Archives of Indian Psychiatry October

Archives of Indian Psychiatry
Official Publication of the Indian Psychiatric Society, Western Zonal Branch
Honorary Editor
G. K. Vankar Professor and Head Dept. of Psychiatry B.J. Medical College and Civil Hospital, Ahmedabad-380016. Cell. : 09904160338
Editorial Board
R. Srinivasa Murthy E. Mohhandas Vikram Patel Nimesh Desai K. S. Jacob Nilesh Shah Chittaranjan Andrade Bharat Panchal Shekhar Sheshadri Ashok Nagpal
Corresponding Members
Dinesh Bhugra Stuart Montgomary Afzal Javed Joseph Johar Prakash Masand Andre Joubert Manoj Shah
Statistics Consultant
Rahul Shidhaye
Distinguished Past Editors

Amresh Shrivastava Mrugesh Vaishnav
Editorial Office
Ward EI Dept. of Psychiatry, Civil Hospital, Ahmedabd-380 016. E-mail : ipswzjournal@yahoo.co.in Phone : 079-65542770 Fax : 079-65542770
Board of Directors Journal Committee

Laxman Dutt Jitendra Nanawala I. R. Rajkumar V. G. Vatwe Mukesh Jagiwala Rajendra Hegde K. S. Ayyar Hemangee Dhavle Govind Bang Shubhangi Parkar Kaushik Gupte Rashmin Cholera Parag Shah Ritambhara Mehta Khyati Mehtalia Anuradha Sovani Charles Pinto Yusuf Matchewala Rjaesh Dhume D.M. Dhavle Shivarathnamma Vivek Kirpekar A. S. Kadri
Type Setting
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Archieves of Indian Psychiatry is the official journal of Indian Psychiatric Society, Western Zonal Branch published twice in a year Subscitpion : Annual subscription rates are Rs. 700/- for individuals and Rs. 1000/- for institutions. Please send DD in favour of Editor, Archives of Indian Psychiatry Payable at Ahmedabad. Correspondence related to advertisements should be addressed to the editorial office. Copyright : Indian Psychiatric Society Western Zonal Branch
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Archives of Indian Psychiatry 10(2) October 2009

Official Publication of the Indian Psychiatric Society, Western Zonal Branch
Mrugesh Vaishnav President
Chairpersons Subcommittees Lata Vaya Awards
Kaushik Gupte Hon. Secretary
Ravindra Kamat C.M.E. Mukesh Jagiiwala Conference Paresh Shah Constitution Shrikant Deshmukh Legal Cell
Shrikant Deshmukh Vice President
Ramesh Mankad Treasurer
Jitendra Nanawala Imm. Past President Vipul Sangani Membership Mukesh Jagiwala Kishor Gujar Representatives of Central Council
Avinash Joshi Mental Health Awareness
Bansi Suwalka Lalit Vaya Mangalam Rathod Lalit J.Shah Pramod Thakre Deepak Rathod Executive Council Mambers
Neena Savant Psychiatric Eduction
Kausor Abbasi Quiz

Contents
In T h is iss u e E d it o r ia l 5 H T T G e n e - E n v ir o n m e n t In te ra c tio n s In H u m a n B e h a v io r R e v ie w A r t ic le N ig h t E a tin g S y n d r o m e : a n o v e rv ie w
Official Publication of Indian Psychiatric Society Western Zonal Branch Volume 10, No.2, October 2009
K h y a ti M e h ta li y a
C h itt a ra n ja n A n d ra d e
A m e y a A m ritw a r N ile s h S h a h A v in a s h D e S o u sa
D e v e lo p m e n ta l P s y c h o p a th o lo g y a n d its r e le v a n c e to C h ild P s yc h ia tr y a C lin ic a l P e rs p e c tiv e W h o c a re s f o r c a r e g iv e rs ?
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P o o ja D a n g a r P a ra g S . S h a h
20
O r ig in a l A r tic le N e w sp a p e r P o r tra y a l o f P s y c h ia tr y T r a d itio n a l H e a lin g p r a c t ic e s in P s y c h ia tric O u t P a tie n ts E f fic a c y o f S o c ia l S k ills T r a in in g a s In te r v e n tio n fo r S tu tte ri n g fo r a d o le s c e n ts v /s a d u lts S tre s s a n d C o p in g a m o n g R e sid e n t D o c t o rs L a x e sh k u m a r P a te l G . K . V ankar R a h u l S h id h a y e G .K .V a n k a r S a d h a n a D e sh m u k h A n u rad h a S o v an i S o h a n g B h a d a n ia M in a k sh i P a rik h G .K .V a n k a r 26 33
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44
C a se R e p o r t F a m ilia l H y p o k a le m ic P e r io d ic P a ra l y s is : A C a se R e p o r t R a ja t O s w a l D ev en d ra C h au d h a ri R ita m b h a ra M e h ta V ip u l P ra ja p a ti B h a v e s h L a k d a w a la G .K .V a n k a r E la v a ts a la S h a r m a D e e p a k T iw a ri B h arat P an ch al S u h a s G a jb h i y e K ra n ti K a d a m N ile s h S h a h H ite s h S h e th P a ra g S h a h 51
O la n z a p in e In d u c e d T a r d i v e D y sto n ia
54
R u m in a tio n D is o rd e r in a n A d u lt: A C a s e R e p o r t
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T r e a tm e n t o f E g o -D y s to n ic H o m o s e x u a l ity w ith B e h a v io u r T h e r a p y U s in g P rin c ip le o f C la s sic a l C o n d itio n in g : a C a s e R ep o rt C o n stip a tio n P o etry Q u iz
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In This Issue
In his editorial,Adrade (p.5) citing several studies concludes that adverse environmental influences are depressogenic or increase the risk of substance abuse in persons with the s allele of the 5-HT transporter gene. However, supportive environmental influences buffer the risk. and hence the importance of social and environmental efforts to mitigate genetic risk factors in psychiatry. Amritwar and Shah(p.7) provide overview of Night Eating Syndrome , a less known disorder. It is characterised by morning aphagia, evening hyperphagia and sleep disturbance for a duration of at leat 3 months. SSRIs can help achive remission in upto 75% patients. Patel and Vankar(p.26) analyze 350 newspaper cuttings regarding mental illnesses and suicide collected over 3 month period in Newspaper Portrayal of Psychiatry.., Two third had suicide theme and the remaining had other mental illness reated themes. In the suicide related themes, About half the cuttings had sensationalized headlines, and detailed discussion of method used was in38%..Helpline related information was almost invisible.Non-suicide related cuttings revealed mentally ill persons identity,about a quarter reinforced negative stereotype of mental illness.The findings have implications for media guidelines for reporting suicide and mental illnesses . Traditional Healing Practices in Psychiatric patients were explored by Shidhaye and Vankar(p.33) Out of 201 psy-
chiatric patients, 54.7% had visited a traditional healer irrespective of the diagnosis.About one in five patient with psychiatric disorder considers traditional healing effective and would recommend it to others with similar problems.
Deshmukh and Sovani (p.38) compared efficacy of social skills training in management of stuttering among adolescents and adults. They conclude that itb was more efficacious in adults compared to adolescents. In Stress and Coping in Resident doctors, Bhadania, Parikh and Vankar(p.44) found that 37% residents were under stress.Fifty five percent residents in stress worked for more than 80 hours a week.First year residents experienced more stress but there were no gender differences.Those at stress used substances and self-blame more frequently.The most important perceived source fof support is colleagues.64% reported experiencing intimidation and harrassment but inappropriate touch or sexual harrassment was rare. This study also has important implications for resident well being. The issue also features case reports of three unusual diagnoses: Familial Hypokalemic Periodic Paralysis(p.51), Olanzepine induced tardive dystonia(p.54), Rumination disorder in an adult patient (p.57) and Treatment of ego dystonic homosexuality (p.59).
Dr. Khyati Mehtaliya MD, Consultant Psychiatris Sakhi Womens Mental Health and Child Guidance Clinic, 301, Ravish Complex , Maninagar Char Rasta Ahmedabad 380008 e-mail: drkhyati@rediffmail.com
Editorial
5HTT Gene-Environment Interactions In Human Behavior

Chittaranjan Andrade
Serotonin is an important neurotransmitter in psychiatry. Serotonin regulates a number of behaviors, including sleep, appetite, sexual functioning, gastrointestinal functioning, and others. Disturbances of serotonergic neurotransmission have been implicated in diverse behavioral symptoms and disorders, including anxiety, obsessive-compulsive disorder, aggression, depression, suicidality, and others.
mental health. In a pathbreaking study, Caspi et al (2003) showed that the risk of depression in response to environmental stress was directly proportionate to the degree of homozygosity for the short allele of the gene (l/ l vs s/l vs s/s). That is, persons with the s/s genotype were at highest risk of stress-related depression; those with the s/l genotype were at intermediate risk, and those with the l/l genotype were at lowest risk. If the s/s genotype is associated with stress-related vulnerability to depression, is the individual doomed to stress-related depression or can the risk be modified? The latter appears to be the case: in another important study, Kaufman et al (2004) showed that adequate social support protected maltreated children from the depressogenic effect of the short allele of the gene.
