Geetha Desai

Consumer perspectives on the concept of recovery in schizophrenia: A systematic review

Subjective descriptions of recovery from schizophrenia may be different from clinical recovery measures. The aim of the review was to identify the consumer perspectives of recovery from schizophrenia. Twenty-five studies within the period of 2000-2013, including qualitative and quantitative studies were reviewed by using different search strategies. An integrated method was used and the findings were coded and related themes were identified under five areas, namely, process orientation, self orientation, family orientation, social orientation, and illness orientation. Recovery was considered as both process and outcome. Patient or client-based definitions of recovery mainly involved factors related to personal wellbeing and social inclusion, that were seemingly distant from the clinical recovery measures. Incorporating consumer descriptions of recovery in recovery oriented services can increase the outcome of the services.

What's 'in the body' is actually 'in the mind'!

Of the many controversies, debates, confusions and disagreements the term ‘somatic symptoms’ means different symptoms to different professionals across the world and in major classifications. What are ‘somatic symptoms’—bodily symptoms or melancholic features? Whereas the DSM IV includes changes in appetite and weight, sleep disturbances, lack of concentration or diminished ability to think or indecisiveness as somatic symptoms, most clinicians and patients talk about headache, body ache, fatigue, tiredness, bodily sensations and other sensory changes. Melancholic features like diurnal variation, early awakening, and retardation are also referred to as somatic symptoms when subclassifying major depressive disorders. Diagnostic uncertainty of the somatoform disorders has been another issue. The reluctance of clinicians in acceptance of somatoform disorders and its sneaking into psychiatric classifications has not resolved any controversy. Uncertainty about the nature of somatic symptoms itself has been rift with controversy—as absence of organic pathology implies a lack of sensitive and appropriate investigations to explain the pathology, for example, computerized tomography, magnetic resonance imaging, and computerized thermography have explained many an unexplained pathology. There are Somatic Inkblot Tests (Cassell, 1990), like the Rorscharch inkblots, to help psychologists understand the meaning and genesis of somatic symptoms for the individual. One wonders whether there is a need for a somatometer! Would somatic symptoms still be considered as symptoms which cannot be measured or are unexplained medically, once future investigations are able to measure or explain them? Further, even clinically, there is little agreement about the number of somatic symptoms and their relation to somatoform disorders—somatoform pain disorder may have just one symptom, where as somatization disorder may have more than a dozen symptoms! One approach to understanding somatizing behaviours is to consider the somatic language of patients as a form of communication, even though it may be concrete and lacking symbolic psychological abstraction (Stoudemire, 1991). This way, somatizing patients may be understood as communicating their subjective perceptions of somatic sensations that accompany their affective distress. This communicative function of the somatic language employed by the somatizing patient has been termed somatothymia by Stoudemire (1991). On similar lines persons may have alexisomia, a difficulty in the awareness and expression of bodily feelings (Ikemi & Ikemi, 1986), and hence ignore the somatic manifestations and verbalize the affective, cognitive experiences. The help-seeking behaviour of persons with somatoform disorders is difficult to understand due to the attitudes of the professionals. The patients do not understand that their physicians do not understand their problems, let alone the illness. Even in this high-tech era there are no ways to explain or understand the pathophysiological mechanisms underlying the complex symptoms (which have no reason to be there, from the physician’s point of view). The doctors search for gains for the patient, little realizing that the main gain is perhaps relief of symptom, understanding their symptom and explaining it to them. Patients’ points of view or evaluation and their experiences need to be given due importance. The degree of discrepancy between somatic pathology and patients’ reactions is a complex phenomenon based on multiple factors, many of which are addressed in this special issue of the International Review of Psychiatry.

