Indian Journal of Psychological Medicine
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   Table of Contents - Current issue
Coverpage
March-April 2017
Volume 39 | Issue 2
Page Nos. 105-218

Online since Tuesday, March 28, 2017

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EDITORIAL  

Empirical reality of dialectical behavioral therapy in borderline personality p. 105
MS Reddy, M Starlin Vijay
DOI:10.4103/IJPSYM.IJPSYM_132_17  
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REVIEW ARTICLES Top

The importance of cholesterol in psychopathology: A review of recent contributions p. 109
Henrique Pereira
DOI:10.4103/0253-7176.203117  
Aim: The aim of this study was to describe systematically recent studies that show the importance of cholesterol in psychopathology. Methods: This study was a review. The following databases were searched for relevant published articles on human studies: MEDLINE, Web of Science, EBSCOhost Academic Search Complete, and Psychology and Behavioral Sciences Collection (papers from January 2012 to March 2016). Results: Eighteen recent papers were selected, and thematic dimensions showing correlations between cholesterol and behavioral and psychopathological variables were depression, suicide, personality, and aggression. Conclusion: This paper demonstrates that recent research corroborates the idea that cholesterol plays an important role in governing behavior and psychopathology in humans. Deepening the studies in this field could be a promising avenue for future research, with implications for treating people with behavior or mental health problems.
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Traumatic brain injury and neuropsychiatric complications p. 114
Saeed Ahmed, Hema Venigalla, Hema Madhuri Mekala, Sara Dar, Mudasar Hassan, Shahana Ayub
DOI:10.4103/0253-7176.203129  
Traumatic brain injury (TBI) occurs when a blow or jolt to the head or a penetrating injury results in damage to the brain. It is the most frequent cause of hospitalization in young people with a higher prevalence in men. TBI is the leading cause of disability and mortality between the ages 1 and 45. TBI can be caused either by the direct result of trauma or due to a complication of the primary injury. The most common etiological factors for TBI are falls, road traffic accidents, violent physical assaults, and injuries associated with athletic activities. Following TBI, significant neurologic complications may occur which include seizures, dementia, Alzheimer's disease, and cranial nerve injuries. In addition, people may suffer from various psychiatric complications such as depression, posttraumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, and other cognitive and behavioral sequel that might significantly increase the comorbidity of the victims. Considering all of the above complications, TBI is one of the significant public health burdens. Literature has shown that only about 25% of people achieve long-term functional independence following TBI. In this paper, we focused not only on the epidemiology but also the etiology, complications following TBI and understanding their underlying pathogenesis. Further, we focused on analyzing the options to improve the treatment and rehabilitation following TBI in future.
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ORIGINAL ARTICLES Top

Use of Jonkman et al. Score for visual quantification of electroencephalography as a tool to assess disease severity in cortical dementias p. 122
R Kiran Kumar, Sadanandavalli Retnaswami Chandra, Girish B Kulkarni, Rose Dawn Bharath
DOI:10.4103/0253-7176.203119  
Objectives: To study electroencephalography (EEG) changes in patients with cortical dementias (Alzheimer's disease [AD] and frontotemporal dementia (FTD). (1) To correlate EEG changes with clinical severity of dementia as assessed by rating scales. (2) To correlate global gray matter volume (GGMV) with EEG scores and clinical severity rating scales. Patients and Methods: This is a prospective cross-sectional study involving patients fulfilling the criteria for Probable AD and FTD. A total of thirty patients (20 = FTD, 10 = AD) underwent detailed neuropsychological evaluation, dementia rating scales, EEG, and magnetic resonance imaging. Five EEG parameters were acquired and each parameter is scaled and the total score was compared with neuropsychological parameters and GGMV. Results: For FTD, the mean age of patients was 58.85 ± 6.87, mean mini-mental state examination score was 13.30 ± 6.33, Hindi mental state examination: 14.35 ± 6.28, mean grant total EEG score (GTES): 7.80 ± 5.39, and mean GGMV: 464580.76 ± 52127 mm3 and for AD, the same were 69.50 ± 8.59, 12.90 ± 5.56, 14.20 ± 5.31, 9.80 ± 5.29, and 483208 ± 47371.5 mm3, respectively. GTES for mild, moderate, and severe FTD are 2.33 ± 1.528, 6.00 ± 3.162, and 10.70 ± 5.677 and for AD it is 4, 7.50 ± 4.041, 15 ± 1.414, respectively. The GGMV for mild, moderate, and severe FTD was 511836 ± 45005, 492693.1 ± 50624, and 430725 ± 30744 and for AD it is 527217.3 ± 36171, 503598 ± 3006, and 440812 ± 33911. Discussion: The most common EEG abnormalities in cortical dementias are reduced frequency of rhythmic background activity. There is a significant correlation between GTES and dementia severity and global gray matter volume but the proportional correlation with GTES and volumetric scores is not significant. Conclusion: EEG is a cheap and sensitive and easily available tool to assess disease severity in patients with cortical dementias and thus helps in planning the type of rehabilitatory interventions and prognostication.
