Deficits in Theory of Mind and Emotional Awareness in Somatoform Disorders

INTRODUCTION

Emotions develop from a less differentiated to a highly differentiated level, and their arrest at a lower level is hypothesized to result in somatization. The present study aimed at investigating the Theory of Mind and emotional awareness in patients with somatoform disorders.

MATERIALS AND METHODS

Twenty patients with somatoform disorders, along with 20 healthy controls matched for age, sex, and education, were recruited after obtaining informed consent. Assessments included semi-structured proforma for sociodemographic and clinical details; Scale for Assessment of Somatic Symptoms (SASS) for somatic symptoms; and Patients Health Questionnaire (PHQ) to assess somatic symptoms, depression, and anxiety. Emotional awareness was measured using the Levels of Emotional Awareness Scale (LEAS), in which the participants had to provide descriptions of feelings of self and the other person in 20 imaginary situations. The responses were scored using a standardized manual. The Theory of Mind was measured using the Social Cognition Rating Tool in Indian Settings (SOCRATIS).

RESULTS

The two groups did not differ on any demographic parameters. Patients with somatoform disorders scored significantly lower on emotional awareness (t = -3.74; P < 0.001) and the Theory of Mind (t = -3.56; P < 0.001). The above differences remained significant even after controlling for comorbid depressive and anxiety symptoms.

CONCLUSION

Patients with somatoform disorders are likely to have Theory of Mind and emotional awareness deficits independent of mood states. Future studies are needed to assess whether these deficits are trait- or state-dependent and whether they are cause or effect.

Health-related life events in patients with somatic symptom disorders: A case control study

BACKGROUND

The positive association between adverse life events and somatoform disorders is a consistent observation. But no systematic studies have evaluated the relationship between health-related life events (HLEs) in patients with somatic symptom disorder (SSD)/somatoform disorders.

AIM

To examine the nature and relationship of HLE in patients with SSD and to assess the correlates of HLE.

METHODS

A total of 50 adult patients with SSD and 50 matched healthy controls from a Neuropsychiatric hospital were recruited. Sociodemographic interview, scale for assessment of somatic symptoms (SASS), Patient Health Questionnaire-15 (PHQ-15) and a semi-structured interview schedule to gather information on HLE were used.

RESULTS

Patients in the SSD group had a significantly higher number of total HLE in general (4.72 ± 2.63, 3.36 ± 1.92; p = .004), major HLE (1.48 ± 1.45, 0.68 ± 0.94; p = .006), during their lifetime in comparison to controls. Infections, trauma, non-communicable diseases and reproductive system-related diseases were the more common types of HLE in SSD group.

CONCLUSION

Our findings may implicate a role of major HLE of patients and HLE of their family members in the pathophysiology of SSD.

Prevalence & correlates of chronic perinatal pain - a study from India

Objectives: To study the prevalence of chronic perinatal pain among mothers who had infants between the ages of 13-25 months in the State of Kerala, India and to report its correlates in the socio-demographic, obstetric and psychological domains. Methods: A total of 9305 mothers selected by cluster random sampling were assessed cross-sectionally for chronic perinatal pain using a questionnaire by Junior Public Health Nurses (JPHNs). In addition, information regarding socio-demographic profile, obstetric history, infant details and perinatal depression were collected. Results: Of the 8302 (89.3%) valid responses, 552 (6.6%) mothers reported chronic perinatal pain. Among those with pain, 142 (25.6%) reported pain during pregnancy, 314 (56.7%) during postpartum and 96 (17.7%) during both periods. The commonest sites of pain reported were back 280 (51%) and pelvic region 110 (19%). Mothers with chronic perinatal pain were more likely to be younger, less educated, employed and from an urban background. Chronic perinatal pain was associated with obstetric complications, delivery by instrumental/caesarean section, non-exclusive breast feeding and higher maternal depression scores. Conclusion: Chronic pain is common among mothers in India during the perinatal period and greater attention needs to be given for it to be recognised and treated early.

