Sathya Prakash

Teratogenicity with olanzapine

Olanzapine, a 2nd generation antipsychotic, is in use in the clinical practice for nearly a decade and a half now. It is classified as a category C drug with very few reports of its toxic effects on the fetus. In general, the risk benefit analysis warrants its use in pregnancy. We report a case of microcephaly and anopthalmos associated with the use of olanzapine in pregnancy. Although a causal role cannot be unequivocally proven, it calls for larger studies to explore this issue.

Is the DSM-5 position on dhat syndrome justified?

The DSM-5 lists dhat syndrome under the section ‘Glossary of cultural concepts of distress’. It describes dhat syndrome as ‘anxiety and distress about the loss of dhat in the absence of any identifiable physiological dysfunction.’ It further clarifies that ‘despite the name, it is not a discrete syndrome but rather a cultural explanation of distress’. This is a marked deviation from the DSM-IV-TR where the syndrome is described under the section ‘glossary of culture bound syndromes’ as a ‘folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with discharge of semen. . .’ It is also a deviation from the ICD-10 which had also given dhat syndrome a separate status under the section ‘neurotic disorders, other’ although it does mention that the syndrome is of uncertain etiology and nosologic status. So, has enough evidence accumulated in the last two decades to change our view on dhat syndrome in this manner? A Pubmed search using the search term ‘dhat syndrome’ yields a total of 44 results of which 38 were published after 1994. Of them, only 8 papers (Table 1) have discussed the issue of its nosological status in some detail. This includes only 3 original articles. We will briefly discuss whether these articles made a good case for the change in stance taken by DSM-5 or not. Mumford (1996) noted that men reporting dhat symptom had higher Hospital Anxiety and Depression Scale (HADS) depression score but not anxiety scores. Also, four out of six men who were diagnosed with depression or dysthymia endorsed the dhat symptom. Based on these findings, Mumford concluded that dhat syndrome was a culturally appropriate form of depression. However, this study had certain major flaws. A fundamental error was to enquire regarding dhat ‘symptom’ and not ‘syndrome’. This issue of dhat ‘symptom’ vs dhat ‘syndrome’ merits further discussion as this is a source of much confusion. Mere reporting of passage of dhat (without associated preoccupation or distress), in a patient presenting to the clinic for some other health condition, that too on being asked a leading question by a clinician, does not constitute dhat syndrome. It is usual for one to encounter in clinical practice a patient reporting occasional passage of dhat on being specifically asked by the clinician. But many such patients suggest that they are not concerned about it or have no problems that they believe are arising due to it. Considering all such patients to have dhat syndrome is obviously incorrect. An analogy to this is the presence of low mood alone without other associated symptoms of depression in a manner that is not persistent and

Psychiatric classification: Current debate and future directions

Classification of health related conditions can be a complex task. This is particularly so in case of psychiatric disorders. The present paper reviews the fundamentals of psychiatric classification, including its basis, history, methods of evaluation, the journey so far and future directions. The various criticisms of current classificatory systems and possible solutions are discussed. Special reference to the research domain criteria (RDoC) approach has been made and implications discussed.

Perceptions Related to Pharmacological Treatment of Opioid Dependence Among Individuals Seeking Treatment at a Tertiary Care Center in Northern India: A Descriptive Study

ABSTRACT Background: Perceptions of individuals with opioid dependence regarding medications used for long-term management of the condition have been explored only by a handful of studies. Interestingly, no study had compared the perceptions regarding buprenorphine, buprenorphine-naloxone, and oral naltrexone in the opioid-dependent subjects from the same setting. Objectives: The present study aimed to examine the perceptions related to treatment of opioid dependence with buprenorphine, buprenorphine-naloxone, and oral naltrexone among individuals seeking help at a tertiary care center. Methods: This was a cross-sectional, observational study with consecutive sampling. Sociodemographic data, Drug Abuse Monitoring System questionnaire, perceptions questionnaire, clinical interview to elicit drug use history, treatment history and details of prior abstinence attempts were completed. Results: Eighty-five subjects were recruited in the study. Fear of becoming dependent (35.3%) was the most common harm reported while withdrawal control (82.4%) was the most common benefit reported with buprenorphine preparations. Precipitated withdrawals (21.2%) were the most common harm reported and prevention of relapse (53%) was the most common benefit reported with oral naltrexone. While patients who believed that buprenorphine or naltrexone were harmful reported durations of treatment that were much shorter than those who did not so believe, there was no statistically significant difference in the actual duration and period of abstinence (p = .34; p = .62). Sociodemographic profile, perceptions related to dosing, nature of medication, expectations from treatment, and duration of illness were also described.

