TIPS IN PSYCHIATRY

AUTISM:

* associated with congenital rubella, PKU, tuberous sclerosis, Rett's disorder.

*show more evidence of perinatal complications

*have significantly more minor congenital physical anomalies than siblings & controls

*4-32% - Grand Mal seizures

*20-25% - ventricular enlargement on CT

*10-83% - various non-specific EEG abnormalities with some indication of failed cerebral lateralisation

*recently one MRI study showed hypoplasia of cerebellar vermal lobules 6 & 7

*another MRI study showed cortical abnormalities particularly polymicrogyria. May reflect abnormal cell migration in first 6 months of gestation

*Autopsy study showed decreased Purkinje cell counts, increased total brain volume, greates avg percentage increase in Occipital, parietal & temporal lobe. No difference in frontal lobes

*PET scan increased diffuse cortical metabolism

* 1/3 patients increased plasma serotonin.

*withdrawl & stereotypies showed increased CSF homovalinic acid. some evidences indicate that symptom severity decreases as ratio of CSF 5-HIAA to CSF HVA increases
ADHD:

*most children do not show evidence of gross structural damage in CNS

*some evidence suggestive that September is the peak month for births of ADHD children with or without co-morbid learning disorders

*Non-focal (soft) neurological signs are frequently seen

*PET scans show decreased cerebral blood flow & metabolic rates in frontal lobes of ADHD children
_________________

ANOREXIA NERVOSA:

*Anorexia nervosa has a negative impact on the immune system and the central nervous system (CNS).

*It is also thought to be linked to serotonin and dopamine abnormalities.

*Many anorectics are diagnosed with obsessive-compulsive behavior at some point in their lives.

*Some have an eating-disordered parent, demonstrating a possible genetic link with the disorder.

*In a long-term set of studies on fifty-one adolescents with anorexia nervosa, eighteen percent of subjects were consistently diagnosed with some type of autism-like disorder at onset and at five- and ten-year follow-ups.

*Researchers have noted that a "small but important minority" of young women with anorexia nervosa may be suffering from undetected and underlying autistic disorders.

*There is increasing speculation that the onset of anorexia has a genetic component. It has been shown that mutations in a certain gene linked to abnormalities with the neurotransmitter chemical serotonin is more common amongst sufferers of anorexia than in the general population.

*Victims of mercury, lead, beryllium and arsenic poisoning have been known to develop anorexia as a symptom thereof.

*Some psychological traits associated with anorexia are consistent with deficiencies in important vitamins and minerals, such as magnesium and the B vitamins.

*Zinc deficiency is common among anorexics, thereby resulting in heightened levels of copper which is associated with depression and nervousness.

*That these deficiencies (or untoward exposure to heavy metals) can produce powerful psychological effects, such as depression, anxiety, and loss of appetite, is not widely known.

*Anorexia is also associated with general anemia.


BULIMIA NERVOSA:

*Research done in 2003, shows a link to the development of bulimia nervosa with an area on the 10p chromosome.

*Familial links include a history of obesity, substance abuse, and depressive disorder.

*Twin studies also strongly support this genetic factor. While both genetics and unique environments contributed to the development of the disorder, twin studies indicate a slightly stronger effect from the genetic predisposition than from environmental circumstances.

*The protein leptin decreases hunger levels in a person, and is more often blocked in patients with bulimia causing abnormal hunger levels in comparison with the norm.

*Due to the binging and purging cycle the stomach is stretched to an enlarged state, and over the progression of time becomes more permanently enlarged, making it necessary for more food to be in the person’s stomach to reach a level of satiety. This is a primary cause of the need for a bulimic to gradually increase the caloric size of their binges, as the original quantities no longer satisfy their enlarged stomach.


Obsessive Compulsive Disorders

*Some research has discovered a type of size abnormality in different brain structures.

*The majority of researchers believe that there is some type of abnormality in the neurotransmitter serotonin

*Recent research has revealed a possible genetic mutation that could be the cause of OCD. Researchers have found a mutation in the human serotonin transporter gene, hSERT, in unrelated families with OCD.

*Using tools like positron emission tomography (PET scans), it has been shown that those with OCD tend to have brain activity that differs from those who do not have this disorder

*It has been theorized that a miscommunication between the orbital-frontal cortex, the caudate nucleus, and the thalamus may be a factor in the explanation of OCD.

*People with OCD may be diagnosed with other conditions, such as Tourette syndrome, compulsive skin picking, body dysmorphic disorder and trichotillomania.

*It is also interesting to note that there is some research demonstrating a link between drug addiction and obsessive compulsive disorder as well. There is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among obsessive compulsive patients may serve as a type of compulsive behavior and not just as a coping mechanism.

*Depression is also extremely prevalent among sufferers of OCD.

*Some cases are thought to be caused at least in part by childhood streptococcal infections and are termed P.A.N.D.A.S. (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections).

*OCD in men at least may be partially caused by low oestrogen levels

*OCD primarily involves the brain regions of the striatum and the cingulate cortex, especially the striatum.

*OCD involves several different receptors, mostly H2, M4, nk1, NMDA, and non-NMDA glutamate receptors. The receptors 5-HT1D, 5-HT2C, and the mu opioid receptor exert a secondary effect. The H2, M4, nk1, and non-NMDA glutamate receptors are active in the striatum, whereas the NMDA receptors are active in the cingulate cortex.