Hypochondriasis: Clinical Profile in a Tertiary Care Psychiatry and Neurosciences Hospital in Southern India - A Retrospective Chart Review

BACKGROUND

Hypochondriasis is a complex disorder in the realm of psychosomatic medicine, yet understudied in India. The aim of this study was to assess the clinical profile of patients diagnosed with hypochondriasis.

MATERIALS AND METHODS

Retrospective chart review was done in a tertiary care psychiatry and neurosciences hospital in southern India. Medical records of adults diagnosed with hypochondriasis between 2000 and 2010 were analyzed. These patients were also rediagnosed retrospectively using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for illness anxiety disorder (IAD) and Diagnostic Criteria for Psychosomatic Research (DCPR) criteria for health anxiety and illness phobia. Data were organized and analyzed using PSPP for descriptive statistics of different variables.

RESULTS

There were 114 patients with hypochondriasis, with the most common belief being about dysmorphic appearance. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed medications. The median follow-up duration was only 2 months. Five percent of the cases fulfilled the criteria for DCPR health anxiety and 20.4% for DCPR illness phobia. DSM-5 criteria for IAD were fulfilled by 45.6% of the cases.

CONCLUSION

Dysmorphic appearance was the most common concern in patients with hypochondriasis and SSRIs the most common medications. The follow-up rate and the diagnostic concurrence with DSM-5 IAD and DCPR were low. Studies assessing the influence of psychopathology and culture on the presentation, course, and prognosis of hypochondriasis would be beneficial.

Parenting in mothers with schizophrenia and its relation to facial emotion recognition deficits- a case control study

BACKGROUND

Difficulties in parenting and Facial Emotion Recognition deficits (FERD) in persons with schizophrenia have been demonstrated independently. However, the relationship between parenting deficits and FERD in mothers with schizophrenia is yet to be explored.

AIMS AND OBJECTIVES

The aims of the study were to assess parenting in mothers with schizophrenia, to examine the clinical correlates of parenting and to examine if facial emotion recognition deficits had an association with parenting.

METHODS

Fifty mothers with schizophrenia and 50 age matched healthy mothers were assessed for parenting and FERD. Parenting was assessed using Arnold's parenting scale and Parent Interview Schedule. Kiddie TRENDS, a modified Tool for Recognition of Emotions in Neuropsychiatric Disorders (TRENDS) was administered to assess facial emotion recognition.

RESULTS

Among mothers with schizophrenia, FERD were noted in emotions of sadness, disgust, anger and surprise. Laxness in parenting was associated with negative symptoms of schizophrenia and also facial emotion recognition deficits.

CONCLUSION

Parenting difficulties are commonly noticed in mothers with schizophrenia. Laxness style of parenting was found more often in mothers with schizophrenia, especially in mothers with blunt affect. Mothers with schizophrenia had difficulties in recognizing emotions of sadness, anger, disgust and surprise and this was associated with laxness style of parenting.

Patterns of Illness Behaviors and its Correlates in Patients with Chronic Nonorganic Pain

Background:

Illness behaviors if abnormal can have significant influence in presentations of chronic pain. The aim of the study was to derive the patterns of illness behaviors and its correlates in subjects with chronic nonorganic pain.

Methods:

Illness Behavior Questionnaire (IBQ) was administered to 301 adult individuals with chronic nonorganic pain. Factor analysis was performed on the IBQ, and relationships of the dimensions of illness behavior with clinical and demographic variables were computed.

Results:

Majority of the sample consisted of women (n = 208; 69%) with 43% from rural background and 58% from below poverty line status. Principal axis factoring resulted in four factors, namely health concerns, affective inhibition (AI), bodily distress, and affective distress with psychosocial problems. The three factors excluding AI had significant intercorrelation among them. There was significant difference in mean scores of factors, bodily distress and affective distress in patients from urban and rural background.

Conclusions:

Illness behaviors in chronic nonorganic pain can be understood as three interrelated factors-health concerns, affective distress with psychosocial problems, and bodily distress. AI might be an independent factor for presentation of chronic nonorganic pain.