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A randomized pilot study of brief intervention versus simple advice for women tobacco users in an urban community in India p. 131
Sonali Jhanjee, Rakesh Lal, Ashwami Mishra, Deepak Yadav
DOI:10.4103/0253-7176.203121  
Aim: The study aimed to assess the efficacy of providing brief intervention (BI) for women tobacco users in a community-based setting. Methods: In this open-labeled randomized study, a representative sample of women (n = 100) from a community in East Delhi were screened using Alcohol, Smoking and Substance Involvement Screening Test. Eligible women were randomized to BI or simple advice (SA) arms. At baseline, they were assessed for tobacco use characteristics and severity of nicotine dependence using Fagerstrom's test for nicotine dependence. Intervention in the form of a single session of BI or SA to quit tobacco was provided at baseline. All participants were assessed at 1 week and 3 months following intervention. The principal outcome was self-reported abstinence from tobacco use at 3 months follow-up. Results: The mean age of the sample was 43 years (standard deviation = 13). Most women were married (80%), housewives (69%), illiterate (61%), socioeconomically disadvantaged and were smokeless tobacco users (94%). The subjects in the BI group were twice more likely to stop tobacco use as compared to individuals in the SA group (odds ratio = 2.2, 95% confidence interval: 0.962–5.197, P = 0.06). Conclusion: The study results are suggestive of beneficial effect of BI. A larger study might provide more significant results.
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Culturally relevant family therapy practice with parents of children and adolescents p. 137
Tania Roy, A Thirumoorthy, R Parthasarathy
DOI:10.4103/0253-7176.203122  
Background: India is diverse in culture, with multiple aspects that may not match with the Western societal picture. Hence, it has often been seen that therapists encounter unique aspects of therapy that is faced during actual practice, which is never written in any textbook or research papers. Substantial information is present through both outcome (efficacy and effectiveness) studies and process research, but it has very little impact of actual Marital and Family Therapy (MFT) practice. This paper throws light into “how” and “what” of family therapy with parents of children/adolescents having psychiatric disorders. Materials and Methods: Focused group discussion was conducted with practicing family therapists and mental health professionals working in Psychiatric Tertiary Hospital (National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India). Qualitative analysis was done to disseminate process issues in therapy. Results: Aspects that are vital for families having children and adolescent with psychiatric disorders include: Academic decline and loss of parental control as main reasons for seeking help, integration of models is noted to be beneficial, therapeutic alliance, intake sessions, conjoint sessions and individual sessions are important, cultural issues like gender of therapist, their cultural belief model, therapist's cultural competence need to be taken into consideration. Conclusions: Challenges and way-outs to overcome these has been mentioned and implications discussed
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Evaluation of modified patient health questionnaire-9 teen in South African adolescents p. 143
Shilpa Aggarwal, Lian Taljard, Zane Wilson, Michael Berk
DOI:10.4103/0253-7176.203124  
Background: This report describes the findings of the survey conducted by South African Depression and Anxiety Group (SADAG) in a cohort of disadvantaged South African adolescent scholars in which PHQ-9 teen version was modified and adapted (PHQ-9M) to improve the response rate. Method: PHQ-9M was administered to 2025 secondary students of 35 schools over 2 years in Gauteng Province, South Africa. Results: The mean age was 15.8 years. 23% of respondents scored 9 or above, 26.7% reported suicidal ideations in last month, 21.8% reported lifetime suicide attempts and 9.3% had severe functional impairment. PHQ-9M showed a fair internal consistency and face validity in this study. Conclusion: The PHQ-9M could be useful in conducting surveys in settings of low mental health literacy after further evaluation of its psychometric properties. The high rates of suicidal ideations, suicide attempts, and functional impairment in this population suggest the need for preventive interventions.
