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Archives of Indian Psychiatry

Official Publication of the Indian Psychiatric Society, Western Zonal Branch

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Archieves of Indian Psychiatry is the official journal of Indian Psychiatric Society, Western Zonal Branch published twice in a year Subscitpion : Annual subscription rates are Rs. 700/- for individuals and Rs. 1000/- for institutions. Please send DD in favour of Editor, Archives of Indian Psychiatry Payable at Ahmedabad. Correspondence related to advertisements should be addressed to the editorial office. Copyright : Indian Psychiatric Society Western Zonal Branch
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Archives of Indian Psychiatry 10(1) April 2009

Archives of Indian Psychiatry


Official Publication of the Indian Psychiatric Society, Western Zonal Branch Mrugesh Vaishnav President

Chairpersons Subcommittees Lata Vaya Awards

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Ravindra Kamat C.M.E. Mukesh Jagiiwala Conference Paresh Shah Constitution Shrikant Deshmukh Legal Cell

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Jitendra Nanawala Imm. Past President Vipul Sangani Membership Mukesh Jagiwala Kishor Gujar Representatives of Central Council

Avinash Joshi Mental Health Awareness

Bansi Suwalka Lalit Vaya Mangalam Rathod Lalit J.Shah Pramod Thakre Deepak Rathod Executive Council Mambers

Neena Savant Psychiatric Eduction

Kausor Abbasi Quiz

Archives of Indian Psychiatry 10(1) April 2009

Archives of Indian Psychiatry


Contents
In This issue Editorial L.P. Shah O ration M aking R ecovery a Reality M rugesh V aishnav President, IPS W estern Zon al Bran ch

Official Publication of Indian Psychiatric Society Western Zonal Branch Volume 10, No.1, April 2009

K hyati M ehtaliya R.Th ara A sho k G .Patel

4 5 6 16

Presidentia l A ddress The Psycholo gy and Psych iatric Consequen ces of T errorism : A n Indian P erspective O riginal A rticle D issociation in Psychiatric Inp atients Stress and S om atic C om plaints in M edical C ollege Stu dents

M rugesh V aishnav

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N ilim a Shah G .K .V ankar A nuradha Sovani Sw ati Bhave Sharad A garkhedkar et al Zindadil G andhi G .K . V ankar Bhavesh M . Lakdaw ala K am lesh R . D ave Ritam bhara Y . M eh ta Parag D hoble G .K .V ankar I.S.N etto B.R avindran Ranjit Patil Sush il G aw ande Rahu l T adke V ivek K irpek ar et al. H itesh Sheth Parag Shah

25 35

Treatm ent R elated D ecisio n M aking in P sychotic In-patients O bsessive C om pulsive D isorder in Patients w ith Schizophrenia Phenom enolog y of D elirium

39 46

51 56

C ase R eport H ypoth yroidism and Psychosis O lanzapine induced hair lo ss and am enorrh ea norm alized after addition of A ripiprazole M irage

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Poetry Q uiz

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Archives of Indian Psychiatry 10(1) April 2009

In This Issue
In an editorial, Thara (p.5)draws attention to sad fact that mentally ill persons continue to be marginalized as regards receiving diability benefits.. Psychiatrists seem to be reluctant to do this for many reasons, although the instrument itself is quite simple. Unfortunately, the mental health lobby remains fragmented and unable to make an impact. She appeals all mental health professionals work towards reaching some benefits for the mentally disabled, and do whatever possible, be it modifying IDEAS, talking to policy makers in the individual states or working with other disability groups. Otherwise we will just let other newer disability groups take an upper hand and the already marginalized mentally ill will continue to languish and be neglected. In Dr. L.P.Shah oration, Ashok Patel (p.6)discusses Recovery in context of mental disorders.The concept of recovery is now getting global acceptance as evidenced by its impact on mental health care policy of several countries. Recovery is not the same as cure. Providing effective treatments to reduce disabling and distressing symptoms is important but it is not enough. Patients will expect professionals to listen to them on general life issues and provide them with the information, skills and support . housing, employment, education, personal finances and participation in mainstream community and leisure activities: each of any of these areas could become central objectives. Mrugesh Vaisnav in his Presidential address discusses terrorism, a global , burning problem.(p.17) Besides mental health consequences of terrorist attacks and their management guidelines, he discusses the religious fundamentalist belief system, justification of terrorist act, personality and mindset of terrorist, social confirmitys well as brainwashing as factors contributing to terrorism. Vaishnav further discusses role of mental health professionals and media in understanding and helping victims of terrorism. The issue also features three major articles on topics on which there is paucity of Indian research. In a study on Delirium by Dhoble and Vanakr(p), one hundred consecutive patients referred to Psychiatry Dept. of a General Hospital and meeting criteria for Delirium DSM IV TR phenomenology was assessed using standard instruments.Disturbance of attention was present in 95% patients, sleep-wakeful cycle disturbance in 90% disorientation in 84%, psychotic symptoms in 85%, motor agitation in 72%.Multiple etiologial factors were common contributing factor to delirium. Dissociative disorders were till recently considered a rare Considering the paucity of research in this field, a study was conducted to look for dissociative phenomena in psychiatric patients.In Study by Shah and Vankar(p.25)A series of 100 patients admitted to the psychiatry ward of a general hospital were selected and The Dissociative Disorders Interview Schedule (DDIS)- wascompleted. Thirty one per cent patients had dissociative phenomena, the most common of which was possession trance syndrome. Most patients with dissociation had a psychotic disorder, had higher number of somatic complaints and a more frequent history of suicide attempts, electroconvulsive therapy and sleepwalking. Thus Dissociation as a phenomenon is very common, possession trance being the most common type in the group studied and structured interviews help in detecting these phenomena. Little research has been done in India in the field of determinants of mental capacity. A large number of patients are admitted against their will in psychiatric settings and are declared incapacitated to take treatment related decisions.A cross-sectional study by Gandhi and Vankar(p.39), 63 patients were interviewed and it was found that around 64 percent of patients had lack of treatment related decision making capacity. Lack of such capacity was associated with level of education, lack of employment and thus less family income. Discrepancies in the presence or absence of such capacity and type of admission suggest that a comprehensive method to judge treatment related decision making capacity should be applied which assess the patient for multiple components

Dr. Khyati Mehtaliya , MD Consultant Psychiatris Sakhi Womens Mental Health and Child Guidance Clinic, 301, Ravish Complex , Maninagar Char Rasta Ahmedabad 380008 Cell: e-mail: drkhyati@rediffmail.com 4 Archives of Indian Psychiatry 10(1) April 2009

Editorial

Where is the disability?


R.Thara

It is well known that most countries of the world recognize psychiatric disability and have programmes to support and empower the mentally disabled. In the USA,, those disabled by mental illness are the largest beneficiaries of the social welfare system. In India, however, this disability is marginalized as much as the persons with it. After a lot of lobbying by many agencies, this disability was included in the Persons with Disabilities Act, 1996 of the Govt. of India. In response to the need for an instrument to measure disability, the IPS developed the IDEAS ( Indian Disability Evaluation and assessment scale) in 2002 and this was gazetted by the Ministry of Human Resources and Empowerment , Govt. of India in the same year. Six years have gone by and disability of mental disorders is being certified in very few states. Psychiatrists seem to be reluctant to do this for many reasons, although the instrument itself is quite simple. Although I had asked for feedback about IDEAS which will enable us to modify it, if necessary, there have been none in writing. If modifications/ changes were required, much could have been done in 6 years. So, where lies the

problem? Is it the mind set of mental health professionals or a reluctance to take on additional work? The lobby group for the mentally retarded is so strong and stay united and have been able to make many advances in policies and programmes for the intellectually disabled. Unfortunately, the mental health lobby remains fragmented and unable to make an impact. We all know that we are able to do precious little for a sub sample of persons with schizophrenia who are very disabled. Why should they be denied small benefits like transport subsidies, transfer of pensions and other small benefits they can reap under the umbrella of disability benefits? I think it is time that all mental health professionals work towards reaching some benefits for the mentally disabled, and do whatever possible, be it modifying IDEAS, talking to policy makers in the individual states or working with other disability groups. Otherwise we will just let other newer disability groups take an upper hand and the already marginalized mentally ill will continue to languish and be neglected.

Dr.R.Thara Director, SCARF

Archives of Indian Psychiatry 10(1) April 2009

Dr.L.P.Shah Oration

Making

Recovery a Reality
Ashok G Patel

Introduction
Recovery is an idea whose time has come. At its heart is a set of values about a persons right to build a meaningful life for themselves, with or without the continuing presence of mental health symptoms. Recovery is based on ideas of self-determination and selfmanagement. It emphasises the importance of hope in sustaining motivation and supporting expectations of an individually fulfilled life. The notion of recovery has recently taken centre stage in guiding mental health policies and practice. Recovery provides a new rationale for mental health services. It has become the key organising principle in underlying mental health services in New Zealand (1998), USA (2003), Australia (2003), Ireland (2005), England (2001), and Scotland (2006), Roberts and Hollins (2007), Watkins, P (2007). The concept of recovery requires further development and it provides a framework which, if seriously adopted, will bring radical transformation of mental health service in the future. This paper presents some of the key ideas and examines their implications for the delivery of mental health services. It is not the last word on the topic of recovery; rather is aims to open up debate about how the recovery approach can be put into practice and what services need to make it happen. However, it is not yet clear what the term means and what is to be entailed in transforming the mental health system to promote it. Recovery has been used with various connotations for the past two decades and has been the object of debate among advocates, providers, family members and other stake holders. Give the broad hetergeneity that has been found in the outcome of serious mental illness, several different meanings of the term recovery are relevant for mentally ill people. Many fortunate people have only one episode of mental illness and then return to their previous functioning with 6

little, if any, residual impairment, i.e. achieving full recovery. However, patients who recover from an episode of a major affective disorder but who continue to view themselves as vulnerable to future episodes may instead consider themselves to be recovering in ways that are no unlike recovering from a heart attack. Many others will recover from mental illness over a longer period, after perhaps 15 or more years of disability, constituting an additional sense of recovery found in medical conditions, such as bronchial asthma. Some individuals are concerned as much with the effects of having been diagnosed with a mental illness as with the effects of illness itself, might also consider themselves to be recovering from the trauma of having been treated as a mental patient. Individuals with co-morbid substance misuse consider themselves to be in dual recovery. It is the vision of social inclusion and self-determination at the heart of recovery. In this context, mental illness is viewed more in terms of prolonged disability, impairment or handicaps than in terms of illness per se. The concept of recovery should be considered recovery in serious mental illness as opposed to recovery from serious mental illness. Focusing solely on promoting recovery from mental illness runs the risk of abandoning people with severe disabilities people who in this sense are not recovering to repeated failure and despair.

Recovery approach consists of Working towards aims that are meaningful to patients Being positive about change Promoting social inclusion for patients, their families and other informal supporters Recovery can best be achieve in supportive environments of shared values, beliefs, spirituality (in a nondenominational sense) and ideologies, enabling sharing of narratives with people of ones own background and world view. Archives of Indian Psychiatry 10(1) April 2009

Ashok G. Patel : Making Recovery a Reality Recovery needs to take account of individual differences and histories as well as social, ethnic, gender and sexual orientation. There can never be one size fits all approach. Being in touch with ones community and ones cultural roots and history helps good mental health. Recovery is based on knowing who you are, where you come from and reintegrating yourself with your own people in your own way. (Lapsley et al, 2002). There are significant differences in the meanings and understanding of recovery, for example, American Perspectives include Excessively individualistic approach Limited understanding of ethnicity and its social consequences for patients New Zealand Perspectives include Values of patients cultural origins Personal meanings as reference points around to which to support their citizenship and combat stigma Recovery has been used in two ways in mental health: 1. it is the intended consequence of the skilful application of medicine, nursing and social care on a specific illness 2. recovery is where individuals actively build a meaningful life for themselves while either continuing to experience mental health problems or following a period of poor mental health. A recovery based approach is not primarily about returning to a pre-illness state but is a process where the individuals and professionals collaboratively work towards a meaningful and satisfying life. A central unit of recovery is that it does not necessarily mean cure (clinical recovery). Instead it emphasises the unique journey of an individual living with mental health problems to build a life for them beyond illness (social recovery). Thus a person can recover their life, without necessarily recovering from their illness. The following questions arise at whatever age symptoms first occur, but they are particularly problematic for young people whose sense of identity is still forming (Larsen, 2004) What has happened to me? What does it mean? Why has it happened? They can only be resolved if the person can discover or rediscover their sense of personal control (agency) and gain a belief in the future (hope). Without hope they cannot begin to build their lives. Recovery is about this process, and the quality of this experience is therefore central. The recovery process can apply to anyone who experiences a significant health problem at any age. It can be applied to general adult, old age, child and adolescent, forensic mental health services, brain disorders and substance misuse problems. In physical health field recovery can be applied to any long term health problems, asthma, diabetes, rheumatoid arthritis, cardiac disease, etc.

Definitions
Recovery means different things to different people, and can also refer to different aspects of the same persons life Recovery in serious mental illness is typically understood to reflect the cessation of symptoms and remediation or resolution of any deficits associated with the illness. The most fundamental meaning that recovery can have for people with serious mental illness is not due to the illness itself, but to the history of stigma and dissemination that have made people with psychiatric disabilities second or third class citizens in their home communities. Growing beyond what has happened to you to make the most of your life! 1:4 of us will experience a mental health problem at some point in our lives. Recovery is seen as having at least three different meanings: As a spontaneous and natural process As a response to effective treatments As a way of growing with or despite continuing disability Clinical recovery : absence of symptoms Social recovery : the ability to live more or less independent life even if symptoms remain A deeply personal, unique process of changing ones attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in ones life as one grows beyond the catastrophic effects of mental illness. (Anthony, 1993). Recovery is the process of regaining active control over ones life. This may involve discovering (or rediscovering) a positive sense of self, accepting and coping with the reality of any on-going distress or disability, finding meaning in ones experiences, resolving personal, social or relationship issues that may contribute to ones mental health difficulties, taking on satisfying and meaningful social roles, and calling on formal and/or informal systems of support as needed (Faulkner and Layzell, 2000). 7

Archives of Indian Psychiatry 10(1) April 2009

Ashok G. Patel : Making Recovery a Reality Recovery is the process of taking responsibility and regaining active control over ones life. This may involve finding and maintaining hope, reestablishment of a positive identity and building a meaningful life (Andresen, Oades & Caputi, 2003). Recovery refers to the experience of people as they accept and overcome the challenge of mental health problems: recover a new sense of self, meaning and purpose in life and grow beyond the catastrophic effects of mental illness (Larsen, 2004). Recovery and social inclusion apply equally to the carers, relatives and friends who must both accept and accommodate the challenge of mental health and related problems themselves and assist their loved ones in the recovery process. Recovery is not the same as cure. Providing effective treatments to reduce disabling and distressing symptoms is important but it is not enough. Some people have problems that recur, are ever present or deteriorated over time, they do need help to restore a sense of self and make the most of their lives. discrimination within health services and in the wider society. Social inclusion is important for recovery and it is not possible without the opportunity to be part of a community, to be a valued member of that community, to have access to opportunities and to contribute. Placing recovery at the centre of mental health services requires change in the way organisations operate and individuals practice their profession. Patients will expect professionals to listen to them on general life issues and provide them with the information, skills and support needed to manage their condition and become active and responsible in their own recovery; they will expect help to access what they think they need to live meaningful lives. An increased emphasis on the need for satisfactory housing, employment, education, personal finances and participation in mainstream community and leisure activities: each of any of these areas could become central objectives. The importance of putting patients at the centre of their care is the main tenet of the new government approach in England and Wales. It includes an expansion of social measures such as individual budgets and selfassessment, including widening of direct payments. This approach does not undermine professionals opinions nor require them t pretend that something is possible when they genuinely believe it is not. It is felt that pre-occupation with risk and a consequential tendency towards riskaverse practice is stifling creativity and innovation.

Components of the Process of Recovery


(Andresen, Oades & Caputi, 2003) 1. Finding and maintaining hope: Believing in oneself Having a sense of personal agency Optimistic about future Re-establishment of a positive identity Finding a new identity which incorporates illness but retains core, positive sense of self Building a meaningful life Making sense of illness Finding a meaning in life despite illness Engaged in life Taking responsibility and control Feeling in control of illness and In control of life

The Evidence Base For Recovery


Most studies have focused on recovery from symptoms, disabilities and dependence on services rather than personally defined outcomes such as recovery of hope, identity and a life regarded by the individual as worth living (Dorrer, 2006) However, even within clinically focused research the evidence shows that within that framework of meaning and evaluation of high proportion of people can and do recovery. Much of the emphasis of longitudinal studies has been on psychotic disorders, in particular schizophrenia.Recovery rates for mental illnesses are noted to surpass the treatment success rates for many physical illnesses including heat disease (NAMHC, 1993, Wall croft, 2006). NAMHC states that recovery rates include:

2.

3.

4.

The experience of recovery from schizophrenia: towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry, 37, 586-594)

Schizophrenia Bipolar Disease Major Depression Addiction Treatment

60% 80% 65-80% 70%

Recovery: A Common Purpose For Services The possibility that outcomes may depend on And Users
Recovery is an important means of promoting social inclusion and challenging marginalisation, stigma and 8 considerably more than effective treatment has been emphasised by Warner (1994). Warner said that recovery is generally linked to productive and satisfying activity Archives of Indian Psychiatry 10(1) April 2009

Ashok G. Patel : Making Recovery a Reality and to doctors expectations; at times and places where doctors are more optimistic about the possibility of recovery, recovery rates appear to be higher. Recovery is about an emphasis on the relationship people have with their problems as a counterweight to the endemic tendency to see people defined as and by their problems. Therefore a recovery approach is as relevant to seeking progress in the context of defined illnesses as it is with problems such as challenging behaviour in learning disability (Banks, 2007, Davidson and McGlashan, 1997). In Schizophrenia (Warner, R, 1994, National Institute for Clinical Excellence, 2002) Complete recovery (a return to pre-illness levels of functioning) occurs in 20-25% of participants, and Social recovery (regaining economic and social independence in 40-45% of participants. In Bipolar Affective Disorder (MacQueen et al, 2001) 40% of participants did not experience detectable inter-episode psychosocial impairment. 7. 8. Recovery is about discovering or re-discovering a sense of personal identity, separate from illness or disability. The language used, the stories and meanings that are constructed have great significance as mediators of the recovery process. These shared meanings either support a sense of hope and possibility or invite pessimism and chronicity. Recovery based services emphasise staff qualities which cultivate their capacity for hope, creativity, care, compassion, realism and resilience. Family and peer support is central for many people in their recovery. Recovery is fundamentally about a set of values related to human living applied to the pursuit of health and wellness. Recovery involves a process of empowerment to regaining active control over ones life. This includes accessing useful information, developing confidence in negotiating choices and taking increasing personal responsibility through effective self-care, selfmanagement and self-directed care. Recovery approaches give positive value to cultural, religious, sexual and other forms of diversity as sources of identity and belonging. Treatment is important but its capacity to support recovery lies in the opportunity to arrive at treatment decisions through negotiation and collaboration. Services need to move beyond the current preoccupations with risk avoidance and a narrow interpretation of evidence - based approaches towards working with constructive and creative risk taking and what is personally meaningful to the individual and their family.

9. 10. 11. 12.

13.

Components of Recovery (SAMHSA 2005)


1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Self-Direction Individualised and Patient Centred approach Empowerment Holistic Non-linear Strength - based Peer support Respect Responsibility Hope 14. 15.

Recovery and Risk The Principles of Recovery


1. Recovery is about building a meaningful and satisfactory life, as defined by the persons themselves, irrespective of on-going or recurring symptoms and /or problems Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness Hope is central to recovery. It can be enhanced by each person seeing how they can have more active control over their lives and also by seeing how others have found a way forward. Self-management is encouraged and facilitated The therapeutic relationship between clinicians and patients moves away from being expert/patient to being coaches or partners on a journey of discovery. Clinicians are there to be on tap, not on top. Recovery is closely associated with social inclusion and being able to take on meaningful and satisfying social roles within local communities, rather than in segregated services (Davidson et al, 2001). Recovery involves issues of ethics and risk. How can the idea of recovery be relevant to someone experiencing an episode of psychosis or mania? It would seem that such a person would need to get better first before recovery can be discussed or even considered. Ethics of focusing on strengths hopes and dreams when a person may be faced with such urgent needs as safety, shelter and stabilisation. Self-determination and patient choice are touted as cornerstone of the recovery process. But what sense does it make to afford choices to a population of individuals whose judgement is impaired by the very conditions we are charged with treating? Does not honouring the choices of someone with an acute or severe mental illness involve abandoning him or her to the ravages of the illness, often to the streets? Doesnt this amount to leaving a vulnerable population of people to rot with their rights on? 9

2. 3.

4. 5.

6.

Archives of Indian Psychiatry 10(1) April 2009

Ashok G. Patel : Making Recovery a Reality Providers ask How can you tell us to promote patient not pose immediate risks to self or others, it is not only choice and self-determination on one hand while holding their right to make their own decisions but also their us responsible for adverse events on the other? Doesnt responsibility. Patients need to have the dignity of risk increasing patient choice increase provider risk? and the right to fail in order to learn from their own mistakes. Recovery requires reframing the treatment enterprise from the professionals perspective to the patients perspective. Although a recovery orientation might in fact increase In this regard, the issue is not what role recovery plays in risk, it is primarily the persons access to opportunities for treatment but what role treatment plays in recovery. How taking risks that needs to be increased, not necessarily can people learn how to manage their condition in the providers or the communitys exposure to risk. particular and their life more generally if they are not allowed to make their own decisions? Mental illness is different from other illnesses because of the issue of risk. However a majority of people with mental illness pose no risk to the community. This population is much more likely to be victimised than to victimise others. On the realm of choice, mentally ill people be allowed to make ones own decisions unless and until there are clear and persuasive grounds for imposing restrictions on this most fundamental of our civil rights. A core principle of the recovery paradigm is the appropriate application of established constructs of informed consent and permission to treat a majority of individuals with serious mental illness a majority of the time. As in other forms of medicine, no matter how expert or experienced the provider, it is ideally left up to the patient and his or her family to make informed decision about care. It is not the practitioners role to make such health care decisions for the patient. A recovery oriented approach brings psychiatry closer to other medical specialities in which it is the specialists role to assess, make diagnosis, educate the patient about the costs and benefits of the effective interventions available and with informed consent provide them. If this basic tenet is accepted, it is difficult to understand how professionals could view their roles as less important or requiring any less skill than those of other specialists such as cardiologists or oncologists. A risk assessment will be needed to identify circumstances in which patients cannot be allowed to act in ways that put others or themselves at risk. An appropriate use of Mental Health Act should be made to allow treatment and care. In a majority of circumstances in which patients do
Rehabilitation:

The Role of Treatment in Recovery


It remains important that treatment decisions are guided by evidence,but given the very high rates of discontinuation of, how such decisions are made may be as important as the decision itself People in recovery speak clearly about the value of negotiation and collaboration concerning treatment decisions with the evidence of an individuals experience, of whether something works or not in practice, given priority over general beliefs of what should work. Treatment is this recontextualised as one out of many tools that can support recovery. It is the shift from an entanglement or passive dependency on services to an active stance of selectivity, thoughtfully and positively using treatment and services to support independence and self-management that characterises journeys in recovery for people with long term conditions.

Facilitating Recovery
1. Hope: Fostering Hope and Inspiring Relationships Unless a person can see the possibility of a meaningful, satisfying and valued life, recovering is impossible. Relationships are central to hope: it is impossible to believe in your own possibilities if everyone around you thinks you will never amount to much and people need someone to believe in them when they are unable to believe in themselves. People

an organised statutory or voluntary sector programme designed to improve ph ysical, mental, emotional and social skills to enable a transition back into society and the work place. regain ing some of what has been lost or taken away due to ill h ealth, for example social status, contacts, self-esteem. having the ability to survive and to learn from lifes challenges. makin g ones own h ealth decision s and learning to manage long term h ealth problems, so as to live well with th e minimum reliance on services.

Restitution:

Resilience: Self-Management:

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Archives of Indian Psychiatry 10(1) April 2009

Ashok G. Patel : Making Recovery a Reality can benefit from the inspiration and support of others who have faced similar challenges. 2. Control: Helping people to take back control over their problems and their lives and facilitating personal adaptation Like any other traumatic and life changing events, mental illness constitutes a bereavement. In order to rebuild their life a person must work out ways of understanding and accommodating what has happened and taking back control over their problems, life and destiny. This will include promoting selfmanagement helping people to work out plans for themselves about how to stay well, manage their ups and downs, and regain equilibrium after a crisis, as well as providing the range of evidence based treatments. Opportunity: Helping people to access those opportunities roles, relationships and activities that are important to them Low expectations on the part of the professionals are one of the biggest barriers to recovery. If people are to rebuild their lives they need access to those social, economic, educational, recreational, religious/ spiritual opportunities and physical health services that most citizens take for granted.

Top Ten Concerns About Recovery


(Davidson et al 2006) 1. 2. 3. 4. 5. Recovery is old news!! What is all the hype? We have been doing recovery for decades!! Recovery-oriented care adds to the burden of already stretched providers Recovery involves cure Recovery happens to very few people Recovery represents an irresponsible fad. This is just the latest flavour of the months and one that also sets people up for failure. Recovery happens only after and as a result of active treatment Recovery-oriented care is implemented only through the addition of new resources Recovery-oriented care is neither reimbursable nor evidence based Recover-oriented care increases providers exposure to risk and liability

3.

6. 7. 8. 9.

