4 ng/ml).

Recurrence of galactorrhea was not seen with monotherapy of SSRI (case-1), switching on bupropion (case-2), and stoppage of SSRIs (case-3).

Conclusion: Galactorrhoea is a rare but unwanted side effect of antidepressants, so clinician need to be aware of this unusual side-effect to manage it well in time.

Key words: Galactorrhoea, Selective Serotonin Reuptake Inhibitors (SSRI), Antidepressants, Hyperprolactenemia

Memory functioning and its correlates in Bipolar Affective Disorder current episode Depression

Neha Sayeed, Amool Ranjan Singh

Associate Professor, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

This study aimed to evaluate the memory functioning in BAD current episode depression in comparison to normal controls. It too aimed to see the memory functions in the study group as per the age, gender and duration of illness. The study was conducted in psychiatry based hospitals in Ranchi city i.e. Central institute of Psychiatry (CIP) and Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) Kanke, Ranchi. Bipolar affective disorder current episode depression, who have been diagnosed by ICD-10, DCR criteria (WHO) and have been attending OPD of CIP and RINPAS. The sample comprised of 60 patients from BAD patients current episode depression (30 males and 30 females) and 60 normal control (30 males and 30 females). The result of the study show that as compared to healthy controls the patient group has significantly poorer performance on memory tasks. In this study we found that females have better remote memory than males across the group of BAD current episode depression. Age was seen as the predictor of cognitive decline in BAD patients and in this study remote memory is seen decreasing with age in BAD patents currently in depression. There was no significant difference in memory functions as per duration of illness.

Keywords: Memory functions, Depression, Age, Gender, Cognition.


Neha Agarwal, Ashish V Saboo, Shrikant B Deshmukh

Dr PDMMC , Amravati, Maharashtra. [email protected]

Introduction: PARAPHILIAS or perversions are sexual stimuli or acts that are deviations from normal sexual behavior but are necessary for some persons to experience arousal and orgasm.

Individuals with paraphilic interest can experience sexual pleasure but are inhibited from responding to stimuli that are normally considered erotic.

The paraphilic person’s sexuality is mainly restricted to specific deviant stimuli or acts.

A special fantasy with its unconscious and conscious components is the pathognomic element of paraphilia with sexual arousal and orgasm being associated phenomena that reinforce the fantasy or impulse.

TRANSVESTISM is a paraphilia in which there are fantasies and sexual urges to dress in opposite gender clothing as means of arousal and as an adjunct to masturbation or coitus.

The diagnosis given when the transvestic fantasy have been acted upon for atleast 6 months.

FETISCHISM is added if the patient is aroused by fabrics, materials or garments.

Case Study: A 18 year old male brought by mother presented with complaints of stealing UNDERGARMENTS of opposite sex since past 3 years gradually progressive over period of time. According to patient and relatives after stealing patient used to observe them and tried wearing them and reported sexual gratification with same. History of frequent masturbation using garments as well. History of being reported to police for the same by neighbours. According to mother 3-4 years back patient had frequent irritable mood and argumentative behavior especially towards family members, suggestive of OPPOSITIONAL DEFIANT DISORDER. The patient and relatives were psychoeducated and the patient given cognitive behavior therapy and supportive psychotherapy.

Keywords: Fetischism, paraphilia, sexual urges

Hashimoto’s thyroiditis presenting as acute psychosis with religious delusion: a case report.

Abid Rizvi, Shaan F., Fatima N

Assistant Professor, Amu Aligarh, Aligarh, Uttar Pradesh. [email protected], [email protected]

Hashimoto’s thyroiditis is the most common cause of hypothyroidism which can have psychiatric manifestation at first presentation which at times, may be so striking that patients are first diagnosed with a primary psychiatric disorder. We here describe a case of 35 year old female patient who presented with acute psychosis with religious themed persecutory delusion. Further evaluation revealed a diagnosis of Hashimoto’s thyroiditis. Patient was started on thyroxin and olanzapine to which she responded and her psychosis resolved in two weeks. Olanzapine was reduced and stopped and, her thyroid function test at the end of three month was within normal range

Key words Hashimoto’s thyroiditis, acute psychosis, religion themed delusion.

Structured pathway of non-pharmacological methods for managing patients with dementia in a tertiary care hospital

Nisha Mani Pandey, SM Tripathi, Bhupendra Singh, S.C. Tiwari

Asst. Professor (Non-medical Research), King George’s Medical University UP, Lucknow, Uttar Pradesh. [email protected]

Background: Management of patient with dementia (PwD) is a difficult task. There is hardly any pharmacological intervention with high level of efficacy. Further, side effects of commonly prescribed drugs for managing behavioural and psychological symptoms of dementia (BPSD) are also reported to be high. Alternatively, non-pharmacological methods (NPM) are well accepted, appreciated and encouraged to be used as first line treatment for managing PwDs [1-3].


Primary objective: To assess the impact of non-pharmacological methods (NPM) in managing PwDs.

Secondary Objective: To develop structured pathway of NPM for managing PwDs.

Methodology: To develop the NPM intervention strategies, a structured proforma has been developed. This proforma is based on the research outcome as well as experiences of the multi-disciplinary team (MDT). After obtaining all basic information from the patient/ their care givers, needed assessments were done by the concerned team member to identify and rate the level of severity of the problem and the type of NPM strategies to be used. A realistic goal is set and periodic assessments are done to note outcome of the applied procedures. Applied NPM includes dietary, psychological, social , occupational, physical exercises, recreational as well as spiritual methods. Psycho-eduaction sessions are held with caregiver.

Results: A total of 42 PwDs and their caregivers were assessed. Each of the subjects were assessed at baseline and at the end. Significant improvement in attitude of caregivers and management of PwDs were noted.

Discussion: Our findings reveal that proper sessions of psycho-education alongwith appropriate NPM strategies lead to increased functionality, reduce caregivers’ burden and ensures dignified life to the PwDs.

Conclusion & Implication: No negative impact of NPM was found. It is a cost-effective approach and therefore, should be implemented to ensure dignified life to elderly mentally ill.

Key Words: non-pharmacological methods (NPM), structured pathway, multi-disciplinary team (MDT), patients with dementia.

Sociodemographic data and clinical profile of patients presenting in memory clinic

Nitish Jhunthra, Shankar Prasad Gorthi, Samir K Praharaj, Shweta Rai

PG, KMC Manipal, Manipal, Karnataka. ni[email protected]

Introduction: With an aging population, there is an increase in the prevalence of dementia. Care of persons with dementia requires a multidisciplinary approach for diagnosis and management. There is a dearth of dedicated clinics in India dealing with dementia. We have been conducting a weekly memory clinic at our hospital dealing specifically with issues of dementia with a collaborative team of Neurologist, Psychiatrist and a Clinical Psychologist. This study examines the cases seen in the memory clinic in the first year.

Methodology: It is a hospital-based study retrospective study analyzing all the patients that were evaluated in memory clinic between August 2016 to August 2017.

Keywords: Sociodemographic data, dementia

Third ventricular colloid cyst - An organic Cause of mania – A case report

Penubarthi Sravanthi, P.Sravanthi

MBBS., Chettinad hospital and research institute, Chennai, [email protected]

Background: A colloid cyst is a slow-growing, benign tumor that occurs in the anterior third ventricle, representing 0.5%-2% of all intracranial tumors. Colloid cysts frequently cause psychiatric manifestations including psychosis, depression, anxiety, Korsakoff type presentations and dementia. We here, report a case who presented as mania with psychotic symptoms, which showed symptomatic improvement after the surgery.

Case report: A 30 year old man was brought to the OPD with symptoms of disinhibited behavior, irritability for 3 months. Family members report he was irritable towards family members , walking in a different way like dancing, more active than his normal, he started suspecting his wife, locking her inside the room, not allowing her to talk to anyone, physically abusing the family members , reduced sleep and appetite, believes that he can do any job and need not work under someone, watching television in high volume throughout the night , sitting in one position and staring at others. Family members report history of similar complaints 1 year back, for which he was not treated but symptoms resolved spontaneously. A CT scan of the Brain showed a hyperdense lesion in the third ventricle. Patient was referred to Neurosurgery and surgery was done for the same. Neuroimaging was repeated after 4 days of surgery. Post operatively , Family members report improvement in his behavior.

Conclusion: It is vital for a clinician to have in depth knowledge of the organic causes of psychiatric disturbance to treat the patients in an effective way.

Keywords: Benign tumour, Korsakoff syndrome, third ventricular cyst

Parenting Styles as Predictor of Delinquency

Nupur Kumari, Manisha Kiran

Research Officer, PGIMER Dr RMLH, New Delhi, [email protected]

Background: Juveniles are the life vein of the society, they are the pillars of the coming times. Relationship between adolescents and their parents are vital. Lack of intimacy, parental involvement, guidance, parental attachment, blaming, and anger can lead to delinquent behavior among adolescents.

Aim: The aim of the present study is to evaluate and compare the parenting style among delinquent and normal adolescents.

Method: The study was conducted at RINPAS. Adolescent with delinquent behavior and normal adolescent were included in the study and their parents were recruited after informed consent. They were assessed on the General Health Questionnaire-12 (GHQ-12; Goldberg and William, 1991), Child Behaviour Checklist (CBCL; Achenbach, 2001) and the Multi-Dimensional Parenting Scale (MDPS; Chauhan and Khokhar, 1985).

Results: Adolescent with delinquent behavior (n=50) and normal adolescent (n=50) were assessed. Parenting Style and CBCL were compared using test. Findings indicated significant difference in the mean scores of various domains at <0.001 level.

Conclusion: Parental affection and care have been suggested to have varying levels of influence on delinquent behavior.

Key Words: Delinquency, Parenting Style, Adolescence

Integrated Treatment for Dual Diagnosis- A Narrative Review

Pallavi Sinha, Amit Garg

Assistant Professor, North Delhi Municipal Corporation Medical College, Delhi, [email protected]

Background: The presence of both mental illness and substance use disorders is commonly called as dual diagnosis disorders. Its management is a somewhat novel admittance in the field of addiction psychiatry. There is no single absolute treatment regimen that works universally for everyone with a dual diagnosis. Management of substance use was initially considered to be separate from treatment for mental health disorders, and care was delivered at different facilities by varying specialists using radically different therapeutic approaches. Integrated treatment for dual diagnosis combines the treatment for mental illness and substance abuse at the level of the mental health professional.

Objectives: The objective of this paper is to critically examine the available literature on the integrated management of dual diagnosis disorders.

Data sources: PubMed, Medline, Google Scholar and manual searches of bibliographies.

Methodology: Seminal papers, clinical trials, review articles, commentaries and chapters were identified keeping the objectives in mind. A total of 36 full text papers were examined by the authors and information collected regarding the mechanism of integrated treatment.

Results and Conclusions: The integrated treatment model has been seen to have multiple advantages and has managed to conquer many of the difficulties faced in the traditional models of treatment. It eliminates the organizational, administrative and philosophical lapses in the parallel and sequential models. Though the current available evidence is consistent and positive towards its effectiveness, much work remains to be done on the organization and financing of integrated programs.

Keywords: Intergrated treatment, dual diagnosis, addiction psychiatry

Depression as a complication of oral isotretinoin: A rare case

Swapna Pandurangi, Monalisa Kakumanu, P. Krishna chaitanya, AdiPratyusha, Sushrut Patil

Post graduate student, Kamineini Institute of medical sciences Narketpally, Narketpally, Telangana. [email protected]

Background: Isotretinoin (Accutane) as it is known in parts of the world, was discovered in 1980. An 13-cis isomer of all trans retinoic acid a derivative of vitamin A used mainly for the treatment resistant severe cystic or recalcitrant nodular acne, usually a well-tolerated medication with a fairly predictable and dose related side effect profile. One of the serious side effects which was fortunately rare unusual experiences of thoughts of self-harm, suicide and depression. It is reported with a prevalence of 1-11%. We present a case report of isotretinoin induced depression.

Case report: A 22 year old female visited to psychiatry OPD with complaints of depressed mood, lack of interest in daily activities, reduced energy, bouts of crying spells, disturbances of sleep and appetite and death wishes since 2 weeks. Examination revealed acne on face for which she was on treatment with Cap isotretinoin 20mg/day since 3 weeks. Patient reported no family history or any major medical and psychiatric illness and was not on any drugs apart from isotretinoin, based on this diagnosis of drug induced depression was made. She was asked to discontinue isotretinoin and was started Tab Sertraline 50mg/day and Clonazepam 0.5mg/day.

Result: Patient showed improvement in her mood symptoms and treatment was continued for 6 months which was later tapered and stopped.

Conclusion: Depression is one of the rare complications of isotretinoin. Predictive factors of drug-related depression remain unclear. Depressive symptoms that develop during the course of treatment need close monitoring and necessitate both antidepressant therapy and discontinuation of the drug. Causal relationship between isoretinoin and depression, versus the potential psychological benefits of effective acne treatment, systematic studies exploring the impact of isoretinoin on mood are needed.

Keywords: Isotretinoin, depression, suicide

Profile of adolescent opioid users seeking treatment at a national level addiction treatment centre

Piyali Mandal, Mohit Varshney, Nileshwar Das, Anju Dhawan

Assistant Professor, AIIMS, New Delhi, [email protected]

Background: substance use among adolescent is a matter of great public health concern particularly with the emerging evidence of increase in use of opioids and other illicit drugs and decrease in the age of initiation of such substances. Recently conducted studies from India have focussed on the drug use problems and related psycho-social factors in community samples. However, there is a scarcity of scientific data on treatment seeking adolescent opioid users. The current study aims to look at the socio-demographic and substance use profile of adolescent opioid users seeking treatment at a national level addiction treatment centre in India.

Methodology: All treatment records of adolescents registered at the adolescent clinic of the centre between the period of January 2015 and December 2016 were retrospectively reviewed and clinical profile of 91 such adolescents were analysed.

Results: The total number of treatment seekers at adolescent clinic was 91, out of which 58% (53) were opioid users. Mean age of the opioid users at presentation was 17±0.8 years and mean age of initiation of any substance was 12±2 years. All of them were males. Majority (94%) hailed from urban areas. Seventy seven percent of them were educated up to 10th standard and 64% had already dropped out of school. Most common opioid used is heroin through chasing route (94.3%). 17% were injection opioid user. Out of all, 92% were dependent opioid users. Other commonly used substances were tobacco (100%), cannabis (81%), alcohol (43%) and inhalants (30.2%). 13.2 % had psychiatric co-morbidity and 28% had family H/O substance use.

Conclusion: High rate of use of opioid in dependent fashion, and delay in treatment seeking indicates the need for immediate attention and further research.

Keywords: Adolescents, opiod

Made affect and Made Volition - a case report

P Uday Kiran, K B Ravi Kumar, D Vijaya Lakshmi

Post graduate, Andhra Medical College, Vizag, Andhra Pradesh. [email protected]

Introduction: Made volition and made affect were less commonly seen in now a days. There is dearth of literature on made phenomenon. Here we report a case with classic presentation.

Case presentation: Mr. X a 26 year old unmarried male patient brought by his grandmother with complaints of laughing to self, singing songs, assaultive and wandering behaviour associated with poor self care and socio occupational dysfunction since 7 years. On examination he was laughing to himself and continuously shouting words “ ja bhayya ja” meaning “go away brother. He told the examiner that it was not he, who laughing and shouting words “ja bhayya ja”, but his friend named Ali was doing these acts using his body. Hence made volition made affect were inferred.