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Communication impairments in children with inborn errors of metabolism: A preliminary study p. 146
Shivani Tiwari, Divya Kallianpur, Kelly Ann DeSilva
DOI:10.4103/0253-7176.203125  
Purpose: Inborn Errors of Metabolism (IEMs) are a group of complex genetic conditions, predominantly affecting the pediatric population. While the understanding and identification of various IEMs has significantly improved over recent times, not much is known about the communication disorders in this population. The present study focused on identification and profiling of communication impairments in children diagnosed with IEMs. Methods: Data was obtained retrospectively from medical records of children visiting a tertiary care hospital over a period of ten years (2005 – 2014). Selected data was reviewed to obtain demographic details, clinical signs/manifestations, laboratory findings, risk factors, developmental disorders and reported communication impairments. Results: The findings of the study showed a variety of clinical signs and laboratory findings in children with inborn errors of metabolism. A few of the risk factors observed in the group were consanguinity, sibling death and family history of other disorders. Many children with IEM displayed communication disorders, most common as the delay in speech and language development. Conclusions: The results of this study showed that various communication disorders were seen in almost half of the children with a diagnosis of IEM. Findings are discussed with implications for future research in this direction.
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Combining metacognitive strategies with traditional cognitive behavior therapy in generalized anxiety disorder: A case illustration p. 152
Paulomi M Sudhir, Systla Rukmini, Mahendra Prakash Sharma
DOI:10.4103/0253-7176.203128  
Context: Generalized anxiety disorder (GAD) is a challenging clinical condition to manage. Recent psychological models of GAD emphasis on the need to focus on metacognitive processes in addition to symptom reduction. Aims: We examined the application of metacognitive strategies in addition to conventional cognitive behaviour therapy (CBT) techniques in an adult patient with GAD. Settings and Designs: Asingle case design with pre- and post-assessments on clinician-rated scales was adopted. Materials and Methods: Twelve weekly sessions of therapy were conducted on an outpatient basis. Assessments were carried out on clinical global impressions scales, Hamilton's anxiety rating scale at pre- and post-therapy points. Statistical Analysis: Pre- and post-therapy changes were examined using the method of clinical significance. Results: A combination of traditional CBT with MCT was effective in addressing anxiety and worry in this patient with GAD. The case illustrates the feasibility of matching therapeutic strategies to patient's symptom list and demonstrates a blend of metacognitive strategies and conventional CBT strategies. Conclusions: In clinical practice, matching strategies to patient's problem list is important to be an effective approach.
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The influence of psychosocial dysfunctions in chronic schizophrenia patients in remission: A hospital-based study p. 157
Sarada Prasanna Swain, Sushree Sangita Behura, Manoj Kumar Dash, Anil Kumar Nayak, Saswati Sucharita Pati
DOI:10.4103/0253-7176.203120  
Background: Psychosocial dysfunctions in the various psychosocial areas in chronic schizophrenic patients predict the long-term course, outcome, and quality of life of these patients, which always varies with years of treatment. Objective: To know the influence and compare the level of psychosocial dysfunctions and severity of disability burden in chronic schizophrenic patients who are in remission with duration of 5 and 20 years. Materials and Methods: The sample was collected from the OPD of Mental Health Institute (COE), S.C.B. Medical College, Cuttack, Odisha, India. This study is a cross-sectional study. A total of 120 remitted schizophrenic patients (60 patients of each group with duration of 5 and 20 years), who fulfilled Nancy Andreasen criteria for Remission were selected for the study. Regional language of dysfunction analysis questionnaire (DAQ) was used to assess the level of psychosocial dysfunctions in personal, familial, social, vocational, and cognitive areas of each patient. Results: Qualitative data were analyzed using Chi-square and quantitative data were analyzed using t-test and correlation as a test of significance. Statistically significant differences (P < 0.05) were found in all five domains of DAQ between two groups. Statistically significant difference (P < 0.05) was found between the two groups with respect to severity of the disability. Conclusion: This study confirms that there are definite and substantial psychosocial dysfunctions in personal, familial, social, vocational, and cognitive spheres with the advancement of the duration of illness in chronic schizophrenic patients.