Recovery Competencies For Staff:


(The New Zealand Mental Health Commission, 2001) These include 1. 2. 3. 4. 5. 6. 7. 8. Understanding recovery principle Recognising and supporting the personal resourcefulness of people with mental illness Accommodating diverse views of mental illness, treatments, and services delivery Understanding and actively protecting the rights of patients Understanding discrimination and social exclusion, its impact on patients and how to reduce it Acknowledging the different cultures and how to work in partnership with them Comprehensive knowledge of community services and resources Knowledge of family perspectives and ability to support their participation

10. Recovery-oriented care devalues the role of professional intervention

The role of Professionals


The recovery approach requires a different relationship between patients and professionals. Roberts and Wolfson (2004) have characterised this as a shift from staff that are seen as remote, in a position of expertise and authority, to someone who behaves more like a personal coach or trainer offering their professional skills and knowledge, while learning from and valuing the patient who is an expert by experience. This is based on openness, trust and honesty and it is the quality of this helping relationship that is crucial. The aim of the professional is thus to provide the patients with the resources information, skills, networks and support to manage their own condition as far as possible and to help them to get access to the resources they think they need to live their lives. The professionals being on tap, not on top. It implies a very different power relationship between professionals and the people they are there to serve.

Archives of Indian Psychiatry 10(1) April 2009

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Ashok G. Patel : Making Recovery a Reality The process of recovery is then fuelled by hope uncomfortable, it is often very valuable to be prepared (Perkins, 2006). This does not mean that in recovery simply to sit and listen while the person attempts to make services everyone my always remain hopeful even in sense of their experience of upset and distress. The person the face of what seem to be insurmountable practical may then be encouraged to write down their symptoms problems. While is true that recovery approaches do and coping strategies, and by focusing on small steps for generally believes that the individuals hopes and dreams change, increase their sense of self-control over are often more important than professional judgements distressing events (Perkins, 2007). about what is realistic, they do not encourage nave As this process builds, the person may work towards the unrealism. formulation of a joint crisis plan with staff. The It also has to be acknowledged that professionals are often professionals should step back a bit when the persons rather bad at making accurate predictions of what is and is confidence grows and takes control over other aspects of not likely to be possible for a given individual in a specific their life. area of their life, and there is a consistent danger that professionals will under-estimate peoples potential. Low The importance of work and employment expectations can all too easily then become self-fulfilled prophecies. One of the most important indicators of progress is when the person is able to step outside the sick role and But recovery does not make a professionals opinions become more than simply a passive recipient of care. worthless. Nor should professionals pretend that Whether it is through work, through caring for family or something is possible when they genuinely believe it is friends or simply through finding that by sharing your life not. story you can provide people hope and aspiration to others, this is often a key step in the recovery process.

The Recovery Journey


The Five Stages of Recovery 1. 2. 3. Moratorium A time of withdrawal characterised by a profound sense of loss and hopelessness Awareness Realisation that all is not lost and that fulfilling life is possible Preparation Taking stock of strengths and weaknesses regarding recovery and starting to work on developing recovery skills Rebuilding Actively working towards a positive identity, setting meaningful goals and taking control of ones life Growth Living a meaningful life, characterised by self-management of the illness, resilience and a positive send of self (Andresen, Caputi and Oades, 2006)

Work and employment remain the primary means through which people connect with their communities and build their lives. Finding you have something to give, as well as needing help is central to building a positive sense of self-esteem and this is at the heart of recovery. Of course, there is a danger that work will be seen as a panacea. There is clearly an important balance to be struck here between the dangers of forcing people back to work and the dangers of excluding them from it through a combination of ignorance, prejudice and lack of effective help. Greater danger lies on the side of exclusion. There is certainly extensive evidence that most people with mental health problems want to work, if only they can be provided with the right kind of help and support (Seebohm and Secker, 2005). If recovery is to become a reality, employment must become one of its key priorities.

4.

5.

The above stages should not be seen as a linear progression that everyone has to go through. They are better seen as aspects of engagement with the recovery process. Davidson and Roe (2007) suggest that many people may appear unwilling to engage with recovery because of the severity of their symptoms, their negative experiences of mental health care, the intolerable side effects of medication or the simple fact that it is sometimes too painful and costly for them to begin to acknowledge that they need the kind of help that is being offered. It is vital that services support these individuals in beginning their recovery journey. In the first place staff must be willing to listen. Listening is a much under-rated skill and, although it may be 12

Carers, relatives and friends


Mental health problems have a profound effect not only on the life of the patient, but also on those who are close to them. Carers, relatives and friends often provide most of the patients support and may have a critical role in promoting inclusion. If they are to do this effectively, they need to understand the patients situation and challenges ahead and receive the necessary support to help them in their recovery journey. Carers, relatives and friends often feel ill-informed and unsupported. Some carers also continue to believe that professionals implicitly, or at times explicitly, blame them for their relatives problems. These are not good conditions for the development of effective partnerships of care. (Repper et al, 2007) Archives of Indian Psychiatry 10(1) April 2009

Ashok G. Patel : Making Recovery a Reality Family and friends also face the challenge of making a recovery in their own right. They too have to re-evaluate their lives by coming to terms with what has happened and making the necessary adjustments. They must discover new sources of value and meaning for themselves, both in their own right and in their relationship with their loved one. They too experience stigma and social exclusion. It is therefore important that mental health services also facilitate the recovery of carers, relatives and friends along with the patients.

Conclusions
Recovery oriented systems of care will offer an active treatment to reduce the signs and symptoms of mental illness and offer rehabilitative interventions to address functional impairments. Systemic transformation will take time and the paradigm shift involved will require at least a generation to materialise in any substantative way. In the interim, it is ironic perhaps that taking the risk of offering recoveryoriented care promises to be one of the few ways possible to increase available resources. The more effective our efforts at promoting social inclusion, the less people will need from mental health services. Once it is firmly established, the recovery vision will allow us to see, albeit in retrospect, that the costs incurred by not taking such risks the costs of chronicity, instititutionalisation and homelessness far outweigh the costs of doing so. We all have something to recover from, whether it is mental illness, addiction, physical illness, physical disability, loss of loved ones, victimisation, loneliness, for change to occur we must recognise what we need to change. Recovery creates a community that all can take part in as it erases the distinctions of position, age, skin colour, religion, language and education and joins us in our common humanity (Sowers, W, 2007). A recovery emphasis is not without its detractors and there are those who consider it as either naively unrealistic or based on linguistic and conceptual distortions. There are also some worries about power and ownership. But there is considerable value in engaging with these difficulties and objections in the service of continued clarification, elaboration and focused research. Recovery is of no value if it is not authentic and both intellectually and clinically robust. A core emphasis on recovery is already finding wide acceptance, providing a clear sense of direction, ambition and guiding purpose for services and organisations that seek to improve mental health of individuals and communities. It has provided a means of drawing into alliance people who use services and those who provide them. There are many good beginnings but still much to learn.

Measuring Recovery
Putting recovery into practice and measuring outcomes have been on-going challenges. An agreed definition of recovery is needed, which can be operationalised into brief, reliable and valid measures, sensitive to multiple view points and able to account for both personal changes and service outcomes. These measures will help to measure change and impact of interventions. They can also contribute to a dynamic model of recovery itself and help to investigate mediating factors. Campbell -Orde et al (2005) give measures developed in the USA that include measurements of hope and empowerment as well as recovery. DREEM (Developing Recovery Enhancing Environments Measure, Ridgeway and Press, 2004; Allott, 2005, Allott etal, 2006) is the most promising recovery sensitive measure. It provides a user - led structure that enables services to measure their commitment to and effectiveness in providing recovery based care. It focuses on service development and enhances collaborative work with people who use services, thus mirroring the principles of the recovery it measures. The Recovery Star ( McKeith, and Burns, 2008) is a version of the Outcomes Star (www.homelessoutcomes.org.uk). It values patients perspectives and enables empowerment and choice. It supports recovery and social inclusion. Recovery is not necessarily a process of moving from first point to the last. In fact, different people will be at different points and may move forwards or backwards as their circumstances change. The Recovery Star looks at ten areas of patients life: Managing Mental Health Self care Living skills Social networks Work Relationships Addictive behaviour Responsibilities Identity and self esteem Trust and hope Archives of Indian Psychiatry 10(1) April 2009

References
1. Anthony, W. A. (1993) Recovery from mental illness: the guiding vision of the mental health service system 13

Ashok G. Patel : Making Recovery a Reality in the 1990s. Psychosocial Rehabilitation Journal, 16, 11 23. Andresen, R., Oades, L., Caputi (2003) The experience of recovery from schizophrenia: towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry, 37, 586 594. Andresen, R Caputi, P and Oades, L (2006) Stages of recovery instrument: development of a measure of recovery from serious mental illness. Australian and New Zealand Journal of Psychiatry, 40, 972 980. Allott, P. (2005) Recovery, in D. Sallah and M. Clark (Eds) Research and development in mental health: Theory, framework and models, Oxford: Elsevier Science Ltd. Allott, P., Clark, M., and Slade, M. (2006) Taking DREEM forward: Background and summary of experience with REE / DREEM so far and recommendations, Report prepared for Director of Mental Health Research, Department of Health, available from authors at Mental health recovery@blieyonder.co.uk Banks, R. (2007) Personal communication received as commentary from the e-advisory group. Campbell-Orde, T., Chamberlin, J., Carpenter, J. and Leff, H.S. (2005) Measuring the promise: A compendium of recovery measures, volume II: The Evaluation Centre at HSRI (www.tecathsri.org/ product_descrpition.asp?pid=129). Davidson, L., and McGlasham, T.H. (1997) The varied outcomes of schizophrenia. Canadian Journal of Psychiatry, 42, 34 43. Davidson, L. and Roe, D. (2007) Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, 16, 459 -470. Davidson, L., Stayner, D.A., Nickou, C., Stryon, T.H., Rowe, M. and Chinman, M.J. (2001) Simply to be let in: Inclusion as a basis for recovery from mental illness. Psychiatric Rehabilitation Journal, 24, 375 388 Davidson, L., OConnell, M., Tondora, J., Stryon, T., and Kangas, K (2006) The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services . 57(5): 640 645. Dorrer, N. ( 2006) Evidence of recovery : The ups and downs of longitudinal outcome studies, SRN Discussion Paper Series, Report No 4, Glasgow: Scottish Recovery Network Faulkner, A. and Layzell, S. (2000) Strategies for living: A report of user led research into peoples strategies for living with mental distress, London: Mental Health Foundation. Lapsley, H., Waimarie, L.N. and Black, R. (2002) Kia Mauri Tau: Narratives of recovery from disabling mental health problems, Wellington: Mental Health Commission Larsen, J.A. (2004) Finding meaning in first episode psychosis: experience, agency and the cultural repertoire. Medical Anthropology Quarterly, 18, 447 471. 16. Mackeith, J. and Burns, S. (2008) Mental Health Recovery Star, Publishes by Mental Health Providers Forum: London (www. mhpf.org.uk) 17. MacQueen, G. M., Young. and Joffe, R.T. (2001) A Review of Psychosocial Outcome in Patients with Bipolar Disorder. Acta Psychiatrica Scandinavica, 103, 163 -170. 18. NAMHC (National Advisory Mental Health Council) (1993) Health care reform for Americans with severe mental illnesses, American Journal of Psychiatry, 150, 1447 -65. 19. National Institute for Clinical Excellence (2002) Schizophrenia: Core interventions in Treatment and Management of Schizophrenia in Primary and Secondary Care. 20. New Zealand Mental Health Commission (2001) Mental health recovery competencies teaching resource kit, New Zealand: Mental Health Commission 21. Perkins, R. (2006) First person: you need hope to cope. In Roberts, G., Davenport, S., Holloway, F. and Tattan, T. (eds) Enabling Recovery: The principles and practice of rehabilitation psychiatry. Gaskell: London. 22. Perkins, R ( 2007 ) Making It ! An introduction to ideas about recovery for people with mental health problems. London : South West London & St. Georges Mental Health NHS Trust 23. Ridgeway, P.A. and Press, A. (2004) Assessing the recovery commitment of your mental health services: A users guide for the Developing Recovery Enhancing Environments Measure (DREEM) UK version 1 December 2004, Allott, P. and Higginson, P. (eds) (www.recoverydevon.co.uk) 24. Roberts, G. and Wolfson, P (2004) The rediscovery of recovery: open to all. Advances in Psychiatric Treatment, 10, 37 -49. 25. Roberts, G. and Hollins, S. (2007) Recovery: our common purpose? Advances in Psychiatric Treatment, 13, 397 399. 26. Repper, J., Nolan, M., Grant, G., Curran, M. and Enderby, P. (2007) Family Carers on the Margin: Experiences of Assessment in Mental Health. Report to the National Coordinating Centre for NHS Service Delivery and Organisation (NCCSDO), London School of Hygiene and Tropical Medicine, 99 Gower Street, London WC1E 6AZ. 27. SAMHSA (Substance Abuse and Mental Health Services Administration) (2005) National consensus statement on mental health recovery (http:// mentalhealth.samhsa.gov/publications/allpubs/ sma05-4129/). 28. Seebohm, P. and Secker, J. (2005) What do service users want? In Grove, B., Secker, J. and Seebohm, P. New Thinking about Mental Health and Employment. Radcliffe: Oxford. 29. Sowers, W. (2007) Recovery: an opportunity to transcend our difference, Psychiatric Services, Vol 58, no 1 (http://psychservices.psychiatryonline.org/ cgi/content/full/58/1/5). Archives of Indian Psychiatry 10(1) April 2009

2.

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Ashok G. Patel : Making Recovery a Reality 30. Wallcraft, J. (2005) Recovery from mental breakdown, in J. Tew (ed) Social perspectives in mental health, London: Jessica Kingsley Publishers, chapter 11. 31. Warner, R. (1994) Recovery from schizophrenia: Psychiatry and political economy (2nd edn), London: Routledge. 32. Watkins. P. (2007) Recovery a guide for mental health practitioners, London: Churchill Livingstone/Elsevier.

Sources of support: Nil

Conflicts of interest: None

Dr Ashok G Patel MBBS DPM FRCPsych Consultant Psychiatrist Calnwood Court, Calnwood Road Luton LU4 OLX United Kingdom

Archives of Indian Psychiatry 10(1) April 2009

15

Dr. Mrugesh Vaishnav


President, Indian Psychiatric Society West Zone Branch ( 2008-09)

Consultant Psychiatrist and Sex Therapist. Director, institute Psychological and Sexual Research, Samvedana Foundation, Ahmedabad Vice President, Indian Psychiatric Society West Zone Branch ( 2007-08) Chairman, Sexuality Medicine Specialty Section of Indian Psychiatric Society (2008-10) Chairman Spirituality & Mental Health Task force Of Indian Psychiatric Society (2006-2007). Editor, Archives of Indian Psychiatry, official Journal of IPS-WZB ( 2004 to 2006) Consultant : Sex Education , Counseling , Research & Training & FPAI. Joint secretary, Indian Andropause Society ( 2004 onwards) President IPS Gujarat State Branch(1987-88) Founder President IAPP Gujarat state Branch (2001-2003)

Correspondence: Dr.Mrugesh Vaishnav Samvedna Below Karnawati Hospital Ellis Bridge Ahmedabad 380006 Phone:079-26578889 Cell:+919825767565 e-mail: drmrugesh@rediffmail.com, mrugeshvaishnav@yahoo.co.in

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Archives of Indian Psychiatry 10(1) April 2009

Presidential Address

The psychology & psychiatric consequences of terrorism: An Indian Perspective


Mrugesh Vaishnav
My Dear Colleagues, ladies & gentlemen. Human beings are like limbs of one another, as they are created from the same essence. When one limb is hurt the other limbs cannot be but in pain. Those who are indifferent to the suffering of others do not deserve to be called a man. Sheikh Saadi The great Iranian poet had said this about those who are insensitive to human pain and misery, and I wonder what he would have said about those heartless brutes masquerading as men who by their own hands cause such heart-rending tragedy as we witnessed in Jaipur, Banglore, Ahmedabad , Delhi, Malegaon, Modasa, & Agartala in the past four months. We as the mental health service providers have an important role to play in training, advising and assisting frontline responders as well as helping in the management of those with psychiatric and psychosocial problems. It also provides us a unique opportunity to sensitize the general population towards vulnerability of every individual to mental disorders and the scope for recovery and healing. So in the present context in my presidential speech I wish to address general issues of terrorism, psychology of the terrorist, psychological effects of terrorism & possible psychiatric interventions strategies to mitigate such effects, and future research in this field to help the nation in fighting this problem. that simple as information about elephant is uncluttered by political, moral, ethical, spiritual or other influences, this is not the case with regard to terrorism. Acts of terror are seldom acts of blind rage. They are planned carefully. We seem to have blindly accepted the terrorist as an almost super-human, demonic figure, possessing near-supernatural abilities. Sadly however, terrorists are all too human and, like most of us, they work for someone.

Foundation for terrorism in India


After 9-11 attack on WTC psychiatrist world over have extensively studied psychology of terrorism. We will use this evidence based literature to understand this issue in over country. Middle-Eastern terrorism is based upon religious, political and racial conflicts both within and between these nations, and the historical relationships between the Islamic world and the West. The cross-border terrorism in India also has historical, religious & political base. However the history is just of five decades i.e. after partition.

Religious influence and ideologies


Extreme religious ideologies play a central role in radicalizing young Muslims, recruiting and indoctrinating them into the terrorist ideology, and eventually asking them to commit terrorist acts. There are several tenets drawn from the Quran, which have been misapplied, taken out of both historical and cultural context. These teachings include the assertion that there must be a continuous state of war between the house of peace (Islamic countries) and the house of war (non-Muslim countries). This state should continue until the non-believers the infidels are converted to Islam, killed or enslaved. Western civilization with their democracy and modernity is viewed as morally corrupt. As such it is taught that it is the duty of every Muslim to wage jihad (holy war) against the unbelievers or the infidels, to create pure Islamic societies all over the world.

Introduction
Defining Terrorism What is terrorism? Leon Trotsky (1920)61 explained the rationale of terrorism in the following way: War, like revolution is founded upon intimidation. A victorious war, generally speaking, destroys only a portion of the conquered army, intimidating the remainder and breaking their will. terror kills individuals and intimidates thousandsone mans terrorist is another mans freedom fighter. Different governments & organizations have defined the word Terrorism differently. These may slightly differ in the language but the basics remain the same. Terrorism is defined by Title 22 of US Code (2002)20 as, politically motivated violence perpetrated against non combatant targets by sub national group or clandestine agents, usually intended to influence an audience By reading about terrorism, we may think we understand the subject. We may feel we might even recognize a terrorist, in the same way we know what an elephant is and looks like even without going to forest. But it is not Archives of Indian Psychiatry 10(1) April 2009

Justifications for terrorism


Terrorism has been explained as a phenomenon that has multi-facetted justifications. Political justifications Several investigators have suggested that the goal of Islamic terrorist organizations is to politicize religion by toppling. Secular governments and establishing authentic Islamic governments and implement Islamic laws. 17

Mrugesh Vaishnav : Presidential Address Social justifications Several sociological reasons suggested for terrorism are poverty, the high rate of unemployment, the cultural insulation and sense of being disenfranchised from their community, feeling hopeless and ineffective, tremendous population increase, 7075% of the population is under twenty-five years of age in Asian & Middle East Islamic country. Extreme Islamic leaders offered them a solution through aggressive confrontations with authority in the name of social justice. Psychological justifications Previous studies of Islamic terrorist acts indicate that terrorists join at a young age ranging from 1726. They were almost all male. The majority was considered to come from model young, middle-class families, were high achievers, intellectual, idealistic and were well educated in modern science and had university degrees. However, terrorists committing acts of terrorism in their home countries often have little education and were unemployed socially alienated and had dropped out of society. Their leaders were 1416 years older, possessed a great amount of charisma and commanded a great amount of respect from their followers. They were considered extremely knowledgeable about Islam, exceptionally influential, were perceived as courageous, fearless of death, and eager for martyrdom, hence they were identity or hero worshiping figures. Personality traits of Terrorist Many reported on the link between personality traits and terrorist acts and the results are mixed. Some scholars suggest that the terrorists have abnormal personalities with clear identifiable character traits. For example, it has been suggested that Terrorist suffer from a disturbed relationship with their own identity and their emotions which leads them to choose violence. Alternatively, they are susceptible to becoming terrorists because they suffer from either an inferiority complex, a lack of sense of independence, assertiveness, low selfesteem and feelings of humiliation, lack of empowerment, absence of empathy and harboring feelings of guilt and loneliness, as well as potentially having injured narcissism, paranoid tendencies, and a pre-occupation with power. They behave in an altered state similar to hypnosis. This state enables them to relinquish their general reality orientation and have their conscious, critical faculties suspended. Other investigators have argued against the idea that terrorists possess particular abnormal personality traits. They believe that terrorists emerge out of a normal psychology of emotional commitment to a cause and comrades. To this group, terrorists were normal and well educated young men. They are, however, rigidly devout in advocating the jihad or holy war against the infidels or non-Islamic believers. They get involved in terrorist acts because it provides them with a sense of self-actualization, 18 fulfillment, status, power and direction to their lives; a way out of their routine life; a highly honored glorious name and camaraderie that is usually impossible to achieve for people like them. Thinking The thinking of terrorists and their leaders is rigid, primitive, and unsophisticated. The choice is limited to right or wrong or dividing the world into good and evil. Their analytical thinking is not developed. 1 Their thinking is built on rejection of the views of others; they possess the absolute right and the opposite view is heretic and apostasy. They like to enforce their political views on others and whoever disagrees with them becomes an infidel. They like to convince their audience to see the world as they do. They are utopian in their thinking. They are looking for a near perfect future. Feelings/emotions The extremists of the Muslim world have been described as impassioned filled with disappointment, frustration, fear, disgust, anger, and hatred toward all other faiths. These negative feelings are against the outside nonMuslim world, their own rulers and whoever disagrees with their views. Others have suggested that the causes for joining a terrorist organization are the need for feelings of excitement and adventure. Others have suggested that terrorists feelings of dissatisfaction stems from problems with their personal life such as inability to hold a job, failure to join the military, failed marriage, addiction, failure to adjust to modernity or dissatisfaction with some personal needs or objectives. Belief system Interviews with incarcerated terrorists have demonstrated that their Islamic religious beliefs were the greatest motivating factor for them to become involved in terrorists activity. They made a strong commitment to their religious beliefs, and they defended them with enormous emotional passion. Their enthusiasm makes them exceptionally dangerous and lethal in their attacks. The mental stress and the ideological commitment that terrorists face encourage reliance on a rigid set of beliefs and inhibit flexibility and openness.

Mindset
There is no unique terrorist mindset. Psychologists have been unable to adequately define the terrorist mindset because there is as much variation among terrorists groups as there are groups. Others have suggested that desperation and lack of hope produce a mindset to which radical extremisms always appealed and for which they are ready to offer a framework of blame, hate, violence, and totalitarian politics. It seems that the mindset of terrorists is a reflection of the extremist ideologies and beliefs that are taught early in life. Archives of Indian Psychiatry 10(1) April 2009

Mrugesh Vaishnav : Presidential Address

Mental illness
Some have suggested that terrorists are mentally ill and have used labels such as psychopathic or sociopath, narcissistic, paranoid, suffer from borderline mental deficits, are schizophrenic types, or passiveaggressive. However, interviews with terrorists from different sites have not found evidence of mental illness. Others have argued that although terrorist actions may seem irrational or delusional to society in general, terrorists in fact, act rationally, their acts require a level of group effort, the careful, detailed planning and well-timed execution of operations and there is no evidence to indicate that they are mentally ill, psychopathic, or otherwise psychologically abnormal.

Criminality
Besides killing they have been involved in stealing & petty criminal activities such as forgery, credit card fraud, marijuana dealing etc. In most cases, the goal was to finance their terrorist plans killing and stealing to financing jihad is permissible.

Interventions plans during such attacks must consider physical, material & psychological impact of terrorism. Although it is impossible to accurately predict the extent, efficacy, lethality, or type of injury that will be caused by Non conventional bioterrorist attacks of greater magnitude, which can affect several thousand to a hundred thousand individuals, but would produce much more severe psychological reactions. Psychological trauma in the aftermath of terrorist attacks leads to disturbances in the mental equilibrium causing maladaptive behavior & diagnosable psychiatric disorders. It is also reported that persons directly affected by disasters have higher rates of post-event psychiatric disorders than persons indirectly affected by disasters. Several studies have reported increased prevalence of PTSD, Depression & Other Anxiety disorders in the aftermath of terrorism. A large number of individuals report medically unexplained physical symptoms. A different form of psychiatric morbidity is listed in following table.

Psychiatric Morbidity
Psychiatric Morbidity Acute Reaction to Stress Adjustment Disorder Brief DepressiveReaction Prolonged Depressive Reaction Mixed Anxiety Depressive Reaction Anxiety states Generalized Anxiety Disorder Mixed Anxiety & Depressive states Panic Attacks Dissociative Disorder Depression Post Traumatic Stress Disorder Others Exacerbation of pre-exiting Mental Illness Exacerbation of Personality Traits Neuro Psychaitric effects of Concussion, head injury, brain damage, epilepsy. Alchohol & other substance abuse Enduring Personality change A number of studies carried out in the New York City and the U.S. populations after the September 11 terrorist attacks showed a high prevalence of PTSD, between 7.5 and 11.2%. in the first two months after those attacks. Depression 9.7%, was the second most commonly reported after PTSD. Gabriel et al (2007) reported the prevalence of PTSD two month after March 11, 2004 terrorist attacks in Madrid, were 44.1% among victims, 12.3% among residents and 1.3% among policemen. Major depression WAS 31% of injured i.e. ten times more and 8.5% i.e. two timws more in general population.. Anxiety disorders, other than PTSD, were reported in fewer than 20% of post-disaster studies, agoraphobia was, after PTSD and depression, the most 19

Cognitive and emotional dissonance


Extremists are caught between old fashion Islamic culture and modernization, which is thought by some to result in anxiety, alienation, rigid beliefs, and inferiority complexes. It has also been suggested that there is a cognitive collision between Western and fundamentalist world views that creates conflict, identity crisis in children, stress and dissonance.

Conformity
Peer pressure, group solidarity, and the psychology of group dynamics help the terrorist members to remain in the group. Terrorists tend to submerge their own identities into the group, resulting in a kind of group mind, group identity, and group moral code that requires unquestioned obedience to the group.

Brainwashing
Brainwashing has been described as a powerful technique to overwhelm victims minds. Terrorist groups attempt to brainwash their members with their particular ideology. It seems that brainwashing through coercive actions or to overwhelm the victims mind prior to becoming terrorists is not needed since the ideologies and beliefs that are conducive to them becoming terrorists were implanted early in life through school, the media, and other extremists teachings.