Dissociative Disorders in a Psychiatric Institute in India - A Selected Review and Patterns Over a Decade

Background: The prevalence — and type — of dissociative disorders is considered to vary across cultures and over time. Aims: The aim of the study was to examine patterns of dissociative disorders among subjects attending psychiatric services over a period of 10 years. Methods: The sample consisted of both inpatients and outpatients attending a psychiatric hospital between 1999 and 2008. Information of those subjects diagnosed to have dissociative disorders was reviewed. A semi-structured proforma was used to collect information about demographic details and diagnosis. Results: A total of 893 patients had been diagnosed with dissociative disorder over the past decade: 591 (66%) were outpatients and 302 (34%) were inpatients. The proportion of patients diagnosed with dissociative disorders ranged between 1.5 and 15.0 per 1,000 for outpatients and between 1.5 and 11.6 per 1,000 for inpatients. The majority of patients were diagnosed with dissociative motor disorder (43.3% outpatients, 37.7% inpatients), followed by dissociative convulsions (23% outpatients, 27.8% inpatients). Female preponderance was seen across all sub-types of dissociative disorder except dissociative fugue. Conclusions: Dissociative disorders are still commonly diagnosed in both inpatient and outpatient settings. Dissociative motor disorders and dissociative convulsions are the most common disorders. Unlike in the West, dissociative identity disorders were rarely diagnosed; instead, possession states were commonly seen in the Indian population, indicating cross-cultural disparity.

Lithium in drinking water and food, and risk of suicide.

Ohgami et al [1][1] reported lithium in drinking water (0.7–59 gm/l) and linked it to suicide rates. However, dietary lithium, which has received scant attention, is found in grains and vegetables, and to some extent animal-derived foods.[2][2] Hence, considering only lithium in drinking water may

Yoga intervention and functional pain syndromes: a selective review

Abstract The definition of functional pain syndromes is varied across literature. No effort has been made to see all functional pain disorder groups under broad nomenclature which would exclude conditions for which pathophysiology is strongly known. Since these disorders are commonly treated with alternative treatment modalities and impose significant burden on health utilization, an effort to look into studies on yoga-based interventions on ‘functional pain syndromes’ (FPS) was made. This study defined FPS as ‘Chronic relapsing remitting pain conditions, the origin of which is difficult to trace with no definite physical pathology on clinical suspicion or available laboratory measures and are valid based on subjective pain reporting, associated distress and socio-occupational dysfunction’. Chronic headache, neck pain, back pain, fibromyalgia, pelvic pain, Irritable Bowel Syndrome, Chronic Fatigue Syndrome, and somatoform pain disorders were included for this review. The review found four meta-analyses on the selected topic both indicating modest efficacy and benefit of yoga in these disorders. Future efforts should be directed to do a large meta-analysis of functional pain syndromes.

The establishment of a mother-baby inpatient psychiatry unit in India: Adaptation of a Western model to meet local cultural and resource needs

Background: Several Western countries have established mother-baby psychiatric units for women with mental illness in the postpartum; similar facilities are however not available in most low and medium income countries owing to the high costs of such units and the need for specially trained personnel. Materials and Methods: The first dedicated inpatient mother-baby unit (MBU) was started in Bengaluru, India, in 2009 at the National Institute of Mental Health and Neurosciences in response to the growing needs of mothers with severe mental illness and their infants. We describe the unique challenges faced in the unit, characteristics of this patient population and clinical outcomes. Results: Two hundred and thirty-seven mother-infant pairs were admitted from July 2009 to September 2013. Bipolar disorder and acute polymorphic psychosis were the most frequent primary diagnosis (36% and 34.5%). Fifteen percent of the women had catatonic symptoms. Suicide risk was present in 36 (17%) mothers and risk to the infant by mothers in 32 (16%). Mother-infant bonding problems were seen in 98 (41%) mothers and total breastfeeding disruption in 87 (36.7%) mothers. Eighty-seven infants (37%) needed an emergency pediatric referral. Ongoing domestic violence was reported by 42 (18%). The majority of the mother infant dyads stayed for <4 weeks and were noted to have improved at discharge. However, 12 (6%) mothers had readmissions during the study period of 4 years. Disrupted breastfeeding was restituted in 75 of 87 (86%), mother infant dyads and mother infant bonding were normal in all except ten mothers at discharge. Conclusions: Starting an MBU in a low resource setting is feasible and is associated with good clinical outcomes. Addressing risks, poor infant health, breastfeeding disruption, mother infant bonding and ongoing domestic violence are the challenges during the process.