Conclusion: It is very important to elicit made phenomena as it has diagnostic and prognostic implications

Keywords: Volition, made affect

Bipolar affective disorder and Wilson’s disease: case report and review of literature.

Poornima Rao S, NIkita Rajpal, Sonali Bali, Namita Kau

Junior Resident, Vidyasagar Institute of Mental Health and Neurosciences, New Delhi. [email protected]

Background: There is limited data available regarding presentation of bipolar affective disorder in a case of Wilson’s disease.

Aim: To present Bipolar Affective Disorder , rapid cycling and Wilson’s disease: case report

Methodology (Case report): The index patient ,Mr.A a 27 year old male who presented with features of overactivity , over cheerfulness , overspending , increased sociability, overfamiliarity , decreased sleep for 8 days duration in August 2017.On detailed evaluation patient had history of severe depressive episode with suicidal ideation, preceding the above symptoms for a duration of 5 months from April to August 2017.Preceding this depressive episode , a hypomanic episode was present in March 2017 lasting for a few days which was preceded by another depressive episode since January 2017.No euthymic intervening period was observed. There is past history of depressive episode in April 2014 lasting for 2 months.

Patient was born of C-section with no perinatal complications. Patient had history of repeated episodes of jaundice at age of 9 years and was diagnosed with Wilson’s disease. Patient was treated with Penicillamine-d and was later added Zinc supplementation. Patient’s symptoms of Wilson’s worsened during June-July 2017 requiring inpatient management in Neurology, though it was not corroborated with change in investigative parameters. Patient continues to be on Baclofen and Zinconia for treatment of Wilson’s.

On physical examination patient had dystonia , incoordination ,dysphagia. Patient’s current blood investigations revealed normal blood counts and liver function tests and Serum copper. Patient was started on Tablet Oxcarbazepine upto 1200mg/day and and Tablet Quetiapine upto 600mg/day with no change in symptoms over 3 weeks and Tablet Lithium carbonate was added. Treatment for Wilson’s disease was continued as per Neurologist opinion.

Patient followed up after 2 weeks with improvement in presenting complaints.

Keywords : Bipolar disorder , Wilson’s disease, rapid cycling

A Case Report of Prader Willi Syndrome with Psychiatric Manifestations

M.Prabavarani, V.Venkatesh Madhan kumar, Jennifer sangeetha

MD psychiatric PG, Institute Of Mental Health, Chennai, Tamil nadu. [email protected]

Introduction: Prader willi syndrome is a genetic disorder due to loss of function of specific genes.About 70% of cases occurs when part of the fathers chromosome 15 is deleted.In another 25% cases the person has two copies of chromosome 15 from their father.PWS affects between 1in 10,000 and 30,000 people.

Case History: A 10 yr old male studying 1 st std in special school muslim by religion bengali speaking talking with self ,not commuicating with others,violent outburst ,increased eating ,sleep disturbances,for the past two months.

Birth h/o. Hypertensive complicaticating pregnancy.FTNVD.Delayed cry,sucking reflex normal, delay in milestone,delay in head control,delay in walking,delay in speech, increased weight gain after one year,around 18 months child is 15kg, says amma by two years.Around three 1/2 years child was not able to communicate to others,there was repetitive movements of tapping head on wall,they consulted psychiatrist he was on valproate syrup.In school, child was not communicating,not listening in class,In home he wont sit quiet,he used to jump here and there,difficulty in falling asleep,hyperphagia.O/E child well nourished,central obesity,short penis.MSE Child irritable,does not sit comfortable in chair,rapport difficult to establish.psychomotor activity increased, speech relevant,QTR increased RT decreased,affect irritable, thought, preception could not be elicited.Investigation karyotyping results awaited. Treatment Haloperidol 1.5mg.1 hs. Trihexiphenidy l 2mg 1od lorazepam 1/2 hs.sodium valproate 200 mg 1-0-1.

Conclusion: PWS has no cure.Diagnostic criteria 4 major 3 minor make us to diagnose PWS.Speech therapy.occupational therapy.

Keywords: Prader willi syndrome, psychiatric manifestation

Have we forgotten “Factious disorder” in psychiatry clinical practice?

Prabhat Sapkota, Aditya Somani, Susanta Kumar Padhy

Junior Resident, PGIMER, Chandigarh, [email protected]

Background: Factitious disorder (FD) is conceptualized as abnormal illness behaviour and is different from malingering. It has diverse presentations and neurological presentations of the same are uncommon. A clinician suspects FD when patient has medically unexplainable symptoms, multiple hospital visits, history/chronology of symptoms is inconsistent/misleading/selective, fluctuating course, normal repeated investigations, magnitude of symptoms consistently exceeds objective pathology and history does not follow natural pattern of a presumed disease. We present a case of Factitious Disorder that was being misdiagnosed and mis-treated as Dissociative disorder for years.

Methodology: Index case is a young man presented with weakness in both the lower limbs and right upper limb inability to walk, eat/dress himself and had to be supported in all his daily chores by his family members. Detailed neurological examination and extensive investigations were normal on repeated admission was of no help, often refused psychiatry admission. Psychiatry examination revealed clear inconsistencies in the history, fluctuating course, socially desirable responses on Thematic Apperception Test (TAT), counterproductive Pentothal abreaction, angry and active denial to accept psychiatric diagnosis. Subsequent to dynamic-oriented supportive psychotherapy sessions, active discussion about occupational issues and rehabilitation, family education he started to participate in physiotherapy session where he was made to exercise his limbs. He was discharged after two months of stay in ward in improved state.

Discussion: The treating psychiatrist must have a high index of suspicion for FD when confronted with such situations. Nonetheless, it remains a challenge.

Keywords: Factitious disorder, psychiatry

Cross-sectional study of Depressive symptoms in students during pre-exam period.

Prateek Yadav

Asst prof, Indian Armed forces, New Delhi, [email protected]

Depressive disorders in children are often associated with poor psychosocial and academic functioning, substance abuse and suicide. Infact Depression is the most common psychiatric disorder associated with suicidal behavior in children and adolescents. Pre-exam period is a stressful time for school going children, adolescent and the propensity of depressive symptoms increases.

Aim: To assess the presence of depressive symptoms in students (class VIII to XI) in pre-exam period, i.e. about 3 weeks prior to the annual exam and to identify variables which are associated with these symptoms.

Method : 700 children from class VIII to XI were taken up after informed consent. Children with known chronic medical or psychiatric condition, were excluded. After exclusion, the study was carried on with 619 children. They were given a structured questionnaire for socio-demographic profile and the Centre for Epidemiologic Studies Depression Scale(CESD) scale. Additionally Screen for Child Anxiety Related Emotional Disorders(SCARED) questionnaire was provided to screen for anxiety symptoms as both are well known to coexist.

Result: 19% of the students showed scores more than the threshold. Presence of problems related to some family member consuming alcohol, experiencing neglect at home, history of physical abuse, students who perceived lack of friends, all were significantly associated with raised scores on this scale. Higher than cut-off scores on CESD was also significantly associated with higher scores on the SCARED scale, showing association with the overall anxiety scores.

Conclusion: The prevalence of Depressive symptoms was found to be more then the known prevalence in this age group, which, could be because of the time period in which this assessment was done, indicating, that the intervention targeted to allay these symptoms must be taken up as these are known to affect the academic performance, interfere with interpersonal relationships and increase the risk of suicide and other psychopathology.

Keywords: Depression, students, pre exam period.

Study of socio-demographic and clinical profile of patients referring to Medical Board

Praveen S R, Guru S Gowda, Channaveerachari Naveen Kumar, Dwarakanath Srinivas, Ravi Yadav, Binu Kumar, Suresh Bada Math

3rd year Junior Resident, National Institute of mental health sciences, Bangalore, Karnataka. [email protected]

Background: Certification by Medical Board has important legal and professional responsibilities when issuing medical certificates.

Aims: To identify the socio-demographic and clinical profile of patients referring to Medical board.

Methodology - We performed a retrospective chart review of patient files from 1 January 2012 to 31 December 2015, who were referred for the certificate for various reasons under Department of Psychiatry/Neurology/Neurosurgery, through the institutional medical board, NIMHANS, Bangalore. Socio-demographic and clinical profiles of the patients were analyzed by descriptive statistics.

Results: One seventy-seven patient were referred to Medical Board for certification in four years period. The mean age of patients was 35.16 years, 99(86%) were male, 96(83%) were married, 34(29%) were referred from Railways, 11 (9%) transport, 12(10%) Magistrate, 57(49%) others. Work reports show 51(44%) work absenteeism, 23(20%) Epilepsy, and 14(12%) undisciplined behavior at the workplace. In total, 23(20%) of them had Epilepsy and 14 (12%) had schizophrenia and other psychotic disorders. After comprehensive evaluation 23(20%) were given fitness, 76(66%) were given unfitness and 16(13%) for other certificates.

Conclusion – This study shows that work-related issues like work absenteeism and epilepsy are the common reasons for the referral for fitness certification. Among functional disorders Schizophrenia and among organic disorders Epilepsy is a common diagnosis. Ethical and legal issues should be kept in mind during such assessments as it involves patient and society rights. Regarding fitness certification only one third were fit, so there is a need for developing a schedule to do a comprehensive assessment of the patient who referred for Medical board certification.

Keywords: Patients refer to Medical Board, Sociodemographic and clinical profile

Divalproex sodium induced Pedal Edema in a female patient: A case report

Dilpreet Kaur Jattana, Alok N Ghanate

PG student, MRMC GULBARGA, Gulbarga, Karnataka. [email protected]

Introduction- Divalproex Sodium is one of the First Generation Mood stabilizing anti-convulsant with expanded clinical indications. It is associated with side effects like GI Distress, tremors, weight gain, hepatitis, pancreatitis and alopecia etc. B/L pedal edema is a neglected and uncommon side effects associated with Divalproex Sodium which needs to be addressed at the earliest as it may be distressing for the patients.

Methodology-A Case report.

Results-This study is about a 35 year old female k/c/o schizo-obsessive disorder with cluster B personality traits (Borderline/Antisocial traits) started on Divalproex Sodium as an augmenting drug during the course of her illness. Patient developed Grade III pitting B/L pedal edema after starting Divalproex Sodium which didn’t subside on diuretics but significantly subsided on discontinuing Divalproex Sodium. The cause effect relationship was supported by double challenge-Re-emergence of pedal edema on restarting Divalproex Sodium.

Conclusion- Divalproex Sodium induced B/L pedal edema could be seen either due to hepatic injury or due to enhancement of GABAnergic activity by raising GABA levels, and influences body fluid dynamics or peripheral vascular resistance. Regardless of any definite mechanism we have found at least that Divalproex Sodium induced pedal edema is a clinically significant complaint and may develop quickly in days rather than years and seems to be completely reversed by early recognition and discontinuation of Divalproex Sodium.

Keywords: Divalproex sodium, Pedal oedema, GABA levels

A Cross-Sectional Study of Non-Compliance to Medications In Patients Of Schizophrenia

Priyanka S. Jog, Rahul Dongre, Maithili Umate

PG Student, Grant Government Medical College, Mumbai, Maharashtra. [email protected]

Introduction: Schizophrenia is a chronic mental illness affecting around one percent of the population. Psychopharmacological advancement has produced drugs which can substantially reduce the symptoms. It requires long term treatment and adherence to the drugs. Despite of this, a major reason for relapses is found to be non-compliance to the prescribed drugs. Hence, drug compliance is vital for long-term prognosis of the condition thereby contributing in reducing relapses and decreasing the burden of the disease.

Aim: To study the prevalence of drug non-compliance, the causes of the same and patients’ attitude towards the illness.

Materials And Methods: -The study is being conducted in a Tertiary Care Teaching Hospital. After written informed consent from the patients and/or relatives, data will be collected from schizophrenic patients visiting the outpatient/inpatient clinics using the following scales: (I) A semi structured proforma for socio-demographic details

(II) Scale for assessment of illness related variables-

Brief Psychiatric Rating Scale (BPRS)

(III) Scales to assess non-compliance reasons and patient’s attitude towards drugs-

Rating of Medication Influences (ROMI)

Drug Attitude Inventory (DAI-10)

Inclusion criteria: Outpatients and inpatients of schizophrenia as confirmed by using

  1. DSM-V.
  2. Patients of ages 18- 60 years.
  3. Language compatibility – English, Hindi, Marathi.

Exclusion criteria

Patients who were on medications for <6 months.

Significant medical illness.

Patients without a reliable informant.

Results: The study is still ongoing. Out of the 22 samples collected till now, 16 patients (72.72%) were compliant to medications and 6 patients (27.27%) were non-compliant. The end results and reasons for non-compliance will be analyzed after the study is completed.

Conclusion: The main factors related to non-compliance are substance abuse, lack of insight and the severity of illness. These issues should be identified early and addressed to.

Keywords: Schizophrenia, Non-compliance, Lack of insight

Computer Related Health Hazards and their Relationship with Psychosocial Factors among Computer Professionals

Nirmalya Chakraborty, Nishant Goyal, Basudeb Das, D. Ram

Senior Nursing Officer, Central Institute of Psychiatry, [email protected]

Background: Millions of people around the world now use computers as their primary work tool. In the last decade or so, the number of hours people use computers has increased tremendously. With this increase in the use of computers, problems have also increased. Computer related health problems are caused by improper use and lack of knowledge about “Safe computing techniques”. The ever increasing use of computers in various fields has led to rise in musculoskeletal problems related to its operation. Apart from ergonomic design factors, number of psychosocial workplace factors have emerged that may influence the biomechanical load or the reactions to workplace stress. The purpose of the study was to assess the magnitude of problems related to computer use related health hazards.

Methods: A total of 100 professionals were included as study subjects. The Conceptual Framework of the study was based on Rosenstock’s (1974) and Becker and Maiman’s (1975) Health Belief Model. Non-probability purposive sampling technique was used. Structured knowledge questionnaire under the sub headings of physiological, psychological and work-related factors were used to collect data. Content validity and reliability of the tool was established.

Result: No significant correlation was found between computer use related factors and health hazards. Significant association was found between the marital status of the respondents and their anxiety, stress and depression score at chi value of 5.8992*, 4.2087* and 3.896* respectively which was significant at 0.05 level at df-98.

Conclusion: The recommendations are offered that study can be replicated on larger sample as the findings cannot be broadly generalized as it was conducted only in one IT firm and was confined to small numbers of computer professional.

Keywords: Computer use related health hazards, Work related factors of computer related health hazards, Computer professionals

Pramipexole in case of catatonia

Purvi Vats, Jayanath B P, Saurabh Jaiswal, Abhishek Kumar, Varun Mehta, Surendra Paliwal, Pranjal De

Junior Resident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Introduction: Catatonia is a commonly encountered syndrome, affecting 10-20% of various psychiatric populations and carrying significant medical co-morbidities. Here we present a case report of a patient presenting with typical catatonic symptoms, not responding to benzodiazepines and electro-convulsive therapy, but responding to pro-dopaminergic drug.