The serotonin transporter protein (5HTT)

The serotonin transporter protein (5HTT) is responsible for the reuptake of serotonin from the synaptic cleft. This protein, therefore, influences the intensity and duration of 5-HT signalling in the brain. Genetic variations in 5HTT influence diverse aspects of mental health. For example, the 5HTT gene, which is located on the short arm of chromosome 17, has been implicated in violent suicidal behavior (Courtet et al, 2001), in anxiety-related personality traits in women (Melke et al, 2001), and in depression subtypes (Willeit et al, 2003) and personality (Thierry et al, 2004) in patients with seasonal affective disorder. A rare mutation of this gene may result in OCD or obsessivecompulsive personality disorder (Ozaki et al, 2003).
5HTT gene-environment interaction and substance abuse

In the most recent study on the 5HTT gene-environment interaction, Brody et al (2009) studied 253 AfricanAmerican children and adolescents in rural Georgia, USA. The mean age of these subjects was nearly 12 years. Use of cigarettes, alcohol, cannabis, and other substances was ascertained from the participants through self-report. Mothers provided data on parenting practices. Given the young age of the sample at recruitment, substance use was expectedly very low at baseline. By age 14, however, 21% of subjects had smoked cigarettes, 42% had used alcohol, 5% reported occasions of heavy drinking, and 5% had used cannabis. This increase in substance use was examined in the context of 5HTT polymorphisms and the quality of parenting. There were two important findings: 1. Among children who received low levels of involvedsupportive parenting, substance use rose three-fold in those with one or two short alleles relative to those with two long alleles. 2. Among children who received high levels of involvedsupportive parenting, presence of the short allele did not increase the risk of substance use. The study therefore shows that the short allele of the serotonin transporter gene is associated with an increased risk of development of substance use in 5
The s/l 5HTT polymorphism

A functional polymorphism in the promoter region of the 5HTT gene has been described. This polymorphism is expressed as a short (s) or long (l) allele. The short allele is associated with a decrease in the level and activity of the 5HTT protein. The pattern of the s/l alleles in the genotype of an individual has been shown to influence the individuals behavior. For example, in separate meta-analyses, Lin and Tsai (2004) found that, in psychiatric subjects, the short allele was associated with an increased risk of violent suicide; alcoholic persons were particularly at risk. In a later meta-analysis, Li and He (2007) found that the presence of the ll genotype was associated with a 22% reduction in the risk of suicide; however, there were gender and ethnic differences in the results.
5HTT gene-environment interaction and depression

Very interestingly, the pattern of the 5HTT s/l alleles present in the genotype of an individual has also been shown to modulate the influence of the environment on Archives of Indian Psychiatry 10(2) October 2009
Chittaranjan Andrade : 5HTT Gene-Environment Interactions children and adolescents. Importantly, this risk is neutralized by involved-supportive parenting. behavior and the low activity allele of the serotonin transporter gene. Mol Psychiatry 2001; 6: 338-341. Kaufman J, Yang B-Z, Douglas-Palumberi H, Houshyar S, Lipschitz D, Krystal JH et al. Social supports and serotonin transporter gene moderate depression in maltreated children. PNAS 2004; 49: 17316-17321. Li D, He, L. Meta-analysis supports association between serotonin transporter (5-HTT) and suicidal behavior. Mol Psychiatry 2007; 12: 47-54. Lin P-Y, Tsai G. Association between serotonin transporter gene promoter polymorphism and suicide: results of a metaanalysis. Biol Psychiatry 2004; 55: 1023-1030. Melke J, Landen M, Baghei F, Rosmond R, Holm G, Bjorntorp P et al. Serotonin transporter gene polymorphisms are associated with anxiety-related personality traits in women. Am J Med Genet 2001; 105: 458-463.
Take-home message
This series of studies tells us that adverse environmental influences are depressogenic or increase the risk of substance abuse in persons with the s allele of the 5-HT transporter gene. However, supportive environmental influences buffer the risk. These data provide strong support for the importance of social and environmental efforts to mitigate genetic risk factors in psychiatry.
Parting note
The 5HTT gene polymorphism is a good example not only of how a gene may influence the experience of certain symptoms but, more dramatically, also of how a gene may influence the expression of a specific behavior. If the output of a computer is a function of the software which is running, so too is the behavior of a human being a function of the DNA which is expressed. However, the influence of the DNA is not invariable, but is modified by constitutional and environmental factors.
Ozaki N, Goldman D, Kaye WH, Plotnicov K, Greenberg

BD, Lappalainen J et al. Serotonin transporter missense mutation associated with a complex neuropsychiatric phenotype. Mol Psychiatry 2003; 8: 933-936. Thierry N, Willeit M, Praschak-Rieder N, Zill P, Hornik K, Neumeister A et al. Serotonin transporter promoter gene polymorphic region (5-HTTLPR) and personality in female patients with seasonal affective disorder and in healthy controls. Eur Neuropsychopharmacol 2004; 14: 53-58. Willeit M, Praschak-Rieder N, Neumeister A, Zill P, Leisch F, Stastny J et al. A polymorphism (5-HTTLPR) in the serotonin transporter promoter gene is associated with DSM-IV depression subtypes in seasonal affective disorder. Mol Psychiatry 2003; 8: 942-946.
References
Brody GH, Beach SRH, Philibert RA, Chen Y-f, Lei M-K, Murry VM. Parenting moderates a genetic vulnerability factor in longitudinal increases in youths substance use. J Consult Clin Psychol 2009; 77: 1-11. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 2003; 301: 386-389. Courtet P, Baud P, Abbar M, Boulenger JP, Castelnau D, Mouthon D et al. Association between violent suicidal
Chittaranjan Andrade, M.D. Professor and Head, Department of Psychopharmacology National Institute of Mental Health and Neurosciences Bangalore 560 029, India e-mail: andradec@gmail.com; andrade@nimhans.kar.nic.in
Overview
Night Eating Syndrome: an overview

Ameya Amritwar Nilesh Shah
Abstract : A less known eating disorder Night Eating syndrome (NES) characterised by morning aphagia, evening hyperphagia and sleep disturbances for a period of at least three months has been described. Exact pathophysiology of this disorder remains elusive in spite of behavioural and Neuro-endocrinological studies and considered to variously to be a sleep disorder, eating disorder or disorder of circadian rhythm. This disorder is associated with stress reaction, abstinence from substance or smoking and many other psychiatric manifestations; apart from significant weight gain and associated metabolic problems. This disorder is thought to exist in significant number of general population, more than that of some more widely discussed eating disorders like anorexia. A multiple reported studies have shown high prevalence of this disorder in obese patients and psychiatric patients in western countries. No such data exists for Indian population. This overview attempts to present Night Eating Syndrome and recent developments in it. Key words : Night eating disorder, etiology. clinical features, diagnosis, management
Introduction
Night Eating Disorder (NES) characterised by lack of appetite in the morning, overeating at night with agitation, sleep disturbances (waking up at least once on most nights of the week to consume food) lasting for at least for a period of three months was first reported by Stunkard, in 1955[1,2,3]. Considered variously as sleep disorder, eating disorder or disorder of circadian rhythm, the exact pathophysiology remains to be understood. There may also be associated dysphoria, specially in evening hours [1,2,3] . This 28 and 29-38years, respectively. No preponderance of males or females, any particular diet type, socioeconomic status, education, type of work or shift duty timings etc. was noted, though 4 female patients (50% of patients) were homemakers. No obvious relationship between psychiatric illness, duration of illness or treatment could be observed. Three patients were obese
(BMI > 30), two overweight (BMI 25-30), and rest three were normal weight [36,37,38]. None of diagnosed patients reported any family history, but two of the 142 screened patients who did not have NES reported that one or more of their family members had symptoms fulfilling criterion of NES, giving overall prevalence of NES reported in family members to be 1.5%.
