Indian Journal of Psychological Medicine
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   Table of Contents - Current issue
January-February 2018
Volume 40 | Issue 1
Page Nos. 1-100

Online since Thursday, January 11, 2018

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The clock drawing test versus mini-mental status examination as a screening tool for dementia: A clinical comparison p. 1
Delnaz Palsetia, G Prasad Rao, Sarvada C Tiwari, Pragya Lodha, Avinash De Sousa
There is a growing incidence of dementia patients in the community, and with this growth, there is need for rapid, valid, and easily administrable tests for the screening of dementia and mild cognitive impairment in the community. This review looks at the two most commonly used tests in dementia screening, namely, the clock drawing test (CDT) and the mini-mental status examination (MMSE). Both these tests have been used in dementia screening over the past three decades and have been the subject of scrutiny of various studies, reviews, and meta-analysis. Both these tests are analyzed on their ability to assess dementia and screen for it in the community, general practice and general hospital settings. The methods of administration and scoring of each test are discussed, and their advantages and disadvantages are explained. There is also a direct comparison made between the MMSE and CDT in dementia screening. Future research needs with these tests are also elucidated.
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Perceptions of accredited social health activists on depression: A qualitative study from Karnataka, India p. 11
Aruna Rose Mary Kapanee, KS Meena, Prasanthi Nattala, Narayana Manjunatha, Paulomi M Sudhir
Background: Depression is a significant public health concern in India, associated with a large treatment gap. Assessing perceptions of Accredited Social Health Activists (ASHAs) on depression can be invaluable as they are selected to work at the interface between their own communities and the health-care delivery system. Aims and Objectives: This study aimed at utilizing a qualitative approach to examine the ASHAs' understanding of depression, their mental health-care practices specific to depression, and their capacity-building needs with regard to identification and helping persons with depression. Subjects and Methods: A cross-sectional qualitative study using two focus group discussions was conducted. The sample comprised 14 ASHAs in the age range of 25–45 years from Bengaluru urban district. The data were analyzed manually by the method of directed content analysis. Results: The ASHAs were found to have inadequate knowledge of the signs and symptoms of depression, its biopsychosocial nature, and its impact on functioning. Causation of depression was narrated in terms of psychosocial stressors. The majority expressed the need for primarily psychosocial interventions for depression. All participants reported their motivation to obtain training in identifying persons with depression and providing simple psychosocial intervention for them. Conclusion: This study indicates that ASHAs have poor knowledge of depression, which could be leading to its low recognition and treatment in the communities they work in. They are therefore likely to benefit from capacity building on depression which includes familiar nomenclature, biopsychosocial elucidation of the illness, life-span approach, understanding of its impact on various domains of functioning, and the treatments available.
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Attitude toward selfie taking and its relation to body image and narcissism in medical students p. 17
Era Dutta, Payal Sharma, Nilesh Shah, Anup Bharati, Sushma Sonavane, Avinash Desousa
Background: The recent and rapidly popularized social phenomenon of selfie taking has been showing an increasing trend. It is thus imperative to assess the knowledge, attitude, and perception of the groups toward this phenomenon. Selfie taking is associated with younger age groups and hence, we aimed to explore the attitudes toward selfie taking and its relation toward body image and narcissism in medical college students. Methodology: This was cross-sectional study and had two groups with Group A comprising 92 first year medical students and Group B including 103 postgraduate (PG) medical students from various specialties. They were interviewed in a single session using the scale of attitude toward selfie-taking questionnaire, Body Image Acceptance and Action Questionnaire (BIAAQ), and the narcissistic personality inventory. Scores obtained were computed using basic descriptive statistics and t-test where appropriate. Results: A strong positive favorable trend toward selfie taking was noticed among both groups (A = 56.5%, B = 45.6%). There was no difference in attitude between the two groups, or difference in the gender between those clicking their own selfies regularly within each group. BIAAQ reflected a significant difference among male subjects of the two groups with PG students was more concerned about body image (P = 0.001), whereas female subjects of both groups showed no such difference. The narcissism traits also showed a significant difference, only when males of both groups were compared again in favor of PG medical students (P = 0.022). Conclusion: This study revealed that selfie-taking is popular among medical students both in their undergraduate and PG period. Further research in diverse clinical and nonclinical populations is warranted to explore the relation between this phenomenon and body image acceptance or narcissistic traits.