Geopolitical factors and mental health I

Natural and man-made disasters carry with them major burden and very often the focus is on immediate survival and management of resulting infectious diseases. The impact of disasters directly and indirectly on the well-being and mental health of those affected often gets ignored. The reasons are often stigma and lack of attention to mental health consequences. In addition, often the focus is on preventing the spread of infectious diseases such as waterborne or airborne diseases. This is further complicated by the fact that often aid agencies in offering aid tend to focus on communicable diseases and not on mental health of populations. This focus may reflect easily to measure outcomes in comparison with mental illnesses as the global burden of disease is likely to increase in the next few decades. There is an urgent need to apply the principles of social justice on social and health care policies, which will lead to elimination of stigma. In this article, we propose that the impact of mental illness as a result of disasters needs to be taken seriously in any planning and delivery of relief. Mental health is likely to be affected both directly and indirectly as a result of disasters and also likely to be influenced by ongoing factors such as poor housing, overcrowding and other social determinants. In addition to deliver equity between physical and mental illnesses, appropriate and adequate resources are needed so that identifiable needs can be met with clear outcomes.

Geopolitical factors, foreign aid and mental health II: Value for money

In the previous accompanying paper, we described geopolitical factors which affect mental health of individuals who suffer directly and indirectly. These disasters whether they are natural or man-made often attract significant amounts of aid and resources - financial and human. In addition, those who offer foreign aid need to be aware of where and how the aid is being spent. In this paper, we propose that aid giving agencies give due attention to the impact the aid should have on mental health of recipients. Global mental health has become a movement, but concerns remain about its efficacy. Therefore, it is imperative that any aid given is given and utilised in a culturally appropriate and culturally sensitive way. In an interconnected and interlinked world, it is likely that when one country or nation is affected by disasters or trauma, it will impact upon others around both directly and indirectly. We present a new measurement tool-CAPE Vulnerability Index which can be used to identify most vulnerable communities so that international aid may be more appropriately targeted. We believe that this index may go some way in assisting governments and policymakers in ascertaining the impact of their aid on the emotional and mental health of individuals. We suggest that their needs to be a ring-fencing of aid to ensure that population mental health is protected and enhanced with a strategic approach inbuilt into the foreign policy the focus needs to shift towards public mental health.

What Adolescent Girls Know about Mental Health: Findings from a Mental Health Literacy Survey from an Urban Slum Setting in India

BACKGROUND

Youth in vulnerable situations are known to have high rates of mental disorders but low help-seeking. Help-seeking is known to be influenced by mental health literacy (MHL), a key concept that is important for the recognition of mental disorders and planning intervention.

AIMS

To explore MHL and help-seeking patterns in a group of young women in an urban slum setting in India.

MATERIALS AND METHODS

A total of 337 young women between 16 and 19 years of age belonging to urban slum settings formed the study sample. Two vignettes on depression and self-harm were used to assess: (a) recognition of the disorder, (b) help-seeking, and (c) knowledge of treatments available.

RESULTS

Only 8% of women were able to label the condition as depression in the first vignette. Though suicidality was identified correctly by the majority of participants 73 (63%), they did not think it needed urgent intervention. Only a few considered mental health professionals as possible sources of help (19.3% for depression and 2.4% for self-harm). Majority of the young women felt friends and parents were sources of help, and that stigma and lack of awareness were the reasons for not considering professional help.

CONCLUSION

MHL regarding depression and suicidality is low among young women from low-income areas. It is a critical and urgent need to encourage early and appropriate help-seeking for mental health problems in this vulnerable population.

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.