Aetiology
Though various behavioural and neuroendocrine studies have been carried out, the exact pathophysiology remains elusive. Considered variously as sleep disorder, eating disorder or disorder of circadian rhythm; strongest evidence supporting the latter comes from neuroendocrine studies. The neuroendocrine characteristics have been described as changes in the circadian rhythm by attenuation in the nocturnal rise of the plasma
A case vignette:
Mrs. A, a 47 year old patient was diagnosed as Major Depressive Disorder about 5 years back, when she presented with complaints of pervasive sadness of mood, lethargy, not being able to work, not enjoying activities she enjoyed earlier; following a stressor at home. Patient weighed about 80 kilograms with a height of 154 centimetres, some 10-16 kilograms overweight. Patient also had blood pressure on higher side for which she was advised small dose antihypertensive medication by a physician along with strict instruction for weight reduction. Over a period of time patient was tried on various antidepressants with best control of her symptoms achieved with combination of Mirtazepine (30 m.g.) and amitriptylene (125 m.g.), on which she is maintained for more than a year. One major problem remained though, or even worsened; and it was patients ever increasing weight. Within a span of 5 years patient had gained considerably to 112 kilograms. Her antihypertensive medication increased in similar proportions. All the investigations such as thyroid profile, gynaecological investigations turned out normal. No amount of counselling, dietary restrictions would prove to be of any use in bringing her weight down. To add to it all, patient always claimed that she barely ate anything in the day. Finally, out of pure frustration; patient was asked whether she ate anything in the night. We were taken by surprise, when patient accepted having multiple sessions of consuming food in the night, at least 4-5 days per week. Her reported intake in the night was much more than what she ate in the day, mostly in the form of sweets and milk products. She was having these symptoms for more than 2-3 years. She was our first case of NES. Archives of Indian Psychiatry 10(2) October 2009 7
Ameya Amritwar : Night Eating Syndrome concentrations of melatonin (the sleep inducing hormone) and leptin (satiety producing hormone) and an increased circadian secretion of cortisol (stress related hormone). The night eaters also have an over expressed hypothalamic-pituitary-adrenal axis with an attenuated response to stress, as expressed by an attenuated ACTH and cortisol response. In conclusion the mechanisms behind the increased CRH stimulation may involve alterations in the neurotransmitter systems, causing increased nocturnal appetite and disruption in the sleep pattern. This may, to some extent, explain the disturbances in the circadian secretions of melatonin and leptin and the behavioural characteristics of the night eating syndrome. Some disturbances regarding blood glucose levels and insulin levels have also been reported, causing their rise in the night hours [4]. Recently SPECT study has shown significant elevation in the serotonin transporters in midbrain of night eaters. This elevation may result as the established heritability of NES; which may be triggered by the stress that night eaters report. Elevation in the serotonin transporter levels lead to decreased post synaptic serotonin transmission which is thought to impair circadian rhythm and satiety [11]. Psychological and emotional components may be important in precipitation but not well understood. Some of the factors commonly associated with onset of NES are acute stress reaction, abstinence from alcohol or opiates/ cocaine abuse and cessation of cigarette smoking. . Various sleep laboratory studies have also been carried out in patients with NES, which is been considered a parasomnia and sometimes even a rare variety of sleep walking. NES is often accompanied by or confused with sleep-related eating disorder, which is primarily a sleep disorder rather than an eating disorder, in which people are unaware of having eaten while asleep. Whilst there is a debate whether night eating disorders are eating disorders or sleep disorders it has become clear that investigating the sleep characteristics is worthwhile. Various sleep disorders found in individuals who have been investigated in a sleep laboratory or sleep disorders centre are Sleep walking, Periodic Limb Movement (PLM), Obstructive Sleep Apnoea (OSA), Irregular sleep/wake pattern disorder, Familial restless legs syndrome, as reported in various studies by Manni et al., 1997; Schenck et al., 1993; Schenck and Mahowald, 1994; Schenck and Mahowald, 2000; Winkelman, 1998; Winkelman et al., 1999 [17,18,19] . In one of the studies, a strong familial component is also reported [35]. Some studies mention possible relationship with antipsychotic medication, specially atypical antipsychotics [12,2]. such night eating syndrome in people who diet during the day and overeat at night, though it was never thought of as a psychiatric illness. Patient delays first meal for several hours after waking up. The patient is not hungry or is upset about how much was eaten the night before. The patient eats more food after dinner than during that meal and consumes more than half of daily food intake after dinner but before breakfast the next day. The patient may leave the bed to snack at night several times. This pattern must persist for at least two to three months. Person feels tense, anxious, upset, or guilty while eating. NES is thought to be stress related and is often accompanied by depression. Especially at night the person may be moody, tense, anxious, nervous, agitated, etc. Patient has trouble falling asleep or staying asleep. Patient has to Wake up frequently and then often eat to fall back to sound sleep. Foods ingested are often carbohydrates: sugary and starch. Behaviour is not like binge eating which is done in relatively short episodes. Night-eating syndrome involves continual eating throughout evening hours. This eating produces guilt and shame, not enjoyment. This disorder can start at any age. Psychological components are thought to be important in precipitation, but are not absolutely necessary features of NES. Though commonly seen in overweight or obese individuals, this is not necessary criteria for diagnosis as up to half the patients suffering from NES may be of normal weight [6,13]. Our study corroborated the reported clinical features from western studies. Almost all patients had no appetite in the morning, had delayed their first food consumption for the day beyond 12:00 noon but consumed food before 3:00 pm. As evening passed by, their consumption of food went on increasing in quantity and frequency; continuing well in to the night. Patients had severe craving for food even following dinner, and all of them consumed some or the other snacks, and sometimes the same food cooked for the supper before retiring to the bed. All experienced difficulty in initiating sleep, which was characterised by awakenings at least 1-2 times/night(avg. 2 awakenings/ night. ranging from 1-4).This would happen at least 3-4 times/week(avg. 3.4). All patients required to consume food to get back to sound sleep. Time most frequently reported for such awakening was between 12:01 am to 2:00 am, followed by 10:00 pm -12:00 am. This is not consistent with binge pattern, as consumption is spread over few hours. All patients were completely aware of their night eating. One patient experienced amelioration of symptoms on stopping olanzapine, where as other patient had relief when fluvoxetine was added to the medications. Most of these patients reported dysphoric mood though not fulfilling criterion for MDD. One patient claimed to have started with the symptoms on adding clozapin to medications. Three of the eight patients were receiving clozapin for treatment. One patient had NES symptoms well before starting any psychiatric treatment and has been experiencing these symptoms for about a decade. Most other patients (5) are experiencing the symptoms for past 1 to 2 years.
Clinical Features
The patient suffering from NES has little or no appetite for breakfast. Proverbial term Refrigerator Raids a common phenomenon proverbially talked about with reference to 8
Ameya Amritwar : Night Eating Syndrome All the patients preferentially consumed sweet food, such as 3-4 pieces of Mava-mithai, Falooda and rice mixed with sweet milk and sometimes up to a dozen of bananas as reported by a patient. Others consumed 2-3 packs Glucose biscuits and 2-3 packs of potato chips which they kept stored in house to avoid any discomfort in the night just like their western counterparts, as reported. None of our patients reported any form of sleep disorders or benzodiazepine abuse which were found to be commonly associated with NES by Manni, Schenck , Mahowald, Winkelman in various sleep laboratory studies[17,18,19]
Management
Treatment for this condition is tricky [33]. Researchers have variously used Cognitive Behavioural Therapy [35,36], dietary modifications, various pharmacotherapy or combination of both for treatment [35]. Pharmacotherapy includes melatonin, leptins given therapeutically as suggested by their deficiency in the evening in these patients [4,9,10]. According to J.A.M.A. (Journal of American Medical Association), carbohydrate containing foods tend to increase serotonin, and they are preferentially consumed by NES patients [10]. Stunkard even has suggested diet rich in tryptophan, such as pea-nut butter which helps in increasing serotonin in body to be consumed by the NES patients [3,4,7,10]. Sleep inducing effect of these foods theoretically implied that SSRI; which increase serotonin concentration in the brain might be useful in this condition, assumption which was also supported by successful use of Sertraline in double blind trials and recent demonstration of elevated serotonin transporters in midbrain of these patients, causing serotonin deficiency in synaptic clefts [11]. There have been reports of other two SSRIs namely paroxetine and fluoxetine being equally effective. These trials have reported a remission rate in excess of 75% [32,33,34] .The combination of pharmacotherapy with cognitive behavioural therapy seems to produce better and sustained improvement [35]. Reports of such specific and effective treatment for NES have further strengthened the claims for identification and inclusion of NES as distinct disorder in DSM [11].