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Spousal caregiver burden and its relation with disability in schizophrenia p. 22
R Arun, S Inbakamal, Anna Tharyan, Prasanna S Premkumar
Background: Schizophrenia, a chronic psychiatric disorder, can affect one's productivity and psychosocial functioning. In Indian context, the responsibility of caring persons with schizophrenia is increasingly on their spouses. Spousal caregiver experience and its relation with disability in schizophrenia need to be studied. Materials and Methods: We conducted a cross-sectional study among 52 outpatients with schizophrenia and their spouses attending a tertiary psychiatric center. The objectives were: (a) to explore spousal caregiver burden in schizophrenia and (b) to assess the relation between disability and spousal caregiver burden. The study adopted recommended ethical principles. Scales such as Burden Assessment Schedule, Indian Disability Evaluation and Assessment Scale (IDEAS), and Positive and Negative Syndrome Scale were used to collect appropriate data. Descriptive analysis, bivariate analysis, and multivariate analysis were done in SPSS software version 16.0. Results: The mean spousal caregiver burden score was 73.5 (standard deviation: 14.0). In bivariate analysis, disability, duration of schizophrenia, severity of schizophrenia, place of residence, and socioeconomic status had statistically significant relation with spousal caregiver burden. Adjusted for spouses' age, gender, and other significant factors in bivariate analysis, the IDEAS global disability score (2.6, [confidence interval 0.5–3.8, P = 0.013]) retained statistically significant association with spousal caregiver burden. Conclusion: Spouses of persons with schizophrenia experience significant caregiver burden. Disability was found to be the most powerful determinant of spousal caregiver burden in the sample. Focus on disability alleviation in the management of schizophrenia may help reduce spousal caregiver burden.
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The confirmatory factor analysis of the original brief intellectual disability scale and alternative models p. 29
Priya Mary Mammen, Minju K Asokan, Sushila Russell, Sherab Tsheringla, SatyaRaj Shankar, Muttathu K C. Nair, Paul Swamidhas Sudhakar Russell
Objective: Brief Intellectual Disability Scale (BIDS) is a measure validated for identification of children with intellectual disabilities (IDs) in countries with low disability resources. Following the publication of the exploratory factor analysis of BIDS, the authors have documented the confirmatory factor analysis (CFA) of BIDS in this study. Materials and Methods: A prospective cross-sectional study was conducted to document the CFA of the BIDS. Primary caregivers (N = 124) of children with ID were recruited and rated the BIDS. We used alternative fit indices for the evaluation of comparative fit index (CFI) and root mean square error of approximation (RMSEA) to evaluate the model fit. The 2-index fit strategy was used to select the best factor model. Results: The model fit index for the original 3-factor model and alternative 2-factor and 1-factor models with 9 items of the BIDS was under identified along with another 3-factor, 7-item model. Another 1-factor, 7-item model was identified but did not satisfy the 2-index fit strategy. A short version of the scale with a 2-factor and 7-item model of BIDS presented the best fit indices of CFI = 0.952 and RMSEA = 0.069. Conclusion: Although the original factor structure of BIDS was not confirmed in this study, another alternative a priori model for the construct validity of BIDS was confirmed. Therefore, the BIDS factor structure has been revised, refined, and trimmed to the final 2-factor, 7-item shorter version. Further documentation of the diagnostic accuracy, validity, and reliability of this shorter version of BDI is recommended.
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Dysfunction among families of children with intellectual disability in india using systems model: Prevalence, Pattern, and Severity of impairment p. 33
Pastin Pushpa Rani, Helen Charles, Paul Swamidhas Sudhakar Russell, KG Selvaraj, Priya Mary Mammen, Sushila Russell, Muttathu K C. Nair
Objectives: Family dysfunction is observed in families with children with intellectual disability (ID). We study the prevalence, pattern of dysfunction, and severity of impairment in these special families using Systems approach. Methods: Sixty-two special families (a child with ID) and 62 typical families (all children with typical development) were included in the present study. The presence of ID was confirmed and quantified with the Binet–Kamat Scale of intelligence or Gesell's Developmental Schedule and Vineland Social Maturity Scales among the special families. In the typical families, brief ID scale was used to rule out ID. Prevalence, pattern, and severity of family dysfunction were assessed using Family Apgar Scale, Chicago Youth Development Study Family Assessment Scale and Global Assessment of Relational Functioning Scale, respectively. Appropriate bivariate analyses were used. Results: About 53% of special families and 19% of typical families had family dysfunction. About 21% of special families and 71% of typical families had the satisfactory relational unit. Areas of adaptability, partnership, growth, affection, resolve, beliefs about family, beliefs about development, beliefs about purpose, cohesion, deviant beliefs, support, organization, and communication were significantly different between special and typical families. The functional impairment was significantly more in the special families. Conclusion: Family dysfunction is more prevalent among special families in India using systems approach. These families should be screened for dysfunction, and family therapy be prescribed when required.
