Janardhanan C. Narayanaswamy

Transcranial direct current stimulation in schizophrenia.

Transcranial direct current stimulation (tDCS) is an upcoming treatment modality for patients with schizophrenia. A series of recent observations have demonstrated improvement in clinical status of schizophrenia patients with tDCS. This review summarizes the research work that has examined the effects of tDCS in schizophrenia patients with respect to symptom amelioration, cognitive enhancement and neuroplasticity evaluation. tDCS is emerging as a safe, rapid and effective treatment for various aspects of schizophrenia symptoms ranging from auditory hallucinations-for which the effect is most marked, to negative symptoms and cognitive symptoms as well. An interesting line of investigation involves using tDCS for altering and examining neuroplasticity in patients and healthy subjects and is likely to lead to new insights into the neurological aberrations and pathophysiology of schizophrenia. The mechanistic aspects of the technique are discussed in brief. Future work should focus on establishing the clinical efficacy of this novel technique and on evaluating this modality as an adjunct to cognitive enhancement protocols. Understanding the mechanism of action of tDCS as well as the determinants and neurobiological correlates of clinical response to tDCS remains an important goal, which will help us expand the clinical applications of tDCS for the treatment of patients with schizophrenia.

Insight facilitation with add-on tDCS in schizophrenia

Impaired insight in schizophrenia patients has been linked with prefrontal deficits. In this open-label study, we examined for potential insight facilitation effects of add-on tDCS (with anodal stimulation of left DLPFC and cathodal stimulation over left temporo-parietal junction) in schizophrenia patients (N=21) with persistent auditory hallucinations despite adequate antipsychotic treatment. Following tDCS, there was a significant improvement in insight with concurrent significant reduction in auditory hallucination severity. Improvement in insight correlated significantly with improvement in severity of auditory hallucinations. These findings suggest improvement of insight with add-on tDCS in schizophrenia with persistent auditory hallucinations.

Monotherapy with tDCS for Schizophrenia: a case report.

positive response to cTBSmight have been related to the association of risperidonewith cTBS orwas primed bya course of low frequency rTMS completed a month before. However, the fact that this patient who suffered fromchronic persistentAVH responded to cTBSbut not to rTMS in addition to the fact that the improvements in her AHRS scores persisted with maintenance cTBS suggest that observed clinical changes were an effect of stimulation by cTBS. The encouraging findings of this case safely treated in a private practice setting aswell as those of the three previously published cases [8,9,10] should be further investigated and confirmed in sufficiently powered placebo-controlled, double-blind studies.

Neural basis of tDCS effects on auditory verbal hallucinations in schizophrenia: a case report evidence for cortical neuroplasticity modulation.

Transcranial direct current stimulation (tDCS) has been reported to ameliorate auditory hallucinations that are nonresponsive/minimally responsive to antipsychotic treatment in schizophrenia. The neurobiological basis of the tDCS effects in ameliorating auditory hallucinations is yet to be explored. In this case report, for the first time, using the novel method for noninvasive assessment of cortical plasticity, we demonstrate potential neuroplasticity effect of tDCS in improving treatment-resistant auditory hallucinations in a schizophrenic patient.

Impact of age of onset of illness on clinical phenotype in OCD

BACKGROUND This study aims to examine the demographic, clinical and comorbid patterns in a large sample of adult OCD subjects at a specialty OCD clinic in India. METHODS Consecutive patients (n=545) who consulted a specialty OCD Clinic over 5 years at a large psychiatric hospital in India were evaluated with the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive-Compulsive Scale, and the Clinical Global Impression scale. RESULTS Earlier age onset of OCD (years) was characterized by male preponderance (19.61±7.98 vs. 25.19±10.39, U=23453.5, p=<0.001), positive family history of OCD (19.60±10.02 vs. 22.27±9.20, U=16590.5, p<0.001) and presence of tic disorder (16.28±8.21 vs. 22.01±9.38, OR=0.86, p=0.001). In addition, early age of onset was associated with presence of sexual obsessions (18.92±7.49 vs. 22.88±9.82, OR=0.96, p=0.02), hoarding (19.61±9.32 vs. 22.21±9.36, OR=0.95, p=0.009), repeating rituals (19.76±8.37 vs. 23.29±9.84, OR=0.95, p=0.006) and need to touch compulsions (16.40±7.19 vs. 22.36±9.43, OR=0.89, p<0.001). CONCLUSIONS Our findings from a large sample not only confirm that early onset OCD could be a valid and distinct subtype of OCD but also support the cross-cultural similarity of early onset phenotype.