*The activity of certain receptors is positively correlated to the severity of OCD, whereas the activity of certain other receptors is negatively correlated to the severity of OCD. Those correlations are as follows:

*Activity positively correlated to severity:

H2
M4
nk1
non-NMDA glutamate receptors

*Activity negatively correlated to severity:

NMDA
mu opioid
5-HT1D
5-HT2C

*The central dysfunction of OCD involves the receptors nk1, non-NMDA glutamate receptors, and NMDA, whereas the other receptors exert secondary modulatory effects.

*Pharmaceuticals that act directly on those core mechanisms are aprepitant (nk1 antagonist), riluzole (glutamate release inhibitor), and tautomycin (NMDA receptor sensitizer). The drugs that are popularly used to fight OCD lack efficacy because they do not act upon the core mechanisms.

BIPOLAR DISORDER:

*Bipolar disorders research Bipolar disorder runs in families. More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a genetic component.

*Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes.
*The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Dizygotic twins have a 23% concordance rate. These concordance rates are not universally replicated in the literature, recent studies have shown rates of around 40% for monozygotic and <10% for dizygotic twins.

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3, which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder

*PET & MRI studies have found anatomical differences in areas such as the prefrontal cortex and hippocampus
_________________


Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder.


In a genome-wide linkage survey, evidence suggesting that the chromosome 22q12 region contains a susceptibility locus for bipolar disorder (BPD).

Two independent family sets yielded lod scores suggestive of linkage at markers in this region near the gene G protein receptor kinase 3 (GRK3).

GRK3 is an excellent candidate risk gene for BPD since GRK3 is expressed widely in the brain, and since GRKs play key roles in the homologous desensitization of G protein-coupled receptor signaling.

It was also shown GRK3 expression to be induced by amphetamine in an animal model of mania using microarray-based expression profiling.

To identify possible functional mutations in GRK3, the putative promoter region, all 21 exons, and intronic sequence flanking each exon, in 14-22 individuals with BPD were sequenced.

Six sequence variants in the 5'-UTR/promoter region, but no coding or obvious splice variants were found.

Transmission disequilibrium analyses of one set of 153 families indicated that two of the 5'-UTR/promoter variants are associated with BPD in families of northern European Caucasian ancestry.

A supportive trend towards association to one of these two variants (P-5) was then subsequently obtained in an independent sample of 237 families.

In the combined sample, the P-5 variant had an estimated allele frequency of 3% in bipolar subjects, and displayed a transmission to non-transmission ratio of 26 : 7.7 (2=9.6, one-sided P value=0.0019).

Altogether, these data support the hypothesis that a dysregulation in GRK3 expression alters signaling desensitization, and thereby predisposes to the development of BPD.


02/03/2007 9:55:01 AM | Add a comment | Send a message | Permalink | View trackbacks (0) | Blog itAsperger's syndrome
Asperger described his patients as "little professors".Asperger's disorder or Asperger's syndrome (AS) is a pervasive developmental disorder most closely related to autism, and commonly referred to as a form of "high-functioning" autism. The term "Asperger's Syndrome" was coined by Lorna Wing in a 1981 medical paper; she named it after Hans Asperger, an Austrian psychiatrist and pediatrician whose work was not internationally recognized until the 1990s. "Aspie" is an affectionate term used by some with Asperger's syndrome to describe themselves; others prefer "Aspergian", or no name at all. Asperger's also has an especially significant part in the controversies surrounding the autism spectrum.

Non-autistics (neurotypicals) possess a comparatively sophisticated sense of other people's mental states. Most people are able to gather a whole host of information about other people's cognitive and emotional states based on clues gleaned from the environment and the other person's body language. Autists (or autistic persons) do not have this ability, and the individual with Asperger's can be every bit as "mind-blind" as the person with profound classical autism. For those who are severely affected by "mind-blindness", they may, at best, see a smile but not know what it means (is it an understanding, a condescending, or a malicious smile?) and at worst they will not even see the smile, frown, smirk, or any other nuance of interpersonal communication. They generally find it difficult or impossible to "read between the lines," that is, figure out those things a person is implying but is not saying directly. It is worth noting, however, that since it is a spectrum disorder, a few with Asperger's are nearly normal in their ability to read facial expressions and intentions of others. Those with Asperger's often have difficulty with eye contact. Many make very little eye contact, finding it overwhelming, while others have unmodulated, staring eye contact that can be "off-putting" to everyday people.

Asperger's Syndrome involves an intense level of focus on things of interest and is often characterized by special (and possibly peculiar) gifts; one person might be obsessed with 1950s professional wrestling, another with national anthems of African dictatorships, another with building models out of matchsticks. Particularly common interests are means of transportation (for example trains) and computers. In general, things with order have appeal. When these special interests coincide with a materially or socially useful task, the individual with Asperger's can often lead a profitable life — the child obsessed with naval architecture may grow up to be an accomplished shipwright, for instance. In pursuit of these interests, the individual with Asperger's often manifests extremely sophisticated reasoning, an almost obsessive focus, and eidetic memory. Hans Asperger called his young patients "little professors", based on the fact that his thirteen-year-old patients had as comprehensive and nuanced an understanding, within their area of expertise, as university professors. It is because of this that individuals with Asperger's are considered to have a higher intellectual capacity while suffering from a lower social capacity.