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Add-on aripiprazole for atypical antipsychotic-induced, clinically significant hyperprolactinemia p. 38
Dhanya Raveendranthan, Naren P Rao, Mukund G Rao, Ajish G Mangot, Shivaram Varambally, Muralidharan Kesavan, Ganesan Venkatasubramanian, Bangalore N Gangadhar
Background: Antipsychotic treatment-induced hyperprolactinemia is a highly distressing and disabling side effect for patients. The use of add-on aripiprazole has been identified as a possible treatment strategy in this situation. However, data on prolactin changes with add-on aripiprazole in a real-world naturalistic clinical setting from India are sparse. Materials and Methods: The retrospective chart review was conducted at the specialty metabolic clinic at the National Institute of Mental Health and Neurosciences, Bengaluru, India. Sixteen patients (female: male = 13:3) who were on a stable dose of antipsychotic medications, complaining of either sexual dysfunction or menstrual irregularities, were prescribed add-on aripiprazole. The serum prolactin values were obtained before the initiation of aripiprazole and during the follow-up. Results: Patients were on treatment with risperidone, amisulpride, and olanzapine and had a prolactin level of 87.1 ± 60.7 ng/ml. Add-on aripiprazole treatment was given with a mean dose of 13.8 ± 7.4 mg/day. Patients had a significant reduction in prolactin level (35.6 ± 29.1 ng/ml) following treatment with aripiprazole (P = 0.004). Conclusions: Add-on aripiprazole could be a clinically useful strategy in patients who develop antipsychotic-induced hyperprolactinemia.
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Psychological dissection of patients having dissociative disorder: A cross-sectional study p. 41
Lohit Somashekar Reddy, NM Patil, Raghavendra B Nayak, Sameeran S Chate, Saba Ansari
Background: Patients present with dissociative disorders as a decompensation to underlying stressful situation. It is clinically important to evaluate the presence, type, and temporal relation of the stressors resulting in dissociation. Further knowing the sociodemographic and psychological profile of the dissociative patient helps in better management. Materials and Methods: The study included 55 dissociative patients aged between 5 to 45 years. Psychiatric diagnosis was made using ICD-10 DCR. Psychosocial stressors and stressful life events were assessed using presumptive stressful life events scale/life events scale for Indian children and clinical interview. Personality and temperament traits were assessed using medico psychological questionnaire and temperament measurement schedule, respectively. Intelligence quotient (IQ) was assessed using standard progressive matrices and colored progressive matrices. Statistical analysis was done using Epi Info 7 software. Results: All patients had significant psychosocial stressors preceding dissociation. Precipitating factor with temporal association was observed in only 83.64%. Family disharmony (41.82%) followed by education-related problems (29.09%) was the most common psychosocial stressors. 61.82% of the dissociative patients had psychiatric comorbidity. Mean IQ of study sample was 92.47. Dissociative children had high emotionality and energy levels but low sociability, rhythmicity, and distractibility. 50% of the adults were neurotic and had emotionally unstable personality. Conclusion: Dissociative disorders are commonly seen in females, adolescents, and in those from lower socioeconomic status and rural areas. They are always preceded by psychosocial stressors. Most of them have comorbid psychiatric disorders such as depression and anxiety. Neuroticism and emotionally unstable personality traits are common in adult patients while temperamental traits such as low sociability, low rhythmicity, low distractibility, high emotionality, and high energy levels are common in children.