Diagnosis
NES has not been formally included in the DSM or ICD as a separate disorder and diagnostic criterion have somewhat changed since its original description by Dr. Albert Stunkard. Though the standard criterion for diagnosis require symptoms in form of 1) Morning anorexia 2) Evening hyperphagia 3) Multiple sleep awakenings associated with craving for food and food consumption on at least three nights per week; the total proportion of daily calorie intake to be taken after dinner to qualify as NES has been variously quoted as 25% in original paper presented by Dr. Albert Stunkard in 1955 [1] to about 1/3 according to some references, and now it is accepted by many researchers that at least 50% of daily calorie intake should be following dinner to qualify for NES[4,8,9,10,12,13]. There are differences among researchers as whether to count desserts after dinner for calorie intake for NES or no [8,9,10] . This has resulted in some diagnostic variations by various researchers. Primary tool used for identifying NES patients by most researchers has been Night eating Syndrome Questionnaire [8,19], devised by Centre for Weight and Eating Disorder, Department of psychiatry, University of Pennsylvania, school of medicine; the pioneering institute in research on NES. This questioner has sixteen questions regarding symptoms and phenomenological aspects of NES. A total score of twenty or more is considered diagnostic of NES [8]. Before a patient is considered for diagnosis of NES, other disorders which may intermittently produce picture similar to NES, for example D.M. which may lead to nocturnal hunger and food consumption should be ruled out. Other sleep disorder such as sleep related eating disorder, where patient doesnt remember about his/her night consumption or obstructive sleep apnoea, where patient may have multiple awakenings which may or may not be associated with food or water consumption should also be ruled out with appropriate history. Some times even occupational factors such as shift duties may have adverse effect on sleep-wake cycle and may produce clinical picture which may be confused with NES [17,18,19,20]. In our study we utilised NES questionnaire for screening and diagnosis. To calculate total amount screening and diagnosis. To calculate total amount of consumed calories and their proportion after dinner, we used standard calorific value for Indian food items [42,43,44]. BMI was calculated using standard formulae [38,39,40,41] Archives of Indian Psychiatry 10(2) October 2009
References
1. Stunkard AJ, Grace WJ, Wolf HG: The night-eating syndrome. American Journal of Medicine. 1955; 19:7886 Leder Mh, Cardinalli DP, Pand-parumal SR(eds).Sleep & sleep disorder: A neurophysiological approach: Springer; 2006.Birketvedt GS, florholmen JR.28:251. OReardon JP, Ringel BL, Dinges DF, Allison KC, Rogers NS, Martino NS, Stunkard AJ: Circadian eating and sleeping patterns in the night eating syndrome. Obesity Research 2004; 12:17891796 Allison KC, Ahima RS, OReardon JP, Dinges DF, Sharma V, Cummings DE, Heo M, Martino NS, Stunkard AJ. Neuroendocrine profiles associated with energy intake, sleep and stress in NES. Journal of clinical endocrinology and metabolism.nov 2005; 90(11): 6214-17 Rand CSW, Macgregor MD, Stunkard AJ: The night eating syndrome in the general population and amongst post-operative obesity surgery patients. Int J Eat Disord 1997; 22:6569 Marshall HM, Allison KC, OReardon JP, Birketvedt G, Stunkard AJ: Night eating syndrome among nonobese persons. International Journal of Eating Disorders 2004; 35:217-22 9
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Ameya Amritwar : Night Eating Syndrome 7. Stunkard AJ, Berkowitz R, Wadden T, Tanrikut C, Reiss E, Young L: Binge eating disorder and the night-eating syndrome. Int J Obes 1996; 20:16 Centre for Weight and Eating Disorder, Department of psychiatry, University of Pennsylvania, school of medicine. Night eating Syndrome Questionnaire. Available at www.med.upenn.edu/weight/night eating.shtml-5k Fairburn C, Brown KD. Eating disorders and obesitya comprehensive hand book. 2nd edition. Guilford Press:USA;2002 Birketvedt GS, florholmen JR, Sundsford J, Osterud B, Dinges D, Bilker W, Stunkard A. Behavioural and neuroendocrine characteristics of NES. Journal of American Med. Association (J.A.M.A).1999.Aug 18;282: 657-663 Allison KC, Wintering N, Stunkard AJ, Lundgren JD. Issues for DSM V: Night Eating Syndrome. Am J psychiatry; April 2008, 165: 4 Allison KC, Carlos MG, Masheb MR, Stunkard AJ. High self reported rates of neglect and self abuse by persons with binge eating disorders and night eating syndrome. Obesity (silver spring).2007 May; 15(5):1287-93 Anderson GS, Stunkard AJ, Sorenson TI, Peterson L, Heitmann TL. Night Eating and weight changes in middle aged men and women. Int J Obes relat Metab disorders 2004;28: 1338-1343 Lundgren JD, Allison KC, Crow S, Odeurdon JP, Berg KC, Galbraith J, Martino NS, Stunkard AJ. Prevalence of NES among people with psychiatric conditions. American Journal of psychiatry (A.J.P).2006;163:153156 Hoek HW: The distribution of eating disorders, in Eating Disorders and Obesity: A Comprehensive Handbook. Edited by Brownell KD, Fairburn CG. New York, Guilford, 1995, pp 207-211 22. Jillon S. Vander Wal , , , , Sandia M. Waller, David M. Klurfeld, Michael I. McBurney and Nikhil V. Dhurandhar. Night eating syndrome: Evaluation of two screening instruments. Eating Behaviours, vol. 6, issue 1, Jan. 2005,63-67 23. Debases Bagchi, Harry G. Obesity : epidemiology, pathophysiology and prevention. CRC press. Tyler and Fransis. Review available at http://books.google.co.in/books 24. Heather Mudget, write s group. Night eating Syndrome and nocturnal sleep eating disorders. Available at http://www.suite101.com/article.cfm/ eating_disorders/89879 25. Wadden T, Stunkard J. Hand book of Obesity treatment. Guilford press:USA;2002 26. Diagnose Me.com. Night Eating Syndrome. Available at http://www.diagnose_me.com/cond/c303927.html 27. Anorexia Nervosa and related Eating disorders (ANRED), Inc2005. Available at http://www.anred.com/nes.html 28. Stunkard A, Berkowthz R, Wadden T, Tantricut C, Reiss E, Young L Binge eating and night eating syndrome. International Journal of Obesity and Related Metabolic disorders.1996.Jan;20(1):1-6 29. Sleep doctor. Night Eating Syndrome. Available..at.sleepdoctor.blogspot.com/2006/01/ night-eating-syndrome-nes.html 30. Selfgrowth.com1996-2009.Night Eating Syndromea case report. Available at:www.Selfgrowth.com/ article/Night-Eating-Syndrome.html. 31. Wikipedia, the free encyclopaedia. Night Eating Syndrome. Available at http://en.wikipedia.org/wiki/ night-eating-syndrome 32. APA guidelines for treatment-2006 sertralin may be effective in NES 33. Barkley L, Vega C. Sertralin may be effective for night eating syndrome. American journal of psychiatry.2006;163:893-898 34. OReardon JP, Allison KC, Martino NS, Lundgren JD, Heo M, Stunkard AJ: A randomized placebo-controlled trial of sertraline in the treatment of the night eating syndrome. American Journal of Psychiatry (in press) 35. Allison KC, Stunkard AJ, Thair SL. Overcoming NESa step by step guide in breaking the cycle. New Harbinger Publication; 1st edition: May 2004 36. Hilt E. Relaxation may help prevent NES. International journal of obesity and related metabolic disorder.2002:vol 21;342-356 37. Allison KS, Lundgren j, Stunkard AJ. Familial aggregation in NES. International Journal of Eating Disorders,2006:vol39;516-518 38. h t t p : / / w w w. m e t l i f e . c o m / L i f e a d v i c e / To o l s / Heightnweight/Dcmen.html 39. Harrison GG.Height-weight tables. Ann Intern Med 1985;103:489-94
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16. Bulik CM, Sullivan PF, Carter FA, Joyce PR: Lifetime comorbidity of alcohol dependence in women with bulimia nervosa. Addiction and Behaviour 1997; 22:437446 17. Adami j. Night eating in obesity: a descriptive study. Nutrition , Volume 18 , Issue 8 , 587 - 589 G 18. Manni, R., Ratti, M.T., and Tartara, A. (1997) Nocturnal eating: prevalence and features in 120 insomniac referrals. Sleep 20, 734-738. 19. Schenck, C.H., Hurwitz, T.D., OConnor, K.A., and Mahowald, M.W. (1993) Additional categories of sleep-related eating disorders and the current status of treatment. Sleep 16, 457-466. 20. Schenck, C.H. and Mahowald, M.W. (1994) Review of nocturnal sleep-related eating disorders. Int J Eat Disord 15, 343-356. 21. Winkelman, J.W. (1998) Clinical and polysomnographic features of sleep-related eating disorder. J Clin Psychiatry 59, 14-19.