Effect of VAPE about mother and infant health on knowledge among primary caregivers of patients with postpartum psychiatric illness:- A pre-experimental study

Post partum psychiatric illnesses are quiet common nowadays, which can interfere with postnatal care of both mother and infant. The present study was a one group pre-test - post-test design, adopted with an aim to enhance the knowledge on mother infant health among primary caregivers of mothers with postpartum psychiatric illnesses conducted in the mother-baby unit, NIMHANS, Bengaluru. Twenty five subjects who met the inclusion criteria were recruited through convenience sampling. After the pilot study, data was collected with a researcher developed tool. The Video Assisted Psycho-Education [VAPE] consisted of three sessions lasting for thirty minutes, taken over three consecutive days following the pre-test. Post-test was done immediately after the last session. Effectiveness of the intervention was established by McNemar test, Paired t-test and Wilcoxon Sign Ranks test. Analysis revealed statistically significant (p<0.001) increase in the post-test mean knowledge scores following the VAPE sessions. There was no statistically significant association between the pre-intervention knowledge score and the socio-demographic variables of the study subjects. The study findings revealed that the VAPE programme was effective in increasing the knowledge of the primary caregivers on mother infant health.

Systematic risk assessment in a mother-baby unit (MBU)–Importance for maternal and infant safety

Introduction

Systematic assessment of risks is an essential component of care in psychiatric mother baby units. Self-harm, infant neglect and harm or the vulnerable physical health of both mother and infant may all pose risks.

Aim

Development of a risk assessment tool and risk assessment among mother-infant dyads at a MBU in Bangalore, India.

Methods

Based on data from 200 admissions, doctors and nurses of the unit developed a 15-item tool for risk assessment. Risk was assessed by both nurses and doctors among 58 consecutive mothers admitted to the unit. Risk domains included risks to self, to infant, related to infant health and feeding and violence faced by mother. Frequencies of various risks were calculated. Nurses’ risk assessments were compared to the residents’ risk assessments.

Results

The mean age of the mothers was 25 (±4) years, age of infant 4 (±4) months and duration of episode was 4 (±14) months. Diagnoses included acute polymorphic psychosis (30%), BPAD (27%) and depression (21%). 47% had high suicidal risk and 28% had made an attempt in the current episode. 22% had expressed ideas of infant harm and 24% had physically harmed the infant. 48% of mothers had been physically violent. Multiple risks were seen in 47%. Doctors were able to identify risks more often than nurses.

Conclusion

Risks for self-harm, infant harm and related to infant health were high. Systematic risk assessment by both nurses and doctors is important in an MBU to ensure adequate care for the mother infant dyad.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Development of a tool to assess Facial Emotion Recognition deficits in mothers with schizophrenia-A preliminary report

There is dearth of studies which have assessed Facial Emotion Recognition Deficits (FERD) in parents and its impact on parenting. To assess FERD in mothers with severe mental illness, a modification of TRENDS (A Tool for Recognition of Emotions in Neuropsychiatric DisorderS) using images of children was developed. Two children emoted six basic emotions,namely happy, sad, fear, anger, surprise and disgust at two different intensities along with neutral facial expressions. These images were then validated by 20 subjects which included 15 healthy controls and 5 qualified psychiatrists.The tool was found to have good inter-rater agreement and internal consistency (Cronbach's alpha+0.712).

Catatonia among women with postpartum psychosis in a Mother-Baby inpatient psychiatry unit

OBJECTIVE

The aims of the present study were to determine the prevalence of catatonia in women with postpartum psychosis, describe its socio demographic, clinical and obstetric correlates and identify predictors of treatment response.

METHODS

Data was extracted from clinical charts of 200 women with postpartum psychosis admitted to an inpatient mother baby unit (MBU) in India over a 3year period.

RESULTS

Of the 200 patients, 20% (n=40) had symptoms of catatonia. Mean catatonia score on the Bush Francis Catatonia Rating Scale (BFCRS) was 14.97±3.2. The most frequent catatonic feature was mutism (n=40, 100%). Adequate response to lorazepam trial in catatonia was seen in half the women (n=18/36), with longer duration of untreated catatonia being associated with poorer response. An adequate response to Electroconvulsive therapy (ECT) was seen in 19 women who did not respond to the lorazepam trial. Women with catatonia had significantly higher rates of onset within the first four weeks of postpartum period (50% vs 31.5%, P=0.022) and a longer duration of untreated psychosis at presentation (79.46±159.88 vs 56.12±47.26, P=0.002) compared to mothers without catatonia.