Case summary: An 18 year old single Hindu male was admitted with complaints of on & off fever for past 12 months, decreased speech productivity for 7 months, bouts of aggressive behaviour for past 4 months and poor oral intake for past month. The examination revealed cogwheel rigidity & tremors with extensor plantar response. The mental status examination revealed catatonic signs with a score of 16 on the catatonia rating scale. The neuroimaging of brain and electroencephalogram did not reveal any abnormality. The patient was given a trial of Lorazepam 8 mg/day & subsequently started on electroconvulsive therapy. He received 9 sessions and additional 8 sessions with Lorazepam and Aripiprazole 15 mg/day but the catatonic symptoms persisted. A neurology consultation was sought and patient was advised Tab. Pramipexole 0.375mg/day in divided doses and Post Encephalitic syndrome was considered as the provisional diagnosis. The patient was discharged and the follow up visit after 3 months reported more than 50% improvement and the dose was optimized to 1.125 mg/day along with the tapering of the antipsychotic.

Discussion: The case demonstrates the masquerading presentation of post encephalitic syndrome as catatonia and subsequent response to a pro-dopaminergic drug.

Keywords: Pramiprexole, Catatonia

Frontal Lobe functioning in Schizophrenia and Bipolar-1 Disorder

Manoj Kumar Pandey, Sumitra Mishra, Radhika Sahal

Sr. Clinical Psychologist, Institute of Mental Health and Hospital Agra, Uttar Pradesh. [email protected]

Background : Patients with schizophrenia have been shown to have frontal lobe function deficits when compared with control subjects. Bipolar disorder is also common and chronic psychiatric disorder which is associated with cognitive impairments such as executive functions. Brain imaging studies comparing patients with bipolar-1 disorder and healthy controls also consistently demonstrate smaller cortical volume in pre-frontal cortex. The degree and pattern of impairment between psychiatric groups have rarely been compared, especially when subjects are psychiatrically stable.

Aim: The present study aimed to investigate whether patients with schizophrenia and bipolar-1 disorder show a distinguishable performance profile in tasks considered sensitive to frontal lobe functioning.

Methods: The sample of the present study consisted of clinically stable patients with chronic schizophrenia (N-30), patient with bipolar mania (N-30, ≥ 5 episodes)and healthy controls(N-30). All the patients were taken from the in-patient and outpatient department of Institute of Mental Health and Hospital Agra using ICD-10 Diagnostic criteria for research. Healthy controls were taken from the general population and they were screened for psychopathology by using GHQ-12. All subjects were assessed with standard neuropsychological tests viz. Wisconsin Card Sorting Test, Stroop Color Word Test, Luria Nebraska Neuropsychologial Battery (Frontal Lobe Scale) and patients were administered PANSS and YMRS for assessing severity of symptoms.

Keywords: Frontal lobe functioning, schizophrenia, BPAD

Prevalence and Co-Morbidity of Nicotine Dependence in Alcohol Dependence Patients Admitted in Tertiary Care Hospital in South India-A Cross Sectional Study

Raghavendra Patil, Meghamala.S.Tavaragi, Mahesh Desai, Arunkumar.C

3rd Year PG,MD Psychiatry,KIMS Hubballi, Karnataka. [email protected]

Introduction: Most individuals with alcohol use disorders are also dependent on nicotine, with con-current smoking ranging from 60-95%.Co-dependent sub-population may have a higher level of nicotine dependence and report difficulty in quitting tobacco use. According to literature 80% of alcoholics smoke regularly and that majority of them die due to smoking related disorder rather than alcohol related disease. Smoking converts moderate drinking to heavy drinking more likely by decreasing the effects of alcohol intoxication and thus worsen the complications due to alcohol.


To assess severity of alcohol dependence

To assess severity of nicotine dependence

To study association between nicotine dependence in alcohol dependence patients

Methods And Methodology: 60 alcohol dependence patients admitted in Psychiatry department of tertiary care hospital of south India from Jan 1st 2017 to June 31st 2017 were taken as sample, after taking informed consent and ethical committee clearance.

Alcohol dependence syndrome diagnosis made according to ICD 10.

Severity of alcohol dependence assessed by using SADQ scale.

Nicotine dependence assessed by Fagerstrom smoking and smokless scales.

Results: Among 60 alcohol dependence patients around 65%(39pts) had nicotine dependence. In ADS (60) pts , 56.7%(34) had severe, 30%(18) had moderate and 13.3%(8) had mild alcohol dependence. Among 65%(39) nicotine dependence patients ,53.8%(21) were smokless,18%(7) smoking and 28.2%(11) had combined nicotine dependence. Among, Smokless(nicotine) 32pts, 62.5%(20) had severe and 37.5%(12) had moderate nicotine dependence. Among smoking(18)pts, 61%(11) had high and 39%(7) had moderate nicotine dependence.

Conclusion: Alcohol and tobacco together are more deleterious to health than use of only a single substance. And results suggest the nicotine and alcohol dependent patients represent a separate population requiring higher attention from the treating psychiatrist. Hence understanding the pattern of tobacco use with co-morbid alcohol use may help in planning appropriate prevention/treatment strategies.

Keywords: Alcohol, Nicotine, Dependence ,Comorbidity

Familial predisposition to Psychotic illness in Huntington’s disease

Rahul Kumar Chakravarty, Ruchita Shah

Junior resident, PGIMER, Chandigarh. [email protected]

Objective: To report a case of 45 year old female with Huntington’s disease with psychotic features.

Case Summary: A 45-year-old woman, married, homemaker presented to psychiatry OPD with fearfulness, suspiciousness and behavioural disturbances for last 5 yrs. History and mental status examination was suggestive of psychotic illness. Neurological examination revealed discrete, involuntary movements affecting her arms and trunk along with postural instability, oro-facial tics and dysarthria. A three-generation-long family history of chorea with anticipation along with schizophrenia-like psychosis in sibling.

Discussion: Psychiatric symptoms accompany in most of the cases reported with the diagnosis of Huntington’s disease. It is a progressive disease which is accompanied by motor, cognitive and psychiatric symptoms. Prevalence of neuropsychiatric symptoms ranges between 33-76%.

Conclusions: Psychiatric symptoms emerge earlier than motor and cognitive symptoms in most cases of familial Huntington’s disease. These families can be a valuable models in understanding of the genetics of non-organic psychosis. Further research is needed in order to clarify the links between genetic loading and the emergence of psychotic symptoms in Huntington’s disease.

Keywords: Huntingtons disease, Familial predisposition

Psychogenic Non-Epileptic Seizures In Turner Syndrome

Rakesh jangde, Abhijeet Singh, Varun Mehta

Junior resident, Central Institute of Psychiatry, Ranchi, jharkhand. [email protected]

Introduction: Turner syndrome afflicts approximately 50 per 1 lakh females. It is characterised by retarded physical growth, gonadal dysgenesis and infertility which is believed to be due to total or partial absence of a single X chromosome in all or part of the cells. It has been associated with comorbidities such as Non-insulin dependent Diabetes Mellitus (NIDDM), hypothyroidism, and psychiatric disorders such as Autism and bipolar disorder. This report discusses the comorbidity of dissociative disorder in a case of turner syndrome which has not been reported before.

Case Presentation: A 27-year-old unmarried Muslim female brought by her brother in law with complains of non-rhythmic repetitive movement of the left-hand lasting for 10-15 minutes occurring on mostly night since the 3rd day of Eid celebrations (July’17). The attacks were followed by lethargy & amnesia for events without any loss of consciousness or urinary/faecal incontinence. For the past 1½ months the patient also had repeated bouts of cough with breathing difficulty occurring almost every day, lasting for 5-10 minutes. The patient also reported to feel sad and reduced sleep since the onset of attack. At the time of presentation, the patient was on thyroxine supplements which was continued. On physical examination, the patient was noted to have a BMI of 24.80 kg/m2 and poorly developed secondary sexual characteristics suggestive of Tanner’s Stage II SMR. The examination of the respiratory system did not reveal any abnormalities and all the laboratory evaluations were non-significant. The ultrasound of the abdomen & pelvis revealed a small uterus with bilateral ovaries raising the possibility of Turner’s syndrome. A gynaecology referral was made and karyotyping with hormonal profile was advised. The patient was started on Tab. Escitalopram 10 mg/day.

Keywords: Turners syndrome, Non epileptic seizures

Case Report - Wilson’s disease presenting as psychiatric disorder

Ramya Rachel Jetty, Suresh Kumar G, Himakar P

Andhra Medical College, Visakhapatnam, Andhrapradesh. [email protected]

Wilson disease is an autosomal recessive metabolic disorder involving copper metabolism and is associated with abnormal liver functions. It is a genetic disorder with hepatic, neurological and psychiatric manifestations. The most common psychiatric manifestations in patients with Wilson’s disease include sudden and changeable mood swings, anger outbursts, personality changes, depression, anxiety and cognitive impairment. when patient initially presents with psychiatric manifestations , it can obscure the primary diagnosis and therefore the diagnosis of Wilson’s disease should be kept in mind. here we present the case of 22yr old male initially presented with behavioural abnormalities and later was diagnosed to be Wilson’s disease.

Introduction: Dr.Wilson published description of 12 patients who presented with extrapyramidal motor disease and an autopsy demonstrating softening of lenticular nucleus and cirrhosis. In the initial description of 12 cases of the disease ,Dr Wilson described presence of schizophrenia-like psychosis in two of his cases. Psychiatric symptoms ranging from major depression, mania, antisocial behaviour to psychoses were observed in cases with Wilson’s disease. It is later found to be a genetic disorder transmitted through autosomal recessive mode and involving copper metabolism characterised by excessive deposition of copper in liver, brain and other tissue. Genetic defect was localised to short arm of chromosome 13 affecting ATPase(ATP7B)1 gene in liver presenting with hepatic manifestations(40%) ,neurologic manifestations(40%) ,psychiatric manifestations occur in one fifth2. Neuropsychiatric and behavioural disturbances are commonly reported in patients with Wilson’s disease with lifetime prevalence estimated to be in the range of 20-100%.

We present a case report in which the patient initially presented with psychotic features, who on investigations found to have Wilson’s disease.

Case Report: A 22year old male born out of non-consanguineous marriage from rural background was brought to psychiatry out patient department of Government Hospital for Mental Care , Visakhapatnam with complaints of behavioural abnormalities since one week with exacerbation of symptoms since 3 days. The behavioural abnormalities are in the form of decreased sleep , decreased appetite , increased irritability ,talking excessively , over socialisation , talking high of self , increased religiosity , increased patriotism, abusive and aggressive behaviour. He was reportedly treated for aggression with inj.Haloperidol the day before he came to us.

Birth and development were normal with no significant past history. In family history his elder brother was found dead in the fields at the age of 10 years and was asssumed to be dead due to some snake bite. His younger sister died due to jaundice and ascites at the age of 13years. Prior to illness , he is a cheerful boy , with average performance at school and regular to school. General physical examination revealed normal vital parameters with no icterus, a ring around his cornea, tatoo of Indian map with cross inside it on his left forearm. Higher mental functions revealed impaired attention span. He is well oriented to time , place , person and his recent/immediate/remote memory were found to be intact with impaired abstract abilities. his Neurological examination revealed no abnormalities in cranial nerves, sensory system and no cerebellar signs with motor system revealing tremors on out stretched hand.

At the time of admission mental status examination revealed an averagely built male, wearing soiled white uniform with tie and greeted the examiner as teacher and saluted the examiner. He was conscious ,uncooperative ,not maintaining eye contact with increased psychomotor activity with decreased reaction time , talking excessively in loud voice. Delusion of grandiosity and second person type auditory hallucination are present. He was found to be irritable throughout the interview. routine blood investigations like CBC, LFT, S.Creatine , urine routine were done and found to be normal.

He was provisionally diagnosed as a case of bipolar affective disorder -mania and was initially started on oral olanzapine and injectable antipsychotics. Later the patient developed tremors and slurring of speech for which trihexyphenidyl was added and for the improvement of affective symptoms lithium carbonate was added. In view of significant family history and acute onset of behavioural abnormalities further work up on case was done with differential diagnosis of Wilson’s disease.

On developmental screening test , his IQ was 84 with dull normal intellectual functioning. On slit lamp examination bilateral KF rings are present. His ultrasound abdomen showed chronic hepatic parenchymatous disease. His MRI brain showed subcortical white matter hyperintensity in left frontal lobe ,calcified high right parietal lobe granuloma and bilateral lentiform nucleus T2 and FLAIR hyperintensity suggestive of Wilson’s disease. Urinary analysis revealed elevated copper levels of 108µg/24hrs and serum ceruloplasmin levels of. 46g/l. he was maintained on olanzapine 15 mg,6mg of trihexyphenidyl,900mg of lithium carbonate and 400mg zinc sulphate. He improved symptomatically with the treatment , was discharged with the same treatment.

Discussion: Wilson’s is a autosomal recessive disorder characterised by inability of liver to transport and store normally absorbed dietary copper resulting in abnormal deposition of copper in basal ganglia , eyes, liver and other tissues. This is an unusual presentation of Wilson’s disease, here the patient had a history of abnormal behaviour for 7 days and with significant family history and a differential diagnosis of Wilson’s disease was considered and on further evaluation he was diagnosed with Wilson’s disease. The patient was controlled on 15 mg of olanzapine and 900mg lithium carbonate. Some authorities believe that neurological and behavioural symptoms can be relieved with use of pencillamaine (mosai et al 1985).some reports stated antipsychotic use as inadvisable. There are reports of effectiveness of clozapine in management of wilsons disease (krim et al 2001). There is further need to study the efficacy if various antipsychotics and chelating agents in the management of wilsons disease.

Keywords: Wilsons disease, Psychiatric disorder

Evaluating motivational enhancement therapy versus life skill training along with pharmacotherapy in management of opioid use disorder

Ravi jaiswal, Sanjay Gupta,

Junior resident, IMS BHU, Varanasi, Uttarpradesh. [email protected]

Background: A national survey on the extent, trends and patterns of drug use in India shows that there are about 2 million current opioid users in India, of which about 500,000 are opioid dependent.

Opioid use disorder is problematic pattern of opioid use leading clinically significant impairment,includes a strong desire to take opioid, difficulties in controlling use, persistent use despite harmful consequences, a higher priority given to opioid than to other activities and obligations, increased tolerance, and a physical withdrawal state.

So its very necessary to design a better management option for treatment of opioid use disorder, so we included both pharmacothery and psychotherapy.

Material and Methods: The study participants recruited from Indoor and outdoor setups of Department of Psychiatry, IMS BHU. The total number of study participants was 60 with equal number of subjects being randomly assigned to Motivational Enhancement therapy group with Pharmacotherapy (Naltrexone 50 mg OD ) and other with Life Skill Enhancement Therapy along with Pharmacotherapy (Naltrexone 50 mg OD).


Semi-structured socio-demographic proforma




Results: Maximum patients in 31-45 year age group i.e. 45%, Mean age 38.3 year.

35% intermediate pass ,married 80%, equal patients both joint and nuclear families,93.3% belong to hindu , unskilled group i.e. 48%,lower socioeconomic status i.e. 61.7%, rural patient i.e. 60%, definite change from precontemplation and contemplation, Mean percentage days abstinent 78.241±29.41,relapse rate 45.6%,significant difference in QOL domains at baseline,4 week,12 week,In readiness to change scale there is significant improvement.