Autists have emotional responses as strong as, or perhaps stronger than, most "neurotypicals", though what generates an emotional response might not always be the same. What they lack is the inborn ability to express their emotional state via body language, facial expression, and nuance in the way that most neurotypicals do. Many people with Asperger's report a feeling of being unwillingly divorced from the world around them; they lack the natural ability to see the subtexts of social interaction, and equally lack the ability to broadcast their own emotional state to the world accurately.

This leads to no end of troubles both in childhood and adulthood. When a teacher asks a child with Asperger's, "And did the dog eat your homework?", the child with Asperger's will remain silent if they don't understand the expression, trying to figure out if they need to explain to the teacher that they don't have a dog and besides dogs don't generally like paper. The child doesn't understand what the teacher is asking, cannot infer the teacher's meaning or the fact that there is a non-literal meaning from the tone of voice, posture or facial expression, and is faced with a question which made as much sense to him as "did the glacier in the library bounce today?" The teacher walks away from the experience frustrated and thinking the child is arrogant, spiteful and insubordinate. The child sits there mutely, feeling frustrated and wronged.


Social interaction and cognitive patterns

Asperger's can also lead to problems with normal social interaction between peers. In childhood and teenage years, this can cause severe problems as a child or teen with Asperger's can have difficulty interpreting subtle social cues and as such be ostracized by his/her peers, leading to social cruelty. The child or teen with Asperger's is frequently puzzled as to the source of this cruelty, unaware of what he is doing "wrong". Recent efforts in the field of special education have worked to correct this problem, meeting with only minor to moderate success.

In adulthood, the person with Asperger's may find it difficult to differentiate between the smiles of a waitress waiting on his table and the woman at the next table who's interested in him. He may well wind up asking the waitress out for a cup of coffee and ignoring the woman at the next table.

The social alienation of people with asperger's syndrome is so intense from childhood that many of them have imaginary friends as companionship.

Asperger's Syndrome is hardly a guarantee of a miserable life, however — far from it. Often their intense focus and tendency to work things out logically will grant them a high level of ability in their fields of interest. Despite their difficulty with social interaction, many possess a rare gift for humor (especially puns, wordplay, doggerel, and satire) and written expression. In fact, sometimes their fluency with language is such that a number of them also qualify as hyperlexic. While their lives will probably not be considered a social success by the common standards, and there are a large number who will remain alone their entire lives, it is possible for them to find understanding people (sometimes also on the autistic spectrum, sometimes not) with whom they can have close relationships. While they face enormous obstacles, some overcome them and prosper in society. Many autists are married and have children; their children may be neurotypical or have an autism spectrum disorder. Many autists don't know they have autism and neither do their friends and family members, because milder forms of autism are widely undiagnosed and misdiagnosed by professionals and widely misunderstood.


DSM definition

Asperger's is defined in section 299.80 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as:

Qualitative impairment in social interaction, as manifested by at least two of the following:
Marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
Failure to develop peer relationships appropriate to developmental level
A lack of spontaneous seeking to share enjoyment, interest or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
A lack of social or emotional reciprocity
Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
Apparently inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
Persistent preoccupation with parts of objects.
The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.
There is no clinically significant general delay in language (e.g., single words used by age two years, communicative phrases used by age three years)
There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills or adaptive behavior (other than in social interaction) and curiosity about the environment in childhood
Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
The Diagnostic and Statistical Manual's diagnostic criteria have been roundly criticized for being far too vague and subjective: what one psychologist calls a "significant impairment" another psychologist may call insignificant.

A series of studies have supported the thesis that there are in fact no or only very few cases that strictly meet the above DSM-IV definition of Asperger's: patients typically show communication impairment, which then qualifies them for a diagnosis of autistic disorder and not Asperger's. See [1].


Relationship to autism

Asperger's syndrome is named after Hans Asperger.Experts today generally agree that there is no single mental condition called autism. Rather, there is a spectrum of autistic disorders, with different forms of autism taking different positions on this spectrum. But within certain circles of the autism/AS community, this concept of a "spectrum" is being severely questioned. If differences in development are purely a function of differential acquisition of skills, then attempting to distinguish between "degrees of severity" may be dangerously misleading. A person may be subjected to unrealistic expectations, or even denied life-saving services, solely on the basis of very superficial observations made by others in the community.

In the 1940s, Leo Kanner and Hans Asperger, working independently in the United States and Europe, identified essentially the same population, Asperger's group being perhaps more "socially functional" than Kanners as a whole. Some of Kanner's originally identified autistic children, might today get an Asperger's syndrome diagnosis, and vice versa. It is a mistake to say that a "Kanner autistic" is a child who sits and rocks and does not communicate. Kanner's study subjects were all along the spectrum.

Researchers are grappling with the problem of how to divide up the spectrum. There is no easy way to do this. It would appear that one can divide the population of autistics in any particular way and define the group accordingly. Autistics who speak, those who don't. Autistics with seizures, those without. Autistics with more "stereotypical behaviors", those with less, and so forth. Some are trying to identify genes associated with these traits as a way to make logical groupings. Eventually, one may hear about autistics with or without the HOXA 1 gene, with or without changes to chromosome 15, etc.