Psychiatric Morbidity after Terrorist attack


Conventional terrorist attacks of small to medium magnitude, affecting from several individuals to several hundred individuals, may not cause extensive loss of life but their psychological impact can be widespread.51 Likely reactions may include severe anxiety, panic behavior and panic attacks, retaliatory attacks on local minority groups.

Archives of Indian Psychiatry 10(1) April 2009

Mrugesh Vaishnav : Presidential Address frequent mental disorder assessed among injured (23.8%), & 10.5%.in general population. The published Indian data in this area is minimal. Gautam et al (1998) in their study on the victims of bomb blast in the bus caused by terrorist activity reported 35.4 percent of psychiatric morbidity at day three and 29.3 percent after 2 weeks. PTSD 12.9%. Depression 9.6% & Dissociative Amnesia 6.4%.

Role of the Media


The images of bodies falling to their deaths from the WTC horrified viewers around the world. As yet, there are no research studies known to the authors, that examine the impact of these particular images upon children; however, a growing number of reports have demonstrated that children exposed to media coverage of traumatic events can develop significant PTSD symptoms. A study of the Oklahoma City bombing concluded that bomb-related television exposure was a primary predictor of PTSD scores and also played a role in sustaining these symptoms. These findings indicate that access to the media should be monitored carefully. Parents should co-view media coverage, be reassuring, and be willing to explain or discuss their childrens fears following television coverage or general media exposure. Teachers may need to be more aware of children and adolescents who show signs of social withdrawal and regression.

Psychological impact of Terrorism on Children & Adolescents Children and adolescents may experience PTSD, traumatic grief, depression, anxiety & somatization during and following a catastrophic event. Symptom complexities will depend upon the childs developmental level, the type and degree of exposure to the trauma, the nature of the aftermath including the horror, bereavement, and ongoing loss of stability and security. In pre-school children there may be symptoms of regression (clinging, bed-wetting, thumb sucking), an onset of aggressive behaviors; fears not directly related to trauma; generalized anxiety; sleep disorders; and somatic complaints. School-age children may develop an obsession with trauma details, become hyper vigilant or more aggressive, experience concentration problems and distractibility, nightmares or night terrors, develop a preoccupation with danger and reminders, somatic complaints, and become withdrawn. They may exhibit fluctuations in behavior; repetitive retelling of events or traumatic play; or may feel an inappropriate sense of responsibility; and may have a tendency towards magical thinking. Adolescents may become aggressive and oppositional, retreat from others, or throw themselves into activities. They may enter impulsively into adult relationships, leave school, or engage in high-risk behaviors such as substance abuse. They may develop eating disturbances, sleep problems or nightmares, difficulties in relationships, and concentration problems. These may be evident from an early stage or may persist into the longer term. Findings strongly indicate the need to incorporate children and adolescents in public, mental health approaches in disaster settings. The horror of disaster be it human-made or natural, may entail a loss of innocence for children and young people. Implementation of good practice interventions with children and adolescents should be based on established guidelines including: (1) systematic assessment and documentation of problems (2) psychological first aid (3) targeted interventions (4) pro-active followup (5) systematic evaluation. Most importantly, the response should be informed by an expectation of positive outcomes and compassionate support for the particular needs of children, adolescents, and their families who have been affected by catastrophe. For, while children may lose their innocence, they need not lose their belief and hope for a positive future. 20

What Interventions Should We Implement?


With the exception of those who are exposed directly to conventional terrorist attacks, reactions of the general public are expected to be mild to moderate. Reactions can be made worse by sensationalizing in the media and poor transfer of specific recommendations by public officials. In the case of non conventional attacks involving chemical, radiological, or biological weapons, however, the reactions of the general public could be quite severe irrespective of the competency of the information. Recommendations for interventions for the general population. Provide information on the believed likelihood of such an attack and of possible impact. Communicate that individual risk is quite low. Clarify that negative health behaviors, which may increase during time of stress (ie, smoking, unhealthy eating, excessive drinking), constitute a greater health hazard than the hazards likely to stem from bioterrorism. Emphasize that the only necessary action against terrorism on the individual level is increased vigilance of suspicious actions, which should be reported to authorities. Clearly communicate the meaning of different levels of warning systems when such warnings are issued. When issuing a warning, specify the type of threat, the type of place threatened, and indicate specific actions to be taken. Make the public aware of steps being taken to prevent bioterrorism without inundating people with unnecessary information. Provide the public with follow-up information after periods of heightened alert. Archives of Indian Psychiatry 10(1) April 2009

Mrugesh Vaishnav : Presidential Address

Intervention following terrorist attacks.


Building Resilience People with less resilience are more vulnerable to emotional dysfunction and psychopathology when exposed to a stressful On the basis of the existing literature. We recommend that public officials should communicate that the public is at some risk due to terrorism and this risk is likely to be long term, but the nation is strong. In addition, public officials should: (1) Invoke historical examples of public resilience (2) Demonstrate enthusiasm for actions at schools, businesses, and community organizations. Interventions Following a Small to Moderate Attack at a Single or Multiple Sites An attack of small to moderate impact will likely generate moderate to major psychological and behavioral reactions. The greater the impact of the attack in terms of harm or lives lost, the greater the reaction. Proximity to the attack site or to a similar type of site, and the number of attacks will influence the severity of psychological reaction in Individuals. Immediate reactions and interventions. The most common immediate psychological reactions to an attack include heightened anxiety, psychological panic reactions (which may be perceived as heart attacks by some, increased problems with sleeping, alcohol/drug use. Absenteeism, and retaliatory actions against minorities identified in some ways with the terrorists. It is important to remember, however, that the vast majority of people are making their utmost effort to help their family and neighbors in the immediate aftermath. Thus, intervening forces should look at the population as a resource, identify people who are ready to help others, and use their assistance. Immediate interventions should consist of the following. Dispatch of police and emergency for coordination and management of activities in the site of the incident and installation of law and order if necessary. Activation of community-based support and intervention systems that should be prepared long before the terrorist attack. Initiation of public announcements that suggest specific actions and provide nonspecific information as to the extent and type of attack. Facilitation of communication by the media, schools, and businesses immediately after an attack. Utilization of local media and the Internet to establish information centers and call-in centers, where relatives can leave messages for their kith & of kin.

depending on the extent and number of sites of the attack, the number of dead people (especially children), the extent of the damage to infrastructure, and the response to immediate interventions. The greater the extent and number of sites and the less effective is the handling of the public immediate reactions, the more severe will the psychological reactions later on. The primary interventions involve providing suggestions for what people and organizations can do on their own and collectively, as well as identifying individuals with severe reactions for referral to appropriate professionals. Individuals should be encouraged to continue to live their lives as normally as possible. Identifying individuals who need more significant help should be kept in contact with others and not isolated. Centers of public meeting should be designated and staffed using a cascade model approach (eg, a lead mental health professional with others trained at lesser levels and volunteers. In many communities, a major spiritual support may come from local religious leadership. Mental health professionals should make contact with support systems in the community. Intervention should be communicated by major media, especially electronic media (TV, radio, internet). This can include: instruction in relaxation techniques, meditation, and positive mental imagery; suggestions for things to do, to enhance a sense of control; advice to limit exposure to the constant retelling of events and to limit young childrens exposure to the media.

Interventions for the people exposed to trauma


Two types of psychological interventions have been developed to alleviate acute distress and preventing chronic PTSD among traumatized people and emergency personnel indirectly exposed to the carnage of terrorism and other disasters. The most widespread intervention has been psychological debriefing, especially Critical Incident Stress Debriefing. The other has been brief CBT similar to interventions developed for treating chronic PTSD, to the survivors of a traumatic experience. More recently, there has been increased interest in the use of medication in high-risk individuals to prevent chronic reactions.

Mid-term reactions and interventions.


In the days following an attack, public psychological reaction may vary from subsiding to greatly increasing, Archives of Indian Psychiatry 10(1) April 2009

Psychological Debriefing A debriefing session usually occurs within a few days after the trauma, lasts for several hours, and can be administered to either an individual or a group. In this supportive and nonjudgmental setting, session leaders ask participants to describe their thoughts, feelings, and behavioral reactions during the event. The purpose is to have participants ventilate their emotions as they relive and process the trauma within the session. Leaders also provide psycho education to reassure participants that acute stress reactions are normal responses to horrific events, and not necessarily indicative of mental illness.

21

Mrugesh Vaishnav : Presidential Address Brief CBT Brief ( 45 sessions) CBT beginning approximately 2 weeks after the trauma has been shown in several studies to speed the rate of recovery and prevent the development of chronic PTSD. CBT in these studies consisted of a combination of prolonged exposure plus elements of stress inoculation training. Medication A third approach to treating acute stress reactions with the goal of preventing chronic PTSD has been the early administration of medication. Three medications have been evaluated, benzodiazepines, propranolol, and hydrocortisone. Results have shown that these medicines have its own limitations. Sertraline and Paroxetine are currently approved by US FDA . Compared with CBT, medication is much more widely available but many individuals may prefer therapy over medication. Moreover, upon discontinuation of medication, there is a significant rate of relapse, which has not been the case with CBT. Suggested solutions for fighting Terrorism Some have suggested that fighting terrorism is the only solution and that authorities should not try to persuade or appeal to the terrorists sense of reason or morals as these methods are futile and may produce the opposite effect. Examples of their solutions include psychological warfare aimed at dividing terrorists political and military leaders and factions; capturing of top hard-line terrorist leaders; providing amnesty programs; reducing terrorists profiles in the media; and showing them as criminals instead of martyrs to their own people; making the terrorist goal too expensive to pursue by making targets harder to attack or damage; not meeting terrorists demands; and not allowing terrorists any gains. In addition to these measures they advocate for a combination of psychological, political, sociological, economical, and religious measures. The promotion of social justice and true democracy; a fight against corruption; decreasing unemployment; restoring a quality educational system and stopping extreme religious teachings and books; allowing a free press and freedoms to civil society. For the Islamic world, their governments should take serious steps to delegitimize the use of religion for political purposes through: implementation of a general policy of separating religion from politics; promoting the transparency of religious practices; development of a zerotolerance policy for messages of hate and a fundamentalist infrastructure; reducing the amount of time devoted to religious programs on TV shows, radio and other media outlets to the level it was in the 1990s; countering extreme ideologies with other ideologies that are not religiously based; promoting alternatives to religion as a solution for corruption; countering extremists teachings such as Islam is the only solution to the corrupt world, that the use of Jihad to spread Islam is a duty and that Islam must prevail all over the world, that Muslims are morally superior to non-Muslims, and that Non-Muslims are infidels. 1. The monitoring of teachings in religious institutions Strict law against Terrorist 2. Punishments for politicians Secularists who are indulging themselves in supporting particular community for their vote bank 3. Formation of all religious & party committee including intellectuals & experts 4. Encourage positive heroes, role models to come forward and provide identity figures to Muslim world e.g. Abdul Kalam, Arif Mohammad Khan etc. 5. Rethinking immigration and refugee policies with the goal of balancing the ratio of immigrants according to religion; mandating total loyalty to their newly adopted countries. The following quotation from Justice Baraks opinion could be used as an illustration of the proper balance between misusing democracy and freedom of expression. He stated that When freedom of expression becomes a tool with which to injure democracy, then there is no reason for democracy to put its head on the block for the executioner. A constitution is not a formula for suicide and individual rights are not a platform for national destructiona democracy does not have to commit suicide in order to prove its vitality.the right to live in a society is prior to express ones opinion.

Research on terrorism and future directions


There has been a paucity of psychological research on the recent phenomenon of using Islamic teachings as the base for terrorist acts. This is probably due to the difficulties and challenges involved in completing research in this area. There is the scarceness of research-based results on terrorism as opposed to historical or philosophical analysis of terrorist acts. Terrorism is a very complex problem that involves several disciplines. The phenomena of terrorism is poorly understood, with no clear definition of the concepts used to study it. The existing knowledge of the psychological make up of terrorists is scanty. In important areas such as their belief systems, thinking, ideology, organization, decision making process, personality dynamics, and motivations. Terrorist movements are clusters of different social groups with different social agendas and with no common characteristics among them. In addition to the above problems Most non muslim researchers lack an in-depth understanding of the language and religious, cultural, psychological, historical, political, and social backgrounds of the population in Islamic countries. Archives of Indian Psychiatry 10(1) April 2009

22

Mrugesh Vaishnav : Presidential Address There is no advanced psychological/psychiatric Bandura, A. (1990). Mechanisms of moral disengagement. training available in educational institutions in the InWalter Reich (Ed.), Origins of terrorism: Psychologies, West, India or in Islamic countries for dealing with ideologies, theologies, states of Mind (pp. 161"191). Cambridge: Cambridge University Press. the issues of radical thinking and terrorism. There is lack of adequate measurement that helps with the study, identification or prediction of radicalism and terrorism. Sensitivity of dealing with issues of religious and political corruption which are prevalent in the Indian & Islamic political systems Fear of retaliation by terrorist organizations against researchers who would be perceived and portrayed as trying to plot against their goals. Extremism and terrorism are increasing and there is an urgent need for a multifaceted research plan utilizing several disciplines to help with suggesting solutions. The psychological part of this plan would include further exploration of important issues, such as the religious-based violence and the influence of religious teachings on extremists and terrorists values, beliefs, attitudes, attributions, motivations, cognitive and emotional states; ideologies, and strategies. Other equally important issues are the effect of the environment and peers; the process of recruiting including leaderfollower relations; organization; decision making process; personality; and group dynamics of individual and terrorist organizations. Holloway, H. C., & Norwood, A. E. (1997). Forensic psychiatric aspects of terrorism. In R. Gregory Lande & David Armitage (Eds.), Principles and practice of military forensic psychiatry (pp. 409"451). Springfield, Illinois: Charles C. Thomas. Hobfoll SE (1991). Traumatic stress: a theory based on rapid loss of resources. Anxiety Res: Int J 4: 187197. Jones FD, Fong YH (1994). Military psychiatry and terrorism. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW (eds). Military Psychiatry: Preparing in Peace for War. Office of Surgeon General, Walter Reed Army Institute of Research: Washington, DC. pp 263 269. Jueregensmeyer, M. (2000). Terror in the mind of God: The global rise of religious violence. Berkeley: University of California Press. Karsenty E, Shemer J, Alshech I, Cojocaru B, Moscovitz M, Shapiro Y et al (1991). Medical aspects of the Iraqi missile attacks on Israel. Israel J Med Sci 27: 603607. Khan AS, Levitt AM, Sage MJ (2000). Biological and chemical terrorism: strategic plan for preparedness Laraque D, Boscarino JA, Battista A, Fleischman A, Casalino M,Hu Y et al (2004). Reactions and needs of tristate area pediatricians following the events of September 11: implications for childrens mental health services. Pediatrics 113: 13571366. Lawal, O. (2002). Social-psychological considerations in the emergence an growth of terrorism. In C. E. Stout (Ed.), The Psychology of Terrorism: Programs and Practices in Response and Prevention (psychological dimension to war and peace). Connecticut, Praeger. Leon Trotsky, (1920). Terrorism and communism dictatorship vs. Democracy. Chap. 4. Accessed online at www.marxists.org/ archive/Trotsky Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K.60,000 disaster victims speak: part I. an empirical review of the empirical literature, 1981e2001. Psychiatry 2002;65:207e39. North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL,et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999;282:755e62. 23

Future directions
Mental health commentators should endeavour to learn more about group behaviour and the predisposing, precipitating, perpetuating and protective factors in the manifestation of fear and fear-related conditions in society. Mental health professionals should endeavour to facilitate dialogue between all parties involved in the terror discourse.

Selected References
Ardila, R. (2002). The psychology of the terrorist: Behavioral perspective. In C. E. Stout (Ed.), The Psychology of Terrorism: A public understanding (psychological dimension to war and peace). Connecticut, Praeger. Aspinwall LG, Taylor SE (1997). A stitch in time: self regulation and proactive coping. Psychol Bull 121: 417 436. Antonovsky A (1987). Unraveling the Mystery of Health. Jossey- Bass: San Fransisco Ayalon O, Lahad M (2000). Life on the Edge: Coping with War, Terror and Violence. Nord Publications (Hebrew): Haifa Archives of Indian Psychiatry 10(1) April 2009

Mrugesh Vaishnav : Presidential Address Ohbu S, Yamashina A, Takasu N, Yamaguchi T, Murai T, Nakano K et al (1997). Sarin poisoning on Tokyo subway. Southern Med J 90: 587593. Orbach, B. (2001). Osama Bin Laden and Al-Qaida: Origins and doctrines. Middle East Review of International Affairs, 5, 54"68. Pearlstein, R. M. (1991). The mind of the political terrorist. Wilmington, Delaware: Scholarly Resources. ONeill, O. (2002) A Question of Trust: The BBC Reith Lectures Cambridge University Press. Pfefferbaum B: The impact of the Oklahoma City bombing on children in the community. Military Medicine 2001;166(12 Suppl):4950. Piven, J. S. (2002). On the psychosis (religion) of terrorists. In C. E. Stout (Ed.), The Psychology of Terrorism: Theoretical understandings and perspectives (psychological dimension to war and peace), VoI. III. (pp. 120H147). Connecticut, Praeger. Post, J. M. (1983). Individual and group dynamics of terrorist behavior. Proceedings of 7th World Congress of Psychiatry. Post, J. M. (2001). Killing in the name of God: Osama bin Laden and Radical Islam. Plenary address to American Association for ForensicPsychiatry annual meeting, Boston Reid, W. H. (2002). Controlling political terrorism: Practicality, not psychology. In C. E. Stout (Ed.), The Psychology of Terrorism: A public understanding (psychological dimension to war and peace), Vol. I. Connecticut: Praeger. Sagrman, M. (2005). Understanding terror networks. International Journal of Emergency Mental Health, 7, 5H8. Sally Wooding, Beverley Raphael (2004), Psychological Impact of Disasters and Terrorism on Children and Adolescents: Experiences from Australia, Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.19,No.1 Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, et al. Psychological reactions to terrorist attacks: findings from the national study of Americans reactions to September 11. JAMA 2002;288:581e8. Silver RC, Holman EA, McIntosh DN, Poulin M, GilRivas V (2002). Nationwide longitudinal study of psychological responses to September 11. JAMA 288:1235 1244. Silke, A. (1998). Cheshire-Cat logic. The recurring theme of terrorist abnormality in psychological research. Psychology Crime & Law, 4, 51H69 Vlahov D, Galea S, Resnick R, Ahern J, Boscarino JA, Bucuvalas M et al (2002). Increased use of cigarettes, alcohol, and marijuana among Manhattan residents after CH. World Federation for Mental Health (WFMH): The Effect of Trauma anViolence on Children and Adolescents: A Global Mental Health Education Program of the World Federation for Mental Health. Alexandria, VA: World Federation for Mental Health and World Health Organisation, 2002. Zimbardo PG (2003). The Political Psychology of Terrorist Alarms. Psychologists for Social Responsbility (http://www.psysr.org/ zimbardo2003.htm).

Sources of support: Nil Correspondence: Dr.Mrugesh Vaishnav Samvedna Below Karnawati Hospital Ellis Bridge Ahmedabad 380006 Phone:079-26578889 Cell:+919825767565 e-mail: drmrugesh@rediffmail.com, mrugeshvaishnav@yahoo.co.in

Conflicts of interest: None

24

Archives of Indian Psychiatry 10(1) April 2009

Original Article

Dissociation In Psychiatric Inpatients


Nilima Shah G.K.Vankar Abstract
Background: Dissociative disorders were till recently considered a rarity.The development of structured questionnaires and interviews have thrown light on the prevalence of dissociative phenomena. Considering the paucity of research in this field, a study was conducted to look for dissociative phenomena in psychiatric patients Aim: To find out the presence and type of dissociative phenomena in indoor psychiatric patients, and study their characteristics. Material and method: A series of 100 patients admitted to the psychiatry ward of a general hospital were selected and The Dissociative Disorders Interview Schedule (DDIS)- a structured clinical interview was administered to them .. Patients with and without dissociation were then compared . Result: 31 patients had the presence of dissociative phenomena, the most common of which was possession trance syndrome. Most patients with dissociation had a psychotic disorder, had higher number of somatic complaints and a more frequent history of suicide attempts, electroconvulsive therapy and sleepwalking. Conclusion: Dissociation as a phenomenon is very common, possession trance being the most common type in the group studied and structured interviews help in detecting these phenomena. Key words: Dissociation, inpatients, psychiatry, possession

Introduction
Dissociative disorders were once thought to be rare and exotic disorders.[1] DSM III (Diagnostic and statistical manual-third revision) [2] in the year 1980 for the first time included dissociative disorders as separate diagnostic entities, and later revised them in DSM IV (Diagnostic and statistical manual- fourth revision)[3] Until this inclusion, no standardized instruments were designed to yield uniform diagnoses of dissociative disorders. Also, structured diagnostic interviews developed for other psychiatric categories did not include the assessment of dissociative disorders. The development of objective screening instruments[4,5] and structured interviews[6,7] filled this gap and promoted empirical research in this field. Several epidemiological studies conducted over the past 15 years have shown that dissociative disorders may have been previously underdiagnosed and that with proper screening and diagnostic instrumentation, a much higher prevalence is encountered. Several studies have assessed

the prevalence of dissociation in community samples around the world[8-12] and in various special populations. (E.g. delinquent adolescents, substance abusers, women in prostitution or survivors of childhood sexual abuse).[1317] Also, inpatient populations have been studied in a number of countries.[18-28] In most of these studies; a dissociative disorder had been correctly diagnosed in only a small percentage of the patients before their inclusion in the study. Dissociative disorders were found to be common in psychiatric outpatients also.[29-32] Given this scenario and the resurgence of interest and systematic research in dissociative disorders in different countries of the world, there is a paucity of research in this area in India. To the best of our knowledge, there is no study carried out to detect the prevalence of dissociative disorders in the psychiatric patients in India, using structured clinical interviews or questionnaires. There are a few case reports of dissociative identity disorder.[33,34] However, the so called atypical dissociative disorders are found to be more common in the country,

Table 1 Prevalence of Dissociation in studies from countries


Study Ross et al, 1991 [18] Saxe et al, 1993 [19] Knudsen et al, 1995 [22] Horen et al, 1995 [20] Latz et al, 1995 [21] Modestin et al, 1996 [28] Lussier et al, 1997 [23] Tutkun et al,1998 [24] Friedl et al, 2000 [26] Gast et al, 2001[27] Xiao et al, 2006 [32] Country Canada United states Norway Canada United states Switzerland United states Turkey Netherlands Germany China Prevalence of dissociative disorders (%) 20.7 15 8.2 17 46*(only females ) 5 9 10.2 8 4.3 3.3
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Archives of Indian Psychiatry 10(1) April 2009

Nilima Shah : Dissociation in Psychiatric Inpatients including the possession syndrome.[35] It has been stated that possession syndrome is commoner in India as compared to the more complex dissociative identity disorder commonly prevalent in Western Europe and North America. This could be because Indians believe in polytheism and re-incarnation whereas deliberate roleplaying is socially approved in the Western countries. [36] With this knowledge and background, we conducted a study to find out the prevalence of Dissociative phenomena of various types in Indoor psychiatric patients in a general hospital setting of Baroda city in Gujarat, India. Table 2 Demographic Characteristics

Aims and Objectives


1) To determine the prevalence of dissociation in indoor psychiatric patients and the proportion of each type of dissociative experience To compare patients with and without dissociation in terms of demographic data, physical and psychiatric diagnoses, co-morbid disorders, associated features and various symptom clusters.

2)

Methodology and Materials


A series of 100 consecutively admitted patients All the patients who were admitted in the Psychiatry ward of S.S.G Hospital. Patients with Dementia, Mental Retardation and who refused to give consent were excluded from the study The Dissociative Disorders Interview Schedule (DDIS). It is a 132- item structured interview used to assess DSMIV diagnoses of somatization disorder, major Depression, borderline personality disorder, alcohol and Drug abuse, and the five DSM-IV dissociative disorders.It is Also used to inquire about a wide range of other Experiences, including trauma history, and about features Thought to be associated with dissociative identity disorder Such as Schneiderian symptoms. it has been found to have A good inter-rater reliability (kappa=0.68) and a false Positive rate of less than 1% for the diagnosed of Dissociative identity disorder. [6] Procedure 100 patients as per the inclusion criteria were recruited. After the initial stabilization of active symptoms, they were explained about the study and a written informed consent was taken if they were willing to participate in the study. After this, the DDIS was administered to them, and the results were recorded along with a few verbatim reports. The data collected was compiled and the sample was divided into 2 groups. Patients with dissociation and Patients without dissociation. These two groups were then compared in terms of demographic data, physical and psychiatric diagnoses that they had received, co-morbid disorders, associated features like history of abuse, history of suicide attempt, 26

Table 3: Diagnosis of the study sample

Diagnosis received Psychotic disorders Bipolar mood disorder Alcohol Dependence Major depressive disorder Others

No. of patients 41 21 20 6 12

Psychotic disorders include Schizophrenia, Brief Psychotic disorder, schizophreniform disorder, schizoaffective disorder Other diagnoses include Catatonia 1, conversion disorder 1, somatoform disorder 1, PTSD 1, Generalized

Archives of Indian Psychiatry 10(1) April 2009

Nilima Shah : Dissociation in Psychiatric Inpatients Two third of the patients were men, had studied upto tenth standard, had mean age of 34.7 years. Psychotic disorders, bipolar disorder, alcohol dependence and major depression were the main diagnoses of the study sample. Prevalence and pattern of dissociative phenomena: As shown in Table 4, none of the demographic characteristic like age, gender,education,employment status,marital status, having children or history of imprisonment were associated with presence or absence of dissociative phenomena. Psychiatric diagnosis and dissociation: As shown in Table 5 , psychotic disorders were associated with more frequent dissociative phenomena, it was not statistically significant. Alcohol abuse was not associated with more frequent dissociative phenomena, in fact not having alcohol abuse was associated with more frequent dissociative phenomenon. Physical and sexual abuse history,suicide attempt , ECT and dissociation: As shown in Table 6, physical comorbid disorders in psychiatric in patients were not associated with increased dissociative phenomena. In our study there was no significant difference found between the patients with and without dissociation in terms of a history of physical and / or sexual abuse. 12 (39%) patients with dissociation had a history of physical abuse and 27 (39%) patients without dissociation had the same. 05 (16%) patients with dissociation had a history of sexual abuse and 07 (10%) of patients without dissociation had the same. However this difference was not statistically significant. 13 (42%) patients with dissociation had attempted suicide atleast once compared to 16 (23%) patients without dissociation and this difference was statistically significant. 13 (42%) patients with dissociation had a history of ECT, whereas 12 (17%) patients without dissociation had a history of ECT. This difference was statistically significant. Physical abuse,sexual abuse were not associated with more frequent dissociative phenomena, though suicide attempt, receiving ECT for treatment and sleepwalking were associated with increased dissociative phenomena as shown in Table 7. Somatic symptoms.Schneiderian First Rank Symptoms ,Borderline personality features and dissociation: As shown in Table 8 dissociative phenomens were not associated more frequent somatic symptoms, Schneiderian First Rank symptoms or with borderline personality disorder features. The patients with dissociation had a higher mean number of somatic complaints (mean 7.97, SD 4.2) than the patients without dissociation (mean 6.41, SD 4.18). This difference was statistically significant. 27

Table4: Types of Dissociative experience

2.