A study on phenomenology of Dhat syndrome in men in a general medical setting

Background: “Dhat syndrome” is believed to be a culture-bound syndrome of the Indian subcontinent. Although many studies have been performed, many have methodological limitations and there is a lack of agreement in many areas. Aims: The aim is to study the phenomenology of “Dhat syndrome” in men and to explore the possibility of subtypes within this entity. Settings and Design: It is a cross-sectional descriptive study conducted at a sex and marriage counseling clinic of a tertiary care teaching hospital in Northern India. Materials and Methods: An operational definition and assessment instrument for “Dhat syndrome” was developed after taking all concerned stakeholders into account and review of literature. It was applied on 100 patients along with socio-demographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. Statistical Analysis: For statistical analysis, descriptive statistics, group comparisons, and Pearsons product moment correlations were carried out. Factor analysis and cluster analysis were done to determine the factor structure and subtypes of “Dhat syndrome.” Results: A diagnostic and assessment instrument for “Dhat syndrome” has been developed and the phenomenology in 100 patients has been described. Both the health beliefs scale and associated symptoms scale demonstrated a three-factor structure. The patients with “Dhat syndrome” could be categorized into three clusters based on severity. Conclusions: There appears to be a significant agreement among various stakeholders on the phenomenology of “Dhat syndrome” although some differences exist. “Dhat syndrome” could be subtyped into three clusters based on severity.

A case of hypochondriasis with dexamethasone and pheniramine dependence

Dexamethasone and pheniramine are well known to have psychoactive effects, and there have been a number of reports of their abuse or dependence. Acute effects of dexamethasone include improved mood...

Natural disasters, armed conflict, and public health

n engl j med 370;8 nejm.org february 20, 2014 782 study completion dates, publication dates, and journal names could help to identify journals more likely to publish specific types of studies, to evaluate 10-year trends in studies funded by the National Heart, Lung, and Blood Institute (NHLBI), and to assess the effect of more recent developments in publishing, such as open access and electronic publication ahead of print. Adequately powered, well-funded clinical trials with relevant clinical end points will always be of interest to journal editors. However, smaller studies with surrogate end points have an important role to play and deserve timely publication as well. Identifying the most appropriate journals for these studies before submission may contribute to more opportune publication of NHLBI-funded studies.From the François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston (J.L.); and the World Health Organization Collaborating Center for Research on the Epidemiology of Disasters, Institute of Health and Society, University of Louvain, Brussels (D.G.-S.). Address reprint requests to Dr. Leaning at the François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, 651 Huntington Ave., 7th Flr., Boston, MA 02115, or at jleaning@hsph.harvard.edu.

Medically Unexplained Somatic Symptoms: Diagnostic and Treatment Issues on the Indian Subcontinent