Kanner's syndrome is described in the article autism.

According to Dr. Peter Szatmari, and others in the field of autism research, if one strictly applies the DSM-IV guidelines, then, in fact, there are almost NO people with "Asperger's syndrome" pointing to the flawed nature of the DSM-IV description.


Leo Kanner discovered another form of autism around the same time as Hans Asperger.Dr. Sally Ozonoff, of the University of California at Davis's MIND institute, argues that there should be no dividing line between "high-functioning" autism and Asperger's, and that the fact that some don't start to produce speech until a later age is no reason to divide the two groups, as they are identical in the way they need to be treated.

Asperger's Syndrome and other forms of autism are often grouped together in a Pervasive Developmental Disorder family.


Probable causes and origins

The causes and origins of autism and Asperger's syndrome is a source of continuing conjecture and debate. Amongst several competing theories are the underconnectivity theory developed by cognitive scientists at Carnegie Mellon University and the University of Pittsburgh, the Neanderthal theory, the extreme male brain theory by simon baron cohen, the lack of theory of mind, and the Preoperational-autism theory, which states that autistic people are those who get neurologically stuck at the pre-operational stage of cognitive development, where much of information processing is at a wholistic-visual level and largely non verbal and musical. This also addresses the issue of the theory of mind where children at the pre-operational stage of cognitive development have not attained decentralisation from egocentrism.

The underconnectivity theory holds that autism is a system-wide brain disorder that limits the coordination and integration among brain areas. Since the brain is known to be modular, researchers examined white matter (which connects various areas of the brain like cables) with the aid of fMRI and found abnormalities in people with autism. Observation thus supports the idea that Asperger's syndrome is a deficiency in coordination among brain areas. This theory is parsimonious, in that it explains why autistic people are matured on certain dimensions eg: visual information processing and logical analysis, and yet are socially and sometimes neuro-physiologically, significantly younger to their chronological age.

Other probable theories, addresses the rise of autism in recent times. They suggests the rise of visual media and thereby the increasing central role of visual information processing in the breakdown of language and the rise of autism.


Effect on relationships

The significant others of people with Asperger's are more prone to major depression than the general population because Asperger's people often have trouble showing affection or understanding the need to show affection, and are very literal and hard to communicate with in an emotional way. It is very helpful for the spouses to read as much as they can about Asperger's syndrome, OCD, hyperlexia and other "comorbid disorders". It also helps to visit the support groups' websites online and talk with other spouses of people with Asperger's Syndrome. A spouse will often be much less angry or depressed if they understand that the Asperger's symptoms are not intentionally directed at them, but that they are part of a neurological condition. That someone does not spontaneously show affection does not necessarily mean that they do not feel it. Thus the spouse will feel a lot less rejected and be a lot more understanding. Light will be shed on the nature of the misunderstandings. They may figure out ways to work around the problems, for example being more explicit about their needs.


A gift and a curse

Recently, some researchers have speculated that many well-known people including Glenn Gould, Nikola Tesla, Albert Einstein and Isaac Newton had AS, as they showed some Asperger's related tendencies (such as intense interest in one subject and social problems); such diagnoses remain controversial, however (cf. BBC News, Einstein and Newton "had autism" (http://news.bbc.co.uk/1/hi/health/2988647.stm), 30 April 2003). The obvious social contributions of such individuals has led to a shift in the perception of Asperger's and autism away from the simple view of a disease just needing to be cured towards a more complex view of a syndrome with both advantages and disadvantages. There is a semi-jocular theory within science fiction fandom, for example, which argues that many of the distinctive traits of that subculture may be explained by the speculation that a significant portion thereof is composed of people with Asperger's. A Wired Magazine article called The Geek Syndrome (http://www.wired.com/wired/archive/9.12/aspergers_pr.html) suggested that Asperger's syndrome is more common in the Silicon Valley, a haven for computer scientists and mathematicians. It created an enduring myth popularized in the media and self-help books that "Geek Syndrome" equals Asperger's syndrome, and precipitated a rash of self-diagnoses. Though these conditions do share overlap, there is a consensus that most geeks are arguably "variant normal" and do not exhibit autistic spectrum behaviors.


Asperger's in the media

Detective Robert Goren from the television series Law & Order: Criminal Intent, has a touch of Asperger's Syndrome. The series has also dealt with a suspect who has a much more pronounced form. Detective Adrian Monk of the television series Monk may very well also have the syndrome.

Detective Vic Mackey from the television series The Shield has a son, Matthew, diagnosed with Asperger's Syndrome.

Georgia Lass from Dead Like Me, with her dead-pan facial expressions, blunt communication style and (earlier in the series) her awkward social skills, may have Asperger's Syndrome.

In production in 2004, the film Mozart and the Whale is a love story between two people with Asperger's Syndrome.

In The Curious Incident of the Dog in the Night-Time, a novel by Mark Haddon, the narrator is a 15 year old boy with Asperger's Syndrome.