CONCLUSION

Catatonic symptoms were identified in one-fifth (20%) of women with postpartum psychosis. Early identification and treatment of catatonia are essential for rapid control of symptoms in this vulnerable population.

Somatization in the dermatology patient: Some sociocultural perspectives

Somatization in dermatology patients is a challenge to diagnose and manage. Somatization presents as medically unexplained dermatologic symptoms, which are commonly encountered in dermatology and psychiatry practices. These cutaneous symptoms are often intriguing and do not fit into any particular known dermatologic condition. Sometimes, they may evoke negative feelings in the practicing dermatologist. The dermatologic somatic symptoms might be one way of communicating psychologic distress in a culturally acceptable method. These somatic symptoms may be masking another psychiatric disorder such as depression. They could also be an adaptive response to a difficult psychosocial situation and means of coping in a culturally meaningful way; therefore, the underlying conflicts need to be understood and managed in the sociocultural context of the symptoms. This chapter discusses the various unexplained physical symptoms in dermatology patients and the need for comprehensive evaluation.

Behaviors are Deceptive in Pain Estimation: A Comparison between Nurses and Psychiatrists

Aim:

This study assessed the influence of pain behaviors on pain estimation by nurses and psychiatrists.

Materials and Methods:

Pain ratings performed by nurses and psychiatrists who observed the case scenarios using role plays were assessed. The data were computed and frequencies were derived. t-test was used to compare the ratings between the groups.

Results:

There was significant difference in the ratings of the pain severity by nurses and psychiatrists.

Conclusions:

Pain assessment is essential for the comprehensive management of pain. Training health professionals in pain assessments is very essential.

Sexual dysfunction among women with Schizophrenia-A cross sectional study from India

Sexual dysfunction among women usually has a multifactorial etiology and is also difficult to study in cultures where open discussions about sexuality are not common. Not much is known about sexual function in women with schizophrenia even though it may have a significant impact on their quality of life and maybe influenced by several factors.

AIMS AND OBJECTIVES

This study aimed to assess the frequency and nature of sexual dysfunction in women with schizophrenia and study its association with marital quality, illness, treatment, and socio-demographic factors.

METHODOLOGY

This was a cross sectional, hospital-based study conducted among 63 women with schizophrenia attending the outpatient services of a tertiary care psychiatric hospital. Sexual dysfunction was assessed using the Female Sexual Function Index (FSFI). Side effects of medications, psychopathology, and marital quality were assessed using standard scales.

RESULTS

Among the 63 women assessed, 44 (70%) reported sexual dysfunction. Impaired desire was reported by all women, impaired arousal by 58 (92.1%), poor lubrication by 30 (47.6%), impaired orgasm by 48(76.2%) poor satisfaction by 44(69.8%) and pain by 23(36.5%). Poor Marital quality ('p' value-0.001), higher scores on general psychopathology of the Positive and Negative symptoms scale of schizophrenia (PANSS) ('p' value-0.049) and side effects such as weight gain, menstrual disturbances, galactorrohea and dry vagina were significantly associated with Female Sexual Dysfunction (FSD) in univariate analysis. However, multivariate analysis found marital quality alone to be significantly related to FSD.

Suicidality in early pregnancy among antepartum mothers in urban India

This study assessed the prevalence and predictors of suicidality among 462 pregnant women in South India. Women in early pregnancy (<20 weeks) attending an urban public hospital antenatal center were assessed for suicidality using a modified version of the Suicide Behaviors Questionnaire-Revised (SBQR) and a single-item (item 10) from the Edinburgh Postnatal Depression Scale (EPDS). Severity of depressive symptoms, family violence, and perceived social support were also measured. The prevalence of suicidality in pregnancy was 7.6 % (35/462). Eleven women (2.4 %) reported having had suicidal plans, and 8 (1.7 %) had made a suicidal attempt during the current pregnancy. Younger age, belonging to a middle socioeconomic status, poor perceived support, domestic violence, depressive symptoms, and having a past history of suicidality predicted suicidal ideation during the current pregnancy. Multivariate analysis revealed depression severity and a life time history of suicidal ideation as being the strongest predictors. The findings underscore the need for assessment of psychiatric and psychosocial factors that confer risk among women in this vulnerable period. The results of the study however may be specific to low-income urban women from this geographical location limiting the external validity of our findings.