Conclusion: Life skill training is also found as effective as MET in treatment of opioid use disorder

Keywords: Motivational enhancement therapy, Pharmacotherapy, Opioid disorder

A Study of correlation of Testosterone levels in bipolar disorder patients with suicide attempt

Ravi Kumar Gupta, Mahendra Kumar Sharma, Sanjay Kumar Jain

PG student, SMS Medical College Jaipur, Rajasthan. [email protected]

Objective: - Study to examine whether there is a relation between testosterone levels and clinical parameters in bipolar suicide attempters.

Methods: - Patients with ICD-10 diagnosis of bipolar disorder in a depressive or mixed episode with at least one past suicide attempt were included. Demographic and clinical parameters, including lifetime suicidal behavior, were assesed.

Results: - The number of major depressive episodes, the maximum lethality of suicide attempts, and the testosterone levels were higher in male compared to female. Current suicidal ideation scores were higher in female compared to male. Controlling for sex, we found that testosterone levels positively correlated with the number of manic episodes and the number of suicide attempts.

Conclusion: - This study suggests that testosterone levels may be related to the course of bipolar disorder and suicidal behavior. Future research should focus on the role of testosterone in the pathophysiology of depression not only suicidal behavior taking into account that depressive disorders are associated with suicidal behavior. Further studies of the role of testosterone in the neurobiology of mood disorders and suicidal behavior are merited.

Keywords: BPAD, Testosterone levels, Suicide attempt

Escitalopram Induced Acneiform Eruptions: A Case Report

Ravindra Munoli, Mahima Acharya, Samir Kumar Praharaj

Assistant Professor, Department of Psychiatry, Kasturba Medical College, Manipal, Manipal University, Karnataka. [email protected]

Selective serotonin reuptake inhibitors (SSRIs) are commonly used for treatment clinical depression and anxiety disorders. SSRIs have a better adverse reaction profile and a higher safety margin in overdoses when compared with other antidepressants. Adverse effects are most often associated with alimentary tract symptoms such as nausea, vomiting, loss of appetite, or diarrhea. Escitalopram is commonly used SSRI. It’s rarely known to cause adverse skin reactions. Present case reports about a 20 years old male, who was diagnosed with early onset dysthymia, had developed acneiform eruptions after starting escitalopram. The lesions subsided after stopping escitalopram. Present case tries to address the rare adverse effect of escitalopram and tries to explore possible mechanism of such lesions.

Clozapine induced eosinophilia in schizoaffective disorder

Ravi Rohan Kisku, Jayanath B P, Saurabh Jaiswal, Shraddha Chaudhary, Abhishek Prasad, Pranjal De, Surendra Paliwal, Varun S Mehta

Junior Resident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Introduction: In clozapine administration, much of the focus is on the potential occurrence of agranulocytosis. However, eosinophilia is also an important albeit rarer complication which may potentially stop therapy. There are reports of discontinuation of clozapine in individuals developing eosinophilia due to the risk of eosinophil infiltration causing organ damage – most notably myocarditis. We report a similar case of eosinophilia due to clozapine in a patient of schizoaffective disorder.

Case Presentation: A 15 year old, single Hindu male, student from rural Jharkhand presented in 2010 with decreased social interaction, smiling and muttering to self, wishes to take own life, self-harm behavior and occasional demanding behavior for 1 year and was diagnosed as a case of schizoaffective disorder – manic type. The patient received an initial failed trial of Tab. Lithium Carbonate & Tab. Chlorpromazine following which Tab. Clozapine was considered and hiked up to 250 mg/day in subsequent visits. Tab. Sodium Valproate 500 mg/day was additionally added for the affective symptoms. The subsequent monitoring of the counts revealed an increasing eosinophil count leading to eventual discontinuation in January 2017 when the eosinophil count was found to be > 11000 /mm3, being 52.6% of a total count of 21600/mm3. Subsequently Tab. Haloperidol was started but the response was poor and it was decided to reintroduce Tab. Clozapine in view of failed trials of Tab. Amisulpride 900 mg/day & Tab. Risperidone 8 mg/day in addition to Tab. Haloperidol. The trial was restarted under regular ECG monitoring and physical examination.

Discussion: The case reiterates the challenges faced in the use of clozapine in clinical practice

Keywords: clozapine, schizoaffective disorder, eosinophilia

A Rare Case of Very Early Onset Schizophrenia- Review of Literature and case report

Rashid Gouri, Shivanand Kattimani, Preeti Jacob

MD Trainee, NIMHANS, Bengaluru, Karnataka. [email protected]

Background: Schizophrenia is a heterogeneous and severe mental disorder. The outcome of schizophrenia has been linked with the age of onset and the presence of family history of the disease. It is highly heritable psychotic disorder and high familial loading is associated with early onset of the disease. Cases of Very early onset schizophrenia (VEOS; defined as an on set of psychos is before 13 years of age) are rare and is clinically and neurobiologically continuous with adult onset disorder. VEOS cases rarely reported within 6 years of age. Confident diagnosis of VEOS is challenging and imperative also as it has potential to affect the cognitive, emotional and social development of the child.

Patient and Methods: Here we present case report of 6.5 year old girl whose symptoms of psychosis developed two years back.We describe the varied clinical features, differential diagnosis, diagnostic and treatment processes and 6 month follow up of this particular case.Also emphasis is on Non pharmacological intervention which is underrated in routine clinical practice.

Observations and conclusions: VEOS is a severe variant of adult schizophrenia associated with greater premorbid impairment, higher familial risk and severe clinical course and limited prognosis. Ability to recognise psychopathological symptoms of schizophrenia to start psychopharmacological and psychosocial interventions at earliest is becoming a central issue in clinical practice.

This report aims to highlight that schizophreniacan occur at an early age and adds to the limited literature on VEOS in the Indian population.

Keywords: Childhood onset schizophrenia,Psychosis, psychosocial interventions, prognosis

Schizophasia Versus Wernicke’s Aphasia: A Case Report

Shameena Abdullah, V.Sathesh

Junior Resident, Kottayam Medical College, Kerala. [email protected]

Wernicke’s aphasia is a condition where primary deficit is in the comprehension of spoken speech. The condition is usually caused by a lesion in the ior division of the MCA involving the Wernicke’s area.. The speech of some schizophrenic patients appears, at least superficially, similar to Wernicke’s aphasia.

A 61 year old male with schizophrenia , on treatment presented in our medicine department with history of fall and irrelevant talk. Consultation was sent to psychiatry department for adjusting the dose of psychotropics. History revealed continuous behavioural illness for the last 35years which initially presented with muttering smiling to self and decreased interaction.. He was not married and lived with his brother and was able to take care of himself till the day of fall. He had the habit of smoking from the age of 13 years. Neurological examination revealed no sensory or motor deficits. On MSE he was ready for the interview but was restless and trying to go in between the interview, poorly kempt and groomed.

There was impaired comprehension in his speech. Perseveration and neologism were present. There was also impairment in naming, repetition and reading.. There was no loosening of association or other thought disturbances. Perceptual abnormalities were not elicited. The speech pattern was not suggestive of formal thought disorders of schizophrenia or any other primary psychotic disorders but was more in favour of sensory aphasia. He was suggested Neurological opinion. Neurologist suggested MR imaging with MRA, which revealed large sub-acute left middle cerebral artery territory infarct.

Wernicke’s aphasia is a close mimicker of formal thought disorder. Only a meticulous physical examination and mental status examination can differentiate between the two. In aphasia, where patients struggle to communicate normal thoughts that others would articulate in normal sentences, in schizophrenia the meaning itself is distorted.

Keywords: Wernicke’s aphasia , Formal thought disorder, Schizophrenia

Trunkal Tardive Dyskinesia due to Lurasidone- A Case Report

Rakesh Mohanty, Basudeb Das

Senior Resident, Central Institute of Psychiatry, Ranchi, Jharkhand. [email protected]

Background: According to diagnostic and statistical manual of mental disorder fifth edition Tardive dyskinesia(TD) is involuntary athetoid or choreiform movements (lasting at least a few weeks) generally of the tongue, lower face and jaw and extremities (but sometimes involving the pharyngeal, diaphragmatic or trunk muscles) developing in association with the use of a neuroleptic medication for at least a few months. Atypical antipsychotics tend to be associated with less propensity to cause tardive dyskinesia than typical antipsychotics. Lurasidone as a novel newer antipsychotic has been reported to have minimal propensity to cause TD. We are reporting a case of Bipolar depression patient who was prescribed Lurasidone, developed Tardive dyskinesia in Lips, extremities and trunk which is rare and first of its kind being reported.

Case: This is a case report of 49 year old married hindu male businessman by occupation educated till graduation who developed tardive dyskinesia in Lips, extremities and trunk following treatment with Lurasidone 80mg for four months. Patient was assessed with abnormal involuntary movement disorder scale(AIMS) and TD was detected. Lurasidone was stopped and tetrabenazine 25mg was started. After one month in follow up, patient reported complete recovery from TD.

Conclusion: This report should alert doctors to the risk that patients may develop serious side effects after long-term use of Lurasidone.

Key Words- Lurasidone; Tardive Dyskinesia; Truncal Dyskinesia.

The impact of family-work conflicts on parenting in families of children with conduct disorder

Bandanadam, Sagar Rani

M.Phil student in Psychiatric Social Work, Dept. of Psychiatric Social Work, Central Institute of Psychiatry, Ranchi. India. [email protected]

“Conduct disorder” refers to a group of behavioral and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. The prevalence of conduct disorder is estimated at between 1.5% and 3.4% of the general child and adolescent population (Bartol & Bartol, 1989; Feehan et al. 1993). The onset of conduct disorder tends to peak in late childhood and early adolescence (Loeber and others, 1993b). About 40% of children and adolescents with CD eventually develop antisocial personality disorder. Overall, conduct disorder appears more often in boys than girls, with a rate of 6% to 10% for males and 2% to 9% for females (APA, 1994). Family-work conflict has been associated with a number of dysfunctional outcomes (Bacharach et al. 1990), decreased family and occupational well-being (Kinnunen & Mauno, 1998), and job and life dissatisfaction (Netermeyer et al. 1996). Insecure attachment between child and both parents seemed to increase the risk of conduct disorder substantially. Parenting style seems to be more important when it comes to predicting aggressive and oppositional behavior patterns

Aim: To assess the impact of family-work conflicts and work-family conflicts on parenting and parent-child relationship in families of children with conduct disorders and normal children.

Methods and Materials: The study will be conducted in the In/Out patients of Erna Hoch Centre for Child and Adolescent Psychiatry, Central Institute of Psychiatry, Ranchi and from the locality of Kanke, which consist of 40 respondents which consist of 20 children diagnosed with conduct disorder and 20 normal. Data relevant to study will be collected accordingly and statistical analysis will be done by applying specific statistical measures.

Keywords: conduct disorder, family work conflict. Parenting and parent-child relationship

Pregabalin dependence and secondary depression in somatoform pain disorder: A Case Report

Romil Saini, Udit Kumar Panda, Siddharth Sarkar

Junior Resident, All India Institute of Medical Sciences, New Delhi, Yamuna Nagar, Haryana. [email protected]

Introduction: Pregabalin is a newer GABA-analogue approved for neuropathic pain, generalized anxiety disorder, fibromyalgia and partial seizures. Over the last decade there has been increasing reports about pregabalin use disorders among individuals with or without prior history of substance use disorders. We present a case of pregabalin dependence in an individual having persistent somatoform pain disorder and depression.

Case Description: A 42 yrs. old male having long standing history of pain over left half of whole body causing significant distress for which repeated investigations revealed no organic cause sought treatment at our centre. Over the years, various medications had been prescribed by various physicians, neurologists and psychiatrists. Patient continued to remain preoccupied with somatic symptoms and developed depressive symptoms with one attempt to self-harm. After being prescribed with pregabalin 75 mg three times a day around 7 months back, patient after experiencing mild relief in acute exacerbations of pain gradually escalated the dose to prolong the therapeutic and psychoactive effects like euphoria and increased energy. Over next few months, he developed pregabalin use in dependent pattern characterized by tolerance, loss of control, withdrawal symptoms in form of palpitations, tremors, irritability and strong desire to use pregabalin, and was taking up to 20 capsules/day (1500mg). At time of presentation, HAM-D score was 19/54. Patient was planned for out-patient detoxification and pregabalin was tapered out by 75mg every alternate day. Motivational enhancement therapy was started. Antidepressant (Agomelatine) and benzodiazepines were prescribed to treat comorbid psychiatric conditions.

Discussion: The case report has been discussed in view of growing literature on abuse potential of pregabalin and to highlight assessment of co-morbid psychiatric conditions while prescribing pregabalin and its analogues.

Key Words: Pregabalin Dependence, Somatoform disorder, Depression

Attitudes toward Psychiatry - A Comparative Study among Medical Interns and Undergraduate Students of Tertiary Care Hospital in Kerala

Sajad.M, Yesudas KF

PG Student, Academy of Medical Sciences, Pariyaram, Kannur, Kerala, [email protected]

Background: The primary aim of the study is to compare the attitude toward psychiatry among final year medical students and interns of tertiary care hospital. Secondary aim is to assess preferred future career choice after graduation.

Materials and methods: A cross sectional study, conducted in a tertiary care hospital of Kerala. Participants consisted of two groups, one group was final year medical students who were yet to start the clinical internship and other group was interns, who had completed their compulsory 2 weeks clinical internship in psychiatry. Participants were individually administered a questionnaire which included socio-demographic data, preference for career choice and Attitude Toward Psychiatry (Balon et al.’s ATP-29) questionnaire. Data analysis (Standard descriptive statistics, Chi square test) was done using SPSS version 20.

Results: A total of 95 participants, out of which final year medical students and interns were 42 and 53, respectively. There was a better positive attitude toward psychiatry by interns in comparison to final year medical students in most of the areas. Overall, in both groups, positive attitude toward psychiatry was reflected. Regarding the choice of career, 20% chose Internal medicine followed by 18.9% in Obstetrics and Gynecology. Only 1.1% preferred psychiatry and 17.9% of them were yet to decide regarding their career choice.

Conclusions: Findings suggest that both groups do not have a negative attitude toward psychiatry and they have a good perception of psychiatry, although there are still some misconceptions about this specialty. These student’s attitudes could favor an appropriate management of patients suffering from mental illness. Even though the majority of students appeared to have favorable attitudes, but they didn’t show a significant change in their intention to pursue psychiatry as a prospective career.

Keywords: attitude, final year, interns, career choice

Trichotillomania: A Case study

Samapti Saha Debsikdar, Nitin P. Patil, Sudhir J Gaikwad

PG Student - MD Psychiatry, Bharati Vidyapeeth Deemed University,Medical College and Hospital, Sangli, Maharashtra. [email protected]

Introduction- Trichotillomania (also known as trichotillosis or hair pulling disorder) is an impulse control disorder, characterized by the compulsive urge to pull out one’s hair, which leads to hair loss balding and distress, and often social or functional impairment. Trichotillomania is often not a focused act, but rather hair pulling occurs in a “trance-like” state.

Case Description: The patient is a 22year-old female, a student of engineering, with an urban background. She presented with a 4-year history of pulling the hair from her scalp. She was unable to resist the urge to pull out hair. Hair-pulling was restricted to times when she was alone and engaged in activity. She was teased by her peers as there were hairless patches on the scalp. Her mother reported that her food intake had decreased and she had become withdrawn. She was not doing the household chores and her academic performance was deteriorating with time.