Prevalence and risk factors associated with tardive dyskinesia among Indian patients with schizophrenia

BACKGROUND Tardive dyskinesia (TD) is one of the most distressing side effects of antipsychotic treatment. As prevalence studies of TD in Asian population are scarce, a cross-sectional study was performed to assess the frequency of TD in Indian patients with schizophrenia and risk factors of TD. METHOD Cross-sectional study of 160 Indian patients fulfilling the DSM-IV TR criteria for schizophrenia and who received antipsychotics for at least one year, were examined with two validated scales for TD. Logistic regression analyses were used to examine the relationship between TD and clinical risk factors. RESULTS The frequency of probable TD in the total sample was 26.4%. The logistic regression yielded significant odds ratios between TD and age, intermittent treatment, and total cumulative antipsychotic dose. The difference of TD between SGA and FGA disappeared after adjusting for important co-variables in regression analysis. CONCLUSION Indian patients with schizophrenia and long-term antipsychotic treatment have a high risk of TD, and TD is associated with older age, intermittent antipsychotic treatment, and a high total cumulative antipsychotic dose. Our study findings suggest that there is no significant difference between SGAs with regards to the risk of causing TD as compared to FGAs.

Idioms of distress

The presentations of psychosocial distress and cultural conflicts are often bodily symptoms, especially in traditional societies and village backgrounds. These might not meet the criteria of the current psychiatric diagnostic systems. Sociocultural milieu contributes to the unique presentations of the stress in the form of idioms of distress. The latter are alternative modes of expressing distress and indicate manifestations of distress in relation to personal and cultural meaning. Health professionals often consider these as hysterical, functional or having functional overlays, and abnormal illness behaviors. Management of idioms of distress would need cultural competence and sensitivity. This article highlights the common idioms of distress in India with specific focus on bodily symptoms.

A Study on First Intake Assessments of In-Patient Referrals to Psychiatric Rehabilitation Services

Background: Psychiatric rehabilitation is an important component in mental health services. The rehabilitation needs of patients with mental illness have been highlighted in various studies. The studies on in-patient referrals to rehabilitation services however are sparse. This study describes the clinical and demographic details and the reasons for referrals to rehabilitation services during the in-patients stay. Materials and Methods: A semi-structured pro forma was used for the assessment of in-patients referred for the psychiatric rehabilitation services. The pro forma included socio-demographic details such as background, family resources, illness related details such as symptom status, risk assessment, medication details. The total number of referrals for a period of 5 months was collected and coded. Results: The total number of referrals for a period of 5 months was 216 and there were 197 forms available for the study. The mean age of the sample was 31.48 ± 10.46 years. Vocational rehabilitation was the commonest reason for referral to the in-patient services. Severe mental disorders were the most common diagnosis of patients refereed to the services. Conclusions: Patients with severe mental illness were most often referred to the in-patient services. This indicates that we need include to rehabilitation in the management plan at the earliest. Vocational rehabilitation is the most common reason for referrals and there is a need to develop services to cater to these needs.

Measurement and assessment of somatic symptoms.

Abstract Somatic symptoms are common presentations in health settings. They can manifest as symptoms of another underlying mental disorder or be termed as medically unexplained. When they are medically unexplained they are invariably subsumed under the diagnostic categories of somatoform disorders. They are associated with interference in functioning, poor quality of life and are burdensome on health resources. The measurement of these symptoms is essential for understanding the individual and planning treatment. There are various instruments that have somatic symptoms measurement in their items. The tools have included somatic symptoms measurement in measuring general psychopathology, somatic symptoms as part of anxiety and depression, somatic symptoms specifically, and as a screening instrument for somatoform disorders. The advantages and disadvantages of common measures have been discussed. It appears that no one measure fulfils the essential criteria of an ideal measure for somatic symptoms. The measures of somatic symptoms should also be culturally sensitive and serve diagnostic, prognostic and heuristic purposes. These aspects are highlighted in the review.