3.

Chart 1:Overlap in dossociative phenomena

4.

Dissociative Fugue 3 3
Type of Dissociative experience Dissociative amnesia

1no. of 2
patients

Dissociative Fugue Depersonalization Dissociative Fugue an d possession tran ce

19

2 3 1

Possession

Depersonalization an d possession tran ce 2 sleepwalking and imaginary playmates and various Depersonalization symptom clusters such as 3 somatic complaints, Schneiderian symptoms and symptoms associated with Dissociative identity 1 borderline personality disorder. Possession trance 19 Total

Statistical analysis:

31

The Epi- Info software was used to perform tests of significance. The chi-square test and the Fishers Exact test were used as applicable at 90% level of statistical significance. Chi- square test was used for categorical data to find out whether observed differences between proportions of events in groups were statistically significant, and the Fishers Exact test was used for numerical data.

5.

Results
1. Demographic characterisiocs of the sample: A total of 100 patients were selected for the study, all of whom completed the DDIS and the following results were obtained: 31% of the patients experienced dissociation.

Archives of Indian Psychiatry 10(1) April 2009

Nilima Shah : Dissociation in Psychiatric Inpatients Table 4: Dissociation and demographic characteristics

Table 5: Dissociation and Psychiatric diagnoses


Pts with dissociation N=31 n, % 17 (56) 07 (23) 02 (06) 02 (06) 03(09) Pts without dissociation N=69 n,% 24 (35) 14 (20) 18 (26) 04 (06) 09(13)

Diagnosis received

Statistical Significance 2 =3.56, df=1, p=0.06 2 =0.07, df=1, p=0.79 2 =5.15, df=1, p=0.02 2 =0.11(with Yates correction ), df=1, p=0.74 _

Psychotic disorders Bipolar mood disorder Alcohol Dependen ce Major depressive disorder Oth ers

Table 6: Dissociation and physical co-morbid disorders


Patients with Dissociation N=31 (n),% 00 16 (52) 04 (13) 02 (07) Patients without dissociation N= 69 (n),% 02 (03) 38 (55) 17 (25) 02 (03) 2 =0.1, p=0.75 2 =1.78, p=0.18 2 =0.08 (with Yates correction), p=0.77

Co-morbid disorders

Statistical Significance

Somatization disorder Major depressive disorder Substance use disorder Borderlin e personality disorder

6.

Characteristics of patients with possession syndrome. Out of 100 patients, 22 reported experiences of being possessed at some point of time during their illness. Their age range was from 20 to 60 years. 12 were men

and 10 were women Most of them had completed primary education, were married and had 2 or 3 children. A majority were unemployed at the time of the interview. A majority of these patients had a psychotic disorder (14), followed by Bipolar mood Archives of Indian Psychiatry 10(1) April 2009

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Nilima Shah : Dissociation in Psychiatric Inpatients Table 7: Dissociation and Associated features

Associated features H/O* Physical abuse H/O Sexual abuse H/O Suicide Attempt H/O ECT^ Sleepwalking Imaginary playmates

Patients with dissociation N=31 (n)=% 12 (39) 05 (16) 13 (42) 13 (42) 05 (16) 00

Patients without dissociation N=69 (n)=% 27 (39) 07 (10) 16 (23) 12 (17) 05 (07) 02 (03)

Statistical Significance Chi-square= 0, p=1 Chi-square= 0.27 (with yates correction), p= 0.6 Chi-square= 3.65, p= 0.056 Chi-square= 6.87, p= 0.009 Chi-square= 6.87, p= 0.009

Table 8: Dissociation and other symptom clusters

Symptom Cl usters

Patients with dissociation N=31 (n),% Range Mean(SD) 2 to 19 7.97(4.2)

Patients without dissociation N=69 (n),% 0 to 15 6.41(4.18)

Statistical Significance

Somatic complaints

F statistic=2.97, p= 0.09

Schneiderian symptoms

Range Mean(SD) Median Range

0 to 6 1.77(1.34) 1 0 to 9

0 to 7 1.54(1.51) 0 0 to 9

F statistic=0.53, p= 0.47

Borderline Personality Symptoms

disorder (5), Alcohol dependence (2) and Major depressive disorder (1). (Psychotic disorders include Schizophrenia, Brief Psychotic disorder, schizophreniform disorder, schizoaffective disorder) Most of the patients experienced being possessed for a period of time ranging from a few minutes to a few hours during which they behaved in a disinhibited and disorganized manner, typically exhibited stereotyped to and fro neck movements or rotatory trunk movements which were experienced as involuntary stated as not in ones control They talked in the manner of the possessing power which was either God, Goddess, evil spirit, dead forefather, witches, devil or ghost. Most of the patients made demands for specific things, some used abusive language and some behaved in an authoritative manner and blessed others during the episode. None of the patients reported any violent behavior during the episode of possession. Those who felt possessed Archives of Indian Psychiatry 10(1) April 2009

by Gods and Goddesses did not feel any emotional distress about the incident and there was no stigma associated with it. All the patients stated having experienced some or the There was a statistically significant negative association between alcohol dependence and dissociative symptomatology; this finding is in contrast to other studies which show a high proportion of dissociative experiences in patients with substance dependence[11,13] which may be because those who reported episodes of disremembered behavior and fugue like episodes were considered as having an alcoholic black-out, as per the DDIS, and therefore were excluded from the group of patients with dissociation. 7. Somatization, attempted suicide and Dissociation The patients with dissociation had a higher mean number of somatic complaints than the patients without dissociation This is in tune with the study 29

Nilima Shah : Dissociation in Psychiatric Inpatients of Saxe et al in which sixty-four percent of the patients with dissociative disorders fulfilled the criteria for somatization disorder and reported an average of 12.4 somatic symptoms which led to a number of medical hospitalizations and consultations. A significant correlation was found between the degree of dissociation and degree of somatization in patients with dissociative disorders. It was concluded that somatization disorder is a frequent and serious comorbid disorder among patients with dissociative disorders in their study. [43] However in our study we note that although somatization disorder as a comorbid disorder was not found in any of the patients with dissociation, the mean number of somatic complaints in patients with dissociation was significantly higher than those without dissociation although the complaints did not fulfill the criteria of somatization disorder. In our study there was no significant difference found between the patients with and without dissociation in terms of Dissociative disorders are considered to be common long term sequelae of child abuse and trauma[44] and abuse histories are common in patients with dissociative disorders. Reported rates of physical and sexual abuse range from 60 to 90 %. [45,46,47] Compared to these rates, the prevalence in our finding was relatively low. Some other form of trauma, probably emotional abuse or neglect or severe familial conflicts may have contributed to the high rates of dissociation. 13 (42%) patients with dissociation had attempted suicide atleast once compared to 16 (23%) patients without dissociation and this difference was statistically significant. Several studies have noted the presence of severe dissociative experiences appearing to be specifically related to an inclination for self-mutilation and suicidal behavior.[48] Some studies indicate that suicidal individuals utilize dissociation to a higher degree than non-suicidal individuals.[49,50] Research indicates that dissociative disorder patients more frequently engage in self-destructive behaviors, use more methods of self-injury, and begin to injure themselves at an earlier age than patients who do not dissociate.[51] The relation between dissociative experiences and self- injurious behaviors is complex. First, several authors have reported the phenomenon of pain analgesia, a dissociative condition which may facilitate self-harm.[52,53] Second, sometimes selfmutilation can be a method of stopping uncomfortable dissociative experiences.[54] Third, sometimes the patients experience amnesia for the episode of selfmutilation.[55] 8. ECT, sleep-walking, imaginary childhood companion and Dissociation 13 (42%) patients with dissociation had a history of ECT, whereas 12 (17%) patients without dissociation 30 had a history of ECT. This difference was statistically significant. In general, a history of ECT suggests a severe and/ or a treatment resistant illness. It can be inferred indirectly that a dissociative psychopathology is associated with a severe and/or chronic illness. Leonard et al conducted a study to find out the path to diagnosis and the experience of patients with dissociative disorders. Of the 55 patients, 76% reported delays in diagnosis (57%, >3 years and 25%, >10 years) with adverse consequences in 64%; 80% had experienced skeptical or antagonistic attitudes from clinicians, rated as destructive by 48%. They were disabled (60% rated as >50% impaired) and were heavy consumers of health services. (48% hospitalized, 68% >5 times, and a number of courses of electroconvulsive therapy) [56] There was a clinically significant difference found between patients with and without dissociation in the history of sleepwalking, although the number of patients who had such a history was small and video or polysomnographic evidences were not available. 05 (16%) patients with dissociation had a history of sleepwalking and 05 (07%) patients without dissociation had such a history. It is an enduring and contentious hypothesis that sleepwalking and night terrors are symptomatic of a protective dissociative mechanism. This is mobilized when intolerable impulses, feelings and memories escape, within sleep, the diminished control of mental defense mechanisms. They then erupt but in a limited motoric or affective form with restricted awareness and subsequent amnesia for the event. It has also been suggested that such processes are more likely when the patient has a history of major psychological trauma. In the study of Hartman D, 6 patients out of 22 having a sleepwalking disorder had a history of severe psychological trauma and an elevated score on scales of dissociation.[57] It is now said that dissociative disorders may arise exclusively or predominantly from the sleep period.[58,59] Mahowald and Schenk[60] state that virtually all patients with nocturnal dissociative disorders evaluated at their centre were victims of repeated physical and/or sexual abuse. There is now overwhelming neurophysiologic evidence in animal models that such physical or psychic trauma may lead to permanent alterations in the functioning of the central nervous system[61,62] predisposing to clinical dissociative disorders. In our study, 2 patients had a history of having imaginary childhood playmates. None of these patients had any evidence of dissociation. The focus on child dissociative identity disorder led clinical investigators to initially focus on childhood fantasy phenomena such as imaginary companionship, as possible developmental precursors for the dissociative disorders. The imaginary companionships are reported in 20 to 60 % of normal Archives of Indian Psychiatry 10(1) April 2009

Nilima Shah : Dissociation in Psychiatric Inpatients children, depending on the age of the child and the definition used. Normal imaginary companionship is widely regarded as benign and is commonly considered to be a sign of creativity in younger children, but it becomes increasingly suspect in older children and adolescents and is thought to be always pathological in adults. In dissociative children, the rates of imaginary companionship range from 42 to 84 % with the highest rates reported for children diagnosed with dissociative identity disorder. 9. Possession Trance Syndrome A possession trance is defined as a single or episodic alteration in the state of consciousness characterized by the replacement of customary sense of personal identity by a new identity. This is attributed to the influence of spirit, power, deity or other person, as evidenced by one or more of stereotyped and culturally determined behaviors or movements that are experienced as being controlled by the possessing agent; full or partial amnesia for the event. In our study, there were 31 patients with dissociation, of which 22 had a dissociative trance syndrome, possession trance type. This was the most common dissociative phenomenon found. It was found in a wide age range of both men and women. It came across as a culture- bound syndrome which is defined as :Recurrent, locality specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM IV category. Many of these patterns are indigenously considered to be illnesses, or at least afflictions, and most have local names. Possession states are seen as widespread and are culturally accepted in about 90 % of the worlds populations.[63] Possession states have also been previously described in India.[64] Similar to other dissociative conditions, a possession state may be considered as both a normative experience in one culture (e.g. religious experience) and symptomatic of disordered personality organization in other cultures. There are at least three different perspectives for understanding the underlying psychopathological basis of possession disorders. [63] First, socio-cultural theories suppose that spirit possession is a culturally sanctioned heavily institutionalized phenomenon. Cultural acceptance of such behaviors and the re-inforcement provided by the environment sustain them. Communication theory views possession as a form of communication exhibited by those oppressed groups who are unable to communicate in another way. In many societies, the persons most affected are women and the poor. It has been proposed that possession and exorcism arise together when there is an oppressive social structure or a loss of trust in Archives of Indian Psychiatry 10(1) April 2009 institutions or in conditions where protest is dangerous or unacceptable and there is a seeming inability to resolve social conflicts. [63] The model of dissociative theory maintains that possession is explained as a return of repressed conflict or desires, where the id wishes to overwhelm the ego in a state of dissociation following a major psychological trauma. In this model, relief from the intrapsychic tension is a primary gain, and attention and sympathy are secondary gains. [63] In our patients, it was noted that the possession episode was culturally sanctioned, the usual stigma of mental illness was not associated with it and the family often preferred to seek help from the faith-healer who attempted exorcism. Contrary to the popular belief that it affects women of low socioeconomic class, we found this phenomenon in men as well. To the patient, the release of strangulated affects served as a primary gain and the attention received from the care givers was a secondary gain that worked as a positive re-inforcement and contributed to the recurrence of the phenomenon in a similar stressful situation This is the first Indian study of its kind using Standardized interviews were conducted using the DDIS, a comprehensive tool for the systematic assessment of dissociation. Small sample size , and possible recall bias are the limitations of the study as the data gathered was on the basis of history given by patients and relatives,

Conclusions Dissociative phenomena are not rare in indoor psychiatric patients, and patients reported various dissociative phenomena including dissociative amnesia, dissociative fugue, dissociative identity, depersonalization and dissociative trance disorder. Structured Interviews help in detecting these phenomena which are not usually spontaneously reported by the patients. The salient features observed in the patients with dissociative phenomena were an association with a psychotic disorder, more number of somatic complaints, a history of suicide attempts, sleepwalking and electroconvulsive therapy. Possession syndrome was the most common form of dissociative psychopathology found. Implications Dissociative phenomena are not a rarity and should be looked for in psychiatric patients in order to avoid misdiagnosis and missed diagnosis. Further studies with large sample size and including patients from diverse socioeconomic and cultural background are required to lucidate these phenomena. Elaborate studies of the psychopathology of patients having possession syndrome need to be done and a cultural sensitivity needs to be developed while studying dissociation in diverse cultures. 31

Nilima Shah : Dissociation in Psychiatric Inpatients 15. Dunn G, Ryan J, Paolo A, Van Fleet J. Co morbidity of References dissociative disorders among patients with substance 1. Putnam F. Diagnosis and Treatment of Multiple use disorders. Psych Serv 1995; 46.153156 Personality Disorder. New York, Guilford; 1989 16. Carrion V, Steiner H. Trauma and dissociation in 2. American_Psychiatric_Association. 1980. Diagnostic delinquent adolescents. J Am Acad Child Adolesc and Statistical Manual of Mental Disorders, 3rd Psychiatry 2000; 39.353359 edition. Washington, D.C.. American Psychiatric 17. Ross C, Farley M, Schwartz H. Dissociation among Association women in prostitution. Journal of Trauma Practice 3. American_Psychiatric_Association. 1994. Diagnostic Volume. 2 Issue. and Statistical Manual of Mental Disorders, 4th edition. Washington, D.C.. American Psychiatric 18. Ross C, Anderson G, Fleisher W, Norton G. The frequency of multiple personality disorder among Association psychiatric inpatients. Am J Psychiatry 1991; 4. Bernstein E, Putnam F. Development, reliability, and 148.17171720 validity of a dissociation scale. J Nerv Ment Dis 1986; 19. Saxe G, vanderkolk B, Berkowitz R et al. Dissociative 174.727735 disorders in psychiatric inpatients. Am J Psychiatry 5. Vanderlinden J, Van D, Vandereycken W, Vertommen 1993; 150.10371042 H. The Dissociation Questionnaire (DIS-Q). development and characteristics of a new self- 20. Horen S, Leichner P, Lawson J. Prevalence of dissociative symptoms and disorders in an adult reporting questionnaire. Clin Psychol Psychotherapy psychiatric inpatient population in Canada. Can J 1991; 1.2127 Psychiatry 1995; 40.185191 6. Ross C, Heber S, Norton G et al. The Dissociative Disorders Interview Schedule. A structured interview. 21. Latz T, Kramer S, Hughes D. Multiple personality disorder among female inpatients in a state hospital. Dissociation 1989; 2.169189 Am J Psychiatry 1995; 152.13431348 7. Steinberg M, Rounsaville B, Cicchetti D. The Structured Clinical Interview for DSM-III-R 22. Knudsen H, Draijer N, Haslerud J, Boe T, Boon S. Prevalence of dissociative disorders in a Norwegian Dissociative Disorders. Preliminary report on a new general psychiatric department (inpatients and diagnostic instrument. Am J Psychiatry 1990; 147.76 daycare), in Proceedings of the Fifth Annual Spring 82 Conference of the International Society for the Study 8. Ross C. Epidemiology of multiple personality disorder of Dissociation. Edited by van der Hart O, Boon S, and dissociation. Psych Clin North Am 1991; 14.503 Draijer N. Amsterdam, International Society for the 517 Study of Dissociation, 1995; p 79 9. Vanderlinden J, Van D, Vandereycken W, Vertommen 23. Lussier R, Steiner J, Grey A, Hansen C. Prevalence of T. Dissociative experiences in the general population dissociative disorders in an acute care day hospital in the Netherlands and Belgium. a study with the population. Psych Serv 1997; 48.244246 Dissociative Questionnaire (DIS-Q). Dissociation 24. Tutkun H, Sar V, Yargic L et al. Frequency of 1991; 4.180184 dissociative disorders among psychiatric inpatients 10. Vanderlinden J, Varga K, Peuskens J, Pieters G. in a Turkish university clinic. Am J Psychiatry 1998; Dissociative symptoms in a population sample of 155.800805 Hungary. Dissociation 1995; 8.205208 25. Rifkin A, Ghisalbert D, Dimatou S, Jin C, Sethi M. 11. Akyuz G, Dogan O, Sar V, Yargic L. Frequency of Dissociative identity disorder in psychiatric dissociative identity disorder in the general population inpatients. Am J Psychiatry 1998; 155.844845 in Turkey. Comp Psychiatry 1999; 40.151159 26. Friedl M, Draijer N. Dissociative disorders in Dutch 12. Murphy PE. Dissociative experiences and dissociative psychiatric inpatients. Am J Psychiatry 2000; disorders in a non-clinical university student group. 157.10121013 Dissociation 1994; 7.2834 27. Gast U, Rodewald F, Nickel V, Emrich H. Prevalence of 13. Ross C, Kronson J, Koensgen S et al. Dissociative co dissociative disorders among psychiatric inpatients morbidity in 100 chemically dependent patients. Hosp in a German university clinic. J Nerv Ment Dis 2001; Community Psychiatry 1992; 43.840842 189.249257 14. Anderson G, Yasenik L, Ross C. Dissociative 28. Modestin J, Ebner G, Junghan M, Erni T. Dissociative experiences and disorders among women who identify experiences and dissociative disorders in acute themselves as sexual abuse survivors. Child Abuse psychiatric inpatients. Comp Psychiatry 1996; 37. 355Negl 1993; 17.677686 361.

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Nilima Shah : Dissociation in Psychiatric Inpatients 29. Boon S, Draijer N. Multiple Personality Disorder in The Netherlands. A Clinical Investigation of 71 Patients Am J Psychiatry 1993; 150.489-494 30. Dorahy M, Mills H, Taggart C, OKane M, Mulholland C. Do dissociative disorders exist in Northern Ireland? Blind psychiatric structured interview assessments of 20 complex psychiatric patients Eur. J. Psychiatry jul.-sep.2006; v20 n 3 31. Sar V, Tutkun H, Alyanak B, Bakim B, Baral I. Frequency of dissociative identity disorder among psychiatric outpatients in a Turkish university clinic, in Program Book, 13th Fall Conference of the International Society for the study of dissociation. Glenview, III, 1996, p 141 32. Xiao Z, Yan H, Wang Z, Zou Z. Trauma and dissociation in China. Am J Psychiatry 2006; 163.1388 1391 33. Adityanjee, Raju G, Khandelwal S. Current status of multiple personality disorder in India. Am J Psychiatry 1989; 146. 1607 1610 34. Gupta A, Kumar D. Multiple Personality Disorder - A Case Report from Northern India. German Journal of Psychiatry ISSN 1433-1055 35. Saxena S and Prasad K. DSM-III sub classification of dissociative disorders applied to psychiatric outpatients in India Am J Psychiatry 1989; 146.261262 36. Varma V, Bouri M, Wig N. Multiple personality in India. comparison with hysterical possession state. Am J Psychother. 1981 Jan; 35(1).113-20. 37. Timo G, Harald M, Maartje K, Fetsje A. Why Dissociation and Schizotypy Overlap. The Joint Influence of Fantasy Proneness, Cognitive Failures, and Childhood Trauma. J Nerv Ment Dis October 2007; 195(10).812-818 38. Moskowitz A, Barker S, Lynsey B. Replication of Dissociation- psychosis link in New Zealand students and Inmates. . J Nerv Ment Dis Nov 2005; 193(11). 722-727 39. Ross C. Dissociation and Schizophrenia. Journal of trauma and dissociation 2004; volume. 5 issue. 3 40. Vogel M, Spitzer C, Barnow S, Freyberger H, Grabe H.The Role of Trauma and PTSD-Related Symptoms for Dissociation and Psychopathological Distress in Inpatients with Schizophrenia. Psychopathology 2006; 39.236-242 41. Bob P, Glaslova K, Susta M, Jasova D, Raboch J. Traumatic dissociation, epileptic- like phenomena and schizophrenia. Neuro Endocrinol Lett Jun 2006; 27 (3). 321-6 42. Bob P, Susta M, Chladek J, Glaslova K, Freybergh P. Neural complexity, dissociation, and schizophrenia. Med Sci Monit, 2007; 13(10). HY1-5 Archives of Indian Psychiatry 10(1) April 2009 43. Saxe G, Chinman G, Berkowitz R et al. Somatization in patients with dissociative disorders. Am J Psychiatry 1994; 151.1329-1334 44. Anderson G, Yasenik L, Ross C. dissociative experiences and disorders among women who identify themselves as sexual abuse survivors.Child abuse and neglect 1993; 17,677-686 45. Coons P, Bowman E, Milstein V. Multiple personality disorder. a clinical investigation of 50 cases. J Nerv Ment Dis 1988; 176,519-527 46. Ellason J, Ross C, Fuchs D. Lifetime axis I and II comorbidity and childhood trauma history in dissociative identity disorder. Psychiatry 1996; 59,255266 47. Ross C, Norton G, Wozney K. Multiple personality disorder. Am analysis of 236 cases. Can J Psychiatry 1989; 34,413-418 48. Demitrack M, Putnam F, Brewerton T, Brandt H, Gold P. Relation of clinical variables to dissociative phenomena in eating disorders. Am J Psychiatry 1990; 147, 1184-1188 49. Orbach I, Kedem P, Herman L, Apter A. Dissociative tendencies in suicidal, depressed and normal adolescents. Journal of social and clinical psychology 1995;14,393-408 50. Orbach I, Mikilincer M, Cohen D, King R, Stein D. Thresholds and tolerance of physical pain in suicidal and non-suicidal adolescents. Journal of clinical and consulting psychology 1997; 65,646-652 51. Saxe G, Chawla N, Vander K. Self-destructive behavior in patients with dissociative disorders. Suicide and life threatening behavior 2002; 32, 313-320 52. Orbach I. Dissociation, physical pain and suicide. An hypothesis. Suicide and life threatening behavior 1994; 24, 68-79 53. Orbach I, Palgi Y, Stein D et al. Tolerance for physical pain in suicidal subjects. Death studies 1996 ; 20,327341 54. Favazza A. Bodies under siege. self mutilation in culture and psychiatry. Baltimore, MD, 1987, Johns Hopkins University Press. 55. Coons P, Milstein V. Self mutilation associated with dissociative disorders. Dissociation 1990; 2, 81-87 56. Leonard, David; Brann, Susan; Tiller et al. Dissociative disorders. pathways to diagnosis, clinician attitudes and their impact. Australian & New Zealand Journal of Psychiatry October 2005; 39(10).940-946 57. Hartman D, Crisp A, Sedgwick P, Borrow S. Is there a dissociative process in sleepwalking and night terrors? Postgrad Med J April 2001 ;77.244-249 58. Fleming J. Dissociative episodes presenting as somnambulism. Sleep Res. 1987;16.263 33

Nilima Shah : Dissociation in Psychiatric Inpatients 59. Schenck C, Milner D, Hurwitz T, Bundlie S, Mahowald M. Dissociative disorders presenting as somnambulism. polysomnographic, video and clinical documentation ( 8 cases ).Dissociation 1989; 4. 194204 60. Mahowald M, Schenk C. Evolving concepts of Human State dissociation. Archives Italiennes de Biologie 2001; 139. 269-300 61. Mahowald M, Schenk C. Status dissociatus- a perspective on states of being. Sleep 1991; 14. 69-79. 62. Mahowald M, Schenk C. Dissociated states of wakefulness and sleep. Neurology 1992; 42. 44-52 63. Pereira S, Bhuli K, Dein S. Making sense of possession state. psychopathology and differential diagnosis. (review). British Journal of Hospital Medicine June 1995; 53(11). 582-6 64. Shanmugan T. Abnormal psychology. TATA Mcgraw Hill publishing co; 171 65. Alexander P, Joseph S, Das A. Limited utility of ICD10 and DSM IV classification of dissociative and conversion disorders in India. Acta Psychiatrica Scandinavia March 1997; 95(3). 177-82 66. Billu Y, Beit-Hallahmi B. Dybbuk-possession as a hysterical symptom. psychodynamic and sociocultural factors. Israel Journal of Psychiatry related sciences 1989; 26(3). 138-49 67. Kolorenko C, Muhamedzanov H. culture bound mental disorders among the Tatars of the Siberian North. International Journal of Circumpolar Health April 2001; 60(2). 275-9 68. Pinerose M, Rosselli D, Calderson C. An epidemic of collective conversion and dissociative disorder in an indigenous group of Colombia. Its relation to cultural change. Social Sciences and Medicine June 1998; 46(11). 1425-8 69. Gaw A, Ding Q, Levine R, Gaw H. The clinical characteristics of possession disorder among 20 chinese patients in the Hebei province of China. Psychiatric services March 1998; 49(3). 360-5 70. Sa-edi G. Ahle Hava. Amir Kabir Pub. 1975 (Persian book)

Source of Support: None Dr.Nilima Shah,MD* Resident, Dept.of Psychiatry Medical College and S.S.G.Hospital Vadodara Dr.G.K.Vankar,MD Prof.and Head Dept.of Psychiatry B.J.Medical College and Civil Hospital Ward E1 Asarawa Ahmedabad 380016

Conflicts of interest: None

Correspondence

Dr.Nilima Shah MD 6, Arthav Flats Opp.Vasant Kunj Bus Stop New Sharda Mandir Road Paldi Ahmedabad 380007 e-mail: itisnilima@yahoo.com Cell:+919979880789

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Archives of Indian Psychiatry 10(1) April 2009

Original Article

Stress and somatic complaints in medical college students


Anuradha Sovani Swati Bhave Sharad Agarkhedkar Shailaja Mane Neelam Oswal Surekha Joshi
Abstract Students in the Indian educational system are known to be under stress much of the time, due to the immense competition involved and the high level of demands on them. Medical college education is a special case of the same stress, since the process of medical education is fraught with pressures right from the entry point, till the student passes out and thereafter. This study assessed 107 students from the first year medical students studying in a medical college in Pune from the state of Maharashtra. They were registered to participate in AACCI1 Life skill education workshops. The findings clearly reflect the high level of stress faced by them as reflected in scores on the GHQ 28, both on total as well as factor scores. The paper discusses implications of the study in terms of the well being of medical college students. Findings showed a clear trend of low depression subfactor scores (mean 9.55) as against much higher means of 14.63 and 14 respectively in the subfactors of somatic complaints and social dysfunction. The results thus point to masked depressions in students, and a tendency to channel anxiety and depression into somatization; there are also concerns about social acceptance among peers.

