Anju Kuruvilla

Perceptions about Intellectual Disability: A Qualitative Study from Vellore, South India.

BACKGROUND Cultural and religious beliefs influence perceptions about health and illness. Data, from India, on perceptions about intellectual disability are scant. This study explored peoples cultural beliefs and attitudes about intellectual disability, perceived needs and burden associated with care in Vellore, south India. METHOD A qualitative methodology using focus groups was employed. Eight focus groups were conducted in three settings and included the mothers of children and adolescents with intellectual disability (four groups, n = 29), community health workers (two groups, n = 17) and schoolteachers (two groups, n = 16). RESULTS Our results suggest that cultural and religious beliefs perpetuated negative attitudes towards disability. This meant that caregivers bore a high burden of care with little support from family or society. The study confirmed the presence of diverse, multiple and contradictory models of disability drawing from biomedical and local religious, social and cultural constructs. CONCLUSIONS Public awareness, education and community-level interventions for reducing the misconceptions and stigma related to intellectual disability are needed in addition to culturally sensitive treatment methods to improve the attitude towards and management of intellectual disability.

Clinical predictors of serum clozapine levels in patients with treatment-resistant schizophrenia

Fixed oral doses of clozapine produce up to 45-fold interindividual variability among its serum levels in patients with treatment-resistant schizophrenia. Although the relationship between serum clozapine level and its therapeutic response is uncertain, the presence of a therapeutic window and level-dependent adverse effects require the estimation of serum clozapine levels. As routine therapeutic drug monitoring of clozapine is not feasible in many clinical settings, identification of clinical predictors of serum clozapine levels is desirable. Hence, we aimed to evaluate the clinical variables associated with serum clozapine levels. We assessed the sociodemographic and clinical profiles, cognition, disability and psychopathology of 101 consecutive patients with treatment-resistant schizophrenia on a stable dose of clozapine, using standard assessment schedules. We determined their serum clozapine levels using high-performance liquid chromatography with ultraviolet detection. While employing multivariate robust regression models, oral clozapine dose (P<0.001), caffeine intake (P=0.04) and Valproate comedication (P=0.005) were associated with serum clozapine levels. Serum clozapine levels above 750 ng/ml increased the risk of seizures (odds ratio 5.15; P=0.03). Clinical variables are useful to model a dosing nomogram for serum clozapine levels. The importance of caffeine consumption and Valproate comedication should be considered during clozapine dose adjustments to enhance its therapeutic response and safety profile.

The Vellore screening instruments and strategies for the diagnosis of dementia in the community.

BACKGROUND Many screening instruments for the diagnosis of dementia are not education and culture fair. In addition, despite good sensitivity and specificity, they result in unacceptable levels of false positives when used in the community. This study aimed to develop appropriate instruments for populations with low literacy and to consider strategies to reduce the false positive rates in low prevalence settings. METHODS Activities of daily living, which are not influenced by education and culture, were used to develop a patient screen and an informant version to identify people with dementia. The instruments were validated in the hospital and in the community setting against the standards of DSM-IV and the education-adjusted 10/66 Dementia Research Group diagnosis of dementia. RESULTS The instruments were administered to 90 patients attending a hospital and 101 subjects living in the community in Vellore, South India. The psychometric properties and inter-rater reliability of these screening instruments were good. While the sensitivity and specificity of the patient screen and the informant version were good their false positive rates were high in the community setting. However, the false positive rates reduced when these instruments were used in combination. CONCLUSION The patient screen and the informant version are short culture- and education-fair instruments. They reduce false positive rates, when used in combination in the community.

Association between CYP1A2 gene single nucleotide polymorphisms and clinical responses to clozapine in patients with treatment-resistant schizophrenia.

Objectives Despite clozapines superior clinical efficacy in treatment-resistant schizophrenia (TRS), its adverse effects, need for periodic leukocyte monitoring, cost and variable clinical outcomes mandate a clinical need to predict its treatment response. Although cytochrome P450 1A2 (CYP1A2) is the principal determinant of metabolism of clozapine, the role of CYP1A2 gene in the clinical response to clozapine is uncertain. Hence, we investigated its association with treatment responses and adverse events of clozapine in TRS. Methods We evaluated four single nucleotide polymorphisms (SNP) in the CYP1A2 gene, clinical responses and serum clozapine levels in 101 consecutive patients with TRS on stable doses of clozapine. We defined clozapine response a priori and investigated allelic and genotypic associations. We assessed the socio-demographic and clinical profiles, premorbid adjustment, traumatic life events, cognition and disability of the participants, using standard assessment schedules for appropriate multivariate analyses. Results Our results revealed that CYP1A2 gene SNP (*1C, *1D, *1E and *1F) were not associated with clozapine treatment response, adverse effects, serum clozapine levels or with disability (p values > 0.10). Conclusion As CYP1A2 gene SNP do not help to predict the clinical response to clozapine, routine screening for them prior to start clozapine is currently unwarranted. We suggest future longitudinal genome-wide association studies investigating clinical and pharmacogenetic variables together.

Genetic association between the DRD4 promoter polymorphism and clozapine-induced sialorrhea.