Result and Conclusion: Treatment began after taking a detailed history and enquiring about possible comorbid conditions.

Considering that the patient had multiple treatments in the past, including tricyclic antidepressants and SSRI’S, with minimal relief, hospitalization was advised.

She was started on Fluvoxamine and Olanzapine. Fluvoxamine was titrated to the dose of 100 mg BD and Olanzapine at 2.5 mg HS. She was also given 4 modified ECT’s on an alternate day basis to facilitate treatment response.

Supportive psychotherapy, directive training and autogenic training sessions were given concurrently.

Behaviour therapies like self-monitoring, relaxation training and awareness training were taught.

Overall, after 15 days of hospitalization patient reported marked improvement in her symptoms. Both patient and parents are happy with the outcome, 3 months into treatment.

Keywords: Trichotillomania management

Body image and dieting concerns in adolescents: a study from South India

Samir Kumar Praharaj, Praveen A. Jain, Avinash Kamath, PSVN Sharma

Associate Professor, Kasturba Medical College, Manipal, Karnataka. [email protected]

Introduction: Body weight and image concerns are common in adolescents. Adolescents with such concerns suffer from health effects of inappropriate dieting and weight loss behaviors. The objective was to study the dieting and body image concerns among adolescents.

Methods: Sample consisted of 2016 sixth to ninth graders from 11 schools of Udupi district of South India. The survey questionnaire included self-reported height and weight and 11-item screening scale for attitude and behavior involving dieting and body image.

Results: Significantly higher proportion of girls wanted to be thinner (58.1% vs 52.4, RR 1.11, 95%CI 1.02-1.20) and afraid of becoming fat (49.4% vs 42.6, RR 1.16, 95%CI 1.05-1.27), whereas, boys exercise more to avoid weight gain (36.2% vs 45.4%, RR 0.79, 95%CI 0.72-0.89), were dissatisfied with body shape (30.3% vs 35.5%, RR 0.85, 95%CI 0.75-0.96) and reported binge eating (16.4% vs 20.9%, RR 0.78, 95%CI 0.65-0.94). Body image concerns were higher among overweight adolescents, both in boys and girls.

Conclusions: Body image and dieting concerns are common among Indian adolescents. Girls wanted to be thinner and afraid of getting fat, whereas, boys report more binge eating, are more dissatisfied with body shape and exercise more to lose weight.

Keywords: Body image concerns, Dietary concerns

A Rare Case Report Of Fahr’s Syndrome

Sandeep Nigam

Junior Resident 1st Year, R D Gardi Medical College, Ujjain, Madhya Pradesh. [email protected]

Introduction: Fahr’s Syndrome is a rare genetically inherited neurological disorder with abnormal calcium deposits in the brain with a prevalence of <1 in 1 lakh individuals. It usually presents in third or fourth decade of life. We report a case of 35years old male who presented in Psychiatry OPD with the chief complaints of:

Difficulty in swallowing

Difficulty in speech

Abnormal hand movements

Reduced sleep

Tingling and numbness in both limbs


On further evaluation and examination it was found that the patient was a case of Mild Intellectual Disability. He had Hypotension and Bradycardia. He was advised MRI Brain which showed bilateral extensive symmetrical calcification in basal ganglia, thalami, periventricular white matter and cerebellar hemispheres which is indicative of Fahr’s Syndrome.

Rehabilitation of Homeless Mentally Ill Women and Reunion In The Family of Origin After Two Decades - A Success Story

Sangeeta Gotewal, Praveen B. Yannawar, Jahanara M. Gajendragad

Senior Mental Health Professional, Institute of Human Behaviour And Allied Sciences, Delhi, [email protected]

Rehabilitation of persons with severe mental illness has not been an easy task for family ever. Family members have to constantly supervise the patient’s medication recovery process and struggle to get them back to normal functioning. There are numerous studies suggesting difficulties associated with the long term treatment and rehabilitation of person with severe mental illness. The combination of mental illness and homelessness is a global phenomenon that is quite cumbersome to deal with. During the psychotic episodes, patients wander away from home, sometimes for long distance and come to the streets, while some of the patients land up in the hospital for treatment through reception orders. The current case study is focused on describing the process of rehabilitation and difficulties encountered in the rehabilitation of a particular person suffering from mental illness. The patient landed in Delhi during her symptomatic state, was belonged to Unnao Distt. of Uttar Pradesh. The patient had left her home twenty years ago during her symptomatic state and had settled in different states and cultures. An attempt was made to understand the complexities of the adjustment difficulties faced by the person who was suffering from mental illness at that time, it was also learnt that patient had got married and was reasonably well. But with repeated relapses a revolving door phenomenon occurred where she continued to land in psychiatric Institute from where the actual story of her rehabilitation began. The patient was first, not only rehabilitated with her husband, but thereafter through sustained efforts, patient’s parents were also contacted back in Maharashtra, that too after a two decades’ gap and was successfully reunited with her family of origin.

Key Words: Rehabilitation, Reception order, Reunion.

Prevalence and Clinical Presentation of Catastrophic Reaction among Dementia Patients at Institute of Mental Health, Chennai

Sanjay Bose, Venkatesh Mathan Kumar.V, Kanmani.V.K

Post graduate, institute of mental health, chennai, tamilnadu. [email protected]

Background: Catastrophic reactions was defined by GOLDSTEIN as short lasting emotional outburst characterized by anxiety, tears, aggressive behaviour , swearing, displacement, refusal, renouncement and compensatory boasting. Empirical studies on the prevalence and correlates of this phenomenon is limited. For the present study we assessed a consecutive series of dementia patients using catastrophic reaction scale (CRS), semi structured psychiatric evaluation and comprehensive neuropsychological assessment.

Materials and Methods: A consecutive series of 75 patients attending the dementia clinic of our institute who met the ICD criteria were included in our study. Appropriate psychiatric examination and neuropsychological assessment was done. Symptomatic presentation of the patients has been assessed using appropriate rating scales and severity has been noted.


Results: Since this is ongoing study, results need to be evaluated. probable results affirmed with current status of data evaluation has been possibly showing high level of anxiety symptoms, depression symptoms, and aggressiveness among the presented individuals of dementia with catastrophic reactions on comparing with dementia patients with no catastrophic reactions.

Conclusion: From this study catastrophic reaction among 75 dementia patients has been evaluated , nearly 33% of patients assessed were found to be have catastrophic reactions and the symptomatic presentation is highly associated with predominant anxiety and depressive symptoms.

Keywords- Catastrophic Reaction, Dementia, Symptomatic Presentation

Pediatric Wilson’s disease presenting as mania:a case report

Saswati Sucharita Pati

P.G Trainee, S.C.B Medical College,Cuttack, Bhubaneswar, Odisha. [email protected]

Introduction: Wilson’s disease is a rare autosomal-recessive disorder with mutation in the ATP7B gene, chromosome 13.Deficient biliary copper excretion leads to excessive copper deposits in the liver, basal ganglia, cornea and kidneys. It may present as hepatic dysfunction, dementia and neuropsychiatric disorders. Hepatic presentations are usually the earliest manifestation in the pediatric age group and neuropsychiatric symptoms more prominent in later years. The manifestations of Wilson’s disease are multiple and the pattern of presentation may vary in different ages of presentation making the diagnosis complicated.

Objective : To follow and review a case of pediatric Wilson’s disease presenting with predominant neuro-psychiatric symptoms.

Results: A 13 year old girl visiting the psychiatry OPD was extremely jovial,talking excessively, distractible, irritable, with inflated self esteem and suspiciousness; symptoms evolving over about 6 months. There had been mild but persistently progressive tremors of the upper limbs noticeable since last 6 months and one episode of generalized tonic clonic seizure 3 days before the visit. The patient was admitted with a provisional diagnosis of mania with psychotic symptoms and treated with lithium and olanzapine.The case was reviewed with the neurology and ophthalmology departments and relevant investigations carried out. The findings of low serum copper level, very high 24 hrs urine copper and MRI showing T2wi and FLAIR sequence bilateral hyperintense signal alterations involving basal ganglia, thalamic and substantia nigra regions helped confirm a diagnosis of Wilson’s disease. Treatment with copper chelants was added. The patient was discharged better and followed up and maintained with olanzapine.

Conclusions: Organic illnesses may masquerade as psychiatric disorders; hence possible associated causes need to be ruled out before confirming a diagnosis when associated with other neurological manifestations. Besides,neurological manifestations,though rare can be the initial presentation in pediatric Wilson’s disease.

Keywords: Wilson’s disease,neuropsychiatric manifestations,mania

Gender Based Assessment Of Burden Of Care And Depression In The Spouses Of Patients Of Schizophrenia

Shachi Singh, Deepti J Puranik, Shubhangi R Parkar

Post graduate resident, Seth GSMC and KEM Hospital, Parel, Mumbai, Maharashtra. [email protected]

Introduction: Spouse is an integral part of the care system for people with Schizophrenia. The demands of being involved in the care of a mentally ill person have an impact on the mental health of spouse. They are at high risk of developing depression.

It is now well studied that there are some basic differences in male and female behavioral responses and coping strategies. We expect a gender based difference in reaction to the spouse’s illness of schizophrenia. Hence this study was undertaken.

Aims and Objective: To compare burden of care and depression in male and female spouses of patients of schizophrenia.

Methodology: A cross-sectional study was conducted at Psychiatry out-patient clinic of a tertiary care hospital. 60 randomly selected spouses (30 wives and 30 husbands) between the ages of 21 to 50 years of the patients diagnosed as Schizophrenia and having the illness for more than 2 years; were recruited. The Burden Assessment Schedule was used to assess the burden experienced by the spouse and Beck’s Depression Inventory was used to measure presence and degree of depression. The comparison between the variables of two groups was done by ‘Chi square test’, and Independent sample ’t’ test.

Results: The female spouses suffered from higher burden of care (50%) as compared to male spouses (16.66%). More of the female spouses (33.33%) suffered from depression that required professional help as compared to male spouses (16.66%).

Conclusion: The female spouses experience higher level of psychological distress than male spouses in the form of burden of care and depression. Preventive strategies to reduce burden of care and psycho-social interventions including assessment of depression in the spouses (with women in focus) and subsequent management of it is essential.

Keywords: Schizophrenia, Depression in spouses

Disulfiram Induced Seizures, in a patient with complete abstinence from alcohol

Vishwanatha Sham Alamela, Mahesh Desai, Arunkumar C, Sameer Belvi M

Senior Resident, Shri B.M.Patil Medical College, Hospital and Research Centre, Vijayapur, Karnataka. [email protected]

Introduction: The D (DSF) is used as aversive agent more than 55years in deaddiction centers(1), DSF (125-500 mg/day) related seizures has been documented in very few earlier reports to cause reversible generalized seizures within 2-4 weeks of administration(3), mechanism is less understood(4).

Significance of Case: To stress on the importance of this side effect in alcohol de-addiction treatment.

Patient description: A Mr. X 38-year-old married male diagnosed as alcohol dependence syndrome since 20 years was admitted in our hospital for de-addiction treatment 1 month back, after detoxification with patient’s consent, started on tablet DSF 250 mg daily at night, tablet lorazepam (LZM) 2 mg at night, tablet multivitamin in the afternoon, following that he had abstained from alcohol for1 month, cross checked with mother. One day patient presented with one episode of generalized tonic-clonic seizures lasted for 5 minutes with post-ictal confusion for 30 minutes, had bite on right side of tongue. No history of head injury, fractures, frothing, fever, antipsychotic drug intake, slowness of movement, and stiff ness of joints or tremors & no past or family history of epilepsy.

Intervention: The patient was admitted, tablet DSF was withholded. Injection LZM 4mg intravenous (I.V) given in tapering doses. Routine laboratory tests were all normal. CT brain was normal, electroencephalography showed abnormal record suggestive of generalized epileptiform activity.

Response to treatment: Patient responded well to I.V LZM, other causes of seizures rules out, with this we concluded the diagnosis of disulfiram-induced seizures.

Discussion & Conclusion: Basal ganglia is one of the major target of DSF metabolites carbon disulfide (CS2) & diethyldithiocarbamate (DDC). Seizures as an adverse effect of DSF is rare but needs to be considered. This would open up areas for further research on mechanisms by which DSF causes seizures and about prevention.

Keywords: Disulfiram induced seizures, Alcohol intolerance

Mirtazapine associated urinary retention in an elderly female – A Case Report

Shilpi Sharma, Lohit. S, Sharanya B Shetty, Sridatta, Abhay Matkar

Postgraduate, SDMCMSH, Karnataka, [email protected]

Mirtazapine, a noradrenergic and specific serotonergic antidepressant (NaSSA) is a preferred molecule for treating depression in elderly patient’s due to minimal side effects. It is preferably used in elderly patients: with parkinsonian symptoms, with risk of developing hyponatremia, in males with risk of urinary retention and with concomitant decreased sleep and appetite.

This is a case report of 65 years old female patient, presenting to hospital with Delirium secondary to hyponatremia and diagnosed to have Dysthymia and Moderate depressive episode with somatic syndrome. Patient during hospitalisation developed urinary retention on Mirtazapine. This is the first case report of Mirtazapine induced urinary retention in a female patient.

Keywords: Elderly; Depression; Mirtazapine; Urinary Retention

Bizarre delusions in Schizophrenia

Shivam Sunil

PG STUDENT, Dr. DY Patil Medical College and Hospital Pune, Maharastra. [email protected]

Bizarre delusions are those that no one in the culture would consider a valid belief whereas non- bizarre delusions are plausible but unlikely to be true. We report two cases of bizarre delusions.

Case 1: This 26-year-old patient presented with a belief that a cat had been injected by a physician into his body 2 years back. The cat was inside him and was running in his body. When the Cat stayed inside his abdomen he had severe backache impairing sleep and day to day activity. He feared that cat would eat the flesh inside him and he needs to change his blood to get rid of the cat.

Case 2: This 24-year-old patient believed that he was possessed by two dogs and an old man which took control of his body for 10 months. In these episode, he starts barking and panting and he claim to believe that the old man is controlling the dogs from inside and whenever he doesn’t obey him he unleashes the dogs for possession. Old man was a distant dead relative who had been put inside by a godman by black magic after his mother’s death. He also had 2nd person auditory hallucination and delusion of control.

In both the cases the delusions were well beyond cultural and rational belief and involve young men in early twenties having average intelligence and developing delusion after a triggering event which was injection in case one and mother’s death in second case. Patients were treated with antipsychotic agents along with electroconvulsive therapy, cognitive behavioral strategies and supportive measures with a satisfactory outcome.

Keywords: Schizophrenia, Bizarre delusions

Eslicarbazepine induced Steven-Johnson syndrome: A rare case report

Shruti Sharma, Kamal Nath, Robin Victor

PG Student, Silchar Medical College and Hospital, Silchar, [email protected]

Stevens Johnson Syndrome (SJS) is a rare severe cutaneous disease which may be fatal at times. One of the important etiology of SJS is drug induced commonly due to drugs like carbamazepine, allopurinol, penicillin, sulfa drugs, ibuprofen, sodium valproate, phenytoin, lamotrigine etc. The objective of this article was to report a rare case of SJS/TEN secondary to Eslicarbazepine administration in a 28 years old male with mild intellectual disability who presented with chief complaints of fever, macular rashes over various body parts, difficulty in speaking and swallowing and painful ulceration of lips and tongue. He had developed obsession of contamination and compulsion of handwashing along with excited behaviour for the last 1 year and was on various psychotropic medications. The peculiarity about this case is that although cutaneous reactions have been reported in the past with carbamazepine group of drugs, the eruptions always occur within 4-5 days of drug administration when the drug has reached its steady state plasma concentration. Here the rashes started after 2 and a half weeks of starting the drug. Moreover even on stopping eslicarbazepine after admission to the hospital and initiation of treatment, new rashes continued to occur. Hence health care professionals should be vigilant regarding the prescription of various drug and prompt recognition and diagnosis of SJS for early initiation of treatment leading to a favorable outcome.