Luke Jackson and his family starred in the British TV program, My Family and Autism (http://www.bbc.co.uk/ouch/tvradio/autism/). Luke is about 14 and has Asperger's Syndrome. He has a brother with dyslexia, a brother with ADHD and a brother with profound autism. He also has three neurotypical sisters. He has written a book called "Freaks, Geeks and Asperger Syndrome" (ISBN 1843100983) which focuses on Asperger's and how it affects teenagers.


Criticisms

Some people, including people diagnosed with Asperger Syndrome argue that asperger's syndrome is a social construct. Professor Simon Baron-Cohen of the Autism Research Centre has written a book arguing that Asperger Syndrome is an extreme version of the way in which men's brains differ to women's. He says that in general men are better at systemizing than women, and that women are better at empathizing than men. Hans Asperger himself is quoted as saying that his patients have 'an extreme version of the male form of intelligence'.


References

[1] Mayes SD, Calhoun SL, Crites DL: Does DSM-IV Asperger's disorder exist?, Journal of Abnormal Child Psychology 2001 June; 29(3), pages 263–271, online version (http://www.findarticles.com/cf_0/m0902/3_29/76558499/p1/article.jhtml)

The ADHD-Autism Connection: A Step toward more accurate diagnosis and effective treatment, by Diane M. Kennedy, ISBN 1578564980 (The aim of this book is to explore the similarities that attention deficit hyperactivity disorder (ADHD) shares with a spectrum of disorders currently known as pervasive developmental disorders.)

Asperger's Syndrome — A Guide for Parents and Professionals by Tony Atwood. This book is considered to be the Bible as far as general AS books go.

Martian in the Playground by Claire Sainsbury. This book is all about the schoolchild with Asperger's Syndrome.

Freaks, Geeks and Asperger's Syndrome by Luke Jackson. This book won the National Association of Special Educational Needs Children's book award. It is written by someone who has gone though all the experiences he is writing about.

Men, Women and the Extreme Male Brain by Simon Baron-Cohen. The author proposes the theory that autism and Asperger Syndrome can be explained as extreme examples of the male type of mind.

02/03/2007 9:43:10 AM | Add a comment | Send a message | Permalink | View trackbacks (0) | Blog itSuicide - Commonest cause of death among Psychiatric Patients
I. Suicide
Commonest cause of death among Psychiatric Patients

Suicide – deliberate self harm (DSH) – Human act of self – intentioned and self-inflicted cessation (death) – attempted suicide.

Suicidal Gesture – Attempted Suicide – Action never intends to die – Attempted suicide – women – completed suicide – 2-4 times commoner in men.

Some Common Themes in Suicide

1. It is a crisis that causes intense suffering and feelings of hopelessness and helplessness.
2. There is a conflict between survival and unbearable stress.
3. There is a narrowing of the person’s perceived options
4. There is a wish to escape (it is an escape rather than a going-towards).
5. There is often a wish to punish self and / or punish significant others with guilt.

Epidemiology

Top 10 causes of death – 9.9 / lakh population / year (1994 figures) – 10-15 / lakh population – the world ranges – 5-30 / lakh population – attempted suicide to completed – 10:! India – Highest Suicide - 18-30 years – highest – Pondicherry, West Bengal, Madras & Bangalore.

Etiology:
Common causes of suicide are
1.Psychiatric Disorders

1.Depression

1-Major depression
2-Depression secondary to serious physical illness.
3-Reactive depression

2. Alcoholism and drug dependence

3. Schizophrenia

and biochemical factors{low levels of 5-HIAA]

II. Physical Disorders

- incurable or painful physical disorders, AIDS, often commit suicide- 13.5% of all

III. Psychosocial Factors

Examination, Failure in Love, Dowry Difficulties, Marital Difficulties, Illegitimate Pregnancy, Family Dispute, Psychopathology, Loss of a loved object, Occupational and Financial Difficulties.

Methods Used

Ingestion of Poisons (about 35%) followed by Hanging (about 23%), Drowning (about 9%), Jumping in front of a train (4 %), Burning (12%)

Men often – Violent Methods

Medico – Legal Aspects

Section 309 of IPC states that – Attempts to Commit Suicide and does any towards the commission of such offence – Punishable with simple imprisonment – which may extend to one year – also be liable to fine.

Section 309 of IPC was repealed by the Court of India in 1994, 1996, Attempt to Suicide - Punishable Offence. So the Section 309 IPC continues.

Major Risk Factors For Suicide

The presence of the following factors increases the risk of completed suicide:

1. Age > 40 years
2. Male Sex
3. Staying Single
4. Previous suicidal attempt(s)
5. Depression (risk about 25 times more than normal)
i. Presence of guilt, self-accusation, agitation, nihilistic ideation, worth-lessness, Hypochondriacal delusions and / or severe insomnia.
ii. More at the beginning or towards the end of a depressive episode
6. Suicidal preoccupation (e.g. a ‘suicide note’ is written or detailed plans are made for committing suicide)
7. Alcohol or drug dependence
8. Severe, disabling, painful or untreatable physical illness
9. Recent serious loss or major stressful life event
10. Social Isolation

Common Misconceptions about suicide
(Modified about Shneidman and Farberow, 1961)

Misconceptions Facts
1. People who talk about suicide, don’t commit suicide-- Nearly 80 % of persons who commit suicide,
2. Suicide happens without warning--give definite warnings and / or clues about their suicidal intentions

3. Suicidal persons are fully intent on dying-- Most suicidal persons are undecided about dying or living.
4. Once a person is suicidal, he is suicidal forever.-- Suicidal person is suicidal only for a limited period of time
5. All suicidal persons are mentally ill or psychotic-- Although the suicidal person is often extremely unhappy, he is not necessarily mentally ill

Management

No longer treatable.