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Long loop reflex 2 in patients with cortical dementias: A pilot study p. 164
Sadanandavalli Retnaswami Chandra, Thomas Gregor Isaac, Mahesh Mane, Srikala Bharath, BC Nagaraju
DOI:10.4103/0253-7176.203126  
Introduction: Dementia is a major public health problem and it appears to be a global epidemic. The prevalence is doubling every 5 years and it is expected that 70% of persons above 60 years will live in developing countries by 2020 and 15% of them are likely to suffer from dementia. Disease modifying treatments work only if initiated very early; however, diagnostic tools are not always able to clearly differentiate the different types in very early stage. Therefore, inexpensive and easily available biomarkers are needed to know if collectively they will improve the sensitivity of specific diagnosis. Therefore, in this pilot study, we have tried to analyze if long loop reflex (LLR2) is differentially affected in these two conditions early in the course of Alzheimer's dementia (AD) and frontotemporal dementia (FTD) based on hypothesis taking into account the anatomical substrates involved. Patients and Methods: Mild cases of clinically probable AD and FTD after appropriate inclusion criteria were subjected for LLR testing in the upper limb at median nerve. The presence or absence of LLR was assessed and also the latency, amplitude, and duration assessed. Results and Conclusion: LLR 2 is differentially affected in both these conditions. Absence of LLR2 was consistently seen in FTD which can be explained by early break down of frontal subcortical circuits in this condition as against AD. This is likely to serve as a very cheap and very early biomarker to differentiate the two common types of cortical dementias.
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Personality profile and short-term treatment outcome in patients with alcohol dependence: A study from South India p. 169
Soundarya Soundararajan, Gitanjali Narayanan, Arpana Agrawal, Pratima Murthy
DOI:10.4103/0253-7176.203127  
Background: Studying personality profiles allows researchers to generate important hypotheses in risk factors and correlates of alcohol use/misuse. Studies examining the association between personality traits and treatment outcome are limited in India. We studied the correlation between personality and treatment outcome in patients with alcohol dependence. Methods: Adult participants with alcohol dependence were recruited from the inpatient and outpatient wards of de-addiction unit of a tertiary care facility in India using a prospective design and followed up after 3 months. Questionnaires administered were revised NEO personality inventory (NEO-PI-R), alcohol use disorders identification test, and advanced warning of alcohol relapse (AWARE). Results: Out of 99 recruited participants (92% males) with mean age of 37 (±8.36) years, 82 (82.8%) patients were followed up to 3 months. E4 (activity) facet of the extraversion domain in the NEO-PI-R significantly correlated with the baseline drinking scores (r = 0.204, P = 0.042, n = 99) and AWARE scores (r = 0.276, P = 0.043, n = 54). There was a significant negative correlation between the E2 (gregariousness) facet and satisfaction with life scores (r = −0.211, P = 0.036, n = 99). Age at first drink was significantly lower among relapsers (P = 0.021). Conclusion: Our study suggests that factors related to extraversion, specifically, high activity might be associated with higher drinking as well as higher risk of alcohol relapse. Predicting alcohol relapse by studying the personality traits would help clinicians in improving treatment outcomes.
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Quantitative balance and gait measurement in patients with frontotemporal dementia and Alzheimer diseases: A pilot study p. 176
Selva Ganapathy Velayutham, Sadanandavalli Retnaswami Chandra, Srikala Bharath, Ravi Girikamatha Shankar
DOI:10.4103/0253-7176.203132  
Introduction: Alzhiemers disease and Frontotemporal dementia are common neurodegenerative dementias with a wide prevalence. Falls are a common cause of morbidity in these patients. Identifying subclinical involvement of these parameters might serve as a tool in differential analysis of these distinct parameters involved in these conditions and also help in planning preventive strategies to prevent falls. Patients and Methods: Eight patients in age and gender matched patients in each group were compared with normal controls. Standardizes methods of gait and balance aseesment were done in all persons. Results: Results revealed subclinical involvement of gait and balancesin all groups specially during divided attention. The parameters were significantly more affected in patients. Patients with AD and FTD had involement of over all ambulation index balance more affected in AD patients FTD patients showed step cycle, stride length abnormalities. Discussion: There is balance and gait involvement in normal ageing as well as patients with AD and FTD. The pattern of involvement in AD correlates with WHERE pathway involvement and FTD with frontal subcortical circuits involvement. Conclusion: Identification the differential patterns of involvement in subclinical stage might help to differentiate normal ageing and the different types of cortical dementias. This could serve as an additional biomarker and also assist in initiating appropriate training methods to prevent future falls.
