Christoday R. J. Khess

Idiopathic Recurrent Catatonia Needs Maintenance Lorazepam: Case Report and Review

Objectives: Catatonia as a phenomenon has been well described with either a schizophrenic illness, severe mood disorders or periodic catatonia disorder. We aim to report a patient who had recurrent catatonia that responded to and required lorazepam for maintenance. Methods: We describe the case of a 28 year old woman who had a history of recurrent catatonia that was unresponsive to most anti-psychotics, but who responded to high doses of lorazepam and needed long-term lorazepam for maintenance. Results and Conclusion: Our patient met the criteria for a diagnosis of idiopathic catatonic disorder. Response to lorazepam suggests that a certain group of patients may require long-term treatment with lorazepam, especially those who may have down-regulation of GABA-A receptors.

Sex difference in symptomatology of manic episode

OBJECTIVE Studies addressing sex differences in the symptoms and course of bipolar affective disorder had been investigated across different phase of bipolar affective disorder. There are few studies in manic phase that have reported inconsistent results. Therefore, we investigated sex difference in symptom presentation of manic episode. METHODS A total of 150 male and 50 female subjects meeting criteria for manic episode according to International Statistical Classification of Diseases, 10th Revision Diagnostic Criteria for Research, giving written informed consent, were included for the study. Those with comorbid major medical or psychiatric disorders were excluded. All the patients were assessed on Scale for Manic States. RESULTS Multivariate analysis of variance using all the items of Scale for Manic Symptoms showed significant sex difference (Pillais Trace F(20,179) = 5.154, P < .001), with large effect size (η2 = .365). In men, there was significantly higher motor activity, psychosis, grandiosity, contact, and humor, whereas mood lability, depressed mood, guilt, suicide, anxiety, and dress scores were higher in women. Discriminant analysis showed that 84% of men and 72% of women could be correctly classified using the Scale for Manic Symptoms. Stepwise logistic regression analysis showed anxiety, guilt, and dress positively predicted female sex and the model explained 24% to 36% of variance. CONCLUSION Symptom presentation of mania differs across sex and a predominance of anxiety and depressive symptoms was found in women, whereas increased psychomotor activity was prevalent in men.

Perceived reasons for and consequences of substance abuse among patients with psychosis.

BACKGROUND Substance use is a common comorbidity with psychotic illnesses. Although several theories exist to explain this link, individual reasons for use may differ. The aim of this study was to evaluate patient perceptions of the reasons for and consequences of their substance use in patients with psychosis and compare them with those of an age-, sex-, and tobacco use-matched control sample without psychosis. METHOD Consecutively admitted patients were divided into 2 groups, those who had substance dependence without psychosis (n = 32), admitted in our addiction unit, and those who had psychotic illness with substance dependence, admitted in our inpatient psychosis unit and referred to as the dual-diagnosis group (n = 62). Patients were administered the Schedules for Clinical Assessment in Neuropsychiatry for ICD-10 Diagnostic Criteria for Research to confirm schizophrenia, bipolar affective disorder, and substance dependence diagnoses and were asked open-ended questions to evaluate the perceived reasons for and consequences of their substance use. The study was conducted from July to September 2006. RESULTS There were significant differences between the 2 groups in reasons for maintenance and relapse of both cannabis use and alcohol use, the 2 most common substances. While the substance dependence without psychosis group attributed both maintenance and relapse to external factors such as nature of work, social milieu, or peer pressure, the dual-diagnosis group attributed them to internal factors such as enhancement of positive mood and alleviation of withdrawal effects. CONCLUSIONS Individuals with psychosis have greater vulnerability to internal factors, which may maintain substance use. Targeting perceived internal factors may play a useful role in management and possibly identification and prevention of psychosis in vulnerable individuals in the future.

High Dose Zolpidem Induced Fetal Neural Tube Defects

Use of zolpidem, a short-acting imidazopyridine hypnotic, has not been associated with teratogenic effects in usual clinical doses. We report a case of fetal neural tube defects occurring in a female dependent on zolpidem and consuming high doses in the first trimester of pregnancy. Possible mechanisms by which high dose zolpidem may lead to teratogenicity are discussed. Clinicians are advised to be aware of the risks of high-dose zolpidem abuse in early pregnancy.