Impact of depressive and anxiety disorder comorbidity on the clinical expression of obsessive-compulsive disorder.

BACKGROUND The identification of distinct subtypes based on comorbidity offers potential utility in understanding variations in the clinical expression of obsessive-compulsive disorder (OCD). Hence, we examined the hypothesis whether patients with OCD with major depressive disorder (MDD) or anxiety disorder comorbidity would differ from those without in terms of phenomenology. METHODS A total of 545 consecutive patients who consulted a specialty OCD clinic during the period 2004 to 2009 at a psychiatric hospital in India formed the sample. They were evaluated with the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Mini International Neuropsychiatric Interview, and the Clinical Global Impression scale. RESULTS Among 545 patients, 165 (30%) had current MDD, and 114 (21%) had current anxiety disorder comorbidity. Patients with OCD with MDD were mostly women who had a greater severity of OCD symptoms, more of obsessions (especially religious), greater occurrence of miscellaneous compulsions (need to confess or need to touch), higher suicidal risk, and past suicidal attempts. Patients with OCD with anxiety disorder had an earlier onset of illness that was associated with prior life events, less of compulsions, more of aggressive and hoarding obsessions, pathologic doubts, checking, and cognitive compulsions. CONCLUSIONS Obsessive-compulsive disorder, when comorbid with MDD, is more severe and is associated with higher suicidal risk. On the other hand, anxiety disorder comorbidity seems to influence not so much the morbidity but the phenotypic expression of OCD.

Clinical predictors of response to treatment in catatonia

OBJECTIVE This study aims at identifying predictors of treatment response to lorazepam in catatonia. METHODS The clinical charts of 107 inpatients, admitted over duration of 2 years, with a primary diagnosis of catatonia were examined for response to lorazepam trial. Trial was considered as having received 3-6 mg per day of lorazepam for at least 3 days. RESULTS Out of these 107 patients, 99 received lorazepam and 8 received electroconvulsive therapy as the first line of management. There were 32 responders and 67 nonresponders to lorazepam. The nonresponders were characterized by rural background (85.1% vs. 62.5%, P=.01), longer duration of catatonic symptoms (108.88 vs. 25.12 days, P=.018), mutism (63.6% vs. 31.3%, P=.02) and presence of first-rank symptoms like third-person auditory discussing-type hallucinations (16.4% vs. 12.0%, P=.03) and made phenomena (7.5% vs. 0%, P=.04). The presence of waxy flexibility (12.5% vs. 4.5%, P=.03) predicted good response. CONCLUSIONS This study identifies that longer duration of illness, presence of catatonic sign of mutism and certain specific phenomena like third-person auditory hallucinations and made phenomena predicted poor response to lorazepam in catatonia. This could provide insight into the prediction and planning of the appropriate treatment strategies in this psychiatric emergency.