The use of clozapine, an effective antipsychotic drug used in treatment-resistant schizophrenia, is associated with adverse effects. Sialorrhea is one such effect, which can be distressing for many patients. Studies on the pharmacogenetics of the adverse effects of clozapine are limited. The aim of the present study was to determine whether clozapine-induced sialorrhea is associated with a 120 base-pairs (bp) tandem duplication polymorphism in the dopamine receptor subtype D4 (DRD4) gene. Ninety-five patients, mean age 35.43±9.43 years, with treatment-resistant schizophrenia and on clozapine were included in the study. Development of sialorrhea in response to the drug, as manifested by drooling of saliva, was documented in 45 (47.4%) patients. Genotyping of the patients was carried out to detect the presence of the polymorphism of interest. Clozapine-induced sialorrhea was found to be associated significantly with the 120-bp duplication in DRD4. The association was found to fit a log-additive model with an odds ratio of 2.95 (95% confidence interval 1.51–5.75; P=0.0006). Thus, the presence of the 120-bp duplication in DRD4 appears to confer a risk for sialorrhea in response to clozapine therapy. The underlying pathophysiology and clinical significance of this phenomenon warrant further investigation.

Situational psychogenic anejaculation: a case study.

Anejaculation is an uncommon clinical entity that may result from a variety of causes, both organic and psychological. Psychogenic anejaculation is influenced by relationship, behavioral, and psychological factors. We present a clinical case of situational anejaculation, which was managed with a combination of techniques that addressed these factors including changes in masturbatory technique, improved marital communication and quality, and reduction of anxiety using cognitive behavioral techniques. It is suggested that the standard techniques of sex therapy be modified and tailored to manage the specific problems of the individual patient.

Psychotherapy across cultures: the form–content dichotomy

The diversity of patients, problems, beliefs and cultures mandates the need to educate, match, negotiate and integrate psychological interventions. This is necessary in all cultures and in every setting. Many schools of psychotherapy offer specific theories and particular techniques, yet they share many common approaches. Their individual techniques allow therapists form and structure to treat different clinical problems, discuss diverse content and use them in varied settings and among people with assorted cultural backgrounds. The heterogeneity within cultures, regions and populations demands that therapists understand the local and individual reality. The apparent contradictions between standard psychological therapies and their use across cultures, when viewed through a form-content framework, allow for matching strategies for specific individuals and their distress, and for choosing the best treatment options from a diverse therapeutic armamentarium. Psychotherapies are at their weakest when they attempt to provide explanations across cultures and are at their strongest when they are used as vehicles for engagement with patients. The challenge is to find a common psychotherapeutic language, which attempts to bridge the divide between the issues facing the patient and the armamentarium of the therapist. The form-content paradigm at least partly explains the complexity of the issues within psychotherapy. It also allows the therapist to move from the therapy-centric orientation of Western approaches to the patient-centric orientations required for success in psychological therapies.

Delusional disorder: An unusual presentation

Delusions with a sexual theme are rare, but when present are usually seen in patients with schizophrenia or other chronic psychotic disorders. We report a case of delusional disorder, with a single belief of a sexual theme. This report focuses on the management issues, wherein a combination of pharmacological and nonpharmacological interventions proved helpful.

Palatal tremor after lithium and carbamazepine use: a case report

IntroductionPalatal tremor, characterized by rhythmic contractions of the soft palate, can occur secondary to pathology in the dentato-rubro-olivary pathway, or in the absence of such structural lesions. Its pathogenesis is only partially understood. We describe a case of probable drug-induced palatal tremor.Case presentationA 27-year-old Indian man had taken carbamazepine and lithium for 7 years for the treatment of a manic episode. He presented with a one-year history of bilateral rhythmic oscillations of his soft palate and tremors of his tongue. There were no other abnormalities detected from his examination or after detailed investigation.ConclusionPalatal tremors may result from medication used in the treatment of psychiatric disorders.

Quality of life and explanatory models of illness in patients with schizophrenia

Background: Patients with schizophrenia hold a variety of explanatory models of illness that influence different aspects of their life including their understanding of the disease, ability to cope and sense of well-being. Aim: To study the association of explanatory models and quality of life in patients with schizophrenia. Materials and Methods: One hundred and thirty consecutive patients with schizophrenia attending a psychiatric outpatient clinic were recruited in the study and administered the Positive and Negative Symptom Scale (PANSS), the modified Short Explanatory Model Interview (SEMI) and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) Scale to assess severity of psychosis, explanatory models of illness, and quality of life. Sociodemographic and clinical details of patients were also recorded. Standard bivariate and multivariable statistics were employed. Results: Higher quality of life scores were associated with better socioeconomic conditions and lower scores on negative and general psychopathology subscales of PANSS. Quality-of-life scores were significantly higher in patients who did not perceive their illness to have negative effects on the different domains of their functioning. Conclusion: Explanatory models of illness are associated with perceived quality of life in patients with schizophrenia. There is a need to focus on attitudes, perceptions and functioning, rather than symptom reduction alone, to enhance the quality of life in schizophrenia.