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Ameya Amritwar : Night Eating Syndrome 40. Pai MP, Paloucek FP. The origin of the Ideal body weight equations. Annual Pharmacology.2000; 34:1066-69 41. Wikepedia, the free encyclopaedia. Body Mass Index. 42. weightlossresourses.co.uk.Indian food calorie content. Available at http://www.weightlossresoursec.co.uk/calories/ clorie-content/Indian-food.htm 43. Kellow j. Eating out on a diet Indian food. New harbinger publication: 2002;123-134 44. Bawarchi,Health and nutrition .Indian food calorie content available at: www.bawarchi.com/healthquerries.co.h
Dr.Ameya Amrritwar, Senior Resident Dr. Nilesh Shah, Professor and Head Dept. of Psychiatry, OPD 21, College Building, LTMMC, Sion Hospital, Mumbai 400022. e-mail : drnilshah@hotmail.com Tel: 022 24011984
11
Review Article
Developmental Psychopathology and its relevance to Child Psychiatry a Clinical Perspective
Avinash De Sousa Abstract

Today more so than ever child psychiatrists worldwide are looking at developmental factors to provide answers to causative factors in psychiatric disorders of children and adolescents as well as adults. This review looks at developmental psychopathology and its relevance to modern day clinical child psychiatry. It probes whether a developmental approach is an appropriate one while examining the influences of genes, environment and social factors in the genesis of child psychiatric disorders. It is looks at research new and old and proposes that a multimodal multi-pronged approach is needed when examining causative factors in various child psychiatric disorders. An approach combining psychology, development, neurosciences and genetics along with biology is a sound one. This paper also looks at the pitfalls of developmental psychopathology research so far and questions that remain to be answered along with research challenges that lie ahead (Key words: Developmental Psychopathology, Child Psychiatry)
Introduction
We have always been taught the importance of a good developmental history when it comes to determining possible causative factors in adult psychiatric disorders. The history of developmental psychopathology as a valuable and firm construct really began with the work of Achenbach. He argued that developmental dimensions should constitute the primary basis for the study of childhood and adult psychopathology and that it is not accept-able to view it as no more than a downward extension of adult mental dis-order. However, in making that point, he emphasized the crucial importance of scientific strategies to test developmental concepts, and noted the inadequacy of all the prevailing theories and concepts that paid little attention to childhood development. Developmental psychopathology has been defined by Achenbach as the study of various psychiatric disorders keeping in mind developmental factors that have contributed towards psychopathology and that affect the course of the disorder while studying the disorder from a lifespan perspective [1]. Many researchers later seconded his view. They had a lot in common, but with critical differences in opinion. They aimed for a bringing together of research into child development and into child psychi-atry but with the need to do so in diverse ways [2-3] . Traditionally developmental psychology has focused on developmental universals over time, whereas it is needed that it focuses on individual differences, life
events, role models, parents, parenting, peer influences and on the modifications and changes that occur with altered circumstances. Child psychiatry had tended to concentrate on the causes and course of individual diagnostic conditions and criteria for better diagnosis along with diagnostic stability over time. Developmental psychology accepted this but argued that a developmental perspective answers many more questions [4]. Some of the questions that developmental psychology addresses are based as to what extent are there agerelated variations in susceptibility to stress. Another is whether there are points in development when psychological qualities became relatively stabilized so that, although behavior might change, it was no longer possible for functioning to be to-tally transformed. For example we know that personality traits are modifiable in the first 20-30 years of life but this often becomes difficult as life moves on[5]. We also know of all the emphasis that has been laid on early intervention and treatment and how delaying treatment may have deleterious effects on prognosis of childhood disorders. Another issue is the reasons for developmental of psychiatric disorders across age groups with some peaking in childhood and some in adolescence [6-7]. Disorders like enuresis, separation anxiety often start in childhood compared to adolescence [8]. Dissociative disorders are commoner in adolescence and rare in childhood [9]. Childhood onset schizophrenia differs markedly in symptomatology than one with an adolescent onset[10]. It is well known that attention
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Avinash De Sousa : Developmental Psychopathology deficit disorder and school refusal behavior have different connotations when they present in childhood and in adolescence [11-12]. These authors were forthright in arguing that a lifespan perspective is essential and that developmental psychopathology perspectives apply as much to adult psychiatry as to child psychiatry. They stressed that develop-ment has to be viewed in terms of biology, culture, psychological development and not just early life experiences[13]. There is need today in child psychiatry to focus on causal processes by incorporating genetics and neuroscience as well as psychological studies in parallel models. There is also a need to recognize that diverse pathways could lead to the same end point and conversely, that a single developmental risk factor could have a range of disparate and variable effects across individuals[14]. For example early disruptive life events may cause anxiety disorders, conduct problems, schizophrenia or somatization in different individuals depending on discrete factors[15]. There is also an emphasis placed on age as an ambiguous variable, reflecting both variation in experiences and different aspects of maturation[16]. We often see children aged 12-14 years who due to life circumstances mature earlier than children who are 1518 years. This maturity is reflected even biologically in the myelination and maturation of their prefrontal cortex[17]. There are three ways today in which concepts have diverged. First, although all writers have implicitly accepted a lifespan view, some have had a main focus on child psy-chopathology[18-20], whereas others have made the lifespan orientation as central to their theory [21-22]. Second, some have seemed to wish to place developmental psychopathology outside of biology and medicine by adopting a nineteenth-century concept of medicine as pre-occupied with single basic causes for utterly distinct diseases unconnected with dimensional risk [23]. Others have seen medicine as providing some of the best examples of developmental psychopathology approaches[24]. Third, and most crucially of all, some have placed the history of develop-mental psychopathology in the writings of Freud, Piaget, and Erikson[25]. The limitations and fallacies of many old perspectives constitute the main reason for a need to have a new refreshing approach of developmental psy-chopathology. Differentiating Normality And Abnormality In Childhood From the outset, developmental psychopathology has been concerned with the extent to which disorder is on the same continuum as normal variation. Genetic findings have been informative, for example, in showing the need to broaden the concept of autism very substantially, with findings raising-queries as to whether the normal population varies in features reflecting a liability to autism[26]. Certain cultures promote violence which would be regarded across many cultures are conduct issues. Institu-tion-reared children who suffered severe deprivation prior to adoption show rather distinctive social relationship difficulties, as reflected in what has been termed disinhibited attachment, but this seems rather different from attachment insecurity as seen in general population samples[27].
The Effect Of Environment Genetic findings on gene-environment correlations led to an appreciation that there can be genetic mediation of the risks associated with adverse en-vironments[28]. A range of strategies to study genetic effects including the study of discordant monozygotic twins, and investigations of the children of twins, as well as the more familiar twin and adoptee designs, have been developed [29]. The result has been a convincing demonstration that there are truly environ-mentally mediated risks. It may be concluded that there are indeed environmental risks for psychopathology, but these extend back into the prenatal period and include physical as well as psychosocial hazards. A good rearing environment may suppress risky genes such that disorders may not manifest at all[30]. Early Life Experiences And Psychopathology The relevance of childrens experiences in and outside the family as possible risk or protective factors in relation to psychopathology had been a crucial part of the philosophy of the mental hygiene movement in the early years of the twentieth century, which constituted a major influence on the establish-ment of child guidance clinics. John Bowlby, via his attachment theory, placed the emphasis firmly on early caregiver-child social relationships in-stead of discipline or toileting practices. Bowlbys most important contribution was his integration of develop-mental psychology and biology and of human and animal research[31]. Harlow did much to force the world to recognize that love was a crucial element and not just stimulation and research into the mechanisms involved in the effects of mother-infant separation were underway via a theory of contact comfort[32-33]. There were also researches in both family re-lationships and stress experiences.
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Avinash De Sousa : Developmental Psychopathology It became clear that experiences had biological effects that played a part in bringing the environment inside biology, thereby provid-ing possible mechanisms for long-term effects. There was also research demonstrating the relevance of birth trauma, perinatal events, maternal responses to pregnancy and child birth, obstetrical complications and early life insults in the development of child psychiatric disorders[34]. Importance Of Early Life Experiences In Psychiatric Disorders Today, more than ever psychiatrists have accepted worldwide that a developmental perspective is essential for studying and understanding psychiatric disorders in adult life[35]. This has placed the neuro-developmental hypothesis for most psychiatric illness in mainstream thinking. This has already been accepted for cases of schizophrenia [36]. Depression in young people is associated with a high risk of major depression in adult life, and attention deficit hyperactivity disorder (ADHD) is followed by a substantial increase in psychiatric illnesses like adult ADHD, conduct problems, antisocial behavior, substance abuse and bipolar disorder in adult-hood [37-38]. The childhood psychiatric illness carrying the highest risk for adult psychopathology is conduct disorder and ADHD and must be treated appropriately at the right time. Child physical and sexual abuse long with childhood neglect is another important risk factor. Parenting styles, teacher influences, bullying and school atmosphere along with peers have also been shown to involve long-term risks[39-41]. Early Research In Developmental Psychopathology Much early research in developmental psychopathology was preoccupied with identifying the effect of some risk or protective factor in isolation from all others. Some researchers challenged this concept. They did not deny that effects could be independent, but they noted the frequency of two-way interplay in what they termed transactional effects[42]. In an influential paper published in 1968, the author argued that some of the supposed effects of social-ization experiences might derive from childrens effects on their rearing en-vironments, rather than the other way round [43]. Thomas and Chess, in their research on childrens temperamental styles, made much the same point [44] . Researchers also showed the importance of parent-child gene-environment correlations. Parental behavior had a passive influence on the rearing environment because parents transmitted both risky genes and risky environments. Child often have various risky genes that they inherit but environmental factors and life event triggers determine whether they manifest with the disorder. Child behavior had active effects because genetically influenced behaviors played a part in shaping and selecting environments and in evoking particular responses in other people[45]. Emergence Of Resilience As A Factor In Child Psychiatric Disorders Resilience, had its origins in the observation that people varied greatly in their re-sponse to stress and adversity. Some become severely impaired, some survive relatively unscathed, and a few appear even to be strengthened through cop-ing successfully with the hazards they face. It has to be said that the potential of the resilience concept still requires much better empir-ical study, but it constitutes a prime example of the developmental psychopathology focus on individual differences in developmental functioning [46]. The study of resilience comprises a growing body of work that has examined coping, hardiness, protective factors, positive youth development, personal and community assets and thriving. It is also related to the work done in positive psychology, strengths based social work and the study of salutogenesis in medicine [47] . Combined, these multiple threads have provided a theoretically sound set of principles that detail how children that face significant amounts of adversity manage not only to survive, but also thrive [48].