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Subacute noninfective inflammatory encephalopathy: Our experience and diagnostic problems p. 183
Sadanandavalli Retnaswami Chandra, Lakshminarayanapuram Gopal Viswanathan, Dodmalur Malikarjuna Sindhu, Anupama Ramakanth Pai
DOI:10.4103/IJPSYM.IJPSYM_433_16  
Introduction: Immune dysregulation associated encephalopathies present with significant psychiatric manifestations and only a few soft neurological and general systemic features. They are generally resistant to treatment with psychiatric medications. Generalized orthostatic myoclonus and faciobrachial dystonic seizures are mistaken as Creutzfeldt-Jakob disease and subacute sclerosing panencephalitis. Patients and Methods: Forty-two patients seen during 2010–2015 and diagnosed as noninfective encephalopathy were analyzed. Those patients with infective causes and those who had significant features of systemic manifestations of vasculitis and other disorders of central nervous system were excluded from the study. They were investigated with cerebrospinal fluid imaging, electroencephalogram (EEG), and antibody profile. Results: More than 70% patients had psychiatric manifestation as presenting features and reported to psychiatrist. Three patients had paraneoplastic and others N-methyl-D-aspartate, voltage-gated potassium channel, thyroid peroxidase, antinuclear antibody related, and few were due to unknown antibody. Conclusion: Serious diagnostic errors are common and early diagnosis is based on high degree suspicion in patients presenting with new-onset refractory psychosis. Soft neurological features should be looked for and EEG serves as a very sensitive tool in establishing organicity.
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CASE REPORTS Top

Dandy–Walker variant with schizophrenia: Comorbidity or cerebellar cognitive affective syndrome? p. 188
Pallavi Sinha, Jatin Tarwani, Pankaj Kumar, Amit Garg
DOI:10.4103/0253-7176.203108  
Dandy–Walker complex (DWC) is a series of neurodevelopmental anomalies involving the posterior cranial fossa. The cerebellum has long been considered to be involved in motor coordination and balance. However, it has now been noted to play an important role in higher order cognitive, emotional, and behavioral functions. The concept of cerebellar cognitive affective syndrome, describing a coherent spectrum of cognitive and behavioral disturbances in adults following cerebellar damage has long been proposed. There have been reported cases of co-occurring psychiatric symptoms and DWC in literature, but the conclusive evidence for an association between the same remains lacking. Herein, we report a case of schizophrenia presenting along with Dandy–Walker Variant.
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A rare case of complicated opioid withdrawal in delirium without convulsions p. 191
B Neeraj Raj, N Manamohan, Divya Hegde, Chandrashekar B Huded, Johnson Pradeep
DOI:10.4103/0253-7176.203109  
Opioids are one of the commonly abused substances in India. Opioid withdrawal symptoms classically include severe muscle cramps, bone aches, autonomic symptoms, anxiety, restlessness, insomnia, and temperature dysregulation. However, reports of cases with delirium during withdrawal are few. A 25-year-old male with severe opioid withdrawal symptoms developed delirium. Investigations were normal. There were no comorbidities, no significant past history and family history. Patient treated for opioid dependence with tapering doses of lorazepam and clonidine. He was discharged with naltrexone. Patient lapsed 3 months later with similar presentation. Complications such as convulsions and delirium are recognized in alcohol withdrawal. However, these are rare as a feature of opioid withdrawal. This case illustrates the need for psychiatrists and physicians to be aware of the possibilities of delirium with opioid withdrawal and monitoring for the same is important because of its complications.
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Arachnoid cyst and psychosis: The troublemaker or innocent bystander p. 194
Soumitra Das, Arjun Kartha, Sumesh Thoppil Purushothaman, Varun Rajan
DOI:10.4103/0253-7176.203107  
Organic underpinning of a psychotic disturbance is often missed. Arachnoid cysts are considered a rare neurological tumor, few of which exhibit any symptomatology. In most cases, they are diagnosed by accident. Literature regarding the coexistence of arachnoid cysts with psychiatric disorders is sparse. Here, we present a case who presented with a typical presentation of psychosis which was not enough for suspecting for an organic etiology.
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Pseudocyst pancreas with delirium in a married alcohol dependent male: A rare presentation p. 196
Gurvinder Pal Singh
DOI:10.4103/0253-7176.203111  
We herein present a patient with a history of heavy alcohol abuse who developed pseudocyst Pancreas and delirium, who came to our hospital for treatment. The patient recovered well with treatment.