Introduction
Few groups are as much the focus of attention and concern where health morbidities are concerned as are our adolescents and youth. Studies on student health and mental health abound, and references can be found from the world over, examining the health and mental health status of students in general. India becomes more of a case in point due to the high levels of stress associated with studying in this country. The courses are demanding, competition is high, and examination anxiety and fear is often a cause for concern. (Bodas, Ollendick and Sovani, 2008; Bhave, Sovani and Joshi, 2009) We are, at the same time, keen that our children and adolescents do well in academics, and worried that they should not suffer for the effort. Maki, Hayami et al (2009) used the interesting concept of a stressometer along with a Japanese version of the GHQ 28 to assess stress levels among their students, famed for being under great and chronic stress. They dubbed the units of stress measured by the stressometer as TNR units and studied them. Lotfi et al (2009) carried out a similar exercise in Iran among their students, once again relying on the GHQ 28 to measure student stress, and documented the large number of students at risk for mental stress. Studies from a variety of countries including Pakistan, Iran and India have focused on incidence of depression, anxiety, suicidality, etc. among student populations. Some studies have looked at specific psychological disturbance, and burnout rates may be high. The level of reported minor psychiatric morbidity ranges from approximately Archives of Indian Psychiatry 10(1) April 2009

one-third for medical students and postgraduate trainee doctors entering their training programs, to over half for doctors who have become medical consultants and general practitioners. Given that these are people on whom there will be a high demand to deliver consistently adequate service and patient care, the stress on them is even higher. There are also some myths about the medical professionals reflecting that doctors are not at risk from stress, that they do not get sick and that if they do, then help is readily available to them. It must be kept in mind that doctors too are human, bound by the same limitations and frailties as their patients. They invest a lot of emotional energy dealing with patients, often neglecting their own needs in the process. This study thus focuses on the degree to which trainee doctors in India present with somatic and other symptoms as endorsed by them on the GHQ 28. This scale is perhaps the most popularly used in many of the studies cited above. (Goldberg and Hillier, 1979) The GHQ was originally developed as a screening tool to detect those likely to have or be at risk of developing psychiatric disorders. This scale is thus a measure of common mental health problems or domains of ranging from 0.78 to 0.95.

Materials and methods


Tool : The GHQ-28, the 28 item version of the test, with a four point response format, was administered to the study sample, with an N of 107. They were asked to only put 35

Anuradha Sovani : Stress and Somatic Complaints their age and gender on the proforma .Names were not asked. They were asked to respond honestly to the questions in the scale, and were reassured that they could write whatever was true for them. The items were in English, since that was the language of instruction for the students, and they were comfortable responding in the language. Procedure: The questionnaire was given as part of the activities preceding a value based Life Skills intervention offered to them in the form of a workshop. The workshop was not timed close to any high stress period vis a vis the medical training curriculum, eg examinations, etc. The questionnaires were distributed to the group, along with answer sheets. The respondents were asked to work independently since there were no right or wrong answers, and the sheets would be taken back in the end by the examiner. Consent was duly taken from the participants, and they were adequately compensated for their efforts by exposing them to the Life Skills Training module by trained resource persons. Analysis of data: The findings were submitted to a simple descriptive analysis by computing the means and standard deviations of the different factor scores, as well as the overall GHQ 28 score of the group. The aim of this paper was simply to establish the degree to which somatic complaints and stress related problems seem to be a feature of the very population that is trained to heal them. Hence, more comparative studies would be reported elsewhere. Intercorrelations between factors are also reported in Table 2. The differences between the factor scores of the group are reported in Table 1 below.

Discussion It is clear from the findings presented above, that Depression seems to be the lowest elevation seen. The focus of the paper was not to see whether the GHQ scores of the students per se were high, but rather to see how the different factors presented in the data. The common perception is that students are highly depressed because of the high demands placed on them, and because of the unrelenting competition in the course of their choice. However, the data clearly shows that somatic complaints (with a mean score of 14.63) are the most frequently occurring factor. It may be kept in mind that each factor is equally weighted in the GHQ, and hence clearly the medical college students whose responses were taken, endorsed somatic complaints the most frequently. Experience of work in the mental health field in India shows that patients very often channelize their stresses through the soma, in other words, they express psychological stress through bodily complaints. It is interesting, though, that the students of a discipline like medicine should do this. Very often, such bodily complaints such as feeling run down, feeling ill, pains in the head or pressure in the head may actually be attributed to fatigue and overwork, both by the students themselves as well as their caregivers. In this study, table 2 shows that there is a moderate relationship between depression and somatic complaints (0.42, p<0.01) Montazeri et al (2003) carried out a study using the 12 item GHQ in Iran, and reported that a two factor solution of an oblique rotation factor analytic treatment of their data yielded the factors of psychological distress and social dysfunction. A similar trend in fact seems reflected in the data presented here, since the excessive somatization reported clearly seems to be an outcome or channelization of psychological distress, a fact that was borne out later in the course of qualitative analysis of responses that emerged in the course of the life skills workshop that was conducted after this data was collected.

Results: The score range obtained was 28 to 98, with a mean score of 51.92 (13.62). 34 of the 107 respondents, ie. about 32% gave a rating of more than 2 on every item of the GHQ, placing them in a potentially stressed range.

Table 1: Factor scores on the GHQ 28.


Factor Somatic Anxiety Social Dysfunction Depression Mean 14.63 13.91 14.00 9.55 SD 3.59 4.54 4.74 4.39

The other important findings that emerged, again in keeping with Montazeri et als factor solution, was the emphasis placed by the respondents of this study on the Table 2 Pearson correlation matrix of factor intersocial dysfunction they perceived in themselves. With a correlations between factors mean score of 14 and a standard deviation of 4.74, social Factors Anxiety Social Depression dysfunction emerged as the second most important factor endorsed by the respondents. At the age when these Dysfunction youngsters are studying in medical college, i.e. at about Somatic .71 ** .42 ** .42 ** 19 years to 24 years of age, they are prone to insecurities regarding their own social acceptability and popularity. Anxiety .55 ** .54 ** If in this span of time they perceive themselves as unable Social .51 ** to handle social relationships comfortably, or realize that Dysfunction they do not have enough time to devote to social pursuits, 36 Archives of Indian Psychiatry 10(1) April 2009

Anuradha Sovani : Stress and Somatic Complaints they would feel distressed. Hence, the other factor found by Montazeri et al also seems to match the study sample we have presented. It is interesting to look at data from Iran or other Middle Eastern, or far eastern countries, because they share with India a similar family structure, and social system, more collectivistic than individualistic in nature. The finding that anxiety, with a mean score of 13.91, follows closely on the heels of the two factors presented above, reflects clearly an awareness on the part of the students that they are experiencing the pressure that comes from doubts about ones own performance and about the acceptability of ones behavior and image in a group of significant others. Another similar Indian study, conducted by Yadav et al (2005) in Delhi, used the GHQ 28 with a yes/no response format, and arrived at similar findings. The study was conducted by them with 350 medical students of Delhi, (140 boys and 210 girls) with a mean age of 18.5 (0.9) yrs. As against a mean score of 1 for the depression subscale, they found means ranging from 2.24 to 2.58 for all the other factors on the GHQ 28. The trends seen in the Yadav et al study, thus, were similar to the ones seen in the present research, although the absolute score values are lower due to a different response format. The findings thus appear to be robust and to persist in studies done across different geographical locations. Table 2, which presents the inter-correlations between scores, reflects clearly the high common loading between anxiety and somatization, with an r value of 0.71 (p< 0.01). Depression, social dysfunction and anxiety are also fairly moderately inter correlated, showing that these are not discrete areas of stress marked off by the respondents. These r values range from 0.51 to 0.55, and are all statistically significant. The findings of this study underline the need to go beyond apparent symptoms and presenting complaints, and to explore possibility of masked depressions among youngsters. In the light of the current spate of student suicides in the state, these findings need careful attention of mental health professionals.

Acknowledgement To AACCI (Association of Adolescent and Child Care in India ) for providing funds for the Workshop and the Brig. Amarjeet Singh , Dean of D. Y. Patil Medical college for consent to work with their students. References
1. Bodas, J. Ollendick, T.H. and Sovani, A. (2008) Test anxiety in Indian children: a cross cultural perspective.Anxiety, Stress and Coping. 21 (4 ) , 387 - 404. Bhave, S., Sovani, A, Joshi, S., Swetha V., Shastri J. (2009) Examination anxiety in junior college youth of Mumbai who participated in LSE training workshops abstract published in the proceedings of the International conference on Life skill Education , RGNIYD Chennai India Maki, K, Hayami, N. (2009) Assessment of stress levels of students centering on the stressometer and the GHQ 28 General health Questionnaire. Stress and Health, 1-16. Lotfi, M.H. Aminian, A.H. Ghomizadea , A. and Noorani, F. (2009) A Study on Psychological Health of First Year University Students in Iran. Iranian Journal of Psychiatry and Behavioral Sciences 3 (2), 103-106. Warbah, L., Sathiyaseelan, M., VijayaKumar, C., Vasantharaj, B., Russell, S and Jacob, K.(2009) Psychological distress, personality, and adjustment among nursing students Nurse Education Today, Volume 27(6), 597-601 Mohammed, S., Javad, J. M., and Vash, H. (2007) Mental health of medical students : A cross-sectional study in Tehran. Psychological reports, 100, 346-354. Ofili, A.N., Oriaifo, I., Okungbowa, E. and Eze, E.U. (2009) Stress and psychological health of medical students in a Nigerian university. Nigerian Journal of Clinical Practice12(2) 126-13312 Firth, J. (1986) Levels and sources of stress in medical students. British Medical Journal, 292, 1177-1180. Sender, R., Salamero M., Valls , A., and Valds, M. (2008) Psychological Variables for Identifying Susceptibility to Mental Disorders in Medical Students at the University of Barcelona. Kawasaki Journal of Medical Welfare, 13(2) 147-151.

2.

3.

4.

5.

6.

7.

Conclusion
The aim of this paper was not to point out absolute levels of stress perceived by medical college students in India, but to attempt to tease out the various factors that seem to contribute to this stress. The state of Maharashtra has recently seen a spate of student suicides in the current year 2010, and studies of student stress thus gain special relevance. The study in this instance was followed by life skills education modules, a vital method to teach young people to cope. (Bhave, 2009) Prevention and empowerment are is finally the only ways to deal with life stress in the young, and the findings of this paper help to underline this fact. Archives of Indian Psychiatry 10(1) April 2009 8.

9.

10. Abdulghani , H. M. (2008) Stress and depression among medical students: A cross sectional study at a medical college in Saudi Arabia. Pakistan Journal of Medical Science. 24 (1), 12-172 37

Anuradha Sovani : Stress and Somatic Complaints 11. Arun P, Chavan BS. (2009) Stress and suicidal ideas in adolescent students in Chandigarh. Indian Journal of Medical Science, 63 (7), 281-287. 12. Goldberg, D.P. and Hillier, V.F. (1979). A scaled version of the General Health Questionnaire, Psychological Medicine, 9, 139-145. 13. Montazeri, A., Harirchi, A.M., Shariati, M., Garmaroudi, G., Ebadi. M. and Fateh, A. (2003) The 12-item General Health Questionnaire (GHQ-12): translation and validation study of the Iranian version. Health and Quality of Life Outcomes, 1. 66-67.11 14. Yadav, S. Chatrath, H. and Prashar A. (2005) Evaluation of stress among medical students.. Presented at International Seminar on Life skill education, RGNIYD, Chennai, India , April 2009. 15. Bhave, SY (2009) Innovative Methods of life skill training program .Indian Journal of life skill education. 1(1),1-12

Dr. Anuradha Sovani Clinical psychologist, Associate Professor and Head, Department of Applied Psychology, University of MumbaiDr. Swati Bhave Pediatrician, Consultant, Indraprastha Apollo Hospital , New Delhi & Executive Director AACCI Dr Sharad Agarkhedkar Head of Dept Pediatrics, DY Patil Medical College , Pimpri, Dr. Shailaja Mane Associate Professor Pediatrics ,DY Patil Medical college ,Pimpri Pune Dr. Neelam Oswal Clinical psychologist, School Counselor, Phaltan, Maharashtra Dr. Surekha Joshi Research co-coordinator ,AACCI ,Mumbai Correspondence: Dr. Anuradha Sovani OM, 31, Shreesh Society, LIC Cross Road, Off. Eastern Express Highway, Thane-400 604, Maharashtra, India. Phone : 25833661 (M) 98210 50528 E-mail : anuradhasovani@gmail.com

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Archives of Indian Psychiatry 10(1) April 2009

Original Article

Treatment Related Decision Making Capacity in Psychotic In-Patients


Zindadil Gandhi G.K.Vankar

Abstract
Little research has been done in India in the field of determinants of mental capacity. A large number of patients are admitted against their will in psychiatric settings and are declared incapacitated to take treatment related decisions. Psychotic patients are considered to have lack of mental capacity and they outnumber the patients with other disorders in involuntary admission. In this cross sectional study total 63 patients were interviewed and it was found that around 64 percent of patients had lack of treatment related decision making capacity. Lack of such capacity was associated with level of education, lack of employment and thus less family income, high score on Brief Psychiatric Rating Scale (BPRS) (Overall, 1968) and low scores on MMSE (Mini Mental State Examination) (Folstein et al., 1968) and SAI-E (David, 1992). Around 62 percent of patients were admitted involuntarily. Twenty-three percents of patients who were involuntarily admitted had decision making capacity present when they we interviewed them and 41 percent of patients who were voluntarily admitted had a lack of that capacity. Discrepancies in the presence or absence of such capacity and type of admission suggest that a comprehensive method to judge treatment related decision making capacity should be applied which assess the patient for multiple components. (Key Words: Psychosis, mental capacity, insight.) Introduction The term competence is used to denote the state in which patients decision-making capacities are sufficiently intact for their decisions to be honored (and conversely for incompetence), regardless of who makes that determination (Grimes et al, 2000). Competent patients decisions about accepting or rejecting proposed treatment are respected. Incompetent patients choices, on the other hand, are put to one side, and alternative mechanisms for deciding about their care are sought (Grisso T et al, 1998). This problem is particularly relevant in psychiatric disorders, in which decision-making capacity is often neither clearly intact nor clearly impaired, and in which mental status may fluctuate as a function of time and therapy (Workman et al, 1987). Psychotic disorders are among the conditions most likely to render the individual incompetent relative to other forms of illness such as depression and vascular diseases (Grisso et at, 1997). Patients are evaluated on the basis of presenting complaints and mental state examination (MSE) by clinicians before admission. Though this method is considered adequate to evaluate patients treatment related decision capacity, it has been found that many patients who are admitted involuntarily under section 19 or detained under Mental Health Act, 1987(MHA) have shown this capacity soon after admission. Capacity to take treatment related decision is an area least studied in India. Little research has been done in the field of determinants of treatment related decision making capacity. In Mental Health Act 1987, the sole right has been given to the medical officer to take decision about patients decisional capacity and admit him under section 19 against Archives of Indian Psychiatry 10(1) April 2009 his will on request of his close relatives. In MHA, nothing is been mentioned about the method to evaluate and take decision about patients capacity. According to Mental Capacity Act, 2005 produced in UK parliament, it is stated that a person is considered unable to make decisions when he is, (a) Unable to understand the information conveyed to him about treatment. (b) Unable to retain the given information. (c) Unable to use that information for decision making for treatment. (d) Unable to communicate his decision about his treatment. All these components can not be evaluated by clinical interview and mental state exam only. Until quite recently, it was common for clinicians to presume that serious mental illness, mental retardation, or cognitive impairment per se rendered a patient incompetent to consent to treatment. Courts across the land have made it consistently clear that the presence of mental illness, mental retardation, or dementia alone does not render a person incompetent. A patient may be psychotic, seriously depressed, or in a moderately advanced stage of dementia, yet still be found competent to make some or all decisions (Cairns et al 2005). The assertion that mental illness and cognitive disorders are not synonymous with critical impairment of decision-making abilities is supported by research on the cognitive functioning of persons with these disorders. Empirical studies of decision-making abilities among persons with mental illness (Appelbaum and Grisso, 1998, 1995; Grisso and Appelbaum, 1995a, b; Grisso and Appelbaum, Mulvey, and Fletcher, 1995), as well as the work of other researchers, provide support for 39

Zindadil Gandhi : Treatment Related Decision Making Capacity the presumptions described earlier. It was found that there is much variability among persons recently hospitalized for mental illnesses in their abilities to understand disclosures about disorders and treatment options and to reason about them to reach treatment decisions. Of special importance, however, most patients hospitalized with mental illnesses performed as well as the research subjects who had no history of mental disorders. Even among patients recently hospitalized for schizophrenia, about onehalf of them- and for some decision-making abilities as many three-quarters, performed as well as the non-ill comparison group (McEvoy et al, 1989). The origins of concerns about subjects decision-making capacities are not difficult to apprehend. Psychiatric disorders, especially the more severe syndromes like schizophrenia, typically affect cognition, emotion, and motivation. Combined with the positive symptoms of psychotic disorders, such as delusions and hallucinations, these impairments might well limit subjects abilities to understand, appreciate, and reason about the choices with which they are faced (Jones, 1995). A strong association was seen between lower insight scores and inability to make decisions. Although the relationship between use of the Mental Health Act and insight is predictable (McEvoy et al, 1989; David et al, 1992), the relationship between decision making capacity and insight has received little attention. Insight has at least three overlapping dimensions: awareness of illness, the ability to re-label unusual mental experiences as pathological, and treatment adherence (David, 1990). We have tried to find out percentage of psychotic patients who have treatment related decision making capacity during the time of interview and to compare different demographics and clinical factors in both groups. An attempt was made to find relation between such capacity and severity of symptoms (BPRS), cognitive functions (MMSE) and insight (SAI-E). Aims and Objectives: To determine the percentage of the psychotic patients admitted who has capacity to make decisions about their treatment. To establish whether decisional inability is associated with specific demographic or clinical factors. To compare decisional capacity of voluntarily and involuntarily admitted patients. Method and materials This was a cross sectional study conducted among consecutively admitted psychotic patients in department of psychiatry, SSG Hospital of Baroda. The period of study was 8 months. Total of 63 patients were interviewed. Patients and relatives both were informed about the study and signatures or thumb impressions were taken of both the patient and the informant on a written consent. Inclusion criteria Patient diagnosed by DSM-IV TR of having any psychotic disorder. 40 Exclusion criteria Education less than 5th standard. Presence of DSM-VI diagnosis of Dementia. Patient having physical or medical problems interfering with the ability to complete the assessments. Patient with high perceived risk of violence. Patient unable to give consent.

Data collection A self-designed semi-structured proforma containing demographic variables like age, gender, education, employment, family income, ethnicity, marital status was administered. Other information of the patient includes diagnosis according to DSM-IV TR, duration of illness, treatment history if there is any, delusions and auditory hallucinations at the time of admission, and section (MHA 1987) used to admit the patient. Rating instruments like Brief Psychiatric Rating Scale (BPRS) (Overall et al, 1968), Mini Mental State Examination (MMSE) (Folstein et al., 1975), Schedule for the Assessment of Insight- Extended (SAI-E) (David, 1992) and Macarthur Competency Assessment Tool for Treatment (MacCATT) (Grisso et al, 1998) were administered along with clinical interview of the patient. To avoid inter-rater bias, the evaluation and rating of instruments in all the patients were done by a single evaluator. The binary rating of decision making capacity is based on the definition of inability to make decisions proposed in the Mental Capacity Act (Dept. of Constitutional Affairs 2005, Chapter 9 part 1).

Study Instruments Macarthur Competency Assessment Tool for Treatment (MacCAT-T) (Grisso et al, 1998): The MacCAT-T is a semi-structured interview that guides the clinician in assessing a patients treatment related decision-making capacity. It provides relevant treatment information for the patient and evaluates capacity in terms of its different components. As such it can detect impairment in four areas: (1).The patients understanding of the disorder and treatment-related information (range 0-6); (2).Appreciation of the significance of that information for the patient (range 0-4); (3).The reasoning ability of the patient to compare their prescribed medication with an alternative treatment (range 0-8); and (4).Ability of the patient to express a choice between their recommended medication and an alternative treatment (range 0-2) (Grisso et al, 1998). Part of validating the MacCAT-T included a study by Grisso and Appelbaum that included 40 acutely hospitalized schizophrenia/ schizoaffective-disorder patients (mean age 39 years, and mostly between 25 and 50 years of age). That study had confirmed reliability and usefulness of MacCAT-T to be in psychotic patients. Archives of Indian Psychiatry 10(1) April 2009

Zindadil Gandhi : Treatment Related Decision Making Capacity The MMSE is a 30 point cognitive test developed in the Brief Psychiatric Rating Scale (BPRS) (Overall et al, mid- 1970s to provide a bedside assessment of a broad 1968). array of cognitive function, including orientation, The BPRS is a 24 questions scale for measuring the attention, memory, construction and language. It has been severity of psychiatric symptomatology. It was developed extensively studied and shows excellent reliability. to assess change in psychotic inpatients and covers a Validity appears good, based on correlations with a wide broad range of areas including thought disturbance, variety of more comprehensive measures of mental emotional withdrawal and retardation, anxiety and functioning and clinico-pathological correlations. The rule depression, hostility and suspiciousness. Its 24 items are of thumb is points 24-20 mild, 19- 11 moderate and less rated on a seven point, item-specific likert scale from 1 to than 11 is severe cognitive impairment. 7, with the total score ranging from 24 to 168 (Overall et al, Schedule for the Assessment of Insight- Extended (SAI1968). The advantage of BPRS is that the inter-rater E) (David , 1992): reliability is reasonably high for a rating scale of this nature. The SAIE is a semi-structured interview that measures A summery article of more than 300 studies using the BPRS three dimensions of insight (treatment compliance, found inter-rater reliability correlative of 0.8 or higher on recognition of illness, and relabelling of psychotic the total score in the majority of studies (Ventura et al, phenomena), as well as awareness of changes in mental 1993). functioning, of the need for treatment and of the Mini Mental State Examination (MMSE) (Folstein et al., psychosocial consequences of illness. It also includes a 1975) question on response to hypothetical contradiction. Data analysis Data analysis was performed using the Epi Info 2002. Table 1 Demographic variables and Statistical parameters like frequencies of different decision making capacity variables, means and Standard Deviation (SD) were calculated. Unpaired t-test for quantitative variables, chiAbsent Statistical Present N=40 significance N=23 square test and fisher exact test for qualitative variables N (%) N (%) were used. p value of 0.05 at 95% confidence limits was used to determine statistical significance. Age (years) t= 0.30 , Results and discussion Range 17-55 15-52 d.f. = 61, 1. Participants of the study: 30.9(10.3) 30.2(09.2) Mean(SD) p = 0.76 During the eight months of study period, total of 243 Education patients were admitted in our wards. Amongst those, 123 3(13.0) 16(40.0) Upto 7th std. 2 were psychotic patients. Other admitted patients included =8.82, 9(39.1) 13(32.5) Upto 12th std. patients of major depressive disorder, substance abuse d.f.=3, 2(08.7) 6(15.0) Some college and those who were admitted for observation on court p =0.031 9(39.1) 5(12.5) Graduate order for certification of mental disorder. Among 123 psychotic patients, 10 patients were above 55 years of Employment age, 12 patients were either illiterate or had education 5(21.7) 24(60.0) 2=10.64, Unemployed level less than 5th std., 14 patients were violent, 21 patients 15(65.2) 10(25.0) d.f.=3, Employed 3(13.0) 6(15.0) p =0.0049 were unco-operative and refused to give consent, 3 Never worked patients had absconded. The interviewed group differed Monthly significantly from the non-participants in terms of marital Family income > 5000 6(26.1) 03(07.5) status and type of admission. More number of non2 =9.80, 2000-5000 10(43.5) 09(22.5) participants were separated from their spouse (2 =16.16, d.f.=3, 1000-2000 4(17.4) 15(37.5) d.f. = 3, p = 0.001) and were admitted against their will p =0.020 <1000 3(13.0) 13(32 .5) under section 19 (2 = 17.56, d.f. = 1, p = 0.00002). Ninetyfive percent of non-participants were admitted Sex 2=2.92, involuntarily. 20(87.0) 27(67.5) Male d.f.=1, 2. Demographic characteristics: 3(13.0) 13(32.5) Female p =0.087 Sixty-three psychotic in-patients were interviewed for this Ethnicity study. The majority of the patients were from age group 21(91.3) 34(85.0) of 20-40 (80.4 percent), with mean age of 39.46(SD=9.53) 2 Hindu =1.82 2(08.7) 03(7.5) Muslim years. Seventy-four percent of patients were male. None ,d.f.=3, 0 02(5.0) Christian of our patients were illiterate as the MacCAT-T requires p =0.61 0 01(2.5) Other level of education up to grade 5 (Grisso et al, 1998). More than half of the sample size were either unemployed or Marital status had never gone to work. Again majority had monthly 11(47.8) 19(47.5) Married family income less than 5000 rupees. Only 9 percent had 2=4.24, 0 6(15.0) Divorced d.f.=3, family income more than 5000 rupees. Majorities were 02(8.7) 03(7.5) Separated p =0.24 Hindus (87.3 percent) and around half of the patients 10(43.5) 12(30.0) Single were married (48 percent) and living with spouse whereas the rest were divorced, separated or single. Archives of Indian Psychiatry 10(1) April 2009 41

