Harish Thippeswamy

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.

Co-morbidities and outcome of childhood psychogenic non-epileptic seizures--an observational study.

PURPOSE To assess the psychiatric diagnoses and outcome in children with psychogenic non-epileptic seizures (PNES). METHODOLOGY This hospital based observational study was performed on 44 children aged <16 years, who suspected to have psychogenic non-epileptic seizures based on video-EEG, from August 2005 to August 2012. The parameters noted were the psychiatric diagnosis, co-morbidities, management assessment and interventions (pharmacological and psychosocial), number and duration of follow-up visits, symptoms at follow-up, functioning as reflected by involvement in the social and scholastic work. RESULTS All forty four children completed the evaluation. Thirty four children were diagnosed as having PNES and the underlying psychiatric diagnosis was conversion disorder (n=34, 77.3%). Co-morbid psychiatric disorders were present in 17 children (50%). The common co-morbidities were intellectual disability (n=8, 23.5%), specific learning disorder (n=5, 14.7%), and depression (n=5, 14.7%). Co-morbid epilepsy was present in 8 (23.5%) children and family history of epilepsy was present in 10 (29.4%) cases. About 17 of 34 (50.0%) patients had a minimum follow-up of 6 months (13.9 ± 4.8 months). Twenty six children (76.5%) remained symptom free at the follow-up of 9.8 ± 7 months. The remaining 10 children (22.7%) had non-epileptic seizures with underlying diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), gratification disorder and other physiological conditions. CONCLUSIONS Conversion disorder is a common diagnosis underlying psychogenic non-epileptic seizures. Outcome was good in 76.5% children with PNES. A multidisciplinary approach is needed in the diagnosis and management of PNES.

Immune system aberrations in postpartum psychosis: An immunophenotyping study from a tertiary care neuropsychiatric hospital in India

Postpartum psychosis (PP) is associated with significant morbidity to both mother and infant. Immune system dysregulation during PP is reported in recent studies. This study attempted to determine immune signatures associated with first-onset PP by flow cytometry. Peripheral blood showed decreased naive CD4 and CD8 T cells, while activated CD8 and memory regulatory T cells (Tregs) were increased in women with PP as against healthy controls. The CD14-CD16+non-classical monocytes, CD11c+myeloid DCs and cytotoxic CD56dimCD16+ were reduced, while CD56brtCD16+/-regulatory NK cells were elevated in women with PP. The variations in immune cell subsets highlight the generalized immune dysregulation in PP.

Factitious Disorder-Experience at a Neuropsychiatric Center in Southern India

Objective: Factitious disorder is amongst the more intriguing but less-studied psychological disorders. Studies from different parts of the world have reported of varying prevalence rates. Here, we try to study the prevalence of factitious disorder in a specific sample of patients attending a neuropsychiatric center in India. Materials and Methods: We did a retrospective review of our institutes database for cases with a diagnosis of factitious disorder in the 10-year duration from 2001 to 2010. We reviewed the available clinical and socio-demographic data. Results: Of the 81,176 patients seen in the 10-year duration, only 8 patients had been assigned the diagnosis of factitious disorder, leading to a prevalence rate of 0.985 per 10,000 patients in this sample. Most of the patients were lost to follow-up; hence. Conclusion: Factitious disorder remains highly underdiagnosed in developing countries like India. Mental health professionals need to be more aware and inquisitive about this particular disorder, so that they do not miss the diagnosis.

Phallicide: a case of auto penile amputation as a mode of suicide.

diagnosed with Bipolar Disorder. Following this, a Complicated Grief Reaction (CGR) ensued, and eight months later, he suddenly one day per- formed penile amputation using a razor blade. He subsequently reported committing the act with intent to end his life. During the process, he had amputated about two-thirds of the shaft of his penis and left his scrotum and testes untouched. He was rushed to the hospital and, after controlling the blood loss and as per surgical advice, he underwent penile recon- struction carried out over seven stages and two years. He was co-operative during the whole course of surgery and expressed regret over his action. The reconstructed penis was without any anatomical/physiological deficits. Detailed evaluation at our hospital revealed an absence of previous suicide attempts, substance use, body image disturbance or disturbance of sexual identity. There were no past/present psychotic or schizophrenia symptoms.

Consultation-liaison approach for the management of psychiatric manifestations in Parkinson's disease and related disorders: A report from Neuropsychiatric Hospital, India

Background: Non-motor psychiatric manifestations of Parkinsons disease have been increasingly noted to contribute to morbidity and mortality. Materials and Methods: We studied the psychiatric manifestations among inpatients with Parkinsons disease and other movement disorders by examining the referrals (N = 127) to consultation-liaison psychiatry services from neurology/neurosurgery between July 2009 and April 2010 using structured clinical proforma. Results: Parkinsons disease and other movement disorders was the most common neurological diagnosis (19%). The most common reason for referral was depression (38%) followed by behavioral problems (33%). Post-assessment, depression rates were higher (54%) and behavioral manifestations were diagnosed as sleep problems (13%), organic psychiatric syndrome (13%), psychosis (8%), anxiety and obsessive compulsive disorder (8%), nil psychiatry (4%). Conclusion: Psychiatric comorbidity is high among in-patients with movement disorders and affective changes are common. Timely assessment using structured clinical proforma would help in enhanced detection of depression in patients with movement disorders.