Key Words: eslicarbazepine, rashes, drug reaction.

Decoding post partum depression challenge to motherhood- A study from perinatal psychiatric service out- patient department from rural Maharashtra.

Shubhangi Sambhaji Dere, Ashwin Jhalani, Rakesh Ghildiyal

Lecturer, MGM Medical College & Hospital, Navi Mumbai, Kharghar, Maharashtra. [email protected]

Aim & Objectives: According to WHO, maternal mental health problems are considered major public health challenge, especially in developing countries. Despite its serious consequences and amenity to treatment, post partum depression (PPD) often remains unrecognized. Author aims to describe cases of patients with PPD with emphasis on its phenomenology, culture- specific risk factors and management.

Methodology: Twenty patients referred to perinatal psychiatry services of psychiatry department in one year and diagnosed with PPD were assessed retrospectively. Patient’s symptoms were evaluated using Edinberg’s Post-partum Depression Scale (EPDS). Data was tabulated and analysed using Microsoft excel.

Results: Mean age of the patients was 25 years and majority were primigravida (60%). Half of the patients had significant psychosocial stressors. Most common mode of delivery was operative (60%), a quarter had pregnancy complications and poor obstetrics outcome. Mean duration of presentation was 4 months post partum. Seven patients had disruption in breast feeding and thoughts to harm baby and of suicide were reported by one patient each.

In management, only two patients needed admission and electro- convulsive therapy. Rest of patients showed good improvement with psycho-pharmacological and psycho-therapeutic interventions except three, who dropped out of treatment.

Discussion: PPD is the most common psychiatric disorder observed in the postpartum period (11-26%). Biological changes, psychosocial stressors along with risk factors contributes to etio-pathogenesis of PPD. Untreated PPD can have adverse effect on health of the mother, infant, mother- infant bonding, overall development of infant and increases chances of future relapses.

Conclusion: PPD is disturbing but treatable. Occurrence of symptoms anytime till 1 year post partum makes screening and diagnosis difficult. In resource scarce country like India, innovative perinatal care can be planned using involvement and training of field workers, nurses, relatives, primary health care professionals, gynaecologists and paediatricians for timely screening, referral and management of PPD.

Cerebral lesion and stress presenting as Ganser syndrome

Shwetali Gholap, Ajit Naik, Manjeet Santre

Resident, BJMC & Sasson Hospital, Pune, Maharashtra. [email protected]

Background-Ganser syndrome is a rare condition of uncertain etiology. Literature shows that people develop Ganser syndrome, either consciously or unconsciously, to avoid an unpleasant situation Also it is fairly common to find it associated with cerebral lesion. Here we present a case of Ganser syndrome who had sudden onset of dissociative features and intracerebral hemorrhage of parietal region.

Case:-A 36 yr old male working as a Police constable was arrested 4 months back with alleged history of homicide. He was brought to casualty with sudden onset symptoms of not able to recognize family members, confusion, irrelevant talk,headache,tingling and numbness in right hand. He was admitted to Medicine ward and investigated thoroughly, findings were suggestive of raised BP and CT findings were suggestive of Acute hemorrhage in left parietal lobe. On psychiatric evaluation he was conscious, not cooperative,communicative,restless with poor eye contact and would reply ‘don’t know’ to most questions asked to him.It was found that he would give approximate answers to certain questions asked to him. He said 5+1=4,3+1=3,i have a girl elder than my age studying in 4 th std, winter season when it was summer, colour of red blanket as black.He was also not able to recognize his brother. Mostly reported that he had difficulty in remembering. His CNS examination was found to be normal by the Neurologist. After his treatment in ward,he started recognizing his brother and was found to be more cooperative for interview.On regular follow up he was found to be recognizing family members,oriented to time,place and person and didn’t gave approximate answers.However his complaints of headache, tingling and numbness persisted,but was reduced in intensity.

Concusion:This case will conclude that superimposed organicity in an already stressful state must have precipitated state of Ganser syndrome

Keywords: ganser,dissociation,stroke

An Imagined Dark Skin Leads To An Attempted Suicide- A Rare Case Of Tanning In Body Dysmorphic Disorder

Silambarasan. D

M.D Post Graduate, Govt. Stanley Medical College, Chennai,[email protected]

Introduction: Body dysmorphic disorder (BDD), a distressing or impairing pre occupation with an imagined or slight defect in appearance. The preoccupation must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. They suffer from obsessions about their appearance that can last for hours or up to an entire day. Compulsive or repetitive behaviors like camouflaging, mirror checking, skin picking, seeking surgery, excessive grooming exists to hide or improve their flaws, although these behaviors usually give only temporary relief. Over the past century patients with BDD have been described as being so distressed over their “ugliness’ that they thought about, attempted, or committed suicide.

Case Report: An 18yr old male referred from medical ward with history of attempted suicide. On psychiatric evaluation he was found to be an introvert, preoccupied about his dark skin, often blamed parents for giving birth to him like that. Despite his friends and family convincing him, of his not much darker complexion, he spent most of his time indoors, applied skin creams and made frequent checks in mirror and selfie photos. Recently, when a girl rejected his love proposal (for a different reason) he assumed it to be due to his dark complexion and decided to end his life by cutting his wrist and neck with a razor. His blood investigations and CT Brain were normal and he had no psychotic features. He was started on Fluoxetine 20 mg 1OD and is currently attending Cognitive behavioral therapy sessions.

Keywords- Body dysmorphic disorder, suicide, Cognitive behavioral therapy.

Delirium in infective brain disorder mimicking substance withdrawal: A Case Report

Samant Singh, Lakhan Kataria, Dhawal Patel, Rohit Bhardwaj

Junior Resident, SBKS MI & RC, Vadodara, Gujarat. [email protected]

Introduction: Neurological Signs and symptoms of Alcohol Withdrawal are very much similar to many neurological disorder. Overlapping of certain symptom complexes viz movement disruption, neuropathy, cognitive decline, delirium etc. both in alcohol use disorder and most neurological disorder might lead to incomplete diagnosis and delay in proper intervention.

Case Report: A 40-year-old male patient of Alcohol Dependence brought to casualty with complaints of altered sensorium, episode of seizure, restlessness, sleep disturbance from last 2-3 days. Patient was a known case of Alcohol Dependence from about 15 years and last intake was around 3 days back. After detailed history and routine investigations (CBC, RBS, LFT, RFT, ELECTROLYTES and URINE), appropriate treatment for alcohol withdrawal was started suspecting Delirium Tremens. As the patient did not improve much, MRI brain was done to rule out organicity, which suggested neurocysticercosis. Patient was then started with Tab. Albendazole and patient improved thereafter.

Conclusion: A multidisciplinary approach towards patient’s management ensures accurate diagnosis and timely intervention.

Keywords: Alcohol Dependence, Alcohol Withdrawal, Delirium Tremens, Neurocysticercosis.

A study of sex hormones and cognitive functioning among elderly depressed women

Chitra Singh, Ram Kumar Solanki, Aditi Ranawat, Mahip Sinha

Senior professor, SMS Medical College, Jaipur, Rajasthan. [email protected]

Background: In India cognitive dysfunctions are often perceived as a mere “brain weakness” connected to ageing and is infrequently diagnosed by primary healthcare centers,(Patel V et al, 2001).In addition to the evidence that estrogen can affect aspects of cognitive functioning around the time of menopause, it must also be considered that the aging process itself may account for some cognitive decline independent of any hormonal effect. A study by Gibbes RB et al [1998], found that estrogen increases choline acetyltraneferase activity in the basal forebrain and hippocampus, regions in the brain that are found to be acetylcholine deficient in patients with Alzheimer disease (AD).The apparent relationship between the menopause transition and cognitive difficulties in some women suggests that such cognitive disturbance may be related to the hormonal changes of the menopause (Yaffe K et al, 1998).

Aims and objectives: The proposed study is to ascertain possible correlation of sex hormones and cognitive functioning among elderly depressed women

Methodology: A cross-sectional,prospective study was conducted at the department of psychiatry, SMS Medical College and hospital Jaipur. 100 newly diagnosed elderly women (drug naive) fulfilling the inclusion and exclusion criteria and willing to participate in the study were recruited after informed written consent.The diagnosis of depression was made according to ICD-10. The patients detailed sociodemographic and illness characteristics were recorded.The severity of depression was assessed by Beck’s depressive inventory (BDI) and cognitive functioning with the help of Hindi Mental Status Examination (HMSE). Further all the patients were subdivided in two groups on the bases of HMSE score,either having cognitive dysfunction (dementia) or not. All the patients underwent laboratory work-up. After an overnight fasting 5 ml of venous blood sample was drawn from anticubital vein by using aseptic techniques in plain and EDTA vials.Serum separated and following investigations were performed-1.Serum estrogen(estradiol)2.Progesterone 3.TSH 4.FSH and 5.LH

Results and Conclusions: In our study significant correlation was found between depression and cognitive dysfunctions among elderly depressed women. A negative correlation of TSH and positive correlation of estrogen observed with HMSE score which were indicative of cognitive dysfunction among elderly women. No significant correlation was found with progestrerone. We conclude that estrogen and TSH are an important link between depression and cognitive functioning.

Key words – sex hormones, cognitive functioning, BDI, HMSE,menpause transition.

The Impact of Attention Deficit Hyperkinetic Disorder on Residual Symptoms in Bipolar Disorder

Soumya Jhanda, Sandeep Grover, Savita Malhotra

Senior Resident, PGIMER Chandigarh, [email protected]

Aim: This study aimed to evaluate the impact of comorbid Attention Deficit Hyperkinetic Disorder (ADHD) on residual symptoms among patients with Bipolar disorder (BD). Methods: Patients aged 13-40 years with history of BD with ADHD (N=30) were compared to patients with BD without ADHD (N=69) for presence of residual affective symptoms during the remission phase of illness. Results: As compared to those without ADHD, patients of BD with ADHD had higher level of residual depressive symptoms in the form of total Hamilton Depression Rating Scale (HDRS) score (p£0.001). Those with BD with ADHD had higher severity of depressed mood (p£0.001), guilt (p=0.03), suicidal behavior (p=0.001), early insomnia (p=0.01), impairment in work and activities (p=0.01) and somatic anxiety (0.03) on the HDRS. In terms of manic symptoms, higher severity was noted only for the symptom of irritability (p=0.04) on the Young Mania Rating Scale (YMRS) in the BD with ADHD group. Conclusions: Comorbid ADHD has negative impact on outcome of BD in terms of increased severity of sub-syndromal symptoms that can negatively affect functionality.

Key Words: bipolar disorder, Attention Deficit hyperkinetic disorder, residual symptoms

Prevalence of medical illness in geriatric patients with psychiatric illness

Suranjita Mazumdar, H. R. Phookun

Post graduate trainee, Gauhati Medical College, Guwahati, Assam. [email protected]

Introduction- Ageing is a universal phenomenon. The ageing process is characterised by a gradual decline in the functioning of all the body systems. Ageing has both physical or health related as well as psychological issues. In terms of physical health, an average elderly Indian is faced with compounded problem of communicable diseases, non-communicable diseases. These diseases are also associated with significantly high psychological morbidity and cognitive impairment in elderly.

Aims- To assess the prevalence of medical illness in geriatric patients with psychiatric illness

Methodology- Study setting- Regional Geriatric Centre, Gauhati Medical College and Hospital. Study design- Descriptive study. Sample- 40 patients admitted from August 2016 to July 2017. Psychiatric diagnosis was made using ICD-10 classification of mental and behavioural disorders and final diagnosis are confirmed by the consultant of department of Psychiatry. Medical illnesses are diagnosed by the consultants of department of Medicine.

Results- Among 40 patients with psychiatric illness, depression was the most common followed by dementia and substance use disorder. In terms of medical illnesses, hypertension was seen in 20 patients followed by Diabetes and CNS related disorders.

Conclusion- The present study establishes the fact that psychiatric co morbidity with various medical illnesses is very common in geriatric age group.

Keyword- Depression, Dementia, Hypertension, Diabetes.

A cross sectional comparison of beliefs towards mental illness among professional contacts for the mentally ill and the general population

Sucheta Tiwari, Sushmita Upadhaya, Dinesh Kataria

Junior Resident, Lady Hardinge Medical College, New Delhi, [email protected]

Introduction: Attitude towards mental illness among those working with the mentally ill has been shown to affect treatment outcomes. General population’s beliefs about mental illness can influence their social integration. This paper aimed to examine attitudes of various potential points of contact for people with mental illness.

Aims and Objectives

To compare beliefs towards mental illness between the general population and professionals.

To compare beliefs towards mental illness between different types of mental health professionals.

Methodology A cross-sectional survey of 217 adults in four categories: general population, psychologists, physicians, and psychiatrists. Instruments included a semi-structured proforma and Beliefs Towards Mental Illness Scale.

Results and Conclusion: Results to be discussed at time of presentation. It was concluded that mental health professionals had a better attitude towards mental illness compared to others, with the greatest difference in the domain of poor interpersonal and social skills.

Keywords: Mental health professinals, Beliefs toward mental illness

Psychiatric Manifestations Of A Silent Brain Abscess-A Case Report

Sunny Dua, Seema Singh Parmar, Mridul Sharma,

Mahaveer Medical College, Moradabad, Uttar Pradesh. [email protected]

Sometimes intracranial lesions may present only with behavioral symptoms without any localizing neurological signs and symptoms. Usually, these lesions present with headache, drowsiness, confusion, seizures, hemiparesis or speech difficulties. Silent brain abscess may at times present only with subtle psychological symptoms of confusion, altered sensorium and behavioral problems without any localizing sign and symptoms.

Development of brain abscess lesion may occur as the result of a variety of infections, trauma, surgery, etc and may be associated with significant morbidity and mortality. Mental status changes are a common but insensitive finding of a brain abscess. We present a case of an elderly male who presented with acute onset psychological symptoms only but on investigation it was found to be silent brain abscess.

Keywords: Focal neurologic deficit, Headache, Silent brain abscess

A Case of Treatment Resistant Body Dysmorphic Disorder

Surabhi Pandit, Saurabh Jaiswal, Shraddha Chaudhary, Jayanath B P, Varun S Mehta, Abhishek Prasad, Surendra Paliwal

Junior Resident, Cip, Ranchi, Jharkhand. [email protected]

Introduction: Body Dysmorphic Disorder (BDD) is characterised by excessive and persistent preoccupation with perceived defects or flaws in appearance. These perceived defects cause significant distress and impairment in role functioning. BDD patients are preoccupied with any aspect of appearance including nose,skin and hair. The patients usually respond to Cognitive behaviour therapy or SSRIs or a combination of both. In this case we present a case of BDD who responded poorly on SSRIs, Antipsychotics along with CBT.