Prevention Centres – Emergency Services – Welfare Centres (of the Patient)

1. All suicidal Threats, Gestures
2. Seriousness of the situation and take remedial
i. Physical Surroundings, Sharp Objects, Ropes, Drugs, Firearms etc.
ii. Surveillance

3. Acute Psychiatric Emergency
4. Counseling and Guidance
i. The Desire
ii. Ongoing life stressors, Teaching coping skills, Interpersonal skills

5. Medication or ECT
02/03/2007 9:38:02 AM | Add a comment | Send a message | Permalink | View trackbacks (0) | Blog itElectroconvulsive Therapy (ECT)
1.1 It is recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/ or when the condition is considered to be potentially life-threatening, in individuals with:

° severe depressive illness
° catatonia
° a prolonged or severe manic episode

1.2 The decision as to whether ECT is clinically indicated should be based on a documented assessment of the risks and potential benefits to the individual, including: the risks associated with the anaesthetic; current co-morbidities;
anticipated adverse events, particularly cognitive impairment; and the risks of not having treatment.


1.3 The risks associated with ECT may be enhanced during pregnancy, in older people, and in children and young people, and therefore clinicians should exercise particular caution when considering ECT treatment in these groups.

1.4 Valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. The decision to use ECT should be made jointly by the individual and the clinician( s) responsible for treatment, on the basis of an informed discussion. This discussion should be enabled by the provision of full and appropriate information about the general risks associated with ECT (see Section 1.9) and about the risks and potential benefits specific to that individual. Consent should be obtained without pressure or coercion, which may occur as a result of the circumstances and clinical setting, and the individual should be reminded of their right to withdraw consent at any point. There should be strict adherence to recognised guidelines about consent and the involvement of patient advocates and/ or carers to facilitate informed discussion is strongly encouraged.

1.5 In all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/ or carer should be consulted.

1.6 Clinical status should be assessed following each ECT session and treatment should be stopped when a response has been achieved, or sooner if there is evidence of adverse effects. Cognitive function should be monitored on an ongoing basis, and at a minimum at the end of each course of treatment.

1.7 It is recommended that a repeat course of ECT should be considered under the circumstances indicated in 1.1 only for individuals who have severe depressive illness, catatonia or mania and who have previously responded well to ECT. In patients who are experiencing an acute episode but have not previously responded, a repeat trial of ECT should be undertaken only after all other options have been considered and following discussion of the risks and benefits with the individual and/ or where appropriate their carer/ advocate.

1.8 As the longer-term benefits and risks of ECT have not been clearly established, it is not recommended as a maintenance therapy in depressive illness.

1.9 The current state of the evidence does not allow the general use of ECT in the management of schizophrenia to be recommended.

1.10 National information leaflets should be developed through consultation with appropriate professional and user organisations to enable individuals and their carers/ advocates to make an informed decision regarding the appropriateness of ECT for their circumstances. The leaflets should be evidence based, include information about the risks of ECT and availability of alternative treatments, and be produced in formats and languages that make them accessible to a wide range of service users


01/03/2007 5:03:29 PM | Add a comment | Read comments (1) | Send a message | Permalink | View trackbacks (0) | Blog itPsychiatric Defence mechanisms
Level 1 Defense Mechanisms - Almost always pathological; for the user these three defenses permit someone to rearrange external reality (and therefore not have to cope with reality); for the beholder, the users of these mechanisms frequently appear crazy or insane. These are the "psychotic" defenses, common in overt psychosis, in dreams, and throughout childhood.

Denial - a refusal to accept external reality because it is too threatening. There are examples of denial being adaptive (for example, it might be adaptive for a person who is dying to have some denial)

Distortion - a gross reshaping of external reality to meet internal needs

Delusional Projection - frank delusions about external reality, usually of a persecutory nature

Level 2 Defense Mechanisms are seen frequently in adults and are common in adolescents. For the user these mechanism alter distress and anxiety caused by reality or other people; while for the beholder, people who use such defenses are seen as socially undesirable, immature, difficult and out of touch. They are considered "immature" defenses and almost always lead to serious problems in a person's ability to cope with the world. These defenses are seen in severe depression, personality disorders, and adolescence. They include:

Fantasy - tendency to retreat into fantasy in order to resolve inner and outer conflicts

Projection - attributing one's own unacknowledged feelings to others; includes severe prejudice, severe jealousy, hypervigilance to external danger, and "injustice collecting". (remember that projection is a primitive form of paranoia, so it is common in today's world)

Hypochondriasis - the transformation of negative feelings towards others into negative feelings toward self, pain, illness and anxiety

Passive Agressive Behavior - aggression towards others expressed indirectly or passively

Acting Out Behavior - direct expression of an unconscious wish or impulse to avoid being conscious of the emotion that accompanies it


Level 3 Defense Mechanisms are often considered "neurotic" but are fairly common in adults. They can have short-term advantages in coping, but they often cause long-term problems in relationships, work, and enjoyment of life for people who primarily use them as their basic style of coping with the world. They include:

Intellectualization - separation of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting on them

Repression - seemingly inexplicable naivete, memory lapse, or lack of awareness of physical status; the emotion is conscious, but the idea behind it is absent

Reaction Formation - behavior that is completely the opposite of what one really wants or feels (e.g, taking care of someone when what one really wants is to be taken care of; studying to be a pilot to cover-up being afraid to fly). Note - this can work in the short term as an effective strategy to cope, but will eventually break down.

