Soumitra Das

Psychosis in secondary empty sella syndrome following a Russell's viper bite

Hypopituitarism can present with psychiatric symptoms. We report a unique case of psychosis in clear consciousness in a case of hypopituitarism due to the secondary empty sella syndrome following a Russells viper bite which was untreated and presented with psychotic symptoms for past 13 years following the snake bite. After the diagnosis of psychosis due to hypopituitarism was made, the patient was treated with levothyroxine and prednisolone supplements and his psychotic symptoms subsided without any psychotropic drugs. Vasculotoxic snake bites can cause hypopituitarism and can present with psychosis. Further research will be needed into the prevalence of this phenomenon.

Clozapine-induced tardive dyskinesia

Sir, Tardive dyskinesia (TD) is an agonizing side effect of long‐term use of antipsychotics, mainly convention but also atypical which is often found to be irreversible. It is characterized by involuntary, repetitive, purposeless movements that vary in localization and form and occur in eight main areas such as tongue, jaw, lips, face, trunk, upper extremities, lower extremities, and respiratory system which can lead to unintelligible speech, respiratory distress with diaphragmatic involvement, falls, shame, guilt, anger, and depression.[1,2] Pathophysiology of TD is complex and still remains elusive with proposed theories such as postsynaptic dopamine receptor hypersensitivity, abnormalities in the striatal GABAergic neurons and degeneration of cholinergic medium spiny interneurons in the striatum, and neurotoxic effects of the free radicals produced by excessive metabolism of dopamine. Clozapine due to its unique low affinity for striatal D2 receptors is relatively free from TD, and due to its anti‐serotonergic (5HT2, 5HT1C) and anticholinergic properties, it is often found to be therapeutic in drug‐induced, even drug naïve patients with TD. However, it is also found to be associated with the development of TD in patients with different psychiatric disorders.[3] Here, we present a case of clozapine‐induced TD following the long use of clozapine monotherapy.

Zotepine-induced convulsion at a low dose in a case of paranoid schizophrenia: Letters to the Editor

W E REPORT A case of seizure that developed in a patient with paranoid schizophrenia on a low dose of zotepine. A 23-year-old man had been diagnosed with ICD-10 paranoid schizophrenia at age 19 years and had been treated with adequate dosage and duration of risperidone, olanzapine, and aripiprazole before the introduction of zotepine. The patient was on tablet amisulpride 600 mg/day for almost a month before zotepine trial was initiated. Zotepine was introduced in view of persistent auditory hallucinations as the patient was not willing to try clozapine due to its side-effects. Zotepine was started with an initial dose of 50 mg/day and gradually increased by 25 mg/day every 5 days. On the 21st day of zotepine, the patient developed seizure characterized by sudden brief and jerky muscle contraction of all four limbs followed by a period of unresponsiveness, frothing from the angle of the mouth, clenching of teeth, and urinary incontinence, which lasted for about 2 min. Although the patient was on tablet amisulpride 600 mg/day along with tablet zotepine, he had never previously experienced an episode of seizure while on amisulpride or any other antipsychotics. No prior history or family history of seizure had been reported. No history of fever or any other symptoms suggestive of meningitis had been reported prior to the seizure episode. The blood investigation, including electrolytes, was normal before the initiation of zotepine and on the day the patient experienced a seizure. Following thorough neurological consultation and keeping the semiology of seizure in consideration, the patient was started on anticonvulsant drugs and reported that the seizure episode had a clear temporal association with the introduction of zotepine. Zotepine was stopped and amisulpride was increased to 800 mg along with anticonvulsant. The patient did not report any further episode of seizure at follow-up visits. Zotepine has proven effective in schizophrenic patients not just for positive symptoms, but also for negative symptoms and cognitive deficits. Hori et al. reported the occurrence of seizures in a patient at a dose around 450 mg/day and mean duration of zotepine therapy before the occurrence of the seizure was 48.3 days, which was longer than that of chlorpromazine treatment. Also, patients having a past history of head trauma showed a high incidence of seizure even with a daily dose of less than 300 mg of zotepine. According to the case report of Khairkar et al., their patient developed seizures at a dose of 350 mg/day. Our patient developed seizures on increasing the dose to 150 mg/day, which is far less than the dose mentioned by Khairkar et al. Seizure in our patient had a direct temporal association with zotepine at 150 mg/day without any brain pathology. Zotepine was demonstrated to have a high affinity to the 5HT1 binding sites in the rat cerebral cortex, and this property was pharmacologically considered to be epileptogenic. This is the first case to reflect the incidence of seizure even at a lower dose of zotepine.