Case Presentation: A 29 years old single Hindu male of urban Jharkhand with history of Chicken pox in 2007 reported with his adopted parents with complaints of preoccupation with facial appearance, suspiciousness, self-harm behaviour and irritability with anger outbursts since 2008. The patient was involved in repetitive mirror checking and seeking cosmetic treatments. There is family history of suicide by both parents. On mental status examination, patient was wearing a cap to cover his scar and was having irritable affect, somatic delusion and delusion of reference. The patient had previous four hospitalisations from 2011-2017. Previous trials included that of various SSRIs at adequate doses including Sertraline, Escitalopram and Fluoxetine along with varying doses of antipsychotics including Aripiprazole, Pimozide, Olanzapine and Trifluoperazine for adequate duration. During admission, he was given trials of Fluoxetine 60mg with Trifluoperazine 15mg and Fluoxetine 60mg with Risperidone 7mg along with Cognitive Behaviour Therapy. Despite the above treatment, the patient showed minimal improvement in psychopathology which was also evident by minimal reduction (10%) in Brown assessment of Belief Scale.

Discussion: It would be done at the time of presentation.

Key words: Body Dysmorphic Disorder, Treatment Resistant BDD

Earlier the ‘early intervention’ in autism spectrum disorder, better the outcome : A Case Report

Susanta Kumar Padhy, Shinjini Choudhury, Soumya Jhanda

Associate Professor, PGIMER, Chandigarh, [email protected]

Introduction: Autism spectrum disorder encompasses a range of neurodevelopmental disorders presenting in early childhood with impairment in social & communicative skills, along with deviant response to various environmental stimuli. Early intervention – both developmental, and behavioural, have good outcome.

Method: Case report

Case description: 5-year old male presented with a history of significant speech delay and impaired language skills, impaired social communication skills, along with impairment in fine motor skills and mild attentional deficit. CARS (Childhood Autism Rating Scale) was also applied and the degree of impairment in various domains was assessed. Sensory profiling was also done to assess his reactivity to various stimuli. A comprehensive management plan was formulated primarily focusing on developmental and behavioural intervention. After identification of the level of impairment, the child was gradually introduced to the desired activity or behaviour in a stepwise manner addressing the identified skill deficits. The parents were involved in the daily activities and the techniques employed for each step explained to them. This was carried out for a period of 6 weeks and the child’s improvement in various fields were noted by parents as well.

Conclusion: Focused intervention strategies involving and teaching parents to support the development of the children with ASD are effective tools of management.

Key words: autism, early intervention

Fetal Hydantoin Syndrome & Intellectual Functioning: A Case Report

Susanta Kumar Padhy, Shinjini Choudhury,

Associate Professor, PGIMER, Chandigarh, [email protected]

Introduction: Maternal use of the anticonvulsant drug phenytoin has been associated with a syndrome of physical and mental abnormalities, known as fetal hydantoin syndrome. Intellectual impairment has been reported in some cases, and a higher propensity of developing learning disorders in these children has also been suggested by some studies.

Methodology: Case report

Results: A 12-year old male presented with complaints of poor scholastic performance without significant impairment of social and adaptive functioning. Birth history revealed the continuous use of phenytoin (gardenal) 300mg/day by mother during the entire period of pregnancy. She had been suffering from brain tumour and seizures. She was unaware of any threat posed to the developing fetus from phenytoin during the pregnancy. Mother also had gestational diabetes. The child’s developmental milestones were slightly delayed and there were symptoms of inattention and hyperactivity during early childhood. His speech has defect in articulation. Physical characteristics of the child suggestive of fetal hydantoin syndrome include – flat nasal bridge, hypertelorism, stiff & tapering fingers and digitalised toes, hypoplastic nails, low hairline, growth deficiency (height below 10th percentile, weight below 5th percentile). Although he had concept of time, shape, numbers, he had poor memory, difficulty in calculation, poor language skills - both verbal and written. His IQ was assessed which came out to be 70.

Conclusion: Cognitive impairment resulting from fetal exposure to phenytoin and its neurological mechanism has yet to be clearly established in studies. Nevertheless, the affected children may benefit from occupational, rehabilitation, physical and speech therapy.

Key words: fetal hydantoin syndrome, phenytoin, intellectual impairment

Epidemiology of completed suicides in a remote tribal population in South India

Susmita Chandramouleeswaran, Mahantu Yalsangi

Assistant Professor,Christian Medical College, Vellore, Tamil Nadu. [email protected]

Background: We obtained information about completed suicides in the tribal communities served by ASHWINI (Association of Health Welfare in the Nilgiris), an NGO.

Objective: To study socio-demographic factors, incidence, causes of suicide in this tribal population in the Nilgiris, and to compare it with Indian data.

Methods: Data retrospectively collected from the records of a 20,000 strong tribal population, for the period April 2010-March 2016. Frequencies and descriptives were calculated using SPSS 20.0. In depth interviews were held among family members of people who completed suicides to understand factors associated.

Results: There were 88 completed suicides in the study period. With a baseline population of 20,000, the annual incidence rate of suicides is 73/100,000. After cancer and stroke, suicide was the third highest cause of death in this population, and the highest cause of death in the age group 15-45 years. 60.2% of the suicides were in the age group 21-40 years. The average age at the time of death was 35.5 years, and the male:female ratio was 2.8:1. Alcohol consumption and dependence were significantly associated with completed suicides in this population.

Discussion: The national average incidence rate of completed suicides is 10.6/100,000.1 The incidence rate of suicides in our population is seven times the national average. The mean age of completed suicide in Indian population is 25 years, and the male to female ratio is 1.78 : 1.3 The average age of suicide in our population was 10 years higher than the national average, and the ratio of male to females was higher. These probably could be because alcohol dependence was strongly associated with completed suicides in this population.

Conclusions: Suicide rate among the population studied was much higher than the national average. A possible explanation for this is higher prevalence of alcohol dependence in this population.

Keywords: Tribal population, Completed suicides

Mobile-based working memory training as a potential therapy for Autism Spectrum Disorder

Surbhit Wagle, Arka Ghosh, Braj Bhushan, Koumudi Patil, Nitin Gupta

PG student, Indian Institute of Technology Kanpur, Uttar Pradesh. [email protected]

Background: Autism is a neurodevelopmental disorder marked by characteristic restricted and repetitive behaviors and deficits in social skills. Current treatments for autism primarily include behavioral therapies which require dedicated manpower, are costly and have limited reach. Working memory, which is implicated in problems in social skills and restricted and repetitive behaviors, appears to be affected in autistic kids. Recent studies have suggested that working memory can be improved by cognitive training.

Given the widespread availability of mobile devices and the demonstrated success of mobile-based apps to aid learning in autistic kids, mobile-based games can be suitable media for providing cognitive training to this group. However, evidence to establish their effectiveness in working memory training for autistic children is lacking. We hypothesize that mobile-based cognitive training can alleviate working memory deficits in autistic kids which in turn will improve social skills and lead to progressive development of more adaptive behavior.

Methods: We are developing a suite of interactive and adaptive mobile/tablet-based games to improve working memory in autistic kids. Performance on working memory tasks at baseline and post-intervention will be used to assess the efficacy of the intervention. Assessment of restricted, repetitive behaviors and social behavior will be done to evaluate the far transfer of working memory training to characteristic symptoms. We will also measure the attrition rate to evaluate the acceptance of the suite.

Results: We have started development of two games for the suite, while more are being designed. In a pilot study, we will evaluate the efficacy of the developed game suite in special schools in and around Kanpur.

Conclusion: Results of this study will provide insights into the efficacy of mobile game-based tools in improving working memory in autistic children and alleviating autistic symptoms.

Keywords: autism, working memory training, Mobile-based games, social skills, repetitive behavior

Gratification disorder- A rare case report

Khushbu D.Tandel, Mehul brahmbhatt, Minakshi Parikh

2nd Year Resident, B.J.Medical College, Ahmedabad, Gujarat. [email protected]

Introduction: Gratification disorder is common in younger children, but often unrecognized and misdiagnosed because unlike in adolescents, it doesn’t involve manual genital manipulation and clinical feature are quite variable.

Method: 8 year old male patient was brought by father in psychiatry OPD with complain of abnormal body movements of limbs since 6 month of age associated with flushing and sweating which was progressively increased.

Result & Conclusion: Infantile gratification is normal behaviour in children. But it could be easily misdiagnosed as epilepsy, or non epileptics paroxysmal movement disorder. Video taping and detailed history taking of these episodic events are invaluable in making correct diagnosis.

Key words: Gratification disorder, epilepsy, movement disorder

Anti NMDA Receptor Encephalitis Masquerading as Psychosis

Hemendra Singh, Murali Tyloth, Udayan Bhaumik, Nishath Fathima

Junior Resident, M S Ramaiah Medical College, Bangalore, Karnataka. [email protected]

Background: Anti N-methyl D-aspartate receptor encephalitis is a novel entity that occurs through multiple stages with psychiatric symptoms at onset. More common in females, it is frequently associated with ovarian teratomas. Most patients initially present to psychiatrists. It should be considered in patients with psychosis as well as dyskinesia, seizures, and/or catatonia, especially in absence of past psychiatric history.

Objective: To describe a case of Anti NMDAR encephalitis in a 22 year old female.

Case Study: Our case was admitted under Neurology in intensive care unit with acute onset fever for two days followed by three episodes of generalised tonic-clonic seizures. Changes in behaviour and sleep pattern with a regressed form of speech post seizures, with fear of being ridiculed and harmed were noticed. There was also history of inappropriate excessive speech output and subsequent neglect of self care.She was found to be inexplicably drowsy in the intensive care unit. Magnetic Resonance Imaging study of brain revealed scattered foci of high signal intensity in supratentorial white matter (limbic) regions. She returned positive for Anti N-methyl D-aspartate receptor antibodies and anti-thyroid peroxidase antibodies while other investigations were normal. In the hospital, she continued to display violent behaviour.Sleep and psychotic symptoms improved with Quetiapine 50 mg and Clonazepam 0.5 mg at night.Started on methylprednisolone,she had further worsening of psychotic symptoms and mycophenolate mofetil was added as a steroid sparring agent.There were no residual symptoms at the time of discharge after two months. Lost to follow-up in Psychiatry, she was reviewed in Neurology and was maintaining well on Methylprednisolone-Mycophenolate Mofetil combination.

Conclusion: This case highlights the importance of keeping Anti N-methyl D-aspartate receptor encephalitis as a differential diagnosis in acute onset psychotic and neurobehavioural symptoms in females with absent family/past history.

Keywords: Psychosis, Anti-NMDA encephalitis

Sexual Dysfunction in Cannabis Dependence: A Hospital Based Study

Udayan Majumder, N.Heramani Singh, R.K.Lenin SIngh, S.Gojendra Singh

Postgraduate Student, Psychiatry, RIMS, Imphal, Manipur. [email protected]

Background - Cannabis has been a part of the recreational and religious ceremonies for years, in India. Although we find many conflicting and controversial studies in this area, we lack studies done on Indian setup to know the detrimental or beneficial effects of this drug on sexual functions.

Aim of the study - To assess the pattern of sexual dysfunctions in cannabis dependant individuals at a tertiary care hospital.

Materials and methods - 35 consenting cannabis dependant individuals (ICD-10, F13.25 cannabinoids dependence with continuous use criteria) were assessed for sexual dysfunction using international index for erectile dysfunction-15, on outpatient basis at RIMS, Psychiatry department during a period from June 2016 to July 2017. International Index of Erectile Dysfunction (IIED)15 which is a 15 question assessment tool that has 4 domains of male sexual function- Erectile, Orgasmic, Sexual desire and Intercourse satisfaction. Subjects having other major psychiatric illness or any major medical illness were excluded from the study. Results were accessed using SPSS version 21.0.

Results- Majority of subjects were from the age group > 30 years. Erectile dysfunction was the highest reported sexual dysfunction and was common in the age group of 31 years and above. Similarly orgasmic dysfunction noted higher in age group >30 years. Sexual desire and overall satisfaction in sexuality as well as satisfaction in intercourse was reduced in the older age group. Statistical significance in any of the dysfunctions with age could not be established in our study. Results were accessed using SPSS version 21.0.

Keywords: Cannabis, dependence, ICD-10, sexual dysfunction, erectile dysfunction, anorgasmia.

Aberrant Cortical Sources And Functional Connectivity During Facial And Body Language Recognition In Schizophrenia

Umesh S, Sai Krishna Tikka, Venkatesh Babu GM, Nishant Goyal

Assistant Professor, Kasturba Medical College, Manipal, Karnataka. [email protected]

Background: The face and the body language together normally contribute in conveying the emotional state of the individual for successful manoeuvring of social situations. Schizophrenia (SZ) patients have impaired facial and body language reading ability compared to healthy individuals. We aimed to assess event related cortical sources and functional connectivity of N170 and Late positive Component (P650, LPC) in SZ patients during a visual task for assessing facial emotion and body language (FaBoConER) and compared with healthy controls.

Methods: 256-channel scalp EEG was recorded in 10 schizophrenia (SZ) patients and 19 healthy controls (HC) while performing the FaBoConER task with congruent and incongruent facial emotions and body language expression. Nine electrodes of interest were selected for assessing LPC and seven for assessing N170. standardized Low-resolution brain electromagnetic tomography (sLORETA) of gamma band (30-50 Hz) was used to assess the cortical current source distribution and functional connectivity.

Results: Significantly reduced gamma band current source distribution of LPC was found in dominant motor cortex during congruent stimulus (Tmax= -6.931, p<0.001) and middle prefrontal cortex during incongruent stimulus (Tmax= -7.154, p<0.001) in SZ patients compared to HC. Significantly increased gamma band functional connectivity of LPC (Tmax=1.031, p<0.001) was found between motor cortex and parahippocampal gyrus bilaterally during congruent task. Also, increased functional connectivity was found between left medial frontal, left superior temporal and right inferior frontal gyrus (Tmax=1.669, p<0.001) during incongruent task. However, gamma band N170 sources and functional connectivity did not significantly differ between the two groups.

Conclusion: We may conclude that region specific reduction and aberrant functional connectivity of cortical sources of LPC during both congruent and incongruent stimulus is found in SZ patients. This may hint towards abnormal processing and modulation of facial and body language. However, N170, which is involved in early processing of facial emotion, is relatively intact.

Keywords: Schizophrenia, Facial and body recognition

A case report on volatile substance abuse with depressive symptoms secondary to anemia

Urvika Parekh, Dhruv Bardolia, Rajat M Oswal

MBBS, Baroda Medical College, Gandhinagar, Gujarat. [email protected]

Introduction: Volatile products are capable of producing a quick and pleasurable sensory experience or’ high’ with rapid dissipation and minimal hangover symptoms. Inhalant abuse is the intentional inhalation of volatile substances to achieve high. Its pathophysiology is not completely understood.

Here we present an unusual case of a female who developed inhalant use disorder secondary to anemia. Her behavior of inhalant use stopped completely after correction of anemia.

Case History: A 50 year old divorced female with a three months history of petrol & kerosene sniffing presented to us having six months history of fatigue, irritability, sadness of mood, lack of interest in surrounding, reduced appetite and sleep disturbance. Three months back at a petrol pump she liked the smell of fumes, getting pleasant feeling of well-being. She felt so good that she started visiting the petrol pump frequently. Gradually she would bring petrol or kerosene in a bottle at home and sniff from the bottle. Later on she started having headache and discomfort when she would not sniff petrol or kerosene.