Zindadil Gandhi : Treatment Related Decision Making Capacity Table 1 suggests that understanding (Mean 3.6) and There is statistically significant difference in the level of expressing a choice (Mean 1.6) were the components in education between patients with or without treatment which the means were more than 50 percent of full score. related decisional capacity (p=0.03). Sixty percent of The rest components had means below 50 percent range patients without capacity had studied only up to 7th std. of full scores. More number of patients with decisional capacity were university educated (39 %). Same way significantly higher proportions of patients without such capacity were 3. Disease characteristics: The DSM-IV TR diagnoses of these patients were as unemployed (75 %) (p=0.0049) and had less family income follows: schizophrenia (47.6 percent), schizoaffective than the patients who had capacity (p=0.02). Similar study disorder (7.9 percent), schizophreniform disorder (17.5 showed no significant relationship between level of percent) and other psychotic disorders (brief psychotic education as well as employment and mental capacity disorder, bipolar disorder etc.) (17 percent). Forty nine per (Cairns et al, 2005). Though around 81% of female patients cent patients were ill for less than 2 years, 38 percent had a lack of capacity, the association between female patients had illness of 2-10 years (38.1 percent) and 12 gender and lack of capacity was statistically insignificant percent had illness of more than 10 years duration. Twenty- (p=0.087). These findings are in keeping with previous three percent of patients were either on no treatment or studies (Palmer et al, 2002) (Cairns et al, 2005). had stopped treatment whereas 62 percent patients were on oral antipsychotic medication. Delusions at time of admission were present in 84 percent of patients, whereas hallucinations were present in 40 percent of patients. Sixtytwo percent of patients were admitted against their will under section 19 MHA 1987. 4. Decision making Capacity according to binary decision: The Binary decision of decision making capacity was taken as guided in the Mental Capacity Act 2005. According to this act, a patient can be declared incapacitated of decision making when even one of the components of capacity is missing, as lack of even one component makes the patient unable to judge the nature of the disease and to take decision for his wellbeing. According to the studies done with MacCAT-T, a component of capacity should be considered present in a patient when the patient scores more than 50 percent in that particular component (Grisso et al, 1998). In our study, Twenty -three (36.5 percent) of the psychotic patients studied had decisional capacity, while 40(63.5 percent) patients were unable to take decisions regarding their treatment. One previous study described the proportion of patients lacking such capacity (20 percent) in a sample of patients admitted for treatment to psychiatric or learning disability services, but this was limited by its small sample size (n=41) (Bellhouse et al, 2003). Other studies showed around 43 percent (Cairns et al, 2005) and 40 percent patients had lack of decision making capacity (Raymont et al, 2004). 5. Components of treatment related decision making capacity: Legal standards focus on certain functional abilities on which the law relies to structure its thinking about competence, including (1) understanding of information that is disclosed in the informed consent process, (2) appreciation of the information for ones own circumstances, (3) reasoning with the information, and (4) expressing a choice (Grisso et al, 1998). We used MacCATT to measure these components. 6. Decision making capacity and demographic characteristics: 42 7. Disease related variables and decision making capacity: We could not find any association between type of psychotic disorder and patients treatment related decision making capacity (p= 0.95). Though around 65 percent of schizophrenics did not have capacity, the association was statistically insignificant. This finding was in keeping with study done on schizophrenics (Moser et al, 2002). One study showed that substantial percentage of schizophrenic patients had lack of capacity (Grisso et al, 1995). Keeping with our study, Bellhouse et al (2003) described that psychosis is not invariably associated with incapacity (six out of nine participants with schizophrenia had capacity to consent to treatment). We found that the duration of illness was also not related with capacity (p=0.31). This was in keeping with previous study (palmer et al, 2004). Whether the patient was on any medication or not was also not determining the presence or absence of capacity (p=0.95). In our study, presence of delusion (p=0.15) or auditory hallucinations (p=0.09) was not significantly associated with lack of capacity. Ninety percent of patients without capacity had delusions on admission, but the association was not significant. This differed from the study by Cairns et al, 2005 in terms of significant relation was found between presence of delusion and absence of capacity in that study, but our study was in keeping with that study Among demographic parameters, low education, unemployment and less family income were associated with lack of decision making capacity. It was also found capacity. In a previous study, cognitive impairment has been shown to be an independent predictor of incapacity in general hospital in-patients (Raymont et al, 2004, Palmer et al, 2004, Moser et al, 2002). Our findings are in keeping with the study of Cairns et al (2005). 8. Capacity and its determinants: Table 10 shows logistic regression analysis done to identify the independent association between different variables and capacity. We found that among all the significantly associated variables (done by chi-square and t-test), insight was strongly associated with presence of capacity. Increase in insight score was associated with Archives of Indian Psychiatry 10(1) April 2009

Zindadil Gandhi : Treatment Related Decision Making Capacity Table: 2 Disease related variables and capacity.
Present N=23 N(%) Absent N=40 N(%)

Statistical sig nificance

DSM-IV-TR Schizophrenia Schizoaffective disorder Schizophreniform disorder Other

10(43.5) 02(8.7) 04(17.4) 07(30.4)

20(50.0) 03(7.5) 07(17.5) 10(25.0)

2 =0.32 ,d.f.=3, p =0.95

Duration of illness 0-2 (years) 2-5 5-10 >10

11(47.8) 05(21.7) 06(26.1) 01(04.3)

20(50.0) 08(20.0) 05(12.5) 07(17.5)

2 =3.57, d.f.=3, p =0.31

Treatment history Oral medications Depot ECT Treatment Nave

14(60.9) 1(04.3) 3(13.0) 5(21.7)

25(62.5) 01(02.5) 4(10.0) 10(25.0)

2 =0.35, d.f.=3, p =0.95

Delusions Present Absent

17(73.9) 6(26.1)

36(90.0) 04(10.0)

Fisher exact 2-tailed p=0.15 2 =2.80, d..f.=1, p =0.09

Auditory hallucinations Present Absent

6(26.1) 17(73.9)

19(47.5) 21(52.5)

Table: 3 Scores on scales and capacity


Present Absent Statistical significance BPRS Range Mean (SD) SAI-E Range Mean (SD) MMSE Range Mean (SD) 24-65 44.4 (8.7) 7-31 19.2 (5.4) 30-82 53.8 (13.7)

Table 4: Scores of components of capacity according to MacCAT-T


Components of capacity Understanding Appreciation Reasoning Ch oice Range 0-6 0-4 0-8 0-2 Mean (SD) 3.6(1.8) 1.9(1.4) 3.4(2.6) 1.6(0.5)

0-27 10.9 (5.8)

t = 2.96, d.f. = 61, P = 0.0044 t = 5.57, d.f. = 61 P = 0.0001 t = 4.14, d.f. = 61 P = 0.0001

Conclusions Competence to consent to treatment is a factor that comes across everyday to the clinicians of different expertise. There is paucity of research in this important area. When a patient is brought to the indoor psychiatric set up, the clinician gets influenced by presenting complaints given by informants. In India, patients are almost invariably accompanied by close relatives, which is in contrast to Western psychiatric practice. Psychotic patients though considered incompetent to take treatment related decisions and are admitted usually under section 19 of MHA 1987 as involuntary admission, may have mental capacity.

19-30 26.8 (2.8)

5-30 19.9 (7.7)

progression of capacity. This finding was in keeping with other study (Cairns et al, 2005).

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Zindadil Gandhi : Treatment Related Decision Making Capacity Table 5: Variables and Capacity:Logistic Regression
var iables Capa city Educ ation Employm ent I ncome Type of adm ission BPRS SAI-E M MSE U nstandar dized C oeff ic ients B .297 1.829E-02 5.222E-02 8.640E-02 -.128 -4.011E- 03 2.702E-02 9.001E-03

Analysis
Standar dize d Coe fficie nt s Beta .042 .077 .181 -.129 -.107 .385 .133 t .635 .364 .743 1.655 -1.186 -.937 3.383 .979 Sig. .528 .717 .460 .104 .241 .353 .001 .332

Std. Error .467 .050 .070 .052 .108 .004 .008 .009

Model 1

R .684

R Square .468

Adjusted R Square .401

Std. Error of the Estimate .37576

Around 23 percent of involuntarily admitted psychotic patients had capacity to take decision of their own treatment when they were interviewed for this study. Inability to take decisions was significantly associated with low levels of insight about the present illness, impaired cognitive functions and severity of psychotic symptoms. Among demographic parameters, low education, unemployment and less family income were associated with lack of decision making capacity. It was also found that 41 percent of voluntarily admitted patients had lack of capacity to make decision of their treatment plan. While judging the decisional capacity through MacCAT-T, it was found that Understanding, Appreciation and reasoning were significantly higher in patients who were admitted voluntarily. Keeping this in mind, the measures to judge decisional capacity should be extended from clinical interview and mental state exam to comprehensive evaluation of insight, cognitive functions and severity of symptoms. A practical method that can judge the components of capacity should be developed. Implications for psychiatric practice: In the clinical setting, patient should be able to process the information provided by the physician on the basis of their values and preferences and to participate actively in developing a treatment plan. They should be able to implement and monitor the plan and to make adjustments as necessary, for example, in response to a change in their condition or to a care-giving spouse becoming ill. Different components of decision making capacity (understanding, appreciation, reasoning and making a choice) should be evaluated in a patient before declaring him as incompetent to take decision about his admission as inpatient. References: 1. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revision, Washington, DC: APA; 2000. 2. Appelbaum BC, Appelbaum PS, Grisso T. Competence to consent to voluntary psychiatric hospitalization: A test of a standard proposed by APA. Psychiatric Services 1998; 49, 11931196. 3. Bellhouse J, Holland AJ, Clare ICH, et al. Capacitybased mental health legislation and its impact on clinical practice: 2) treatment in hospital. Journal of Mental Health Law 2003; July: 24-28. 4. Cairns R, Maddock C, et al. Reliability of mental assessment in psychiatric in-patients. British Journal of Psychiatry 2005; 187: 372-378. 5. Cairns R, Maddock C, Buchanan A, et al. Prevalence and predictors of mental incapacity in psychiatric inpatients. British Journal of Psychiatry 2005; 187: 379385. 6. Capacity Bill. H/C 53/4. 2004. Department of Constitutional Affairs. London. Stationary Office. 7. Centers for Disease Control and Prevention, USA, Epi Info Version 3.3.2. Release Date: February 9, 2005. 8. David AS. Insight and psychosis. British Journal of Psychiatry 1990; 156: 798-808. 9. David AS, Buchanan A, Reed A, et al. The assessment of insight in psychosis. British Journal of Psychiatry 1992; 161: 599-602. Archives of Indian Psychiatry 10(1) April 2009

Strengths: The only study of its kind done in India. Consecutive selection of psychotic in-patients and little difference between participants and nonparticipants. Reliability of the interview maximized by rating the patients by one examiner. Ours is a cross-sectional study. This study can be extended to check for the achievement of decisional capacity after treatment and the factors related to progression of capacity. Fifty percent of the psychotic in-patients during the study phase could not be interviewed. Had they been, the prevalence of incapacity would probably have been higher

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Zindadil Gandhi : Treatment Related Decision Making Capacity 10. Folstein MF, Folstein SE, McHugh P: Mini-Mental 19. Moser DJ, Schultz SK, Arndt S, et al. Capacity to State: a practical guide for grading the cognitive state provide informed consent for participation in of patients for the clinician. Journal of Psychiatric schizophrenia and HIV research. American Journal of Research 1975; 12: 189-198. Psychiatry 2002; 159: 1201-1207. 11. Grimes A, McCollough, L, Kunik M, et al. Informed 20. Overall J, Gorham D: The Brief Psychiatric Rating Scale. consent and neuro-anatomic correlates of Psychological Reports 1962; 10: 799812. intentionality and voluntariness among Psychiatric 21. Palmer BW, Nayak GV, Dunn LB, et al. Treatment Patients. Psychiatric Services 2000; 51: 15611567. related decision making capacity in middle aged and 12. Grisso T, Appelbaum PS. The MacArthur Treatment older patients with psychosis, A preliminary study Competence Study, III: abilities of patients to consent using MacCAT-T and HCAT. American Journal of to psychiatric and medical treatment. Law and Human Geriatric Psychiatry 2002; 10; 207-211. Behavior 1995; 19:149174. 22. Palmer BW, Dunn LB, Appelbaum PS, et al. Correlates 13. Grisso T, Appelbaum PS. Comparison of standards of treatment-related decision-making capacity for assessing patients capacities to make treatment amongst middle-aged and older patients with decisions. American Journal of Psychiatry 1995; 152: schizophrenia. Archives of General Psychiatry 2004; 1033-1037. 61: 230-236. 14. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients 23. Raymont V, Bingley W, Buchanan A, et al. The capacities to make treatment decisions. Psychiatric prevalence of mental incapacity in medical inpatients Services 1997; 48: 1415-1419 and associated risk factors. Lancet 2004; 364: 142115. Grisso T, Appelbaum PS. Assessing Competence to 1427. Consent to Treatment: A Guide for Physicians and 24. Statistical Package for Social Sciences, version 12, Other Health Professionals. New York, SPSS Inc., Chicago, 2002. Oxford University Press, 1998. 25. The Mental Health Act. Dept. of Health and Family 16. Jones GH. Informed consent in chronic schizophrenia. Welfare, Govt. of India: Section 15, 19. Chapter IVBritish Journal of Psychiatry 1995; 167: 565 568. Admission and Detention in Psychiatric Hospital and 17. McEvoy JP, Appelbaum PS, Geller JL, et al. Why must Psychiatric Nursing Home, 1987. some schizophrenic patients be involuntarily 26. Workman RH, Molinari V, Rezabek P, et al. An ethical admitted? The role of insight. Comprehensive framework for understanding patients with anti-social Psychiatry 1989; 30: 13-17. personality disorder who develop dementia. Journal 18. Mental Capacity Act, Chapter 9, 2005: Department of of Ethics, Law and Aging. 1997; 3: 79-90. Constitutional Affairs. London. Stationary Office.

Sources of support : None

Conflicts of interest : None

Zindadil Gandhi, M.D. Resident, Medical College Vadodara 395001 G.K.Vankar M.D. Professor & Head Dept of Psychiatry. B.J. Medical College & Civil Hospital, Ahmedabad 380016 Cel:09687284967 e-mail: *Correspondence

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Original Article

Obsessive Compulsive Disorder in Patients with Schizophrenia


Bhavesh M. Lakdawala Kamlesh R. Dave Ritambhara Y. Mehta
Abstract Introduction: OCD comorbid with schizophrenia has been seen since long. Patients having this co-morbidity has significant impairment in functioning in many domains of life. There are reports of few atypical antipsychotics induced OCD in patients with schizophrenia. Aims & Objectives: To assess extent & phenomenology of OCD; to study its socio-demographic relations; to find out depression in OCD patients & to assess relation of OCD & particular antipsychotics given in patients with schizophrenia. Methods: 60 patients with schizophrenia were evaluated for OCD for 6 months duration using DSM-IV-TR criteria. SAPS, SANS , Y-BOCS , HRSD AND GAF scale were used. Results & Discussion: Out of 60 patients, 16 (26.7%) had OCD. All the patients with OCD had both obsession and compulsion .37.5% of OCD patient had depression which was not spastically difference in OCD and non OCD patients. Type of antipsychotics either typical or atypical was not related to OCD prevalence. Key words: OCD, schizophrenia antipsychotics

Parkinsonian symptoms, poorer executive brain function, The clinical phenomenon of OCD coexistent with reduced capacity for global, social and economic schizophrenia has intrigued clinicians for over a century. functioning, longer periods of hospitalization and diverse In the 19th century, Westphal1 considered OC symptoms range of co-existing neuropsychiatric disorders. to be either a prodrome or an integral part of schizophrenia, SSRIs and Clomipramine have been found effective in as did Bleuler2 earlier in this century. Others reported that reducing OC symptoms in schizophrenia patients and such comorbidity was rare and suggested that the improve overall functioning .Low dose Olanzapine has schizophrenic patients with OCD had a comparatively been found useful as an augmenting agent with benign clinical course. More recent evidence, however, antidepressants in reducing OC symptoms Many case suggests a higher rate of coexisting OCD and schizophrenia reports of Risperidone & Clozapine induced OCD in than was previously thought (3.5% to 46.6%), a finding patients with schizophrenia should be kept in mind in these supported by various clinical observations. Furthermore, patients management. in a recent review, Hollander7 found that OC symptoms coexist with a diverse range of neuropsychiatric disorders Aims and Objectives in patients with schizophrenia. It remains unclear. There is significant overlap of the 1. To assess extent and phenomenology of OCD in patients with schizophrenia proposed functional circuits and dysfunction at the 2. To study association of such comorbidity with socioneurotransmitter level between OCD and schizophrenia demographic characteristics, symptoms of which may lead to co-expression of symptoms. schizophrenia, depression and treatment with Interactions are multiple and complex, especially in regard antipsychotic drugs. to the serotonin and dopamine systems. Severity of OC scores correlated with poor performance in areas of cognition. OCD may constitute a distinct cluster separate from psychosis in schizophrenia and raise the Material and Methods This was a cross-sectional study. The study was possibility of a distinct subtype of schizophrenia. 14,17,18 Some authors have called this entity as Schizo- conducted in New Civil Hospital, Surat. The hospital is obsessive disorder. Within this type, several clinically attached to Government Medical College, Surat. It is one discrete groups were described. OCD patients who become of the largest hospitals in the South Gujarat, being run by psychotic; schizophrenic patients exhibiting OC symptoms State Government. and patients with comorbid OCD & schizotypal personality Sixty patients with schizophrenia visiting the Out Patient Department of Psychiatry were evaluated for OCD. All disorder. Patients displaying co-morbid OCD and schizophrenia the patients were explained about the procedure, its have been shown to have significantly higher positive purpose and were assured of confidentiality of the and emotional discomfort symptoms, negative symptoms, information. A predetermined proforma was admitted to

Introduction

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Archives of Indian Psychiatry 10(1) April 2009

Bhavesh Lakdawala : OCD in Patients with Schizophrenia each patient. OCD was evaluated on the basis of DSMIV-TR criteria32,33. Inclusion Criteria 1. Definite diagnosis of schizophrenia as per DSM-IVTR criteria and clinical interview. 2. Patients with whom an hour long interview was possible. Exclusion Criteria Patients with schizophreniform disorder, schizoaffective disorder, affective psychosis, organic brain syndrome, mental retardation, pervasive developmental disorder and substance induced psychosis were excluded. Study was done for 6 months duration from October04 to March05. Severity of schizophrenia symptoms was assessed by using Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the assessment of Negative Symptoms (SANS).29,30 Severity of OCD was assessed by using Yale-Brown Obsessive Compulsive Scale (YBOCS).27 Severity of depression was assessed by using Hamilton Rating Scale for Depression 24 items (HRSD). 28 Occupational and social functioning were assessed by using the Global Assessment of Functioning (GAF) Scale.31 The data were tabulated and categorized. Variations were analyzed by Chi-square test, continuous variables were analyzed by t test. p value of 0.05 was used for determining statistical significance. may coexist. OCD may appear before psychosis as reported by Khanna, et al (2001). Total 19 (31.7%) patients had depression. 37.5% of OCD patients had depression. Mild depression (15.8%), moderate depression (15.8%), severe depression (21.1%) and very severe depression (47.3%) found in these patients. Depression found was equally common in OCD and non-OCD patients Other Variables & OCD Majority of patients (90%) had either paranoid or undifferentiated type of schizophrenia. .Nine patients had paranoid while 6 patients had undifferentiated schizophrenia. Difference between these two groups was not found statistically significant in OCD presentation. Average duration of schizophrenia was 7.9 (sd 6.3)years. Average duration of OCD was 4.2 (sd=4.1) years Early or late onset of schizophrenia was not related with higher OCD presentation. Average age of onset of schizophrenia was 27.4(sd = 8.9) years. Average duration of treatment of schizophrenia was 5.8 (sd=5.1) years. no impact of treatment length of schizophrenia on OCD. Type of antipsychotics either typical or atypical was not related to OCD prevalence. This finding is not consistent with the previous studies by Baker RW, et al (1997), Poyurovsky, et al (1996), Remington et al (1994) and Kopala et al (1994) reporting Risperidone and Clozapine induced OC symptoms in patients with schizophrenia. The above results are based on the current data. It does not take into account the effect of any previous treatment(s). OCD and Schizophrenia symptom severity: Patients having OCD had comparable SANS score to nonOCD group. Affective flattening subscale was significantly higher (p<0.05) in non-OCD than OCD groups. This finding is opposite to those of Tibbo, et al (2000) and Poyurovsky, et al (1998) who noted significantly higher scores on negative symptoms in OCD subgroups of patients and Hwang, et al (2000) who reported greater negative symptoms and more impaired executive functioning in patients with OCD. Reasons for this difference may be different methods of study, non-standardized sampling, no training in applying this scale (Raters Bias) and effect of antipsychotic treatment on symptom profile. Patients having OCD had comparable SAPS score than non-OCD group. Positive formal thought disorder subscale was not much different in OCD and non-OCD group. This finding is consistent with those of Berman, et al (1998) who hypothesized that OC symptoms are independent of schizophrenic symptoms. Lysaker, et al (2000) who noted significantly higher positive and emotional symptoms in patients displaying comorbid OCD and schizophrenia. Poyurovsky, et al (1999) reported lesser severity of the formal thought disorder in patients with both schizophrenia and OCD, but this study was in patients with first episode schizophrenia. By comparing the GAF scale <40 and >40, in patients with and without OCD, no statistically significant difference 47

Results and Discussion


Prevalence of OCD in patients with schizophrenia Out of 60 patients, 16 (26.7%) had OCD. All the 16 patients met the DSM-IV-TR diagnostic criteria of OCD .This finding is comparable with previous studies, reporting OCD in range of 3.5-46.6% in schizophrenia patients .Eisen, et al (1997) reported that 7.8% of the 77 patients meeting DSMIII-R criteria for both OCD and schizophrenia spectrum disorders. 6Berman, Merson, Viegner, et al (1998) discovered 25% incidence rate of OCD in 102 patients with chronic schizophrenia. 22 Mean age of patients studied was 34.9 years (SD 9.9). Mean age of patients with OCD was 32.6 years (SD 4.1). Socio-demographic profile and OCD in patients with schizophrenia As shown in Table patients having schizophrenia with and without OCD were similar regarding demographic characteristics like age, gender, religion ,marital status, education, occupation and income. The results are comparable with previous studies4,5,11,13All the patients had both obsession and compulsion. 37.5 % of OCD patients had poor insight into their symptoms. Thus in schizophrenia substantial proportion of patients with OCD might have poor insight. None of the patients had onset of OCD before schizophrenia onset. This is consistent with the argument of Reznik, et al (2001) stating that there may be OC-Schizophrenia-a new diagnostic entity and discrete group like schizophrenia patients with co-morbid OCD or schizophrenia patients exhibiting OC symptoms may exist and case report of Gangdev (2002) who reported that OCD and psychosis Archives of Indian Psychiatry 10(1) April 2009

Bhavesh Lakdawala : OCD in Patients with Schizophrenia Table 1: Demographic Characteristics and OCD in schizophrenia
Characteristics Details OCD patients N=16 (%) 22-51 32.6(4.1) 0 7(43.8) 7(43.8) 1(6.2) 1(6.2) 10(62.5) 6(37.5) 15(93.8) 1(6.2) 4(25.0) 1(6.2) 1(6.2) 7(43.8) 3(18.8) 5(31.3) 6(37.5) 1(6.2) 1(6.2) 3(18.8) 8(50.0) 7(43.8) 1(6.2) 0 10(62.5) 6(37.5) 0 Patients without OCD N=44(%) 20-60 2(4.6) 14(31.8) 17(38.6) 6(13.6) 5(11.4) 32(72.7) 12(27.3) 32(72.7) 12(27.3) 7(15.9) 6(13.6) 1(2.3) 19(43.2) 11(25.0) 22(50.0) 9(20.5) 3(6.8) 3(6.8) 7(15.9) 23(52.2) 16(36.4) 4(9.1) 1(2.3) 25(56.8) 18(40.9) 1(2.3) P value