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Suicidal nonorganophosphate poisoning in a Tertiary Hospital in South India: Nature, Prevalence, Risk Factors p. 47
Rohit Ninan Benjamin, Thambu David, Ramya Iyadurai, KS Jacob
Background: People who deliberately ingest poisons commonly present to emergency departments of hospitals in India. However, there is a dearth of information on poisoning using nonorganophosphorus pesticides. Methods: This prospective, hospital-based study attempted to examine the nonorganophosphorus poisons used to attempt suicide. Data on sociodemographic characteristics of patients, site and source of poisons, co-ingested substances, premeditation, and reason for poisoning were collected. A multinomial logistic regression was performed to determine association between poison class and these exposure characteristics. Results: Three hundred and forty-one cases of attempted suicide presented during the 6-month period (1.7% of all emergency room admissions). The majority was predominantly male and was young adults. Poisoning was the most common mode (91.7%), followed by hanging (7.3%) and self-injury (3, 0.9%). Pesticides (44.3%) including organophosphates (25.5%) were the predominant poisons, followed by pharmaceuticals (27.9%), caustics/chemicals (12.0%), and plant poisons (7.0%). One hundred and nine were available for prospective interview as the others who presented were not detained for prolonged observation the emergency department. Most patients who ingested such poisons were women, from rural backgrounds and were educated. The majority sourced the poisons from home, consumed poison at home, and mixed the poison with water; these attempts were impulsive and seemed to be in response to relationship conflicts. In the multivariate analysis, education (P = 0.08) and poison source (outside the home) were significant predictors of pesticide ingestion. Conclusions: Suicidal poisoning results from a complex synthesis of socioeconomic and psychological factors; certain patterns of poisoning are likely to be more prevalent in demographic niche groups.
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Interepisodic functioning in patients with bipolar disorder in remission p. 52
Mareena Susan Wesley, M Manjula, Jagadisha Thirthalli
Background and Objectives: Patients with bipolar disorder (BD), despite recovering symptomatically, suffer from several functional impairments even in remission. The actual causes of impaired functioning are less known. Materials and Methods: The study aimed to examine the clinical and psychosocial determinants of functioning in patients with BD in remission. A cross-sectional single-group design was adopted (n = 150). Participants meeting the study criteria were screened with Mini-International Neuropsychiatric Interview Scale. The selected participants were administered various tools to assess the level of functioning and the clinical, psychosocial determinants of functioning. Results: The clinical characteristics of the sample included early age of onset of illness, presence of precipitating factors, fewer episodes, minimal comorbidities, history of psychotic episodes, family history of mental illness, good medication adherence, and low depression and mania scores. Psychosocial factors included higher stress and moderate social support and self-esteem in the sample. Poor functioning patients had a history of longer hospital stay and had greater scores on depression, mania, stress, and maladaptive coping styles than better functioning patients. Conclusion: Higher depression, mania, stress, and maladaptive coping strategies were related to poor functioning, while higher medication adherence, self-esteem, and social support were related to better functioning.
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Can plasticity transform functions in neurodegeneration in children as well as adults? an observational study p. 61
Sadanandavalli Retnaswami Chandra, Safwan Ahamed, Chandra Sasitharan Vidhya Annapoorni
Introduction: Creativity is a physiological need based biological function very essential for survival. However, generally in disorders of progressive cognitive dysfunction creative skills are lost. However there are situations where these potentials are temporarily enhanced. Patients and Methods: We did an observational study of children and adults, 5 adults and 2 childrens, who showed extraordinary creativity evaluated based on evidence shown by patient, peers and re produced in test situation. Discussion: Our observational study reveals spontaneous interest in new and useful creative activity in our patients with various disorders causing progressive cognitive dysfunction. This observation reveals creative gain of function does take place in the face of progressive cognitive dysfunction in the setting of several diseases and it serves as a treatment option in behaviour management. Whether it is due to disinhibition of creative areas in the brain or facilitated function in regenerating data linking circuits needs further study. Conclusion: Set goals which are survival instinct based activities are probably removed by neurodegeneration and thereby the innate creativity gets disinhibited and expressed in wonderful forms of creativity. Whether special creative circuits in the brain, which causes this extraordinary creativity also needs to be studied. These creative skills in some of our patients served as effective pharmaco sparing agents during periods of aggression and agitation by engaging them in those activities, utility of which can be considered as a therapeutic option.