Clinical features and psychiatric comorbidity of epicrania fugax

Background: Epicrania fugax (EF) is a rare newly described primary headache characterized by paroxysms of unilateral pain radiating across one hemicranium. Aim: We aimed to describe 10 new cases of EF and assess the psychiatric comorbidity. Materials and Methods: Cases of EF were identified from patients attending the neurology outpatient department of a tertiary level referral and teaching hospital by the first author during a period extending from January 1, 2015 to April 31, 2017. Case ascertainment was done as per ICHD 3 beta criteria from among patients presenting with complaints of headache after detailed history and clinical examination. Clinical and demographic features were noted and patients were subjected to Mini Neuropsychiatric Interview to screen for psychiatric comorbidity followed by Becks Anxiety/Depression Inventory. Results: A total of 10 subjects were obtained during the study period, 4 males, and 6 females. Mean age of subjects was 45.3 years (standard deviation-10). Seventy percent had anteroposterior, and 30% had posteroanterior radiation of pain. The most common character of pain was stabbing (50%) followed by electrical (40%) and pressing (10%). None of the subjects had autonomic symptoms or focal symptoms in the scalp while 30% subjects had hyperesthesia in the affected area of the scalp. Six subjects (60%) patients had episodic course while 40% had chronic course. Sixty percent had comorbid anxiety while one (10%) had comorbid depression. A significant relation was obtained between duration of disease and occurrence of anxiety as well as Becks Anxiety Inventory scores while there was no correlation with attack duration. There was also a nonsignificant correlation between visual analog score and occurrence of anxiety symptoms. Conclusions: Our study conclusively proves the existence of EF as a rare, distinct primary headache syndrome in our study population. It has a significant psychiatric comorbidity consisting of 60% of generalized anxiety disorder, 10% of panic attacks, and 10% of depression.

When obsessive compulsive disorder responds only to electroconvulsive therapy: A rare case for maintenance electroconvulsive therapy?

450 Journal of Neurosciences in Rural Practice ¦ Volume 9 ¦ Issue 3 ¦ July-September 2018 Only 40%–60% of cases of OCD show the response to combination therapy. Next line of treatment in OCD is somatic treatment such as ECT, repetitive transcranial magnetic stimulation, and transcranial direct current stimulation but evidence regarding the effect of ECT are sparse.[2] A recent systematic review published in 2015 showed that the role of ECT in the routine treatment of OCD is not significant, but it proposed the beneficial effects of ECT in OCD under special circumstances.[1] Most of the cases who improved on ECT were benign. Furthermore, evidence of the positive responses to ECT were more commonly described in recent studies than the older one.[1] Here, in our case, the patient was tried with multiple SSRIs and clomipramine but did not show any response where ECT surprisingly benefited the patient by reducing the obsessions and related dysfunctions. Even though ECT has poor evidence as a treatment of OCD, we can consider it in such cases where we do not have any other options to implement. As our patient maintained improvement while on ECT but worsened soon after the stoppage, maintenance therapy of ECT in OCD can be considered in special cases. Maintenance ECT has the potential of preventing implementation of invasive procedure like neurosurgery when OCD becomes refractory to treatment.

A comment on “blue whale challenge: Perceptions of first responders in medical profession”

Indian Journal of Psychological Medicine | Volume 40 | Issue 4 | July-August 2018 391 concern of potential bias. It cannot be expected that trials would be conducted for every clinical condition for which there are no approved medications. In most cases, it is the sponsor’s decision as to which drug is to be tested and which clinical condition is to be addressed. Thus, off-label use of psychotropics has become an important approach in clinical psychopharmacology and we believe that it will remain so in spite of several concerns.

A case of clozapine-induced skin picking behaviour

There is some evidence consistently linking the occurrence of de novo obsessive-compulsive disorder (OCD) with clozapine. This skin-picking disorder is also known as impulsive-compulsive disorder-unspecified which with an increasing convergence with OCD has been placed in the current Diagnostic and statistical manual of mental disorders-fifth edition by American Psychiatric Association (DSM-5), in the category of the obsessive-compulsive and related disorders. To the best of our knowledge, there is no literature relating antipsychotics like clozapine with the occurrence of skin-picking behaviour. In this article, we present a case in whom skin-picking behaviour emerged during the upward dose titration of clozapine and was successfully treated with escitalopram.

Psychosis as an indicator of recurrent non-Hodgkin’s lymphoma: a rare presentation

Psychotic manifestations of brain tumours are rare but described in the literature mostly along with other neurological deficits. Memory loss, difficulty in attention and concentration, depression, anxiety, and mood symptoms are commonly described in brain tumours. A schizophrenia-like picture without a deficit in motor or sensory function may land the clinician into a diagnostic dilemma. Primary central nervous system lymphoma (PCNSL) is a highly malignant disease with high mortality and needs immediate attention. Our case which had a unique recurrence in the postoperative period with psychotic symptoms can be an eye-opener to be more vigilant about underlying clinical extension.

Arachnoid cyst and psychosis: The troublemaker or innocent bystander

Organic underpinning of a psychotic disturbance is often missed. Arachnoid cysts are considered a rare neurological tumor, few of which exhibit any symptomatology. In most cases, they are diagnosed by accident. Literature regarding the coexistence of arachnoid cysts with psychiatric disorders is sparse. Here, we present a case who presented with a typical presentation of psychosis which was not enough for suspecting for an organic etiology.

Lurasidone-induced oculogyric crisis

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