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Efficacy of myofascial unwinding and myofascial release technique in a patient with somatic symptoms – A case report p. 199
Manu Goyal, Kanu Goyal, Manish Bathla, D Kanimozhi, D Narkeesh
DOI:10.4103/0253-7176.203113  
Depression is an aversion to activity disorder which could lead to somatic dysfunctions such as insomnia, excessive sleeping, body aches, listlessness, and irritable bowel syndrome. The World Health Organization has projected the depression to be the second leading cause of disability worldwide by 2020. The physical and mental ill effects of somatic depression can be addressed using the osteopathic manipulative treatment. Therefore, the purpose of the present case report is to explore the effect of myofascial release (MFR) technique and myofascial unwinding (MFU) in the somatic depression. We reported a case of a 39-year-old female diagnosed as dysthymia with moderate depression with somatic symptoms. She was treated with MFR and MFU for 4 weeks. Depression was scored using Hamilton Depression Rating Scale (HDRS), and quality of life was measured using the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). Both were administered preintervention and 6 weeks postintervention. The application of MFR and MFU resulted in the improved scores on both HDRS and Q-LES-Q-SF. The present case positive results have proven the effectiveness of MFR and MFU as an important adjunctive treatment strategy.
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Leukodystrophy presenting as hyperactivity and bipolarity with uncommon adverse drug reaction p. 202
Roshan Sutar, Anirban Ray, Shekhar P Sheshadri
DOI:10.4103/0253-7176.203115  
Leukodystrophy is a group of demyelinating neurodegenerative diseases of brain with varied presentation and multiple etiologies. Prognosis is predominantly dismal. Misdiagnosis and wrong treatment are common in this group of rare neurological disorders, especially when it presents with psychiatric symptoms. In this case, importance of neurological and radiological evaluation and need for high diagnostic suspicion in treatment-resistant psychiatric disorders is highlighted.
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Secondary eating disorder: A reality? Case report of post brain injury sequelae p. 205
Aparna Das, Deeksha Elwadhi, Manushree Gupta
DOI:10.4103/0253-7176.203112  
Traumatic brain injury (TBI) can lead to changes in eating behavior patterns. This report describes the case of a patient with alcohol dependence presenting with behavioral changes and eating disorder following frontal lobe trauma. A 42-year-old male, premorbidly well-adjusted presented with alcohol use in dependent pattern for years. He sustained a subdural hematoma in the frontal lobe following a road traffic accident 10 years back. Post-TBI, the patient, started having low frustration tolerance, aggressive outbursts, disinhibition, difficulty in persisting with tasks, apathy, amotivation, and craving for food with inability to control intake on the sight of food. On testing, a deficit in frontal lobe functions was seen. Magnetic resonance imaging scan showed large areas of gliosis and encephalomalacia involving both frontal lobes with parenchymal loss. Eating disorders have been reported after TBI. This case report underscores a major role of frontal-subcortical circuits in regulation of eating habits.
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Delayed Stevens–Johnson syndrome secondary to the use of lamotrigine in bipolar mood disorder p. 209
Kunal Kishor Jha, Durgesh Prasad Chaudhary, Tshristi Rijal, Semanta Dahal
DOI:10.4103/0253-7176.203130  
Lamotrigine is a mood-stabilizing drug used in maintenance treatment of bipolar I disease. There are adverse effects with lamotrigine such as a headache, blurred vision, diplopia, somnolence, ataxia, dizziness, rash, Stevens–Johnson syndrome (SJS), and toxic epidermal necrolysis. SJS is a life-threatening, blistering mucocutaneous disease. SJS is characterized by the presence of flat, diffuse erythematous maculopapular rashes with the involvement of <10% of the body surface area. Standard trigger is drugs including anticonvulsants, antibiotics, and Mycoplasma pneumoniae infection. We report a case where a patient developed SJS secondary to delayed-type hypersensitivity reaction after 6 months of the use of lamotrigine, while his initial response during the first 6 months did not show any sign of SJS.
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LETTERS TO EDITOR Top

Cushing's syndrome and treatment-resistant depression p. 213
Lekhansh Shukla
DOI:10.4103/0253-7176.203114  
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Autonomous sensory meridian response: What is it? and Why should we care? p. 214
James V Lloyd, Thomas P. O. Ashdown, Lucy R Jawad
DOI:10.4103/0253-7176.203116  
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Asymmetric, tender gynecomastia induced by olanzapine in a young male p. 215
Mohit Kumar Shahi, Sujita Kumar Kar, Amit Singh
DOI:10.4103/0253-7176.203118  
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Gender differences in persistent delusional disorder p. 216
Karishma R Kulkarni, Rashmi Arasappa, M Krishna Prasad, Amit Zutshi, Prabhat K Chand, Pratima Murthy, Kesavan Muralidharan
DOI:10.4103/0253-7176.203123  
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Salami slicing of data set, translational plagiarism, and self-plagiarism: The storyline p. 218
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/0253-7176.203131  
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