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.