On examination she was quite pale and lab investigations showed that her Hb was 5.9 gm%. She was diagnosed as suffering from iron deficiency anemia based on hemogram. Patient was admitted and was treated with Inj. of Iron Sucrose, Inj. Multivitamins (including Vitamin B12 500 mcg) and Tab.Sertraline 25mg OD and Tab.clonazepam 0.5 mg HS. After 4 weeks of treatment, she stopped using inhalant completely and had no craving for inhalation as her anemia got corrected.

Discussion: This is an unusual case of inhalant use disorder which was secondary to iron deficiency anemia prompting an exploration of pathophysiology of IUD related to iron deficiency. Further study of iron levels in patients suffering from inhalant use disorders can be carried out.

Keywords: Anaemia, Volatile substance abuse

Prevalence of Psychiatric co morbidity among patients with malignancy and its relation with site of malignancy.

Vikesh Gupta, Ravi C. Sharma, Rahul Gupta, Vineet Kumar

Junior Resident, IGMC Shimla, Shimla, Himachal Pradesh. [email protected]

Introduction: Cancer is a serious illness that has an effect on physical and emotional wellbeing of patients and their families. Cancer patients have to face many important issues like fear of death, interruption of life plans, changes in body image and self-esteem, changes in social role and lifestyle, thus increasing the risk of various psychiatric ailments in them. The aim of this study was to find out the prevalence of psychiatric co-morbidity among patients with malignancy and its relation with site of malignancy.

Materials and methods: We conducted the study at Indira Gandhi Medical College, Shimla (Himachal Pradesh) among the patients diagnosed histo-pathologically with any malignancy and attending outdoor patient services, in the Department of Radiotherapy, IGMC Shimla. It was an observational, cross-sectional study. The duration of study was one year (August 2016 through July 2017). We diagnosed patients on the basis of ICD-10 classification. Data was collected, cleaned, and entered in excel spreadsheet and data analysis was done using Epi info version software.

Results: There were total 226 patients out of which 112 were males (49.5%) and 114 were females (50.5%). Mean age of patients was 51.3 years with a SD 12.8 years. The prevalence of psychiatric co-morbidity in our study was found to be 35% (95 % CI 29%-42%). The maximum psychiatric co-morbidity was found in the patients of Cancer breast (44%) followed by GIT malignancy (43.7%), genitourinary (36.5%), oral cavity (35.5%) and respiratory system (26%). The difference in psychiatric co-morbidity between these cancers was found to be statistically insignificant (p = 0.51).

Conclusion: Prevalence of Psychiatric co-morbidity was found to be high among cancer patients. There is an urgent need to address the mental health issues in all cancer patients thereby improving their quality of life.

Keywords: Malignancy, Site of malignancy, Psychiatric comorbidity

Children with Speech Delay – A Retrospective Chart Review

Vimalanathane, Sivabalan, Thirunavukarasu, Rajkumar, Arul Saravanan, Sai Balasubramanian, Arun Narayan Pradeep

Postgraduate, SRM Medical College, Hospital & Research Centre, Pondicherry, [email protected]

Introduction: Speech delay is a common problem in children less than 6 years. The reported prevalence of language delay in children two to seven years of age ranges from 2.3 to 19 percent. Various psychiatric disorders such as pervasive developmental disorders, attentional deficit disorder, oppositional disorder, mental retardation, specific developmental disorders of speech and language, poor social interaction and anxiety disorders may manifest as speech delay in the early period. Usually, these children are initially seen by the primary care physician who gives reassurances and often fails to refer them to a psychiatrist. In these cases, the children miss out on the specialised assessment that they require. Therefore, it is essential to evaluate each child with speech delay. Early identification and starting appropriate therapy as early as possible is very important for good clinical long term outcome. In this context, this study was carried out to investigate socio-demographic and other factors associated with speech delay.

Materials And Methods: A retrospective study design was used to collect data from case files of children aged less than 6 years who were referred to the psychiatric OPD for speech delay with normal hearing between May 2015 and May 2017. Their socio-demographic details, antenatal, perinatal and postnatal details, medical comorbidities, psychological assessment reports such as developmental and social quotient, and other psychiatric comorbidities were collected and evaluated.

Results: Results will be presented after the study completion.

Conclusion: This study’s findings may prove relevant to therapists when planning comprehensive and effective treatment for such children.

Keywords: Speech delay, Specific developmental disorders of speech and language, pervasive developmental disorders, mental retardation

Neurobiological correlates of suicidal behavior and sleep quality in remitted bipolar I patients

Vigneshvar Chandrasekaran, Karthick Subramanian, Venkatalakshmi Penchilaiya, Siddharth Sarkar, Shivanand Kattimani, Hanumanthappa Nandheesha,

PG student, JIPMER, Puducherry, [email protected]

Objectives: About 25-50% of Bipolar Disorder-I (BD-I) patients attempt suicide and are more likely to have further attempts during their lifetime. Sleep disturbances in interepisode period is associated with increased risk of suicidal behaviors. Altered biomarker levels such as low Brain Derived Neurotrophic Factor (BDNF) and higher Matrix Metalloproteinase-9 (MMP-9) have been implicated in suicidal patients. The current study evaluates for biomarker specificity in BD-I patients who had made lifetime suicide attempts and those who had poor sleep quality in a south Indian population.

Methodology: BD-I patients in remission (n=25) were recruited after confirming the diagnosis with Structured Clinical Interview for DSM-IV-TR (SCID-I). The illness course was retrospectively computed using the National Institute of Mental Health Life Chart Methodology (NIMH-LCM). Suicidal behavior and subjective sleep quality were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS) and the Pittsburgh Sleep Quality Index (PSQI) respectively. Serum BDNF and MMP-9 levels were correlated with suicidal behavior and sleep quality.

Results: About 20% of the sample had a history of suicide attempt and about half the study population (48%) were poor sleepers. MMP-9 levels had significant positive correlation with history of suicide attempts. BDNF levels did not reveal any significant correlation with suicidal behavior or sleep quality.

Discussion: Prevalence rates of suicide attempts in the study population are comparable with contemporary research findings. Nearly half the remitted patients were poor sleepers, implicating the role of circadian rhythms in pathophysiology of BD. Though BDNF levels did not correlate with suicide, elevated MMP-9 levels reiterate its role in suicide similar to previous studies. No association could be made out between biomarker levels and sleep quality.

Conclusion: Increased levels of MMP-9 could reflect the lifetime suicide risk in BD-I, whereas biomarker levels were not associated with sleep quality during remission. Such findings need replication in studies with a larger sample size.

Keywords: Bipolar 1, Sleep quality, Suicidal behavior

HD-tDCS for auditory hallucinations in Schizophrenia

Vanteemar Satyanarayana Sreeraj, Rujuta Parlikar, Dinakaran Damodaran, Soumya Selvaraj, Harleen Chhabra, Venkataram Shivakumar, Ganesan Venkatasubramanian

InSTAR program, Schizophrenia clinic, Department of Psychiatry & WISER program, Translational psychiatry laboratory, Bengaluru, [email protected]

Background: Transcranial direct current stimulation (tDCS) is a novel weak intensity electrical stimulation that has been found to be effective as an add-on treatment in alleviating persistent auditory hallucinations in schizophrenia. Conventional tDCS is known to stimulate wider cortical areas than intended due to the larger electrodes and need for placement of both anode and cathode in two different areas. High-Definition tDCS (HD-tDCS) using smaller electrodes would provide more focal and predictable neuromodulation. Method: In this open label study we evaluated the clinical utility of add-on HD-tDCS in 18 patients with Schizophrenia with auditory hallucinations persisting despite antipsychotic trials. Left temporo-parietal junction was stimulated by central cathodal stimulation surrounded by four anodal return electrodes with 4x1 ring montage using 1.5-2mA direct current. Each patient received 10 sessions of stimulation over five consecutive days with two per day session three hours apart.

Result: On paired sample t-test a significant reduction in auditory hallucinations (t=3.628, p=0.002), positive symptoms (t=3.326; p=0.004) and negative symptoms (t=3.885, p=0.001) were noted in auditory hallucination rating scale, scale for assessment of positive symptoms (SAPS) and scale for assessment of negative symptoms (SANS). Conclusion: This is the first study showing utility of HD-tDCS in schizophrenia. HD-tDCS seems to be a promising technique in reducing psychopathology in patients with schizophrenia with persistent auditory hallucinations. Further randomized trails are needed to ascertain our findings.

Key words: High Definition transcranial direct current stimulation (HD-tDCS), auditory hallucinations, schizophrenia.

This work is supported by the Swarnajayanti Fellowship Grant, Department of Science and Technology, Government of India to GV (DST/SJF/LSA-02/2014-15)

To study the burden and attitude of caregivers of schizophrenic patients.

Mohd, Wasim, Chitra. Singh, R. K. Solanki

Resident Doctor (JR-3), S.M.S. Medical College Jaipur, Makrana, Rajasthan. [email protected]

Background: Schizophrenia is a dark shadow in an individual’s life. The patients with schizophrenia are frequently hospitalized and usually need long term care and treatment in order to reduce negative impacts. Families in India are involved in most aspects of care for person with several mental illnesses. Families not only provide practical help and personal care but also provide emotional support to their relatives.

Methods: Two groups, one of 100 caregivers of schizophrenia and another one of 50 caregivers of diabetes mellitus were selected. The structured self-report tools including Burden Assessment Schedule (BAS) a rating scale to assess caregiver burden and The Family Attitude Scale (FAS) a rating scale to assess expressed emotion were administered to both the groups. Appropriate statistics was applied to compare both groups.

Results: Caregiver of schizophrenic patients have higher BAS score and FAS score compare with caregivers of Diabetes Mellitus.

Key words: Expressed emotion, caregiver burden, schizophrenia, diabetes mellitus.

Knowledge about Schizophrenia among Family Members and Stigma Experienced By Them

Kamlesh Kumar Sahu, Sudeshna Basu Mukerjee, Soma Sahu

Associate Professor (PSW), Government Medical College & Hospital, Chandigarh. [email protected]

Against the universality of stigma, studies across the globe present different pictures of stigma experiences in different countries and communities. Stigma is universal but experiences are local. Although numerous studies documented perceive or experienced stigma of the person with schizophrenia (PWS), comparatively little research has been done to explore how courtesy stigma limits the social support and social opportunities available to family members of stigmatized individuals; which has significance implication on management of schizophrenia. Objectives of the study are to explore the knowledge about schizophrenia among family members of the persons with schizophrenia and courtesy stigma experienced by them. Cancutta University

Methodology: Descriptive study design was employed for the study. Using mixed method of data collection for the purpose of breadth and depth of understanding of stigma experienced by the 100 families of a PWS who were living in the community with a person suffering from schizophrenia. Socio-demographic and Clinical Datasheet especially designed for the study, Knowledge about Schizophrenia Interview were the tools of the study.

Result: Family members of PWS experienced great degree of stigma which was higher when their knowledge about schizophrenia was poor.

Conclusion: There is a need of imparting knowledge about schizophrenia among family members of PWS to dispel stigma.

Keywords: Schizophrenia, Courtesy stigma family, Knowledge

Post-partum psychosis in Sturge  Weber syndrome More Details: a case report

Anantprakash S. Saraf, Sneh Babhulkar, Vinay Kumar, Vivek Joge

Resident Psychiatrist, MGIMS Sevagram Wardha, Nagpur, Maharashtra. [email protected]

Introduction: Sturge Weber Syndrome, also known as leptomeningeal angiomatosis is a rare vascular neurocutaneous disorder primarily involving capillary-venous malformations of the face, eyes, and leptomeninges. Although frequently associated with neurological and ophthalmic disturbances; the literature regarding the behavioural manifestations of SWS is sparse. The most frequent associations found are mood disorders, disruptive behaviour disorders, adjustment disorders and substance-related disorders.

Case Report: A 45-year-old female presented with acute onset of suspiciousness, irritability, aggression and sleep disturbances, one day after she delivered her second child. She was ignoring the care of her newborn and trying to flee away from the hospital. She had increased psychomotor activity, irritable affect, persecutory and referential delusions, third person auditory hallucinations, with reference to herself and her newborn child. She had a similar episode 4 years back lasting about 3 weeks after giving birth to her first child. She also had history of seizures and right sided weakness in childhood, which remitted later. On physical examination, she had large left-sided portwine stain involving ophthalmic and maxillary division of trigeminal nerve. Her ophthalmic examination revealed left-sided capillary haemangioma with proptosis, band shaped keratopathy and raised intraocular pressure in left eye; and amblyopia in right eye. A provisional diagnosis of Sturge Weber syndrome with postpartum psychosis was made and after taking care of safety of the baby, she was started on tablet olanzapine 10 mg at night. She started responding within a week while the olanzapine was titrated to 15 mg at night. Her metabolic and endocrine parameters were within normal limits and CT scan did not show any calcification.

Conclusion: Although psychiatric manifestations have been previously reported in cases of SWS, this is probably first report of SWS presenting as Post-partum psychosis. It signifies the need for special care in such cases especially during peripartum period.

Keywords:  Sturge-Weber syndrome More Details, Postpartum psychosis

A Curious Case Of Catatonia With Epilepsy In An Adolescent Girl

Soumyadeep Saha

PGT, Institute of Psychiatry, IPGME&R, SSKM Hospital, Kolkata, West Bengal. [email protected]

Introduction: Catatonia, a psychomotor syndrome with marked decrease in environmental reactivity which ranges from resistance to instructions {negativism); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses {mutism and stupor) including purposeless and excessive motor activity without obvious cause {catatonic excitement). Other features being stereotyped movements, staring, grimacing, and the echoing of speech. It was first described by the German psychiatrist Kahlbaum in 1874, occurring in several psychiatric and neurological disorders.

Presentation: 16 yr old girl, nil contributory past, family, personal history ; well adjusted premorbid temperament presented to psychiatric emergency with C/O limb rigidity, immobility, mutism - 1.5yrs ; muttering, aggressive behavior - 1 yr, h/o disrobing herself 1 yr back. last 8 months, she developed multiple convulsions with incontinence, LOC, post-ictal confusion.

Examination: Vitals Stable.

Limb Rigidity + Hypertonia

Kirby’s examination revealed stupor, non reactive to painful stimuli, apathetic, posturing, mask facies, gagenhalten, negativism, mitgehen.

Treatment: Patient was admitted immediately & was put on I.V Lorazepam 10 mg in divided doses as at the time of presentation catatonic symptoms were prominent with no seizure activity (normal EEG report). Treatment continued for 7 days. Catatonic symptoms improved with decrease in BFCRS score = 16. Same treatment continued with repeated monitoring of BFCRS showing remarkable improvement of target symptoms. Patient was discharged adding Tab.Sodium Valproate 600mg daily keeping in mind H/O GTCS; with Tab. Lorazepam 6mg daily

Conclusion: Albeit rare, case reports have supported co-occurrence of catatonia with epilepsy; making clinical scenario complex & difficult to perceive. Only higher degree of clinical suspicion , routine investigation, imaging & early intervention can delineate & manage such conditions, otherwise the morbidity & mortality will hike.

Keywords: Catatonia, Epilepsy, BFCRS

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