Displacement - separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening

Dissociation - temporary and drastic modification of one's personal identity or character to avoid emotional distress

Rationalization :is the process of constructing a logical justification for a decision that was originally arrived at through a different mental process.


Level 4 Defense Mechanisms are common among most "healthy" adults and are considered the most "mature". Many of them have their origins in the "immature" level, but have been honed by the individual to optimize his/her success in life and relationships. Use of these defenses gives the user pleasure and feelings of mastery. For the user, these defenses help them to integrate many conflicting emotions and thoughts and still be effective; and for the beholder their use by someone is viewed as a virtue. They include:

Sublimation - transformation of negative emotions or instincts into positive actions, behavior, or emotion

Altruism - constructive service to others that brings pleasure and personal satisfaction

Suppression - the conscious decision to delay paying attention to an emotion or need in order to cope with the present reality; able to later access the emotion and accept it.

Anticipation - realistic planning for future discomfort

Humor - overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about) that gives pleasure to others; (humor lets you call a spade a spade, while "wit" is actually a form of displacement.

01/03/2007 4:57:28 PM | Add a comment | Send a message | Permalink | View trackbacks (0) | Blog itSyndromes in Psychiatry
Wernicke’s encephalopathy
An acute reaction to severe thiamine deficiency mostly d/t chronic alcohol use.
C/b ocular signs (nystagmus & external ophthalmoplagia)
Higher mental function disturbance(disorientation, confusion, recent memory disturbances)
Apathy & ataxia.
Peripheral neuropathy & malnutrition may be co-existent.

Korsakoff’s psychosis
Also d/t severe thiamine deficiency d/t chronic alcohol use.
C/b amnestic syndrome with gross memory disturbances
Confabulation
Insight often impaired.

Marchiafava-Bignami syndrome
A rare disorder most probably d/t alcohol-related nutritional deficiency.
C/b disorientation, personality & intellectual deterioration, hallucinations, epilepsy, dysarthria, ataxia & spastic limb paralysis.

Holiday Heart
Atrial or ventricular arrhythmias, especially paroxysmal tachycardia, after drinking a binge of alcohol in individuals showing no other evidence of heart disease.

Hemp insanity (cannabis psychosis)
Asso with cannabis.
Acute schizophreniform disorder with disorientation & confusion
Good prognosis.

Amotivational syndrome
Lethargy, apathy, loss of interest, anergia, reduced drive & lack of ambition d/t chronic cannabis use.
Van Gogh syndrome
Dramatic self-mutilation occurring in schizophrenia.

Pfropf schizophrenia
A syndrome of schizophrenia occurring in presence of mental retardation.

Oneiroid schizophrenia
A subtype of schizophrenia with acute onset, clouding of consciousness, disorientation, dream-like states & perceptual disturbances with rapid shifting.

Alice in Wonderland syndrome
Perceptual distortion of shape, size, colour& reciprocal position of objects. seen with schizophrenia, migraine

PAD syndrome
Phobic-Anxiety-Depersonalization syndrome.
Commoner in women 20-40 years.
C/b diffuse anxiety, multiple phobias, panic attacks, depersonalization, derealization & depressive features.

Othello syndrome (conjugal paranoia)
A psychosis in which the content of delusions is predominantly jealousy (infidelity) involving spouse.

Clerambault’s syndrome (erotomania)
A psychosis in which the content of delusions is erotic.
Most often in women with erotic conviction that a person with higher status is in love with the patient.

Kadinsky-Clerambault’s syndrome
A syndrome of mental automatism

Folie a deux
Induced delusional disorder c/b sharing of delusions b/w 2 persons.
So is folie a trios, folie a quatre, folie a famille…

Capgras’ syndrome (delusion of doubles)
C/b delusional conviction that other persons in environment are not their real selves but are their own doubles.
There are 4 types
1. Typical Capgras’ syndrome(illusion des sosies)- pt sees a familiar person as a stranger who is imposing as the familiar person.
2. Illusion de Fregoli pt falsely identifies strangers as familiar persons.
3. Syndrome of subjective doubles pt’s own self is perceived as being replaced by a double.
4. Intermetamorphosis pt’s misidentification is complete including both external appearance & personality.

Fregoli’s phenomenon
Delusion that a persecutor is taking on a variety of faces like an actor.

Cotard’s syndrome
Delusion that one has lost everything- possessions, strength & even bodily organs such as heart.
Seen in severe depression where pt has extreme nihilistic delusion (e.g. may think that his bowels are rotting and he will never pass stools again)

Ganser’s syndrome (hysterical pseudodementia)
Commonly found in prison inmates.
C/b vorbeireden- approximate answers- person understands nature of questions but answers wrong.