Ethical dilemmas of medically unexplained symptoms

Medically unexplained symptoms (MUS) are common across health settings. These are defined as "physical symptoms that prompt sufferer to seek healthcare but remain unexplained after an appropriate medical evaluation". Expectedly, MUS are often associated with significant health-seeking behaviours that add to the burden on health resources.

Yoga-based intervention in patients with somatoform disorders: an open label trial

Somatoform disorders are common mental disorders associated with impaired functioning and increased utilization of health resources. Yoga-based interventions have been used successfully for anxiety, depression, and chronic pain conditions. However, literature on the use of yoga in treatment of somatoform disorders is minimal. The current study assessed the effect of a specific yoga-based intervention in patients with somatoform disorders. Consenting patients meeting ICD-10 criteria for somatoform disorders were offered a specific yoga module (1 h per day) as a treatment. Assessments including Visual Analogue Scale (VAS), Brief Pain Inventory (BPI), and others were carried out at baseline and after 2, 6, and 12 weeks. Sixty-four subjects were included in the study and 34 completed 12 weeks follow-up. Significant improvement was noted in pain severity from baseline to 12 weeks after regular yoga sessions. The mean VAS score dropped from 7.24 to 2.88. Worst and average pain score in the last 24 h on BPI dropped from 7.71 to 3.26 and from 6.12 to 2.0,7 respectively. Results of the study suggest that yoga-based intervention can be one of the non-pharmacological treatment options in somatoform disorders. These preliminary findings need replication in larger controlled studies.

Yoga intervention and functional pain syndromes: a selective review

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.

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.

Antipsychotics in pregnancy and lactation

Research on psychotropic medications during pregnancy and lactation is limited as often involves complex ethical issues. Information on safety of psychotropic drugs during these critical phases is either inconclusive or undetermined. Many women with severe mental illness have unplanned pregnancies and require antipsychotic medication during pregnancy and lactation. Multiple issues have to be considered while choosing safe treatments for pregnant and lactating women and the best approach is to individualize the treatment. Medication should be guided primarily by its safety data and by the psychiatric history of the patient. Important issues to be kept in mind include pre-pregnancy counseling for all women, including planning pregnancies; folate supplementation, discussion with patient and family regarding options, and active liaison with obstetricians, ultrasonologists and pediatricians. Whenever possible, non-pharmacological approaches should be used in addition.

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.

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.

The Question is the Answer: concerns and queries raised by patients and caregivers referred to rehabilitation services

BACKGROUND

The philosophy of recovery emphasises consumer participation and engagement in developing effective rehabilitation services. Assessment of consumer perspectives and concerns lies at the heart of responsive and relevant rehabilitation frameworks.

AIM

The study aimed to document and examine patient and caregiver queries, at their first contact with Rehabilitation Services.

METHODS

The sample consisted of 124 consecutive inpatients and their accompanying caregiver/s, referred to Psychiatric Rehabilitation Services, within a tertiary care psychiatric hospital in India. The data were collected using the semi-structured Inpatient Intake proforma during the intake session. The spontaneous queries raised by patients and/or caregivers were documented and content analysis identified themes, separately for patients and caregivers.

RESULTS

The results indicated both similarities and differences in the frequency of themes that emerged from questions asked by patients and their caregivers. Two prominent themes centered on specific queries about rehabilitation services and the treatment and prognosis of the psychiatric illness.

CONCLUSIONS

The findings have implications for training, practice and research in the field of psychosocial rehabilitation. Recommendations are made for training and practice frameworks to facilitate consumer-service provider communication towards the development of responsive recovery-oriented services.

On somatic symptoms measurement: the scale for assessment of somatic symptoms revisited

BACKGROUND

Scale for assessment of somatic symptoms (SASS) has been widely used for assessing somatic complaints since many years. With impending changes in the classificatory system on somatoform disorders, we re- assessed the test-retest reliability and inter-rater reliability of SASS.