Age in years

Range Mean(SD) 11-20 yrs 21-30 yrs 31-40 yrs 41-50 yrs 51-60 yrs Male Female Hindu Muslim Service unskilled.lab Professional Unemployed Household Primary Secondary H. Secondary Graduate Uneducated Married Unmarried Divorced/sep. Widow/er 1000-3000 3000-5000 >5000

0.71

Gender Religion Occupation

0.65 0.16 0.77

Education

0.61

Marital Status

0.88

Family Income (Rs./Mth)

0.67

Table 2: Content of obsessions and compulsions in OCD patients


Content of Obsession Contamination Pathological doubt Intrusive thoughts Sexual Symmetry/Precision No. of patients (%) 13(81.3) 7(43.8) 7(43.8) 2(12.5) 2(12.5) Content of compulsion Washing Checking Need to ask or confess Slowing Symmetry Hoarding No. of patients (%) 13(81.3) 7(43.8) 4(25.0) 6(37.5) 2(12.5) 1(6.3)

found . This finding is not consistent with Fenton & McGlashan (1986) & Berman, Merson, et al (1999) who reported reduced capacity for global, social and economic functioning in schizophrenia patients with OCD. Reason may be different methods of study and effect of antipsychotics on global functioning. Y-BOCS (Mean=14.8, SD=4.8) & HRSD (Mean=20.3, SD=&.2)

Summary and Conclusions


Out of 60 patients with schizophrenia studied, 16(26.7%) had OCD by using DSM-IV-TR criteria. 48

There was no statistically significant association of OCD comorbidity with patients age, gender, religion, occupation, education, marital status and family .All the OCD patients had both obsessions and compulsions. Obsessions found were those of contamination (81.3%), pathological doubt (43.8%), Intrusive thoughts (43.8%), sexual (12.5%) and symmetry/precision (12.5%). Compulsions found were those of washing (81.3%), checking (43.8%), need to ask or confess (25%), slowing (37.5%), symmetry/precision (12.5%) & hoarding (6.3%).37.5% of OCD patients had poor insight into their symptoms. Depression was found in 31.7% of studied patients and 37.5% of OCD patients. Archives of Indian Psychiatry 10(1) April 2009

Bhavesh Lakdawala : OCD in Patients with Schizophrenia

References
1. 2. 3. 4. Westphal K : Uber Zwangsvorstellungen. Archiv. Fur Psychiatr. und Nervenkr. 1878; 8: 734-750. Bleuler E : Dementia Praecox and paraphrenia. Edinburg, Livingstone, 1919. Rosen I : The clinical significance of obsessions in schizophrenia. J. Ment. Sci. 1957; 103: 778-785. Eisen JL, Beer DA, Pato MT, et al : Obsessivecompulsive disorder in patients with schizophrenia or schizoaffective disorder. Am. J. Psychiatry 1997; 154: 271-273. Fenton WS, McGlashan TM : The prognostic significance of obsessive compulsive symptoms in schizophrenia. Am. J. Psychiatry 1986; 143: 437-441. Hwang MY, Craig T : Obsessive-compulsive and panic symptoms in patients with first admission psychosis. Am. J. Psychiatry 2002; 159: 592-598. Hollander E : Obsessive compulsive related disorders. Washington DC, American Psychiatric Press, 1993. Zohar J : Is there room for a new diagnostic subtype the schizo-obsesive subtype? CNS Spectrum 1997;2:49-50. Berman I, Pappas D, Berman SM : Obsessive compulsive symptoms in schizophrenia: Are they manifestations of a distinct subclass of schizophrenia? CNS Spectrum, 1997; 2:45-48. Hwang MY, Morgan JE, Losconzcy MF: Clinical and neuropsychological profiles of obsessive-compulsive schizophrenia: A pilot study. J. Neuropsychiatry and Clin. Neuroscience 2000; 12:91-94. Poyurovsky M, Fuchs C, Weizman A : ObsesiveCompulsive disorder in patients with first-episode schizophrenia. Am. J. Psychiatry 1999; 156: 1998-2000. Insel TR, Akiskal HS : Obsessive-compulsive disorder with psychotic features: a phenomenologic analysis. Am. J. Psychiatry 1986; 143:1527-1533. Berman I, Kalinowski A, Berman SM, Lengua J, Green Al : Obsessive and compulsive symptoms in chronic schizophrenia. Comprehensive Psychiatry 1995;36: 6-10 Berman I, Merson A, Viegner B, Losconzcy MF, Pappas D, Green AJ : Obsessions and compulsions as a distinct cluster of symptoms in schizophrenia: A neuropsychological study. J. Nerv. Mental Dis. 1998; 186:150-156. Venkatasubramaniam G, Ramesh Kumar TC, Khanna S : Obsessive-compulsive disorder and psychosis. Can. J. Psychiatry 2001; 46:750-754. Iain W, Julie M: The significance of obsessions & compulsions in schizophrenia: A literature review & Case study. Reznik I, Mester R, et al : Obsessive compulsive schizophrenia: A new diagnostic entity? J. Neuropsychiatry and Clin. Neuroscience 2001; 13:115116. Arnold Werner : Obsessive-compulsive symptoms in schizophrenia: Am. J. Psychiatry 1997; 154:1635. Nemchand A, Ratzoni G, Poyurovsky M, et al : Obsessive compulsive disorder in adolescent 20.

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schizophrenia patients. Am. J. Psychiatry 2003; 160: 1002-1004. Lysaker P, Bryson G, Marks K et al : Association of obsessions and compulsions in schizophrenia with neurocognition and negative symptoms : J. Neuropsychiatry and Clin. Neuroscience 2002;14:449453. D. Marazziti : What came first: dimensions or categories? Br. J. Psychiatry 2001; 178:478-479. Gangdev P : The relationship between obsessive compulsive disorder and psychosis. (Case report & Case series). Australian Psychiatry 2002; 10:405. Stephanie Kruger et al : Prevalence of obsessive compulsive disorder in schizophrenia and significance of motor symptoms. J. Neuropsychiatry & Clin. Neuroscience 2000;12:16-24. ODwyer AM, Marks I : Obsessive compulsive disorder and delusions revisited. Br. J. Psychiatry 2000; 176:281-284. Lysaker PH, Mark KA, Picone JB et al : Obsessive and compulsive symptoms in schizophrenia: Clinical and neurocognitive correlation. J Nerv. Mental Dis. 2000; 188(2):78-83. Goodman WK, Price LH et al : The Yale-Brown Obsessive compulsive scale; 1: Development, use and reliability. Arch. Gen. Psychiatry 1989; 46:1006-1011. Goodman WK, Price LH et al : The Yale-Brown Obsessive Compulsive Scale, II: Validity. Arch. Gen Psychiatry 1989; 46: 1012-1016. Hamilton M : A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 1960; 23:56-62 Andreasen NC : Scale for the assessment of positive symptoms (SAPS). Iowa City, University of Iowa, 1984. Andreasen NC : Scale for the assessment of negative symptoms (SANS). Iowa City, University of Iowa, 1983. Jones SH, Thornicroft G et al : A brief mental health outcome scale Reliability and validity of the Global Assessment of Functioning (GAF). Br. J. Psychiatry 1995; 166(5): 654-659. Kaplan & Sadock : Synopsis of psychiatry. 9th edition, 2003. Sadock B. & Sadock V : Comprehensive Textbook of psychiatry, 7th edition, 2000. Storebel CA, Szarek BL : use of Clomipramine in treatment of obsessive compulsive symptomatology. J. Clin. Psychopharmacology 1984; 4:98-100. Zohar J, Kaplan Z, Benjamin J : Clomipramine treatment of obsessive compulsive symptomatology in schizophrenia patients. J. Clin. Psychiatry 1993; 54:385-388. Berman I, Sapers BL, Chang HMJ et al : Treatment of obsessive-compulsive symptoms in schizophrenic patients with Clomipramine. J. Clin. Psychopharmacology 1995; 15:206-210. Baker RW, Bermanzohn PC, Wirshing DA et al : Obsessions, compulsions, Clozapine and Risperidone. CNS Spectrum 1997; 2:26-31. 49

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Bhavesh Lakdawala : OCD in Patients with Schizophrenia 38. Hwang MY, Rho J, Opler LA et al : Treatment of obsessive-compulsive schizophrenic patients with Clomipramine. Clinical and neuropsychological findings. Neuropsychiatry Neuropsychol. Behav. Neurol. 1995; 8:231-233. 39. Poyurovsky M, Hermesh H, Weizman A : Fluvoxamine treatment in Clozapine induced obsessive-compulsive symptoms in schizophrenic patients. Clin. Neurpharmacology 1996;19:305-313. 40. Remington G, Adams M : Risperidone and obsessivecompulsive symptoms (letter). J. Clin. Psychopharmacology 1994; 14: 358-359. 41. Kopala L, Honer WG : Risperidone, serotonergic mechanisms, and obsessive-compulsive symptoms in schizophrenia (letter). Am. J. Psychiatry 1994, 151:1714-1715. 42. Marusic A, Farmer A : Antidepressant augmentation with low dose Olanzapine in obsessive-compulsive disorder (correspondence) Br. J. Psychiatry 2000; 177:567. 43. Reznik I et al : Obsessive and compulsive symptoms in schizophrenia: A randomized control trial with Fluvoxamine & neuroleptics. J.Clin. Psychopharmacology, 2000;20 : 410-416. 44. Luborsky L : Clinicians judgement of mental health. Arch. Gen. Psychiatry 1962; 7:407-417

Sources of support : None

Conflicts of interest : None

Bhavesh M Lakdawala, M.D.* Kamlesh R Dave, M.D.** Ritambhara Y Mehta, M.D.*** **Associate Professor, Dept of Psychiatry. Govt. Medical College & Civil Hospital, Surat. ***Professor & Head, Dept of Psychiatry. Govt. Medical College & Civil Hospital, Surat

Correspondence : Dr. Bhavesh M Lakdawala, M.D. Assistant Professor Dept of Psychiatry.B.J.Medical College, E-1 ward ,Civil Hospital, Ahmedabad-380016 e-mail : dr_bmlakdawala@yahoo.co.in Cell : 09687284967

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Archives of Indian Psychiatry 10(1) April 2009

Original Article

Phenomenology of Delirium
Parag Dhoble G.K.Vankar Abstract: In this study , one hundred consecutive patients referred to Psychiatry Dept. of a General Hospital and meeting criteria for Delirium DSM IV TR phenomenology was assessed using Confusion Assassment Method and Delirium Rating Scale R 98.Delirium Etiology Rating Checklist was completed for all patients. Disturbance of attention was present in 95% patients, sleep-wakeful cycle disturbance in 90% disorientation in 84%, psychotic symptoms in 85%, motor agitation in 72%. As per standardized etiological checklist, metabolic and endocrinal disturbances (65%), systemic infections (60%), drug intoxications (34%), neoplasm (22%) and traumatic brain injury (20%) were five most common contributing factors to delirium. Key Words: Phenomenology, etiology, Delirium Introduction Delirium involves a constellation of symptoms reflecting widespread disruption of higher cortical functions that characteristically occur with an acute onset and fluctuating course. With the help of instruments like Mini Mental Status Examination disorientation is assessed as key indicator to diagnose delirium and other cognitive and noncognitive aspects of delirium are often ignored.1 Although our understanding of the clinical epidemiology of delirium has advanced considerably over the past decade, however, the interrelationship of delirium symptoms and their relevance to aetiology, treatment experience and outcome are poorly understood.2 Delirium is not fully understood by the experts, so the rest of us have a difficult task. There are problems with terminology; delirium synonyms include acute confusional state, organic brain syndrome and even, reversible dementia.3 This disorder is seen more commonly in medical and surgical wards than in psychiatric wards. It complicates the hospital stays of 20% of the people over the age of 65 years, and is found in up to 87% of older patients in intensive care wards.4Further, for reasons which are not always clear; the one year mortality rate following delirium may be as high as 40%.5 The diagnostic criteria have changed over time. The revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders define delirium as a disturbance of consciousness, attention, cognition and perception. While this classic presentation of delirium is considered to be common, many patients present with noncognitive disturbances. These patients having language, thought process, motor disturbance misdiagnosed as having primary psychiatric illness without evaluating for underlying cause for delirium, the results of which can be dangerous. There have been remarkably, few systemic studies of delirium signs and symptoms in large cohort of patients. David Meagher et al6 (2007) published detailed study of Phenomenology of delirium using DRS-R-98. Half of the 100 patients in the study were men, and the mean age of Archives of Indian Psychiatry 10(1) April 2009 the group was 70.1 years. A mean aetiological categories of 3.5 with neoplasm (67%), systemic infection (63%) and metabolicendocrine disorder (45%) being the most common contributing causes. The study reported high incidence of non-cognitive symptoms in delirium. They found sleep-wake cycle disturbance in 97%, perceptual disturbances 50%, delusions in 31%, lability of affect in 53%, language disturbances in 57%, thought process abnormalities in 54%, motor agitation in 62%, motor retardation in 62% and disorientation in 76% of patients. Sandburg et al(1999)7 studied 315 patients using DSM IIIR and found delusions in 20%, hallucinations in 22%, psychomotor agitation in 32%, psychomotor retardation in 60% and labile affect in 31% of cases. In another study of delirium using DSM III-R, Koolhoven et al8(1996) found sleepwake cycle disturbance in 87%, fluctuating symptoms in 40%, confusion in 100%, delusion in 27%, perceptual disturbances 67%, lability of affect 93% and motor agitation in 80% of cases.

Methods We conducted a prospective cross-sectional study of delirium symptoms in 100 cases of Diagnostic and Statistical Manual of Mental DisordersIV TR delirium referred from in patient service at SSG Hospital, Baroda. Patients assessed on daily ward rounds by primary treating physician as having altered mental state. When these patients were referred to psychiatrist, resident on duty initially screened patients with the Confusion Assessment Method.

Inclusion criteria The patients diagnosed with Delirium according to DSMIV TR 9 criteria were included in the study.

Exclusion criteria While collecting data difficulty arose in collecting information about unknown patients. In case of terminally

51

Parag Dhoble : Phenomenology of Delirium ill patients data collection was difficult as neither patient 15 points on severity scale with maximum score of 39. For nor relatives cooperated. Such cases have to be excluded determination of item frequencies in this study, any item scoring at least 1 was considered present. from the study. Delirium Aetiology Rating Checklists Attribution of aetiology based on all available clinical information was made by the palliative care physician according to a standardised delirium aetiology checklist with 12 categories.12

Consent The procedures and rationale for the study were explained to all patients, but because of their delirium at entry into the study it was presumed that most were not capable of giving informed written consent. Because of the noninvasive nature of the study, patients assent with proxy consent from next of kin, where possible or a responsible caregiver for all participants was obtained. Assessment Demographic data, psychotropic drug exposure, relevant history and findings of the investigations done were collected. Nursing staff and house officers were interviewed to assist rating of symptoms over the previous 24 hour. The Confusion Assessment Method (CAM) It is based on Diagnostic and Statistical Manual III-R criteria and widely used as an initial screening tool in diagnosis of delirium.10 Delirium Rating Scale-R-98 (DRS-R-98) It is a revised version of original Delirium Rating Scale which has been modified for detailed assessment of both cognitive and non-cognitive symptoms. It was validated both as a total scale having 16 items and a severity scale having 13 items for repeated measures and it has high interrater reliability, sensitivity and specificity for detecting delirium. Each item is rated 0 (absent/normal) to 3 (severe impairment).11 Delirium typically involves scores above

Results
The age of the patient was in the range of 30 to 82 years with mean of 54.18. More than half of the patients were above sixty years of age. The male to female ratio was 66:34. Among cognitive items, inattention (95%) was most common disturbance and disorientation (84%) was least frequent. Other cognitive disturbances were in the range of 95% to 84%.Sleep disturbance were most common (92%) and language disturbances were least common (46%) noncognitive disturbance. Eighty five patients had evidence of psychosis, as defined by score of 2 on item 2 i.e. perceptual disturbances, item 3 i.e. delusions or item 6 i.e. thought disturbance . Thirty five of these patients scored 3 on one of these three items, indicating florid psychosis. Out of these 85 patients who had psychosis, 74 patients had perceptual disturbances, 67 patients had delusions and 62 patients had thought process abnormality. Perceptual disturbances were correlated with delusions (r = 0.293, p=0.037), lability of affect (r=0.693, p=0.000), motor agitation (r= 0.303, p=0.021),

Table- 1 Frequency of delirium symptoms rated with the Delirium Rating Scale-Revised-98 and recorded if present at different level of severity n = 100.
DRS-R98 score Present at any severity %

0
Sleep-wake cycle disturbance Perceptual disturbance Delusion Lability of affect Language Thought process abnormality Motor agitation Motor retardation Orientation Attention Short-term memory Long-term memory Visuospatial ability 8 26 33 38 55 38 28 42 16 5 10 6 10

1
23 19 24 34 20 27 22 18 22 27 34 13 16

2
27 32 21 16 14 15 33 26 40 43 30 31 46

3
42 23 22 12 12 20 17 13 22 25 26 50 28 92 74 67 62 46 62 72 58 84 95 90 94 90

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Archives of Indian Psychiatry 10(1) April 2009

Parag Dhoble : Phenomenology of Delirium attention (r=0.529, p=0.000) and long term memory (r=0.371, p=0.002).It was negatively correlated with motor retardation (r=-0.313, p= 0.036). Motor abnormalities were the most common as a group, constituting 98 % of all patients. Among these 98 patients, 72% had motor agitation, 58% had motor retardation and 26% had mixed symptoms. Motor agitation was negatively correlated with motor retardation(r=-0.534, p=0.002).Long term memory and short memory disturbance present in 94% and 90% of the patients respectively. Both long-term and short-term memories were correlated (p=0.265, p=0.015). Attention disturbances were most common cognitive disturbances present in 95% of patients and it was correlated with perceptual disturbances (r=0.529, p=0.000) .Orientation was impaired in 84% of the patients out of which 24% were disoriented to time , 42% were disoriented to time and place and in 22% disorientation to person was present. Sleep wake cycle disturbances were present in 92% of patients. Language disturbance and lability of affect present in 46% and 62% of the patients respectively. Lability of affect was positively correlated with perceptual disturbance (r=0.697,p=0.000) and attention (r=0.599,p=0.000). Table-1 Frequency of aetiological categories rated with Delirium Aetiology Rating Checklist
Aetiological category Metabolic/endocrinal disturbances Systemic infections Drug intoxication Traumatic brain injury Drug withdrawal Extracranial neoplasm Intracranial infections Cerebrovascular episode Organ insufficiency Other systemic Seizures Intracranial neop lasm Other CN S Frequency 65 % 60 % 34 % 20 % 19 % 19 % 15 % 10 % 4% 4% 3% 3% 3%

disorder of cognition with prominent disturbance of attention, but also highlight the high frequency of noncognitive disturbances. The frequency of sleep and motoric disturbances were higher than previous studies.6 The incidence of delirium was higher in males as compared to females patients in ratio 66:34.and more than half of the patients were in the age group of 61 and above years. It supports findings of previous studies which defines male gender and old age risk factor for delirium.13 Physicians usually looked for the single cause of delirium but there is now growing understanding that delirium most commonly has multifactorial aetiology as in this study mean of 2.58 aetiological categories with s. d. = 0.80 were noted per case.14 Metabolic and endocrinal disturbances (65%), systemic infections (60%), drug intoxications (34%), neoplasm (22%) and traumatic brain injury (20%) were five most common contributing factors to delirium. Cognitive disturbances Disturbance of attention is a cardinal symptom of delirium according to Diagnostic and Statistical Manual of Mental DisordersIV-TR 9 and in our analysis it was present in 95% of the patients which is consistent with most of previous studies.6Neuroimaging studies suggest that disruption to the frontal cortex, anteromedial thalamus, right basal ganglia, right posterior parietal cortex and mesial-basal temporo-occipital cortex are particularly important.15 These findings are consistent with models of delirium that involve disruption of attentional systems in the brain, including those responsible for arousal. Disorientation was the least frequent cognitive symptom (84%) in our study. Even though many non-psychiatric physicians rely on bedside tests of orientation to time, place and person as their principal mental status evaluation, almost 16% of our delirious patients had no evidence of disorientation and only 62% had evidence of greater than mild disturbance of orientation as suggested by score 2 or 3. The use of disorientation as a key indicator of delirium is thus fraught with the likelihood of missed cases. Delirious disorientation with rare exceptions obeys the law that the unfamiliar is mistaken for the familiar, as when a patient in hospital surrounded by hospital personnel thinks he is at home surrounded by family and friends. Incidentally, it is shown that this law does not apply to those few patients having schizophrenia who are disoriented; such patients are apt to mistake the familiar for the unfamiliar, as when a patient who has never been abroad says the place is some remote foreign country .16 Two mechanisms are thought to direct the way in which susceptible neurons contribute to the development of delirium: excessive neurotransmitter release and abnormal signal conduction. Overactivity of muscarinic cholinergic neurons in the reticular-activating system, cortex, and hippocampus 17 likely contributes to the disturbances of higher cognition e.g. disorientation, concrete thinking, and inattention which is typical of an episode of delirium. Noncognitive disturbances Motor agitation (72%) was most common motor disturbances followed by motor retardation (58%) and 53

A mean of 2.58 aetiological categories with s. d. = 0.80 were noted per case. As per standardized aetiological checklist, metabolic and endocrinal disturbances (65%), systemic infections (60%), drug intoxications (34%), neoplasm (22%) and traumatic brain injury (20%) were five most common contributing factors to delirium. Overall patients had mean Delirium Rating Scale R-98 total score of 25.26, s.d. 4.06 and severity score of 19.84, s.d. 3.88.

Discussion
This work is an attempt to investigate wide range of symptoms of delirium, the studies about which are lagging particularly in Indian context. We assessed the frequency and severity of less studied noncognitive symptoms including disorganized thinking, language impairment and other components using Delirium Rating Scale-R -98.Our findings not only support the concept of delirium as a Archives of Indian Psychiatry 10(1) April 2009

Parag Dhoble : Phenomenology of Delirium mixed symptoms (26%).Referral of the hypoactive type was apt to be delayed and it was more likely to be missed or neglected by the doctors in charge. Similarly, the mixed type often did not elicit the doctors attention until hyperactive symptoms emerged. Among 100 patients studied, eighty five patients had evidence of psychosis, as defined by a score of 2 on item 2 (perceptual disturbances), item 3 (delusions) or item 6 (thought disturbance) on the DRSR98. Thirty five of these patients scored 3 on one of these three items, indicating florid psychosis. Out of these 85 patients who had psychosis, 74 patients had perceptual disturbances. Similar results were obtained by Morse and Litin (78%) and Koolhoven et al8 (67%).Delusions were present in 67% of patients. Morse and Litin found delusion in 68% of cases but frequency was less in other similar studies such as Meagher et al (31%) and Sirois (19%). It is evident that perceptual disturbances were most common psychotic features and correlated with motor agitation and delusions. Cuttings study18 of psychotic delirium patients revealed approximately equal numbers of delusions and hallucinations (47.3% vs. 51.4%) while most of the other studies reports predominance of perceptual disturbances among psychotic features. Thought disturbances were not studied as a separate group in most of the previous studies, it was present in significant number of patients in our study (62%).Because most of the delirious patients developed psychotic symptoms or disturbing behaviour, they were referred for psychiatric evaluation more promptly than patients with other organic mental disorders. Sleep wake cycle disturbances which was associated with naps, nocturnal disturbances or day-night reversal was very common, present in about 90% of cases. Even though it was not included in diagnostic criteria of Diagnostic and Statistical Manual of Mental DisordersIV-TR, similar results were obtained in previous studies by Meagher et al6 (97%) and Rockwood et al19 (98%).Sleep wake cycle disturbances can be attributed to alteration in tryptophan: phenylalanine ratio and tryptophan is a precursor for serotonin which is required for normal sleep cycle.20 Language disturbances are other less studied symptom which was not included in original delirium rating scale. In present study it was present in significant number of the patients; in 46% of cases .Unfamiliarity with such symptom can lead misdiagnosis of the condition as primary psychiatric illness and mismanagement. Some neurologists have viewed delirium as a disorder of attention. However, the frequency of non-cognitive symptoms and their lack of association with the severity of objectively measured attention impairment strongly support the view of delirium being a broader neuropsychiatric disorder. Unfortunately, DSMIV criteria do not adequately reflect the importance of these other symptoms, for example, sleepwake cycle disturbance, altered motoric behaviours, and thought content and process abnormalities. Sleepwake cycle disturbance may underlie the fluctuating nature of delirium severity over a 24 h period . 54 Conclusion The study began with the background that Delirium is a common life threatening condition which often goes unnoticed there are problem with terminology and phenomenology of delirious symptoms. We have concluded that broadly features of delirium can be divided in to cognitive and noncognitive symptoms. Though cognitive symptoms were more common, noncognitive symptoms present in significant group of patients. Psychotic symptoms were also very common and ignoring such symptoms and labelling it as functional symptoms can be dangerous. Limitations 1. Current study is done in consultant liaison setting which can lead to sampling bias as many patients were referred to rule out possible primary psychiatric component. 2. This is a cross sectional study in which symptoms were assessed only once. It would be more useful if symptoms were assessed throughout the course of the illness to have better understanding because of fluctuating nature of the illness. 3. Impact of the ongoing medications including psychotropic ones on change in symptomatology of delirium need to be assessed. Future direction Future research in this area should be prospective and should examine importance of non cognitive factors associated with delirium particularly psychosis and the outcome of psychotic vs. nonpsychotic delirium. Specific psychotic symptoms should be examined separately, as they may have different risk factors. Understanding more about psychotic features in delirium may increase our understanding of delirium itself as well as increase our understanding of psychotic features in other disorder

References
1. Rudberg MA, Pompei P, Foreman M, Ross R, Cassel C : The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity. Age and Ageing 1997; 26:169175 Francis J: A half-century of delirium research: time to close the gap. Journal of American Geriatric Society 1995; 43:585586. Sadock BJ, Sadock VA ,eds. Kaplan and Sadocks Comprehensive Textbook of Psychiatry .8th edition ,volume I. Baltimore :Lippincott Williams and Wilkins;2005 Musselman DL, Hawthorne CN, Stoudemire A: Screening for delirium: a means to improved outcome in hospitalized elderly patients. Reviews in Clinical Gerontology 1997; 7:23556 Cole MG. Delirium in elderly patients. American Journal of Geriatric Psychiatry 2004; 12(1):7-21.