Response rate of lorazepam in catatonia: A developing country's perspective

BACKGROUND Catatonia is a syndrome characterized by concurrent motor, emotional, and behavioral symptoms. Short-term benzodiazepine administration and electroconvulsive therapy have proven to be safe and useful for treatment of this syndrome. AIMS This study aimed to explore the evidence of effectiveness of lorazepam as a first line treatment for catatonia in a tertiary psychiatry centre in India given the lack of facilities for ECT in primary care centers of developing countries. We examined the response rate of lorazepam in Catatonia. METHODOLOGY Clinical charts of 107 inpatients, admitted over a duration of two years, with a primary diagnosis of catatonia were examined for response with lorazepam trial. Trial was considered as having received 3-6 mg per day of lorazepam for at least 3 days. RESULTS Among the patients who were given lorazepam treatment, 32 out of 99 (32.3%) showed response (with complete resolution of catatonic symptoms). Improvement in catatonic symptoms was seen in 68 out of 99 (68.7%) patients. CONCLUSIONS Lorazepam is cost effective and could rapidly relieve catatonic signs, even without the use of ECT in a significant proportion of catatonic patients. Its early use can prevent disease progression and complications.

Does insight have specific correlation with symptom dimensions in OCD

OBJECTIVE To study relationship between insight and clinical characteristics in subjects with obsessive-compulsive disorder (OCD). METHOD Sample included 545 consecutive patients with a primary diagnosis of DSM-IV OCD who consulted a specialty OCD Clinic at a tertiary psychiatric hospital in India between January 2004 and December 2009. They had been evaluated with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) symptom checklist, severity rating scale and the item 11 for insight, the Mini International Neuropsychiatric Interview (MINI) and the Clinical Global Impression scale (CGI). Regression analyses were performed to identify predictors of insight. RESULTS The sample had 498 (91%) subjects with good insight (score≤2) and 47 (9%) subjects with poor insight (score>2) as per the Y-BOCS item11. Poor insight group had a significantly higher score on the Y-BOCS compulsions (p<0.001) and total score (p=0.001), the CGI-Severity (p=0.001) and a higher rate of contamination fears (p<0.001) and washing compulsions (p<0.001). Good insight group had a significantly higher frequency of aggressive obsessions (p<0.001). In linear regression, contamination dimension (p=0.007) and Y-BOCS total score (p<0.001) predicted poorer insight and presence of forbidden thoughts (p=0.006) predicted better insight. LIMITATIONS Study sample is from a specialty OCD clinic of a major psychiatric hospital in India and therefore, generalizability to other clinical settings may be limited. CONCLUSION Poor insight is associated with severe form of OCD, and is associated with contamination dimension. That degree of insight has specific correlation with certain symptom dimensions adds to the growing knowledge on the dimensional aspect of OCD. Insight has to be systematically assessed in all OCD subjects particularly in those with contamination fears. Failure to systematically assess insight may have treatment implications.

Is Familial Obsessive-Compulsive Disorder Different from Sporadic Obsessive-Compulsive Disorder? A Comparison of Clinical Characteristics, Comorbidity and Treatment Response

Background: Familial and sporadic subtypes of obsessive-compulsive disorder (OCD) have been proposed, but have not been well studied. The aim of the study was to compare the clinical characteristics, comorbidity and treatment response of familial OCD with sporadic OCD. Sampling and Methods: We reviewed the clinical records of 84 familial OCD patients and 80 randomly selected sporadic OCD patients from a specialty OCD clinic in India. All the subjects had been evaluated using the specially devised topical OCD evaluation proforma, the Yale-Brown Obsessive Compulsive Scale and the Clinical Global Impression scale. A diagnosis of OCD was made according to the DSM-IV criteria. Results: Familial OCD was associated with earlier age at onset, a greater duration of untreated illness and more compulsions, particularly ordering and cognitive types. It was also associated with greater comorbidity, especially depression and other anxiety disorders, and treatment non-response. The sporadic group had more sexual obsessions and predominant obsession subtypes of OCD. In regression analysis, ordering compulsions, cognitive compulsions, absence of sexual obsessions, lifetime comorbidity of major depression and anxiety disorders and a greater duration of untreated illness predicted familial OCD. Conclusions: Our findings support the observation that familial OCD could be phenotypically different from sporadic forms of OCD and therefore a putative subtype of OCD.