MATERIALS AND METHODS

SASS was administered twice with a gap of 24 h on 20 subjects for test retest reliability. Two clinicians assessed inter-rater reliability on 20 subjects. Kendall tau B and Cronbach's alpha were calculated from the data.

RESULTS

All of the items except burning sensation, weakness of mind and trembling had strong correlation with values >±0.40 on both test retest and inter-rater reliability; burning sensation and trembling were not reported by any subject. On inter-rater reliability the items constipation, diarrhea, lack of libido weren't scored by any subjects. Cronbach's alpha for test retest was 0.982 and 0.840 indicating good internal consistency.

CONCLUSION

Majority of the symptoms in SASS had high correlation in both test retest reliability as well as inter-rater reliability, however few items needs revision.

Postpartum psychosis in a woman with Graves' disease: a case report

OBJECTIVE

Thyroid dysfunction is common during pregnancy and the postpartum period and is known to cause psychiatric disturbances. A woman with Graves' disease and psychosis in the postpartum period is described.

METHODS

A 22-year-old woman with Graves' disease developed fluctuating orientation, catatonia, delusions of persecution and auditory hallucinations 3 days following childbirth.

RESULTS

The report discusses the clinical presentation. Treatment of both conditions led to the resolution of symptoms.

CONCLUSION

Graves' disease with postpartum psychosis may present with delirium, catatonia and prominent auditory hallucinations and responds well to a combination of psychotropic and antithyroid drugs. Thyroid dysfunction should be assessed for and managed adequately in postpartum psychosis.

Assessing abnormal illness behavior in post-stroke patients: a preliminary report

BACKGROUND

Abnormal illness behavior (AIB) can contribute poor functioning in an individual along with significant increase in health care utilization. It has been studied in various disorders. This study examined the feasibility of assessing abnormal illness behavior in individuals with stroke who were undergoing treatment in a psychiatric and neurological rehabilitation center.

MATERIALS AND METHODS

Subjects who were admitted to the department of psychiatric and neurological rehabilitation ward for post-stroke rehabilitation treatment were assessed using screening version of Illness Behavior Questionnaire (SIBQ).

RESULTS

The total number of subjects who were screened was eight. The mean score of SIBQ was 6.125 ± 1.35. With the cut off score of 7, five subjects had abnormal illness behavior.

CONCLUSIONS

The above study highlights that it is feasible to screen individuals with stroke undergoing rehabilitation for possibility of abnormal illness behavior.

Medication Adherence, Work Performance and Self-Esteem among Psychiatric Patients Attending Psychosocial Rehabilitation Services at Bangalore, India

CONTEXT

Work benefits mental health in innumerable ways. Vocational rehabilitation can enhance self-esteem. Medication adherence can improve work performance and thereby the individuals' self-esteem.

AIM

To test the hypothesis that there would be a significant correlation between medication adherence, work performance and self-esteem.

SETTING AND DESIGN

A quantitative, descriptive correlational research design was adopted to invite patients attending psychiatric rehabilitation services to participate in the research.

MATERIAL AND METHODS

Data was collected from a convenience sample of 60 subjects using the 'Medication Adherence Rating scale', 'Griffiths work behaviour scale' and the 'Rosenberg's Self-esteem scale'.

STATISTICAL ANALYSIS USED

Analysis was done using spss18 with descriptive statistics, Pearsons correlation coefficient and multiple regression analysis.

RESULTS

There were 36 males and 24 females who participated in this study. The subjects had good mean medication adherence of 8.4 ± 1.5 with median of 9.00, high mean self-esteem of 17.65 ± 2.97 with median of 18.0 and good mean work performance of 88.62 ± 22.56 with median of 93.0. Although weak and not significant, there was a positive correlation (r = 0.22, P = 0.103) between medication adherence and work performance; positive correlation between (r = 0.25, P = 0.067) medication adherence and self-esteem; positive correlation between (r = 0.136, P = 0.299) work performance and self-esteem. Multiple regression analysis showed no significant predictors for medication adherence, work performance and self-esteem among patients with psychiatric illness.