The Effect Of Age On Child Psychiatric Disorders Despite its centrality in developmental psychopathology concerns, age differ-ences in susceptibility have been investigated only to a very limited extent. The nature and degree of brain plasticity does change with age but we know surprisingly little about the mechanisms. It is known that myelination starts at 5-6 months of age and completes by 30-35 years of age. Changes in neuronal number, synaptic density and effects of hormones too vary across various age groups in different parts of the brain [49-50]. Antisocial behav-ior may exist in two forms i.e. life course-persistent antisocial behavior (which typically begins early and is associated with neurodevelopmental impairment) and an adolescence-limited variety, which is less strongly associated with risk factors both biological and experiential and is determined more by environment and life events[51]. The validity of this differentiation has been mainly supported by other research, but it is clear that an onset of conduct disorder in childhood does not usu-ally lead to life-long persistent problems [52]. The Role Of Genetic Factors Early claims in the field of behavioral genetics tended to use terms such as the gene for schizophrenia or bipolar disorder, with the misleading implication of a
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Avinash De Sousa : Developmental Psychopathology somewhat direct deterministic effect. In many circumstances, there is co-action between genes and environments, and it is misleading to conceptualize ef-fects as due to either nature or nurture[53]. Today we are sure that most psychiatric disorders are polygenic in nature and it is very difficult to blame genes alone for causation. Many gene loci that have been determined have not been replicated across various populations and few genetic causes like that for disorders like mental retardation as well as Retts syndrome have been firmly established[54]. For many years, few psychosocial researchers showed much interest in the varied mechanisms by which environments might have long-term effects[55]. Crossfoster-ing studies have shown that the effects are environmentally mediated, and neuro-chemical investigations have indicated that the mediation conies about through effects on gene expression. Environments cannot change gene se-quences, but they can change gene expression, which is a necessary process for genes to have effects[56-57]. Evidence from both human and animal studies suggests that there are biological programming effects from environmental influences dur-ing sensitive periods of development. A human example is provided by the longterm effects of institutional deprivation, which have been found to be surprisingly persistent and highly sensitive to specific developmental phases. There is increasing evidence on the neuro-endocrine ef-fects of acute and chronic stress experiences[58-59]. At present, we lack evidence on the role of the neuroendocrine changes on psychological sequelae, and that stands out as an important research challenge. It will also have to be seen whether diverse transcultural factors influence neurobiology and neuroendocrinology [60]. The New Epigenetic Concept Of Mental Illness The development of the idea and the first use of the term epigenotype occurred as far back as 1942. Conrad H. Waddington suggested the existence of epigenetic mechanisms to explain the control of gene expression programmes during development[65]. Implicit in the term epigenetics is that these mechanisms are labile and are erased and reset. Over the years the definition of epigenetics has shifted a little, such that these mechanisms are not limited to development only, although there is still an understanding that epigenetic marks controlling gene expression are stably transmitted through cell divisions. For the purposes of this review, epigenetics can be loosely defined as the transmission and perpetuation of coding information that is not based on alteration of the DNA sequence. These coding changes may be mediated via chemical marking of the DNA sequence itself (DNA methylation) and/or chemical tagging of histone proteins that bind DNA and are molecular tools by which gene expression levels are controlled. Today research has shown the contribution of epigenetic mechanisms to brain function, and consequently dysfunction in the form of neuropsychiatric disorders. In the classical sense epigenetics describe the machinery and process involved in regulating gene expression, particularly during development. In this respect we have outlined a sub-group of genes, namely those subject to genomic imprinting, for which the epigenetic control is very important and when this goes wrong can result in clinical conditions. Although it is not entirely clear at present, work from animal studies suggests that imprinted genes play an important role in the brain and may well contribute more generally to neuropsychiatric disorder in humans[66-67]. In addition to pre-programmed gene regulation, there is a growing body of evidence suggesting that epigenetic mechanisms may also provide a molecular memory of environmental experiences. This has been clearly shown in animal models[68] and indicated in studies of human twins[69]. In some circumstances the epigenetic changes simply reflect long-term changes in gene expression levels. However, alterations to the epigenetic code may not result in gross changes in gene expression per se, but provide an additional level of molecular information. A good example of this has been provided by studies of acute and chronic cocaine use in rats. These drug regimens give rise to subtly different histone modifications around the promoter of the FosB gene [70] , but not differences in expression per se. Instead, it is thought that this may underlie the fact that expression of the FosB gene variant, DFosB only partially desensitises to chronic cocaine treatment. Although clearly epigenetic mechanisms are of potential clinical relevance, a key question is whether
Neuro-Imaging And Developmental Psychopathology The development of structural and functional brain imaging initially positron emission tomography (PET), magnetic resonance spectroscopy (MRS) and then magnetic resonance im-aging (MRI)has opened up new possibilities to investigate brain-mind interconnections. Thus, studies of individuals with autism have produced evidence of differences in interconnectivity of brain functioning [61] . When combined with longitu-dinal studies, brain imaging may also throw light on the brain changes as-sociated with both neural development [62] and the development of psychopathology [63-64]. Serial studies in the same population across various ages may help determine neurobiological factors that determine psychopathology and its variations across the life span.
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Avinash De Sousa : Developmental Psychopathology they are accessible to pharmacological intervention. There are a number of histone deacetylase (HDAC) inhibitors and DNA methyltransferase inhibitors that are currently being used and/or tested as anticancer drugs [71]. However, how applicable these are to treating neuropsychiatric disorders is not clearalthough valproate has HDAC inhibitor properties and may, in part, exert its action through epigenetic effects on the schizophrenia candidate gene Reelin [72]. Currently a problem exists between the specificity of the epigenetic changes that may occur (i.e. specific modifications, key time points and discrete brain regions)[73-74] , and the general influence of HDAC and DNA methyltransferase inhibitors on gene expression. It is hoped that the ongoing epigenome project[75] and the development of more specific drugs may address these issues. The Need Of The Hour In keeping with the whole of science, but especially biomedical science, interdisciplinary collaboration has played a major role in the discoveries, and that will certainly continue to be the case. The particular challenge for clinical scientists is the need to develop exper-imental medicine in which there can be a two-way interplay between clinical advances and scientific advances, and not just the mechanized application at the bedside of findings deriving from basic science[76]. The big questions that demand our attention involve five key issues. 1. Given the evidence on the importance of multiphase causal pathways, what are the mechanisms involved in phase transitions such as those from the precursors and prodromata of schizophrenia to overt psycho-sis? Or from early physical aggression or disruptive behavior or inattention / overactivity to life course-persistent antisocial behavior and antisocial personality disorder. 2. What are the causal processes involved in the direct and indirect pathways from the presence of a susceptibility gene, on through gene expression, to manifestations of particular phenotypes ? What is the im-portance of gene actions through geneenvironment correlations and interactions ? How do genes and environments come together in causal pathways in either normal development or psychopathology ? 3. How do the neural changes involved in brain development relate to the alterations in the workings of the mind as they apply across both the span of development and psychopathology. 4. What are the causal mechanisms involved in individual differences in responses to stress and adversity ? What is the role of personal agency in successful coping with stress and adver-sity? The development of positive, rather than negative, mental sets or internal working models seems likely to be important, but how do such sets develop and how do they operate ? 8. 5. What underlies the age differences we see in rates and patterns of psy-chopathology and in styles of response to psychosocial hazards or to physical substances? A central tenet of developmental psychopathology is that children are not just little adults, but what are the processes in-volved in ageindexed variations ? We need to look at newer diagnoses that could be incorporated in DSM-V keeping developmental psychopathology in mind. Developmental Trauma Disorder as suggested by some researchers to encompass the multiple traumatic events a subject may undergo during the developmental phase is one such example [77]. We also need to focus on complex comorbidities (more than 5 child psychiatric diagnoses existing together) that exist in child psychiatry and find integrative treatments that focus on this disorders as a spectrum rather than looking at them as individual disorders [78]. We also need to integrate the findings of neurobiology and psychological factors along with a developmental psychopathological perspective to gain fresh insight into issues like the links between ADHD and mood disorders, ADHD and antisocial personality disorders, causation of autism spectrum disorders and the role of resilience and temperamental adversity and ADHD. Of course, clinical practice in psychiatry or psychology or pediatrics raises a host of Issues beyond these, but the importance of developmental psychopathology lies in its role in making us frame particular sorts of ques-tions about development and about psychopathology, and in suggesting what might be useful research strategies to pursue. Developmental psychopathology is not, and should not become, a big theory or ideology Also, it con-stitutes a central feature in the whole of biology and of medicine, and we need to ensure that we do not cut ourselves off from these broader fields. The pioneers who paved the way to the growth of developmental psychopathol-ogy tended to be iconoclasts who challenged set ways of thinking and who re-fused to accept the given wisdom just because it came from senior figures who held positions of power. We should follow their model and do the same in pursuing our interest in taking developmental psychopathology forward.