2. 3.

4.

5.

Archives of Indian Psychiatry 10(1) April 2009

Parag Dhoble : Phenomenology of Delirium 6. Meagher DJ, Moran M, Raju B, and Gibbons D: Phenomenology of delirium Assessment of 100 adult cases using standardised measures. The British Journal of Psychiatry 2007; 190: 135-141. Sandberg O, Gustafson Y, Brannstrom B, Bucht G: Clinical profile of delirium in older patients. Journal of the American Geriatrics Society 1999; 47:13001306 Koolhoven I, Tjon-A-Tsein MRS, van der Mast RC: Early diagnosis of delirium after cardiac surgery. General Hospital Psychiatry 1996; 18:448451 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Text revision Washington, DC, American Psychiatric Association, 2000. 13. Camus V, Gonthier R, Dubos G. Etiologic and outcome profiles in hypoactive and hyperactive subtypes of delirium. Journal of Geriatric Psychiatry and Neurology 2000; 13:38-42. 14. Trzepacz, P. T. Update on the neuropathogenesis of delirium. Dementia and Geriatric Cognitive Disorders 1999; 10, 330 334. 15. Levin M, Delirium: A Gap in Psychiatric Teaching .American Journal of Psychiatry 1951; 107:689-694. 16. Brown TM. Basic mechanisms in the pathogenesis of delirium. In: Stoudemire A, Fogel BS, Greenberg DB, eds. Psychiatric Care of the Medical Patient. 2nd Ed. New York, NY: Oxford University Press; 2000:571-580. 17. Cutting J: The phenomenology of acute organic psychosis. British Journal of Psychiatry 1987; 151:324332. 18. Rockwood K: The occurrence and duration of symptoms in elderly patients with delirium. Journal of Gerontology Biological and Medical Science 1993; 48:M162-M166 19. Miller PS, Richardson JS, Jyu CA: Association of low serum anticholinergic levels and cognitive impairment in elderly pre-surgical patients. American Journal of Psychiatry 1988; 145:3425. 20. Balan, S., Leibowitz, A., Zila, S. O., et al: The relation between the clinical subtypes of delirium and the urinary level of 6-SMT. Journal of Neuropsychiatry and Clinical Neurosciences 2003; 15, 363 366.

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10. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horowitz RI. Clarifying confusion: the confusion assessment method. Annals of Internal Medicine 1990; 113:941-948. 11. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, et al. Validation of the Delirium Rating Scale-revised98: comparison with the delirium rating scale and the cognitive test for delirium .Journal of Neuropsychiatry and Clinical Neurosciences 2001; 13(2):229-42. 12. Inouye SK. Predisposing and precipitating factors for delirium in hospitalized older patients. Dement Geriatr Cogn Disord 1999; 10:393-400.

Source of support: None

Conflicts of interest: None

Dr.Parag Laxman Dhoble Resident in Psychiatry Medical College,Baroda Dr.G.K.Vankar Professor and Head Dept.of Psychiatry B.J.Medical College and Civil Hospital Ahmedabad 380016 Correspondence: Parag Laxman Dhobale Assistant Professor R.D. Gardi Medical College Surasa, Ujjain, M.P. e-mail: dr_paragdhoble@yahoo.com

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Case Report

Hypothyroidism and psychosis- A Case Report


Ivan S Netto Bipin Ravindran Ranjit Patil Abstract
Asher reiterated the relationship between psychosis and hypothyroidism in 1949 and coined the terminology Myxedema madness. Since then numerous case reports continue to explore and report on the neuro-psychiatric consequences of hypothyroidism. This case report of psychosis due to a general medical condition would be of special interest to the clinician, as hypothyroidism presents atypically at times as a psychotic disorder which poses as a diagnostic dilemma. Some criteria for diagnosis, management and prognostic factors have been highlighted. (Key words: Hypothyroidism, psychosis)

Introduction
In general hypothyroidism affects 4% to10% of women increasing with age. [1] Hypothyroidism is more common in older women than in younger women and 10 times more common in women than in men. 5% to 15% of myxedematous patients have some form of psychosis. [2] No typical constellation of psychotic symptoms is likely in the myxedamatous patient. Delusions, visual hallucinations auditory hallucinations, perseveration and paranoia with or without impaired levels of consciousness are seen. Psychosis typically emerges after the onset of physical symptoms. [3]

showed mild confusion and disorientation to time. Her memory was difficult to test as there was marked psychomotor slowing. She had auditory and visual hallucinations. She had persecutory delusions and her insight and judgment were lacking. Haemoglobin, Haematocrit (PCV),Serum Cholesterol,Serum triglycerides,Direct HDL,and ECG were normal. The serum T3 levels were 0.10, ng /ml 6th and 10th week (after treatment) respectively. (reference range 0.52- 1.98 ng/ ml) The serum T4 were 0.14, ng /ml (reference range 4.311.9ng/ ml) The serum ultra TSH were 81.136 (reference range 0.306.02 mIU/ml ) She was treated with Levothyroxine sodium 100 mcgms, tab Fenofibrate 200 mg and tab Ezetimibe 10 mg one tablet daily. She also received tab. Risperidone 2 mg twice daily and tab. Trihexyphenydyl 2mg twice daily only for two weeks. She continued to be only on thyroid replacement treatment thereafter. Her follow up thyroid function tests were as follows: The serum T3 levels were 0.96, and 0.82 ng /ml 6th and 10th week (after treatment) respectively. (reference range 0.521.98 ng/ ml) The serum T4 were 17.88 and 7.2 ng /ml during 6th and 10th week (after treatment) respectively. (reference range 4.311.9ng/ ml) The serum ultra TSH were 0.173 and 0.491 on the 1st week (before treatment), 6th and 10th week (after treatment) respectively. (reference range 0.30-6.02 mIU/ ml)

Case report
A 40 year old married female presented to us with the psychological complaints of lethargy, lassitude, hearing voices not present, abnormal persecutory ideas, unable to work, excessive sleep, self neglect and muttering to self. Her physical complaints were constipation, amenorrhoea, puffiness of face and hoarseness of voice. All her physical symptoms had an insidious onset and gradually developed over a period of 4 years but she presented mainly for treatment of her psychiatric symptoms which began abruptly since 1 month. She was 10th standard educated, pre-morbidly well adjusted and had no past history or family history of any psychiatric or medical illness. She has not received any other medication prior to treatment and had not undergone any surgical thyroid operation. On general examination her temperature was 97.7 (F) 36.5 (C), her pulse 64 beats per minute and her blood pressure was 170/80 mm of Hg. Her skin was dry and she did not have any prominent thyroid swelling. CNS showed delay in relaxation of deep tendon reflexes. On mental status she was lethargic and showed self neglect. Her psychomotor activity was markedly decreased and she preferred to lie down on the couch rather than sit. She had covered her face with a scarf and she was dressed in warm clothes because she had intolerance to cold. She 56

Discussion:
Hypothyroidism is one of the important, less know and frequently missed causes of Psychosis due to a general medical condition. It is important because it has a good prognosis responding well to thyroid replacement treatment if initiated early, less known because little has been written about it, often missed because the textbook description of hypothyroidism is not the rule but rather the exception. Archives of Indian Psychiatry 10(1) April 2009

Ivan S Netto : Hypothyroidism and Psychosis In Ashers (1949) classic paper on myxoedematous madness in 14 patients, 5 showed an organic reaction with hallucinations and persecutory ideas, 5 the picture of schizophrenia with marked paranoid coloring, 2 presented as advanced dementia and 2 with depressive features. The constant type of psychosis described in hypothyroidism is one with general confusion and disorientation with persecutory delusions and hallucinations, and occasional bouts of restless violence. The diagnosis clue is got from the myxoedematous appearance of the patient and not from the kind of mental symptoms. Hypothyroidism is a much commoner cause of psychosis than is usually believed. If the case responds to thyroid replacement treatment it is of course no absolute proof of the myxoedematous origin of the psychosis, because almost any type of psychosis can even improve spontaneously. If the mental changes persist after adequate thyroid treatment, this does not mean they were not due to hypothyroidism. It is generally agreed that metabolic changes can produce irreversible damage as in prolonged hypoglycaemia, pellagra, or in cretinism. The longer the myxoedema is left untreated the poorer is the outlook for recovery. Nevertheless, when mental symptoms that have been present in a hypothyroid patient clear dramatically within a few weeks of starting thyroid replacement it is reasonably certain that they were due to hypothyroidism. [4] In Primary hypothyroidism the TSH level is high and T4 is low. A low free T4 level in the setting of a serum TSH level that is low normal or only mildly elevated is indicative of central hypothyroidism. An elevated TSH level in the setting of normal free T4 is more often seen in sub clinical hypothyroidism. [5] Successful treatment with thyroid replacement usually reverses the psychiatric and neurological sequelae of hypothyroidism. The clearing of psychiatric symptoms usually follows a week after initiation of thyroid replacement. Addition of antipsychotics may lead to earlier remission of psychotic symptoms. Atypical antipsychotics initiated at low doses are well tolerated. Discontinuation of thyroid supplements may lead to the return of symptoms. Neuro-psychiatric symptoms tend to improve with treatment and normalization to a euthyroid state, though the pattern is inconsistent and complete recovery is uncertain. [6] The organic psychoses do better than psychoses with predominantly functional symptoms when treated with thyroid replacements. Patient with a mental illness exceeding 2 years had a poorer response to thyroid treatment alone.[7] Thyroid dysfunction presents with a wide variety of neuropsychiatric problems which pose as diagnostic dilemmas. Was she a case of a psychotic disorder due to a general medical condition hypothyroidism or Schizophrenialike psychosis with co-morbid hypothyroidism? The above mentioned patient showed vague un-diagnosed physical signs and symptoms of hypothyroidism since 4 years and had an abrupt onset of psychotic symptoms Archives of Indian Psychiatry 10(1) April 2009 about 1 month duration when she presented for psychiatric treatment. She was pre-morbidly well- adjusted and had no past or family history of any psychiatric illness suggestive of schizophrenia-like psychosis. On mental status she showed paranoid delusions, confusion, disorientation to time, auditory and visual hallucinations. Her biochemical investigations showed primary hypothyroidism. She was treated with thyroid replacements, atypical antipsychotics, cholesterol and lipid lowering agents and showed good improvement with treatment. Her psychotic symptoms dramatically responded to thyroid replacement treatment as her biochemical tests returned to normal and they did not recur on stopping of anti-psychotics. It cannot however be stated that her condition improved with thyroid replacement alone as low doses of anti-psychotics helped in earlier remission of symptoms. The second possible diagnosis of a schizophrenia like psychosis with comorbid hypothyroidism needs also to be kept in mind. In the light of the above physical and psychiatric findings she was diagnosed to be suffering from Psychotic disorder due to a General Medical condition (DSM IV R)[8]Other mental disorders due to brain damage and dysfunction and to physical disease organic delusional (schizophrenia like) disorder (ICD F06.2)[9] This case report describes some criteria for diagnosing a psychotic disorders due to a general medical condition hypothyroidism. As thyroid replacement treatment brings about a good recovery, early diagnosis and treatment is recommended as delay can lead to further neuro-psychiatric complications.

References
1. 2. Redmond GP. Hypothyroidism and womens health. Int J Fertil Womens Med 2002, 47:123-127 Vanderpimp MP, Tunbridge WM. Epidemiology and prevention of clinical and subclinical hypothyroidism. Thyroid 2002;12:839-847 Heinrich TW, Grahm G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited. Prim Care Companion J Clin Psychiatry. 2003 Dec;5(6):260266 Asher R. Myxoedematous madness. Br Med J 1949;2:555-562 Bermudes R A, Psychiatric illness or thyroid disease? Current psychiatry 2002 May Vol. 1 No.5 Davis J D Tremont G. Neuropsychiatric aspects of hypothyroidism and treatment reversibility. Minerva Endocrinologica 2007 March;32(1):49-65 Tonks,C.M Mental illness in hypothyroid patients. British Journal of Psychiatry 110,706-710 57

3.

4. 5. 6.

7.

Ivan S Netto : Hypothyroidism and Psychosis 8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4 th ed. Washigton DC: American Psychiatric Association; 1994. 9. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization; 1992

Source of support: None Dr. Netto Ivan S M.D. Dr. Bipin Ravindran M.D. Dr. Ranjit Patil M.D. Parmar Plaza Clinic, E -10 Parmar Plaza Shivarkar Road, Fatimanagar, Pune 411040 Correspondience: Dr. Ivan S. Netto M.D. Parmar Plaza Clinic, E -10 Parmar Plaza Shivarkar Road, Fatimanagar, Pune 411040 E-mail: drisnetto@gmail.com Phone:020-26860228 Cell:+91942208127

Conflicts of interest: None

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Case Report

Olanzapine induced hair loss and amenorrhea normalized after addition of Aripiprazole
Sushil Gawande Rahul Tadke Vivek Kirpekar Sudhir Bhave Madhuri Vaidya
Abstract Hair loss and amenorrhea secondary to antipsychotics are troublesome side effects for the female patients. It can be a cause of noncompliance if remain unrecognized. We report a case of Olanzapine induced hair loss and amenorrhea normalized after addition of Aripiprazole. Mechanisms and switching strategies have been discussed. Key Words : Olanzapine, Hair loss, Amenorrhea, Aripiprazole

Introduction : Medication-induced alopecia and amenorrhea are occasional side effects of many psychopharmaceuticals. These side effects, alone or in combination, are of main concern especially in female patients. Many female patients become noncompliant to antipsychotic treatment because of these adverse effects. Amenorrhea secondary to typical antipsychotics is not uncommon. It is also reported with atypical antipsychotics like Risperidone, Olanzapine, Amisulpride and Ziprasidone (1, 2). Hair loss secondary to typical antipsychotics has been commonly reported with Haloperidol (3). Isolated cases of hair loss due to atypical antipsychotics have been reported in the literature. Among atypical antipsychotics case reports are available with risperidone, olanzapine and quetiapine (4). In spite of intensive search in the literature we could not find any case report of olanzapine induced severe hair loss and amenorrhea in the same individual. Occurrence of these side effects due to atypical antipsychotics might be more than the few reported cases as many clinicians do not specifically ask for the hair loss and many patients do not report it considering it unrelated to the drugs taken. Keeping this in mind and to highlight different outcomes, we report this case. Case : A 20 year old female patient, an engineering student, presented in a psychiatry OPD of a tertiary care hospital Archives of Indian Psychiatry 10(1) April 2009

3 months back with symptoms of suspiciousness against her family members ,hearing voices of few people in her locality even if she is alone, disturbed sleep and appetite since last one year. Patient was diagnosed as a case of paranoid schizophrenia and started on treatment in the form of tablet Olanzapine 10 mg once daily. We gradually increased the dose of Olanzapine to 20 mg once daily. Patient showed remarkable improvement with this treatment in one month. During follow up visit patient complained of excessive hair loss and amenorrhea. She complained of losing a significant amount of hairs after washing or combing it, and noticed her pillow and bed sheet covered with hairs in the morning. These complaints were distressing her as well as her family members. She was not on any other medications apart from Olanzapine. Trichotilomania was ruled out with detail history. We ruled out the dermatological causes for hair loss with the help of dermatologist and other causes for amenorrhea with the help of gynaecologist. By considering olanzapine as an offending agent for above side effects we tapered off olanzapine over a week and shifted patient to tablet Aripiprazole 10 mg once daily, based on the case reports available to suggest effectiveness of Aripiprazole in the cases of Olanzapine induced amenorrhea. During next month visit patient regained her menses and showed distinct improvement in the hair loss. We increased the dose of Aripiprazole to 15 mg to control residual psychotic features. At the end of 1 month of this treatment 59

Sushil Gawande : Olanzapine Induced Hair Loss and Amenorrhea 3 months back with symptoms of suspiciousness against There are few reported cases of alopecia secondary to her family members ,hearing voices of few people in her olanzapine in the database from Eli Lilly Canada Inc, with locality even if she is alone, disturbed sleep and appetite an estimated incidence of less than 0.01%. The cellular since last one year. Patient was diagnosed as a case of mechanism of hair loss by olanzapine or psychotropic paranoid schizophrenia and started on treatment in the drugs is not known. One hypothesis is that these form of tablet Olanzapine 10 mg once daily. We gradually medications chelate zinc and selenium, which are believed increased the dose of Olanzapine to 20 mg once daily. to be crucial to hair growth. However, the efficacy of Patient showed remarkable improvement with this routine zinc and selenium supplementation remains treatment in one month. unconfirmed (11). During follow up visit patient complained of excessive hair loss and amenorrhea. She complained of losing a significant amount of hairs after washing or combing it, and noticed her pillow and bed sheet covered with hairs in the morning. These complaints were distressing her as well as her family members. She was not on any other medications apart from Olanzapine. Trichotilomania was ruled out with detail history. We ruled out the dermatological causes for hair loss with the help of dermatologist and other causes for amenorrhea with the help of gynaecologist. By considering olanzapine as an offending agent for above side effects we tapered off olanzapine over a week and shifted patient to tablet Aripiprazole 10 mg once daily, based on the case reports available to suggest effectiveness of Aripiprazole in the cases of Olanzapine induced amenorrhea. During next month visit patient regained her menses and showed distinct improvement in the hair loss. We increased the dose of Aripiprazole to 15 mg to control residual psychotic features. At the end of 1 month of this treatment patient was well maintained on Aripiprazole without any hair loss and menstrual irregularities. Discussion : Olanzapine is a thienobenzodiazepine atypical neuroleptic that is generally considered safe and well tolerated, compared with typical neuroleptics. However, we wish to inform clinicians of a potential toxicity associated with its use; that is, hair loss and amenorrhea. Drug-induced alopecia involves an interruption of hair growth when the hair follicles prematurely enter into the telagen (resting) phase. Spontaneous, diffuse hair loss generally occurs within 3 months of initiating therapy; it is usually reversible upon discontinuation of the offending drug (5,6). Several psychotropic medications have been implicated most commonly, Valproic acid and Lithium. Rarely, antidepressants (including Tricyclic antidepressants, Selective Serotonin Reuptake Inhibitors and Nefazodone) are implicated. (7,8,9,10). Discontinuation of the medication or dose reduction almost always leads to complete hair regrowth (5). Both typical and atypical antipsychotics are hypothesized to cause amenorrhea by their action of dopamine antagonism in tubero-infundibular dopaminergic pathway. 60 Switching strategies to other antipsychotics in the patients developing hair loss and amenorrhea due to antipsychotics are not yet established. Studies are available to suggest effectiveness of switching to quetiapine in patients developing amenorrhea due to Haloperidol and Risperidone (12). Studies are also available to suggest effectiveness of Aripiprazole in the cases of hyperprolactinemia and amenorrhea associated with Olanzapine, Amisulpride and Ziprasidone.(1,2) In the above case we did switch the patient to Aripiprazole based on the available study of effectiveness of Aripiprazole in the cases of amenorrhea. Olanzapine causing both the side effects in the same patients can be explained by the two different hypotheses stated above but improvement of both medication induced side effects with discontinuation of Olanzapine and addition of Aripiprazole explains the need to evaluate the dopaminergic mechanism responsible for hair loss and amenorrhea. More studies are required for better understanding of this issue. References : 1. Wolf J.; Fiedler U. Hyperprolactinemia and amenorrhea associated with olanzapine normalized after addition of aripiprazole , Journal of Clinical Pharmacy and Therapeutics, Vol. 32, 2007 , pp. 197198(2). Mixalis Saitis MD, Georgios Papazisis MD, PHD , Konstantinos Katsigiannopoulos MD et al, Aripiprazole resolves amisulpride and ziprasidoneinduced hyperprolactinemia, Psychiatry and Clinical Neurosciences,Vol.62 , 624 624 Takashi Kubota M.D., Tamiko Ishikura M.D, Itsuki Jibiki M.D. , Psychiatry and Clinical Neurosciences Volume 48 Issue 3, Pages 579 - 581Published Online: 28 Jun 2008 Journal compilation 2008 Japanese Society of Psychiatry and Neurology. McLean, Rachael M.; Harrison-Woolrych, Mira, Alopecia associated with quetiapine. International Clinical Psychopharmacology, 22(2):117-119, 2007. Mercke Y, Sheng H, Khan T, Lippmann S. Hair loss in psychopharmacology. Ann Clin Psychiatry 2000; 12:3542. Gautam M. Alopecia due to psychotropic medications. Ann Pharmacother 1999;33:63. Archives of Indian Psychiatry 10(1) April 2009

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7. 8.

Sushil Gawande : Olanzapine Induced Hair Loss and Amenorrhea Parameshwar E. Hair loss associated with fluvoxamine 10. Gupta S, Gilroy WR. Hair loss associated with use. Am J Psychiatry 1996; 153:5812. nefazodone. J Fam Pract 1997; 44:20 . Zalsman G, Sever J, Munitz H., Hair loss associated with paroxetine treatment: a case report. Clin Neuropharmacol 1999;22:2467. Ruiz-Doblado S, Carrizosa A, Garcia-Hernandez MJ, Rodriguez-Pichardo A. Selective serotonin re-uptake inhibitor (SSRIs) and alopecia areata. Int J Derm 1998;38:7989. 11. Leung M, Wrixon K, Remick RA, Can J Psychiatry, 2002 ; 47(9):891-2. 12. Shingo Naitoh, M.D., Keizo Yoshida, M.D., Tetsuo Shimizu, M.D. and Takio Sugita, M.D. Effectiveness of Switching to Quetiapine for Neuroleptic-Induced Amenorrhea, J Neuropsychiatry Clin Neurosci 15:375377, 2003.

9.

Sources of support : None Sushil Gawande, Assistant Professor Rahul Tadke, Assistant Professor Vivek Kirpekar, Professor Sudhir Bhave, Professor Madhuri Vaidya, MS(OBGY), Assistant Professor

Conflict of Interest : None

NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Digdoh, Nagpur.

Correspondence : Dr. Sushil Gawande Department of Psychiatry NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Digdoh, Nagpur e-mail: sushil.gawande@rediffmail.com Cell:+919322013915

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Appreciation Reviewers for Archives issues 2008-09 Dr.Nilesh Shah Dr.K.S.Jacob Dr.R.Srinivasa Murthy Dr.Vikram Patel Dr.Shekhar Sheshadri Dr.Savita Malhotra Dr.Sudhir Kumar Dr.Nandita Maitra Dr.Anurag Mishra Dr.Bharat Panchal Dr.D.M.Dhawle Dr.S.K.Chaturvedi Dr.M.S.Bhatia Dr.R.C.Jhiloha Dr.Amita Dhanda Dr.Ritambhara Mehta Dr.Anuradha Sovani Dr.Ravindra Kamat Dr.Rajesh Kumar

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Archives of Indian Psychiatry 10(1) April 2009

Poetry

Mirage
Small child dressed shabbily, His eyes dusty, hair shaggy. As I will grow big, I would have sweets many, I would play throughout day, and would be free from elders tyranny. Tomorrow I will be happy, Hearing HITESH, laugh heartily. Schoolboy donning dress neatly, His eyes sleepy, hair curly. As I will grow big, I will see movies many, I will roam throughout day, And would be free from teachers tyranny. Tomorrow I will be happy, Hearing HITESH, laugh heartily. Teenager sporting T-shirt trendy, His eyes dreamy, hair lengthy. As I have gone grown big, I will have girl friends many, Soon completing boring study, Would have job early and marry promptly. Tomorrow I will be happy, Hearing HITESH, laugh heartily. Worried man wearing suit perfectly, His hair receding, eyes weary. Soon my son will grow big, After building his career brilliantly, He would earn money plenty, And would fulfilled my dreams many. Tomorrow I will be happy, Hearing HITESH, laugh heartily. Old man wearing clothes dirty, His vision dimly, hair hoary. Now I have grown old, Fate has made joke cruelly, Soon completing life sickly, Will die and free from misery. In next life I will be happy, Hearing HITESH, WEEP heartily.

Dr Hitesh Sheth Superintendent and Psychiatrist 202,Aashrayadeep Apartment Gautamnagar Society. Alwa Naka, Manjalpur,Vadodara, Gujarat,India. e-mail: hiteshcsheth@rediffmail.com Cell : 98241682430

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Quiz
What is nocebo phenomenon? Bipolar IV disorder refer to .......... Give names of Expressed Emotions (EE) of family members that are found to be protective against relapse in a patient of Schizophrenia. 4. What is the mechanism of action of Varenicline? 5. Normal pressure hydrocephalus is characterized by triad of .............., .............. and ............ . 6. Who authored the book The Myth of Mental Illness:? 7. Name the congenital disorder characterized by typical craniofacial anomalies like microcephaly, mid face hypoplasia, short palpebral fissure, micropthalmia, strabismus, ptosis, low nasal ridge, smooth philtrum, thin upper lip and small jaw, and is caused by fetal exposure to toxins during prenatal period. 8. Dialectical behavior therapy is commonly used for . . .............. . 9. Indian Psychiatric Society was founded in the year ................... . 10. The first issue of Indian Journal of Psychiatry was published in .the year ........... 11. Which disorder is known as Kanners Syndrome ? 12. Full form of computer software SPSS used for research purpose is ................... 13. Who won the Nobel prize for developing psychosurgical techniques ? 14. The Indian version of TAT had been prepared by........... 15. The five stages of behavior, through which a person passes while undergoing treatment of substance dependence? 1. 2. 3.

Contributed by Dr.Parag Shah MD


Asst.Prof of Psychiatry Medical College Vadodara e-mail:drparagsshah@rediffmail.com

cell:+919426138318

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Archives of Indian Psychiatry 10(1) April 2009

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15

Experiencing adverse effect of placebos Major depression alternating with mania/hypomania caused by taking antidepressants Warmth & Positive remarks Partial agonist at nicotinic acetylcholine receptor Dementia, gait disturbance & urinary incontinence Thomas Stephen Szasz Fetal Alcohol Syndrome Borderline personality disorder & Parasuicidal behavior 1947 1958 Autistic Disorder Statistical Package for Social Sciences Egas Moniz Uma Choudhary Precontemplation, Contemplation, Preparation, Action, Maintenance