Mr.S is a 17-year-old unmarried male, an only child, currently studying in 12th standard in a school in New Delhi. He originally hailed from a village about 100 km south of NewDelhi. His family hadmoved to the city 3 years ago, primarily with the hope of providing him a better education. However, over the past 2 to 3 years, Mr. S had not been doing well in his studies; he had been getting much lower marks than what was expected of him from his previous performance. Mr. S acknowledged that this was the case. He complained of an inability to concentrate, forgetfulness, and fatigue. He also complained of vague body aches, abdominal discomfort, weakness, and sleep disturbances. These symptoms periodically worsened, followed by periods of relative improvement, but hewas never totally symptom free. For the past 2 to 3 years, he had been experiencing nocturnal emissions and sometimes passed whitish discharge (which he referred to as “dhat”) in his urine. Such instances occurred two or three times a week. His symptoms worsened the day after such episodes, with some improvement in the intervening days. He had been told by his friends and had also read in magazines that the whitish discharge was semen, and that losing too much of it would be harmful to the body. The magazines described a variety of symptoms ranging fromweakness and body aches to impotence and death. Mr. S had consulted a local allopathic physician, who prescribed some vitamin supplements. The patient wondered how his symptoms could improve as long as he did not stop passing dhat, and he raised this question during a subsequent consultation. The physician dismissed his concern, saying that loss of semenwas harmless. The patient felt that his physician did not understand his problems and stopped consulting him. He then consulted an Ayurvedic physician, who agreedwith the patient’s understanding of the illness. The Ayurvedic physician prescribed certain herbal medications thatwere supposed to conserve semen and increase its density. However, despite several months of treatment, the discharge continued to occur, as did the other symptoms. The patient consulted two other allopathic physicians but did not follow up regularly. He was initially seen by an internist at ourhospital andwas referred to thedepartment of psychiatry. The patient reported the various symptoms detailed above to the psychiatrist as well. Thus, the patient was experiencing a number of somatic symptoms with an underlying preoccupation with loss of dhat and its debilitating effects. Significant distress and dysfunction were also evident. However, persistent, pervasive sadness and ideas of hopelessness, helplessness, or worthlessness were not evident. The psychiatrist made a diagnosis of “dhat syndrome” (other neurotic disorders) according to ICD-10. (Dhat syndrome is also described in DSM-5 in the Glossary of Cultural Concepts of Distress.) Mr. Swas scheduled forweekly counseling sessions.Keeping in mind the patient’s strong beliefs regarding the nature and causation of his illness, premature dismissal of a physical basis for his symptoms was avoided. This was particularly important given the fact that the patient had stopped consulting aphysicianwhohad earlier dismissed loss of semen as the cause of his symptoms. Instead, the first session focused on listening to the patient’s complaints in detail and acknowledging his distress and that his symptoms were real. This session also served to establish rapport with the patient and tomake it clear to the patient that the psychiatrist did not ridicule his views regarding the illness. The second session focused on the patient’s perspective of the illness and its various symptoms, as well as which symptoms bothered him most and why. In the next session, the psychiatrist conducted a detailed history and physical examination focusing on possible medical causes. While acknowledging the patient’s distress, the psychiatrist conveyed to him that there was no serious underlying illness. A genital examination was also performed, and the patient was told that there was no abnormality in the genitalia and that his condition would not, in any way, interfere with his future sexual performance. The patient was quite reassured to hear this and said that he had been very worried about his sexual performance after marriage. In the next session, alternative methods of tackling his symptoms (other than stopping thewhitish discharge) were considered without directly confronting the patient’s beliefs. The psychiatrist explained in simple terms the functioning of the male reproductive system and why the discharge occurred. He also explained that at the patient’s age a large number of young men similarly passed whitish discharge without experiencing the troubling symptoms that he experienced. Thus, in this session, the patient was prepared for considering alternative possibilities. In the next session, the psychiatrist suggested that the patient adopt a healthy lifestyle including a balanced diet and

Secondary mania following cancer chemotherapy with capecitabine

Mania-like states occurring due to neurological, metabolic or toxic conditions, without a primary mood disorder have been reported in scientific literature as secondary mania. A major clinical problem in such situations often stems from the difficulty to understand if the mood disturbance is indeed secondary to an organic cause or a coincidental primary mood disorder. Chemotherapy regimens have been associated with multiple psychiatric complications, including psychosis, mania and anxiety. Capecitabine is implicated to be associated with encephalopathy whose clinical presentation often mimics that of psychosis. However, presentations with mania have not been reported until with the capecitabine and oxaliplatin combination chemotherapy regimen. In this report, we describe a case of secondary mania in a patient suffering from carcinoma colon on treatment with chemotherapy regimen of capecitabine and oxaliplatin.

A qualitative study on psychopathology of dhat syndrome in men: Implications for classification of disorders

BACKGROUND Dhat syndrome is regarded by many as a culture bound syndrome of the Indian sub-continent. However the nosological status, conceptual understanding of the condition as well as the diagnostic guidelines are all mired in controversy. AIMS The current study aims to study the psychopathology of Dhat syndrome in men by using a qualitative approach and to arrive at an operational definition for diagnosing Dhat syndrome. METHOD The qualitative approach consisted of five Focus Group Discussions (FGD) and five Key Individual Interviews (KII) with participants, consisting of patients as well as doctors - both allopathic as well as traditional. RESULTS Detailed analysis revealed valuable data regarding the symptoms, causes, treatment measures, socio-cultural context, psychiatric co-morbidity, nature of the disorder and various other phenomenological dimensions. Ideas for future nosological positioning were also specifically looked for. Operational definition and diagnostic guidelines were also arrived at based on the analysis as well as on previous literature. CONCLUSION Although lot of agreement existed among various stakeholders about symptoms and presentation, they varied significantly in their opinion on nature of the condition and treatment. Suggestions for ICD 11 have been made.