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56. Rutter M. Implications of resilience concepts for scientific understanding. Ann NY Acad Sci 2006 ; 1094 : 1-12. 57. Weaver ICG, Cervoni N, Champagne NA. Epigenetic programming by maternal behavior. Nat Neurosci 2004 ; 7 : 847-854. 58. McEwen B, Lasley EN. The End of Stress as We Know It. Washington DC : Joseph Henry Press ; 2002. 59. Gunnar M, Quevedo K. The neurobiology of stress and development. Annu Rev Psychol 2007 ; 58 : 145-173. 60. Kartmann F. Transcultural Psychiatry : from practice to theory. Transcult Psychiatry 2010 ; 47(2) : 203-223. 61. Frith U. Autism : explaining the enigma. Oxford : UK Blackwell ; 2003. 62. Sroufe A. Psychopathology as an outcome of development. Dev Psychopathol 1997 ; 9 : 251-268. 63. Rapoport JL, Addington AM, Frangou S. The neurodevelopmental model of schizophrenia : update 2005. Mol Psychiatry 2005 ; 10 : 1-16. 64. Suomi SJ. Aggression and social behavior in rhesus monkeys. Novartis Foundn Symp 2005 ; 268 : 216226. 65. Waddington CH. The epigenotype. Endeavour 1942; 1 : 18-20. 66. Isles AR, Wilkinson LS. Imprinted genes, cognition and behavior. Trends Cogn Sci 2000 ; 4 : 309-318. 67. Isles AR, Davies W, Wilkinson LS. Genomic imprinting and the social brain. Philos Trans R Soc Lond B Biol Sci 2006 ; 361 : 2229-2237. 68. Jirtle RL, Skinner MK. Environmental epigenomics and disease susceptibility. Nat Rev Genet 2007 ; 8 : 253-262. 69. Zoghbi HY. Postnatal neurodevelopmental disorders : meeting at the synapse. Science 2003 ; 302 : 826-830. 70. Richards EJ. Inherited epigenetic variation : revisiting soft inheritance. Nat Rev Genet 2006 ; 7 : 395-401.
43. Bell RQ. A reinterpretation of the direction of effects in studies of socialization. Psychol Rev 1968 ; 75 : 81-95. 44. Thomas A, Chess S, Birch HG. Temperament and Behavior Disorders. New York : New York University Press ; 1968. 45. Plomin R, Bergeman CS. The nature of nurture : genetic influences on environmental measures. Behav Brain Sci 1987 ; 14 : 373-427. 46. Charney KDS. Psychobiological mechanisms of resilience and vulnerability for successful adaptation to extreme stress. Am J Psychiatry 2004; 161 : 195-216. 47. Masten AS. Registering progress and risk resilience in adolescent development. Ann NY Acad Sci 2004 ; 1021 : 310-319. 48. Walsh F. Family resilience : a framework for clinical practice. Fam Process 2003 ; 42(1) : 1-18. 49. Calabrese F, Molteni R, Racagni G, Riva MA. Neuronal plasticity : a link between stress and mood disorders. Psychoneuroendocrinol 2009 ; 34(suppl 1) : S208-S216. 50. Berluchi G, Buchtel HA. Neuronal plasticity : historical roots and the evolution of meaning. Exp Brain Res 2009 ; 192(3) : 307-319. 51. Moffitt TE. Adolescence limited and life course persistent antisocial behavior : a developmental taxonomy. Psychol Rev 1993 ; 100 : 674-701.
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Avinash De Sousa : Developmental Psychopathology 71. Laird PW. Cancer epigenetics. Hum Mol Genet 2005 ; 14(1) : R65-R76. 72. Dong E, Agis-Balboa RC, Simonini MV, Grayson DR, Costa E, Guidotti A. Reelin and glutamic acid decarboxylase 67 promoter remodeling in an epigenetic methionine induced mouse model of schizophrenia. Proc Natl Acad Sci USA 2005 ; 102 : 12578-12583. 73. Vu TH, Hoffmann AR. Imprinting of the Angelman syndrome gene UBE3A is restricted to the brain. Nat Genet 1997 ; 17 : 12-13. 74. Champagne FA, Curley JP. How social experiences change the brain. Curr Opin Neurobiol 2005 ; 15 : 704-709. 75. Bradbury J. Human Epigenome Project. PLoS Biol, 1, e82. 76. Hudziak JJ. Developmental Psychopathology and Wellness : Genetic and Environmental Influences. Washington DC : American Psychiatric Publishing; 2008. 77. De Bellis M. Developmental traumatology. Psychoneuroendocrinol 2001 ; 27 : 155-170. 78. Caron C, Rutter M. Comorbidity in child psychopathology : concepts, issues and research strategies. J Child Psychol Psychiatry 1991 ; 32(7) : 1063-1080.
Sources of support : None Dr. Avinash De Sousa MD, DPM, MS, MBA, DPH, DHA Consultant Psychiatrist Visiting School Psychiatrist Mumbai
Conflict of Interest : None
Address for correspondence Carmel, 18 St. Francis Road, Off SV Road, Santacruz (W), Mumbai-54. Phone : 91-22-26460002 e-mail: avinashdes999@yahoo.co.uk
19
Review Article
Who cares for caregivers?

Pooja Dangar Parag S. Shah
Abstract Legal, social and economic factors have changed the mental health care delivery system. Persons with mental illness are now treated in the community and they live with or in close proximity to their family. The burden, stress, and socioeconomic effects on the people caring for them are not sufficiently appreciated. The societal neglect is evident from the absence of any established framework that protects their rights. Health professionals and policy makers need to develop greater insight into the care giving experience, interact with caregivers more collaboratively, and implement strategies that facilitate better outcomes for all family members. It is important to help them to protect their individuality, provide support, respite care, legal protection, respect and consideration for the role they perform. It is the need of the hour to realize that all individuals including caregivers have basic human rights that need to be addressed. Key Words: Mental health, Caregivers, Rights
Introduction Historically, people who have mental disorders were isolated from society in large stand-alone mental institutions on the outskirts of cities. The health care philosophy that sustained these large institutions also perpetuated the image that these people were dangerous and, therefore, unable to live in society. In the 1960s, the shift from hospital to community-based care was supposed to reduce the load on hospitals, help early recovery and prevent chronic disability among mentally ill persons as well as effect substantial savings for indoor hospital care. But this policy of treating mentally ill people in the community could not exist without the family members who almost always bear the main burden of care. Families play an increasingly important role in facilitating the provision of mental health services in the community. Carers are referred to in literature as the glue that holds the system together (Chapman, 1997) and the paraprofessionals who play a significant role in the service delivery system (Abramowitz et al, 1989). Who Are the Carers? Caregivers are the person most closely engaged in a patients experience with illness and also involved in maintaining a persons ability to live independently at home. In this care giving process, carers life is in some way restricted by the need to be responsible for the care of the patient. They have been referred to as the primary source of care for persons with a severe illnessthey provide housing, financial aid, companionship and emotional support (Pickett-Schenk et al, 2000). Family members rarely become carers by making a rational decision about what they are going to do with their lives, rather, the caring role creeps up on them, as it becomes clear that their relative is going to need help for much longer. In a country like India (a home of one sixth of worlds mentally ill); families are the main caregivers for patients suffering from psychiatric illness. 20
Burden of Care Individuals perform multiple roles in life such as family role, occupational role and social role. Becoming a caregiver introduces additional role and therefore requires some rearrangement of priorities and redirection of resources. The average amount of time that caregivers spend on care giving is about 20 hours per week. Even more time is required when the care receiver has multiple disabilities. The presence of ill person at home affects all family members, problems occur in the areas of health, recreational activities, social and marital relations, along with finances. Factors contributing to the burden are: Changing Societal structure: the societal structure has changed due to factors like small families, nuclear families, working woman, increasing rate of marital breakdown, migration to different cities and social isolation. This combination leaves smaller family units shouldering responsibilities for increasing caregiving demands. (Kapoor, 1992; Sethi et al, 1978). Increased survival of patients: With latest advances in medical science, survival of patients with illness / disabilities has risen. In Australia, one person in five will at some stage in their life experience the burden of a major mental disorder (Australian Bureau of Statistics, 1998). About 1.25 million American families live with persistently mentally ill members. A fundamental lack of services in the community: It leads to an over-reliance on family members. Despite their central role in the healthcare of their relative with an illness, only a minority of carers receives services from health agencies (Dixon et al, 2000). World Health Report 2001 stated that 40% of the countries in the world dont have mental health policy and over 30% have no special programs related to mental and behavioral disorders. Moreover, health plans most often dont cover mental and behavioral disorders unlike other illness. Archives of Indian Psychiatry 10(2) October 2009
Pooja Dangar : Who cares for caregivers? Literature mentions about both objective and subjective burden placed on the caregivers. Objective burden (Reay-Young, 2000) can be: Economic losses: Financial losses, inability to maintain current employment status, loss of newer opportunities and potential for professional development are the problems faced by carers in their routine life (Abramowitz et al, 1989; Brady, 1996; British Columbia Ministry of Health, 1993; Berry, 1997; Chapman, 1997). Impaired physical health: In a study conducted by the NSF in 1997, over 70% of carers surveyed felt that their health had suffered because of their caring role. Disruption of relationships: Familial relationships can suffer due to patients behavior which can be extremely difficult to cope with or disruptive. (Abramowitz et al, 1989; Brady, 1996; British Columbia Ministry of Health, 1993; Chapman, 1997). Factors increasing the burden: Instead of gaining community support, there is reduction in social networks due to the disruption of routine social and leisure activities as well as stigmatization that occurs hand-in-hand with a diagnosis of mental illness (Abramowitz et al, 1989; Brady, 1996; British Columbia Ministry of Health, 1993; Chapman, 1997). Lowered self-esteem and increased isolation and withdrawal due to stigma and lack of resources (Brady, 1996; Wintersteen et al, 1988). Grief on witnessing disintegration of personality of a close family member who was on the verge of realizing his/her potential in the formative years (adulthood) and suffered from major disorder like schizophrenia. There is a grieving that needs to be done for this lost person, a grieving that will help the carer adjust to the new person the sufferer has become (Berry, 1997) For disorders like dementia, as the disease progressesthe person may experience the loss of self-esteem, dependency, and there can be behavioural difficulties such as agitation, aggression or delusions. Carers need to spend increasingly longer time providing care than do carers with other disorders. The highest proportion of time is spent in communicating, supervising, and helping with eating and toileting (Varghese et al, 2004). Economic burden faced is extensive, which is explained by the increased propensity for people with disorders like dementia to use expensive private medical care services, in addition to giving up work to provide care (Varghese et al, 2004). A large majority of persons with mental illness either remain unemployed or underemployed, which further adds to the financial burden of the families. Direct costs involve cost of traveling, taking time off from work for both the patient (if employed) and caregiver, and cost of psychotropic drugs (long duration of treatment increases cost). Families from the poorest countries are particularly likely to have used expensive private medical services and to be spending more than 10% of the per capita GNP on health care (Prince, 2009). Carers are often thrown in the deep end, with little or no formal training in mental illness. They also face a lack of information about the disorder and its medication, a lack of resources and treatment facilities and, at times, a lack of responsive professional (Abramowitz et al, 1989).