Chronology of alcohol dependence: Implications in prevention

Background: Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us design strategies for the prevention for ADS, which aims at reducing the occurrence of ADS. Objective: To study the age-wise and order-wise chronologies of ICD-10 (DCR) dependence criteria in individuals with ADS. Materials and Methods: Consecutively admitted and consenting inpatients with ICD-10 (DCR) diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II. Results: The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion and International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) dependence was 18.72 years (SD, 6.84), 24.33 years (SD, 9.21) and 27.51 years (SD, 9.28), respectively. In age-wise chronology, tolerance, loss of control and craving were present in 97.53%, 80.24% and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%) or loss of control (18.5%) was observed in the first criterion in 55.5% of the subjects. Conclusions: Knowledge of chronology, its frequencies and time duration between various milestones in the development of the dependence criteria may enable the selection of the target population at an early stage. The pattern of development of dependence may provide us with an opportunity for interventions to reduce the incidence of ADS, as a step toward primary prevention. Adequate training of the primary care personnel and early psychiatric referral may help in the reduction in the incidence of ADS.

Substance abuse co-morbidity in schizophrenia: An inpatient study of course and outcome

Background: Differences in opinion exist among researchers in relation to the course and outcome of substance abuse co-morbidity in schizophrenia. Aim: To compare the pattern of remission of symptoms in positive and negative schizophrenics with and without a history of substance abuse. Methods: Seventy schizophrenics were divided into two groups based on the history of presence or absence of substance abuse/dependence. Thirty-eight patients (54.3%) were diagnosed as having co-morbid alcohol/substance abuse/dependence. Patients were rated at two-weekly intervals on the Positive and Negative Syndrome Scale (PANSS) with one follow-up rating by the end of the third month. Co-morbid substance abusers were predominantly represented by a positive syndrome and non-abusers by a negative syndrome at the time of admission. Results: Psychopathology remitted much faster in the substance-abusing group but after discharge, these patients tend to return to their pre-admission state. Conclusion: The following hypothesis is proposed based on the findings of the present study: ‘Short-term inpatient outcome of substance-abusing schizophrenics is significantly better than non-substance abusing schizophrenics because of the faster rate of remission of their symptoms.’ A corollary to the above hypothesis may be evolved—‘through intense inpatient follow-up one may be able to differentiate substance-abusing and non-abusing schizophrenics’.

Factor Structure of CIWA-Ar in Alcohol Withdrawal

Objective. To identify the underlying factor structure of alcohol withdrawal syndrome, as measured with CIWA-Ar. Methods. Exploratory factor analysis was conducted on the items of CIWA-Ar. On 201 alcohol-dependent male patients seeking treatment for alcohol withdrawal at 36 hours of abstinence. Results. A three-factor solution was obtained that accounted for 68.74% of total variance. First factor had loading from four items (34.34% variance), second factor also had four items (24.25% variance), and the third had two items (10.04% variance). Conclusions. Factor analysis reveals the existence of multidimensionality of alcohol withdrawal as measured with CIWA-Ar and we found three factors that can be named as delirious, autonomic and nonspecific factors.

Delayed-onset delirium tremens – a diagnostic and management challenge

Background: Delirium tremens (DT) is one of the most serious complications of alcohol withdrawal, affecting 5–10% of in-patients with a mortality rate up to 15%. DT, characterised by delirium and tremors, appears within 48–72 h of abstinence and persists for about 5–10 days. Case presentation: We report a case of DT in a young man with delayed onset on the 15th day after the cessation of alcohol use, despite an uncomplicated detoxification with benzodiazepine treatment. Conclusion: We hypothesise that the intake of country liquor in our patient, which contains higher percentages of alcohol, causes a prolonged imbalance of N-methyl-d-aspartic acid and glutamate receptor activity, leading to the picture of delayed-onset DT and that an atypical presentation at the time of admission and atypicality in early course are clinical pointers to the subsequent development of delayed-onset DT.