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Unrecognized prevalence of macrocytosis among the patients with first episode of psychosis and depression p. 68
Ramdas Sarjerao Ransing, Suvarna Patil, Krishna Pevekar, Kshirod Mishra, Bharat Patil
Background: Mood disorders and psychosis has been reported among the patients with macrocytosis; however, its prevalence among the first episode of psychosis and depression is unknown. The purpose of the study was to establish the prevalence of macrocytosis among the patients with the first episode of depression and psychosis. Materials and Methods: In this cross-sectional study, three groups comprising patients with first episode of depression (n = 100), patients with the first episode of psychosis (n = 100), and healthy controls (n = 100) were included. Blood samples were collected from each participant and analyzed using the automated coulter counter. The hematological variables (e.g., macrocytosis, anemia) in the three groups were compared using the Chi-square and analysis of variance tests. Results: The prevalence of macrocytosis among patients with depression and psychosis was 2.6 (8%) and 3.3 times (11%) higher, respectively than that among the healthy controls (3%). In addition, the hemoglobin concentration, mean corpuscular volume and mean platelet volume in patients with first episodes of psychosis and depression significantly differed from those in healthy controls P < 0.001. Conclusion: This study showed that the prevalence of macrocytosis among the first episode of depression and psychosis was higher than healthy controls. Macrocytosis may have etiological and prognostic significance among these patients. Prospective studies are needed to explore the clinical significance of macrocytosis among the patients with depression and psychosis in the clinical practice.
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A pilot study of correlation between intelligence quotient, Social quotient, and Ayurveda parameters in children p. 74
Satyam Sharma, Anuradha Balsavar, RP Beniwal, Triptish Bhatia, Smita N Deshpande
Background: Intelligence quotient (IQ) and social quotient (SQ) are comparable in predicting intelligence status. The latter is assessed whenever IQ testing is not possible. According to Ayurveda, Buddhi (intelligence) is affected by Prakriti (body constitution) which depends on the predominance of Tridosha and Triguna. There is a paucity of studies to examine their association. The study was designed to examine correlation among IQ, SQ, performance quotient (PQ) and maladaptive behaviour; and to find out their relationship with primary (Anubandhya) and secondary (Anubandha) doshas with intelligence in children with mild to moderate intellectual disability. Methodology: Children (n = 120) were recruited from outpatient department of a tertiary care hospital as part of a clinical trial of a novel Ayurveda formulation. Stanford Binet Scale, Vineland Social Maturity Scale, Seguin Form Board Test, and Maladaptive Behavior Schedule-II were administered. Ayurvedic parameters were assessed clinically by Ayurveda practitioner. Separate regression analyses were carried out to look for associations. Results: IQ and SQ were positively correlated (P = 0.01). Maladaptive behavior and SQ were negatively correlated (0.05). SQ was associated with secondary dosha (P = 0.002) and stage of disease (Roga Kriyakala) (P = 0.015). IQ was also associated with secondary dosha (P = 0.008). Conclusion: SQ and IQ are positively correlated. The correlation of Anubandha (secondary) dosha was high on IQ and SQ.
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A 12-week comparative prospective open-label randomized controlled study in depression patients treated with vilazodone and escitalopram in a tertiary care hospital in North India p. 80
Manish Bathla, Shazia Anjum, Manpreet Singh, Saminder Panchal, Gurvinder Pal Singh
Background: Depression is a leading cause of morbidity in modern world and introduction of selective serotonin reuptake inhibitors (SSRIs) was a revolution for treating depression. However, sexual dysfunction and weight gain always remained an issue for patients leading to discontinuation of treatment. Vilazodone is a novel SSRI and literature show better efficacy and decrease weight gain and sexual dysfunction. Aim of study: This study aims to compare the efficacy, sexual dysfunction, and weight gain caused due to vilazodone and escitalopram. Methodology: This is an open-label randomized, controlled study; 60 patients diagnosed as depression were divided into two groups of 30 each. One group was started on vilazodone and one on escitalopram randomly. The groups were compared on the basis of efficacy, weight gain, and sexual dysfunction by applying Hamilton Depression Rating Scale (HDRS) and Arizona Sexual Experience Scale (ASEX) at baseline, 4, and 12 weeks interval. Statistical analysis was done by applying Chi-square, t-test, and fisher exact test and descriptive analysis. Results: Vilazodone group shows fall in HDRS with 18.77 ± 4.3, 14.83 ± 3.68, and 9.63 ± 3.06 while it was 18.8 ± 4.09, 14.3 ± 2.96, and 8.43 ± 2.1 at baseline, 4, and 12 weeks, respectively. ASEX score in vilazodone was found to have 16.87 ± 2.97, 15.37 ± 3.1, and 11.73 ± 3.55 while on escitalopram, 16.4 ± 3.35, 17.13 ± 3.48, and 18.37 ± 4.09 at first visit, 4, and 12 weeks, respectively. Patients on vilazodone had mean weight of 69.63 ± 7.7, 69.83 ± 7.83, and 69.9 ± 7.69 while on escitalopram, 72.47 ± 7.95, 72.87 ± 7.9, and 75.6 ± 8.46 at baseline, 4, and 12 weeks, respectively. Conclusions: Our study shows that vilazodone has better efficacy, lesser weight gain, and lesser sexual dysfunction.