La-Belle-Indifference
Lack of concern towards symptoms despite apparent severity of disability produces.
Seen in pts with conversion & dissociation disorder(hysteria).

Briquet’s syndrome (Somatisation disorder)
A chronic or recurrent illness with either a dramatic or complicated medical history.
A pt with at least 25 unexplained medical symptoms for a diagnosis or with 20-25 unexplained symptoms for a probable diagnosis.

Munchausen syndrome (Factitious disorder, Polysurgis, Professional patients, Hospital hoboes, Hospital addiction)
Pt repeatedly simulates or fakes diseases for sole purpose of obtaining medical attention.

Munchausen syndrome by proxy
Pt intentionally produces physical signs & symptoms in another person who is under pt’s care.

Ekbom syndrome (Restless Legs syndrome)
Pt experiences extremely uncomfortable feeling in leg muscles during walking.
Asso with insomnia.

Gelineu’s syndrome
Narcolepsy.
Asso with hypersomnia.

Pickwickian syndrome
Sleep apnea commoner in elderly & obese persons, asso with hypersomnia.

Kleine-Levin syndrome
C/b hypersomnia
Hyperphagia
Hypersexuality

Clumsy Child syndrome (Motor dyspraxia, Motor skills disorder, Developmental coordination disorder)
C/b poor coordination in daily activities of life.

Idiot Savant syndrome
Pervasive impairment of functions but certain islets of precocity or splinter functions may remain.

Heller’s syndrome (Disintegrative psychosis)
A type of childhood psychosis with age of onset 3-5 years.
C/b rapid downhill course leading to deterioration & development of neurological deficits.

Asperger’s syndrome
Predominantly in boys.
Less severe form of pervasive developmental disorder
Autism without significant delay in language & cognitive development.
schizoid personality
pedantic speech
preoccupation with obscure facts

Rett’s syndrome
Occurs in girls.
After an apparently normal early development & normal head circumference at birth, there is deceleration of head growth b/w age of 5-30 months.
Loss of purposive hand movements & acquired fine motor manipulative skills with subsequent development of stereotyped hand movements.

Strauss syndrome
Attention deficit hyperkinetic disorder, Minimal brain dysfunction, Organic drivenness.

Gilles de la Tourette’s syndrome
C/b multiple motor tics
Multiple vocal tics
Duration of >1 year

Kanner syndrome
Failure to develop attachment with a parenteral figure & pre-occupation with inanimate objects.

Syndromes associated with dementia
Alzheimer’s disease
Pick’s disease
Parkinson’s disease
Shy-Drager syndrome (Multisystem degeneration)
Huntington’s chorea
Steel-Richardson syndrome (progressive Supranuclear palsy)
Binswanger’s disease (subcortical arteriosclerotic encephalopathy)
Wilson’s disease
Leigh’s disease
Creutzfeldt-Jacob disease
Gerstmann-Straussler-Scheinker disease
ALS-Parkinson’s-Dementia complex of Gaum

Syndromes associated with mental retardation
Down’s syndrome
Turner’s syndrome
Kleinfelter’s syndrome
Cri du chat syndrome
Fragile X syndrome
Hartnup’s disease
Tay-Sachs disease
Gaucher’s disease
Niemann-Pick disease
Lesch Nyhan syndrome
Hurler’s disease
Hunter’s disease
Sanfillipo’s disease
Renpenning’s syndrome
Sturge-Weber syndrome
Crouzon’s syndrome
Apert’s syndrome
De Lange syndrome (Amsterdam dwarfism)

Some Culture-Bound Syndromes are as follows

Dhat syndrome
A culture-bound syndrome prevalent in Indian subcontinent.
C/b complaint of passage of ‘dhat’ in urine.
Multiple somatic symptoms.
Asthenia
May be anxiety, depression or sexual dysfunction associated.

Koro
Prevalent in Asia including India.
Affected male pt believes that his penis is shrinking & may disappear into his abdominal wall & he may die.
Females affected infrequently, believing that their breasts & vulva are shrinking.

Amok
Prevalent in South-East Asia.
C/b sudden, unprovoked episode of rage in which affected person runs about & indiscriminately injures or kills any person who in encountered on the way.

Latah (Startle reaction)
Prevalent in South-East Asia & Japan.
More in women, c/b automatic obedience, echolalia & echopraxia.

Windigo (Wihtigo)
Prevalent in native American Indians.
Pt believes that he has been transformed into a wihtigo, a cannibal monster, occurring especially during times of starvation.

Shinkeishitsu
A defense syndrome, mainly of anxiety but with obsessive features occurring in young Japanese thrown into a modern industrial society for which they are not equipped. They feel inadequate, lost & unloved.

Susto
Occurs in Latin America.
Pt believes that his body is entered by a magical substance & that he is altered. It takes on a delusional quality.

Piblokto (Arctic Hysteria)
Occurs in Askimos.
Often female, who screams & tears off her clothes, throw herself on ice in extremely cold conditions.
She may imitate the cry of a bird or an animal.
The episode lasting for 1-2 hours, f/b amnesia of events.