Inpatient suicide in a psychiatric hospital: fourteen years' observation

Inpatient suicide is an important issue all over the world. Patients admitted to psychiatric hospitals have increased rates of suicide in comparison to the rate in general population (Appleby et al., 2006; Hunt et al., 2007). The risk factors for suicide among inpatients are not essentially the same as the risk factors for suicide in other population groups (Powell et al., 2000). In comparison to the abundant information on inpatient suicide in Western countries, there is a paucity of data on inpatient suicide in Asia. Thus, the goal of the present study was to describe the sociodemographic and clinical factors for completed in-patient suicide and to compare those with matched living controls. This is a retrospective 1:1 matched case-control study which was undertaken at Central Institute of Psychiatry, Ranchi, India. This study pertains to 10 suicide cases that occurred at Central Institute of psychiatry, Ranchi, Jharkhand, India between the years from 2000 to 2013. For this study, each suicide case was matched with a living control based on the following criteria (in descending order of importance): (1) sex; (2) diagnoses; (3) age; and (4) admission period, from the inpatient population of the institute. Thus, a living control group consisting of 10 patients was selected. After obtaining ethical permission, data were extracted from medical case notes by one researcher and recorded. To ensure blindedness as to the case-control status of the case notes, the senior researcher obtained the medical case notes medical records section. The records were copied and to minimize information bias and to maintain blindness, information regarding the period after the censoring date (the date of death of the case) was also removed from the control’s record. Method of chart review was followed for data collection. Data were analyzed using Statistical Package of Social Sciences (SPSS) 20th version for Windows. Table 1 summarizes sociodemographic and clinical variables of patients of two groups. In parallel with other studies on inpatient suicides, schizophrenia and affective disorders were the most common diagnoses in our study (Cassells et al., 2005; Dong et al., 2005; Neuner et al., 2008; Bowers et al., 2010). In the present study a trend toward significance was observed in terms of family type and religion in line with earlier studies (Bansal et al., 2011; Ramdurg et al., 2011). All suicide completers belonged to Hindu religion whereas in control group 30% belonged to Islamic religion. In Hinduism, life is seen as a cycle and reincarnation is seen as part of this cycle. Thus, attitudes to suicide in Hinduism are more liberal and less

Does withdrawal seizure occur in opioid dependence syndrome? A case series

PROSOPAGNOSIA IS A neuropsychological syndrome characterized by difficulty in recognizing human faces or facial expressions, without elemental visuospatial deficits. Individuals with this syndrome often feel distressed in everyday life. Cases of prosopagnosia caused by cerebrovascular events or neurodegenerative disease have been described. Here we describe a case of prosopagnosia, probably developmental in origin, in which the patient was referred to the outpatient psychiatric service. Developmental prosopagnosia is gradually becoming known mainly through the mass media or Internet, but patients are rarely referred to psychiatric services despite significant distress. The present patient gave informed consent to publish this letter. A 23-year-old Japanese man was refereed to the outpatient psychiatric service at Niigata University Hospital by a contact physician at his workplace. The patient was suspected of an autism spectrum disorder (ASD) because of his communication difficulty at work, although the physician did not find any evidence to support it at the initial interview. Physical examination, screening imaging, urine and blood tests showed no significant medical and neurological conditions. He was psychologically distressed but was not diagnosed as having any DSM-IV disorders. He described difficulty, however, in memorizing the faces of several colleagues and supervisors at his office in a telecom company even though he had been working with them for at least a few years. The difficulties had been present from his childhood to date, thus he managed to cope using various strategies to identity individuals: hairstyle, physical constitution, clothes, voice tone, characteristic speech and desk position in the office. The results of visual perception test for agnosia were as follows. The patient successfully answered all tests with regard to object recognition, primary visual function and recognition of symbols. Checking the center of lines was 6% to the left, showing no evidence of hemispatial neglect. In contrast, the errors in face recognition were significant as compared to the norm: famous face naming (100%), famous face pointing (69%) and perception of facial expression (17%). Additional deficits in unknown face discrimination (75%), unknown face matching (50%), perception of gender (75%) and perception of age (63%) suggested an apperceptive type of prosopagnosia. Individuals with developmental prosopagnosia rarely visit the mental health clinic unless they have comorbid psychiatric conditions. With increasing public attention on developmental disorders, the present patient was suspected of having ASD, which is also characterized by deficits in non-verbal communication used for social communication, including a total lack of facial expression and/or poor understanding of that. Although there is a superficial similarity between difficulty in interpersonal communication and some autistic features, as evidenced by the autism-spectrum quotient (31 points), the present patient suffered mainly from prosopagnosia, and his social–emotional reciprocity and ability to develop and maintain relationships was not impaired. Developmental prosopagnosia should be listed as a rare neuropsychiatric condition in the differential diagnosis of ASD.