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A case of obsessive–Compulsive disorder comorbid with miyoshi myopathy p. 86
Arpit Parmar, Rohit Verma
Obsessive–compulsive disorder (OCD) is a common neuropsychiatric disorder, with predominant involvement of cortico-striato-thalamo-cortico circuitry. Although late-onset cases (>35 years) usually show an association with various neurological disorders involving basal ganglia and thalamus, it is not the case with the young-onset patients. There have been no reports of OCD comorbid with dysferlinopathy which is usually considered as a disease involving only muscles. However, recently, studies suggest involvement of brain in this disease. Here, we report a case of dysferlinopathy comorbid with OCD and discuss the related literature.
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A case of rapidly progressing frontotemporal dementia p. 89
Debasweta Purkayastha, Praveen Arathil, Dinesh Narayanan
Frontotemporal dementia commonly presents as a gradual change in personality, social conduct, and language ability, often sparing memory loss in early stages. We report a case of a 55-year-old female with rapid progression of memory impairment and other cognitive functions in a span of 2 years.
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Amisulpride reexposure and tardive dyskinesia p. 91
Ajeet Sidana
To highlight the association between amisulpride and onset of tardive dyskinesia (TD) in patient suffering with psychosis not otherwise specified (NOS), who has already been treated with amisulpride for many years. A 40-year-old female suffering with psychosis NOS since 19 years presented with recurrence of positive symptoms in the form of delusion of persecution, ideas of grandiosity since last 3 months. She was treated with amisulpride up to 400 mg/day and developed involuntary oro-buccal-lingual movement within 2 months of amisulpride therapy. Amisulpride an atypical antipsychotic can lead to the development of TD in patient who already received amisulpride for many years in the past. Reexposure with amisulpride can lead to early onset of TD due to blockade of already unregulated postsynaptic supersensitive dopamine receptors.
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Quetiapine-induced diabetic ketoacidosis p. 93
Soumitra Das, Dhanya S Palappallil, Arjun Kartha, Varun Rajan
Psychomotor retardation and extrapyramidal symptoms have limited the conventional antipsychotic use. Atypical antipsychotics though widely prescribed with good tolerability and efficacy, the metabolic complications associated with them are of clinical importance. Diabetic ketoacidosis (DKA) is a fatal complication of atypical antipsychotic use. We report a case of new-onset diabetes presenting as DKA with quetiapine use.
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Early marked behavioral symptoms in bilateral posterior cerebral artery stroke: A disguised presentation p. 96
Sourav Khanra, Neelanjana Paul, Swapan Mukherjee
Clinical signs and symptoms of posterior cerebral artery (PCA) stroke are varied and can be challenging to diagnose at early stage. A case of bilateral PCA infarct presenting with marked behavioral symptoms and minimal neurological symptoms is presented here. A 34 years old female had presented with marked behavioral symptoms, blurring of vision and tingling sensation in left half of body. Though the latter complaints resolved following day, her behavioral complaints persisted. Magnetic Resonance Imaging (MRI) of brain revealed acute non-hemorrhagic infarct in bilateral PCA territory. Psychotropics were beneficial for her behavioral symptoms. Isolated behavioral symptoms in PCA stroke led to speculate anatomical substrate for those symptoms. We discussed possible anatomical substrates for behavioral symptoms. Our case adds to the existing literature on a range of disguising presentations in PCA stroke and also emphasizes those distinctions between 'neurological' or 'psychological' or 'psychiatric' disorders are often sketchy.
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Desvenlafaxine overdose-induced toxic cardiomyopathy and acute left ventricular failure: A case report p. 99
Sandeep Kumar Goyal, Chanchal Gera, Mamta Singla, Nitin Kumar
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