Anti-NMDA receptor encephalitis presenting as postpartum psychosis—a clinical description and review

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is increasingly being recognised to be associated with protean neuropsychiatric manifestations. Anti-NMDAR encephalitis is considered to be the most common amongst the autoimmune-mediated encephalitic disorders. It is caused by the autoantibodies against GluN1 subunits of N-methyl-D-aspartate (NMDA) receptor and manifests with prominent psychiatric symptoms, especially during the initial phase of illness. Literature anti-NMDAR encephalitis presenting with postpartum psychosis is scant. In this report, we present a 28-year-old lady with postpartum psychosis as presenting manifestation of anti-NMDAR encephalitis and discuss the neuropsychiatric manifestations of this emerging entity.

What is in a name? Causative explanatory models of postpartum psychosis among patients and caregivers in India

Background: Explanatory models (EMs) influence decision-making related to treatment and compliance. There is little knowledge about belief systems related to postpartum psychosis in different cultures. Aims: To study EMs of illness among women with postpartum psychosis and their family members in India. Method: A total of 123 women with postpartum psychosis and their caregivers were assessed to understand their beliefs regarding causes of postpartum psychosis using Short Explanatory Model Interview (SEMI). Local names were listed and emerging themes were analysed. Results: Respondents often held more than one EM and only one-third held a biomedical EM. Other common models included stressors unique to childbirth, marital stress and supernatural causes. Local names reflected the underlying models. Conclusion: Non-biomedical EMs are common in women with postpartum psychosis. Cultural and social factors unique to childbirth appear to influence these models. There is a need to enhance awareness and knowledge about this serious disorder in the community.

Delusion of paternity

There has been an attempt to classify delusions related to various stages of procreation under a single rubric called ‘delusional procreation syndrome’ (Manjunatha et al., 2010). Most commonly reported among these phenomena is delusion of pregnancy (Chaturvedi, 1989; Manoj et al., 2004). There have been two reports of ‘delusion of maternity’, (Hrdlicka, 1998; Manjunatha et al., 2010), but only one previous report of ‘delusion of having spouse’ and ‘delusion of paternity’ (Manjunatha et al., 2010). Mr A, a 45-year-old unmarried man was admitted to hospital with a twoyear history of social withdrawal. He had a history suggestive of mild mental retardation and complex partial seizures that were well controlled with medications. He was very friendly with one of his female cousins. A few years ago, when she got married, he started asking his parents for marriage. When his cousin delivered a baby girl a year ago, he started claiming that he also has a daughter. Her name was ‘Priya’ (name changed for confidentiality) and he interacted with her every day. To his parents, he described her as a small child who stays with him in his room and that he planned to buy things for her and to send her to school. His parents saw him sitting and talking to himself and laughing many times in a day as if he was interacting with someone invisible. On questioning about how he can have a child without a wife, he would say that he had a wife called ‘Parvathy’ (name changed for confidentiality). However, he never described her any further. His life was preoccupied with these symptoms and experiences. He was diagnosed as having delusional disorder and was treated with risperidone 6 mg and trihexyphenidyl 4 mg, with which he showed significant improvement. This patient had a delusion of paternity that he was father to a child. In addition, he possibly had a ‘delusion of having spouse’ but this was never well elaborated. There are two ways of understanding this phenomenon. Firstly, from a psychodynamic perspective, the patient may have had a subconscious sexual wish to possess his cousin. Being unacceptable to the super ego, this wish was repressed by the ego. The cousin got married and had a child. The belief of having a child unconsciously implied a wish fulfilment of sexual union with his cousin. An alternative explanation can be formulated using Erikson’s theory of stages of psychosocial development (Erikson, 1968). The patient was in his early 40s when his cousin got married, which is the stage of intimacy versus isolation. The marriage of the cousin may have evoked a desire for intimacy which correlated with his requesting his parents to get him married. The next stage of development is of generativity versus stagnation. This correlated with the onset of his ‘delusion of paternity’ that he had a daughter, when he was 44-years-old. The belief gave him the chance to fulfil his desire for generativity. This report adds to the very limited literature regarding this concept.

Life events and depressive symptoms among pregnant women in India: Moderating role of resilience and social support:

Background: Recent life events may be significant risk factors for depression during pregnancy. However, its association with the individual’s resilience and social support is not clear. Aims: To understand the association between life events and depression during pregnancy and whether the association is moderated by resilience and social support. Methods: This study is part of a prospective cohort study on perinatal mental health in an urban antenatal clinic, which included 589 women recruited in the first and early second trimester. Participants were administered the Life Events Checklist adapted from the Social Readjustment Rating Scale by the authors to assess life events; Edinburgh Postnatal Depression Scale (EPDS) and Connor–Davidson Resilience Scale-10 to assess depression and resilience, respectively. The relationship between life events (12 months prior to the time of assessment) and antenatal depression and the moderating role of resilience and social support was analysed. Results: Thirty-eight women (6.5%) who had depression (EPDS score ⩾ 11) had significantly higher number of life events (i.e. on average three; U = 3,826; p < .01), lower resilience scores (U = 4,053; p < .01) and lower perceived social support (U = 2,423; p < .01) as compared to those who were negative for depression on EPDS. Life events predicted depression during pregnancy; however, the relationship was moderated by social support but not by resilience. Conclusion: The pregnant women who experienced life events may experience depression during the first trimester of pregnancy, but the effect could possibly be reduced by enhancing the social support.