CONCLUSIONS

Medication monitoring and strengthening of work habit can improve self-esteem thereby, strengthening hope of recovery from illness.

Does pain behavior influence assessment of pain severity?

CONTEXT

Nurses are involved in assessment of pain in most clinical settings. Pain continues to be underestimated and undertreated.

MATERIALS AND METHODS

This study assessed the rating of pain severity by nurses who observed the two case scenarios using role plays. The data were computed and frequency distribution was derived.

RESULTS

Majority of the nurses underrated the pain and based their ratings on various factors.

CONCLUSIONS

It is important to increase the awareness among nurses about comprehensive assessment of pain for better management.

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.

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.

A comparative study of psychopathology, symptom severity, and short-term outcome of postpartum and nonpostpartum mania

OBJECTIVES

Most studies acknowledge that postpartum psychosis is a variant of bipolar disorder with certain unique clinical features. There have been several descriptions of similarities and differences between postpartum psychosis and postpartum mania to support this conclusion. However, not many studies have compared postpartum-onset and nonpostpartum-onset mania. This study compared short-term outcome, clinical features, and severity of symptoms between these two groups.

METHODS

Two groups of women (n = 30 each) matching the study criteria were recruited from psychiatric inpatient units in India during the period from April 2007 to August 2008. They had been systematically assessed for psychiatric symptoms and symptom severity using the Comprehensive Psychopathology Rating Scale (CPRS), Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), and Global Assessment of Functioning Scale (GAF). To evaluate short-term outcome, all assessments were conducted within a week of admission and were repeated at six weeks.

RESULTS

Women with postpartum-onset mania had higher scores on the HDRS, indicating more depressive symptoms. The score on the anxiety factor of the HDRS was also higher in the postpartum group. Based on CPRS ratings, perplexity, muscle tension, worrying, inner tension, lability of mood, lassitude, and disorientation were more common in the postpartum group, while typical manic symptoms were more common in the nonpostpartum group. Duration of hospital stay and short-term outcome were, however, similar in the two groups.

CONCLUSIONS

Symptoms of depression and anxiety are more common and more severe in mania of postpartum onset and typical manic symptoms are fewer. However, six-week outcomes appear similar to those of nonpostpartum mania.

Therapist concerns and process issues in grappling with functional autobiographical amnesia

Dissociative amnesia is relatively rare form of the dissociative disorder. This paper aims at describing the salient features of a case of functional autobiographical amnesia in a young adult and the approach adopted in the psychological management of this case. The case highlights concerns of the therapist at various stages of the therapy process.

Pain with no cause! Nurses' perception

CONTEXT

Nurses are called upon to assess chronic pain in health settings and their perceptions about chronic pain are likely to influence the pain assessment and pain relief.

SETTINGS AND DESIGN

This survey as a part of chronic pain education workshop was conducted at National Institute of Mental Health and Neurosciences, Bangalore, India, by pain education group. Here we present the observations collected during the workshop on chronic pain held for nurses.

MATERIALS AND METHODS

A semiqualitative method was used to survey the perceptions about chronic pain among nurses. The survey form consisted of 28 statements about chronic pain with options of agree and disagree to be marked prepared by the pain education group.

STATISTICAL ANALYSIS USED

The data were computed and frequency distribution of different statements was derived.

RESULTS

The total number of participants was 44. Two-thirds of the nurses had good knowledge about pain behaviors. About 70% of the nurses reported that severity of pain to be assessed by observing patient's behavior and felt that if a house wife complains of pain it is to avoid work. Only 11% of the nurses provided correct responses related to discussion on pain being psychological; 90% had poor knowledge about pain communication on pain to be treated only for the underlying cause.

CONCLUSIONS

These observations highlight the fact that inadequacies in knowledge about chronic pain exist among nurses; the main areas include pain communication and pain treatments. It is important to include proper pain curriculum and training for chronic pain assessment and management.

Measurement and assessment of somatic symptoms

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.