Subjective burden (Reay-Young, 2000) can be: Subjective burden experienced by caregivers is directly linked to the experience of objective problems (Cuijpers et al, 2000). Caregivers burnout is suggested by their feelings of anger, resentment, grief, guilt, dependency and other distressing emotions. They report their inability to care for a long time, wish that they could just leave care giving to someone else, unfavorable experiences in interactions with health professionals, feeling that they have lost control of their life and being uncertain about managing their role. (Berry, 1997). In India, families have surprising reported inactivity, not participating in household chores, slowness and poor personal hygiene of the patient as more distressful than aggressive and assaultive behaviors (Gopinath PS et al, 1992). Also, financial costs were found to be the most commonly experienced felt burden (Pai S et al, 1981).
Burden of Care: Unique in Mental Health The care giving burden is unique to carers of people with a mental illness. Physically ill people are ordinarily deeply involved in getting well and returning to their presickness social roles. In contrast, mentally ill people often cannot abide by the usual rules of social settings, may engage in behaviors considered socially repugnant, sometimes deny that they are ill, and frequently treat their caregivers with hostility instead of gratitude (Karp et al, 2000). Studies have found that the relatives with chronic schizophrenia experienced severe burden than those of patients with chronic lung disease (Gautam. S et al, 1984). As a result, thousands of mentally sick persons, some of them afflicted quite seriously, who are neither on medication nor are institutionalized, lead the life of a destitute. Discarded by their families and uncared-for by any voluntary agency, their existence is woefully dehumanized. Archives of Indian Psychiatry 10(2) October 2009
Caregivers Or Potential Patients? Caregivers stress is a daily fact of life for many family members. Apart from sharing the biological vulnerability, care giving itself acts as a psychosocial stressor, enough to precipitate depression and other psychiatric illnesses in the caregivers. This is especially true if they do not receive enough support from family, relatives, friends, and the community as a whole. They experience psychological distress in form of worries, depression, anger, fear, guilt, 21
Pooja Dangar : Who cares for caregivers? and stigma. Higher levels of both objective stress (care receivers behavior problems) and subjective stressors (caregivers feeling of overload) influence the various dimensions of caregiver health, namely: poorer selfreported health, more negative health behaviors, and greater use of health care services. Women, in turn are more vulnerable due to reduced social and economic support. Studies show that more than half of caregivers are women. Important studies describing caregivers vulnerability to suffer from mental disorders are: A diagnosis of major depression in older medical inpatients is independently associated with poor mental health in their informal caregivers 6 months later (McCusker, 2007). The potential compromise of caregivers health brought on by demands of role is poignantly exemplified in well publicized Canadian story known as Latimer Case where father had taken extreme action of killing his child with disability. The fathers explanation for committing this act emphasized feelings of stress he experienced relating to take care of his child, childs degree of pain and sense of helplessness regarding the same. In a national survey of 1500 carers, 59% reported their physical health was worse because of their caring responsibilities, while 85% identified detrimental changes in their level of emotional health (Carers NSW, 2003). Of the 1500, those caring for a family member with a mental disorder reported that the negative attitudes of health professionals and the general public contributed to the deterioration in their own health status. Carers of mentally ill patients are much more likely to have a common mental disorder than carers or coresidents of controls (Varghese et al, 2004). Thus, as mental health professionals, it seems that we need to decide whether we want to provide them Caregivers rights today or else Patients rights tomorrow. I need to choose between going to work to earn money and spending time to take care of the patient. Both seem indispensable. What should I do? What if I get physically, mentally or financially exhausted? Is there an END TO THIS (care)? HOW LONG will this (care) continue? When will I be able to live MY LIFE Do I have a right to live a healthy life? The health care system needs to find an answer to these questions. We need to realize their (unmet) needs. Health policy makers need to be sensitive enough not only about the human rights of mental health patients but also their caregivers. Caregivers across globe have felt the need and expressed desire to create a formal policy satisfying their needs and protecting their rights (well supported by mental health advocacy groups). A formalized caregivers Bill of Rights has been suggested by Wendy Lustbader, which asserts that all individuals have needs that have to be fulfilled. It includes: 1) 2) 3) 4) 5) 6) 7) 8) 9) Protecting ones individuality, taking care of self so that with more capability better care can be given. Seeking help from others & recognizing ones limits. Getting angry, depressed, or expressing themselves. Receiving consideration, affection, forgiveness, and acceptance in return to care giving. Deciding when to help and when not to help. Finding the balance between family, work and care giving. Setting attainable goals. Treating one self well, same as the person for whom caring. Accepting that their best is good enough.
Current Caregivers Policy Across Globe (Montgomery Et Al, 2003) In United States the National Family Caregiver Support Program (NFCSP) provides direct services (e.g., counseling, respite care), financial compensation to family caregivers, tax incentives, etc. Caregivers are provided financial help by Federal Medicaid law (the Cash and Counseling demonstration). Recently more laws were passed providing workers with paid family leave. In australia extensive support is provided to caregivers, including general community support services, respite care, information and counseling, employment-related initiatives, and cash benefits by policies like the National Home and Community Care Program (HACC) and National Respite for Carers Program. In Canada no formal national caregiver strategy is in place for caregivers except some support provided via the tax system. The Long-Term Care Act of 1994 authorizes funding for caregiver support services, including respite care.
Caregivers (Human) Rights? Universal declaration on human rights has enshrined each individual with right to highest attainable standard of physical and mental health. Caregivers of mentally ill people are also human beings with legitimate claim to human rights. We have to take into account that caregivers are important component of health care delivery system and by recognizing their rights; we are not helping only caregivers but also the patients (indirectly) and society (largely) to cope up with the increasing burden of mental illness. Mental health professionals frequently encounter in clinical settings, questions asked by care givers like these ones: What if I get sick? Who will care whom? Will I outlive the patient? 22
Pooja Dangar : Who cares for caregivers? In Germany and Japan no formal national caregiver strategy is in place, but Long Term Care Insurance (LTCI) Program builds in explicit policies to recognize and support family caregivers. In United Kingdom National Strategy for Carers provides pension policy and social security benefits. In India government provides tax benefit and free bus and railway pass at a concession rate that help to ease burden on patients family (Varghese et al, 2004). Under Mental Health Act it is proposed that the costs of maintenance of mentally ill persons detained as inpatient in any Government Psychiatric hospital or nursing home shall be borne by the State Government concerned. This helps caregivers in reducing financial burden of care giving. It is well evident that only few countries have formulated special policies for carers of mentally ill and that too insufficient. to other tasks such as shopping, running errands, visiting doctor, relaxing or socializing. Establishing and recognizing support groups which help to decrease subjective burden of caregivers by decreasing negative emotions (by adaptation and acceptance), forming friendships, re-establishing social networks, hope and positive role models as well increasing the sense of power and competence as self help groups have the ability to influence legislation, redirecting community services and influencing attitudes of people who lack intimate contact with mentally ill (Wyman et al, 2008). They also help in decreasing objective burden by increasing knowledge about illness and health services, demystification of the illness and shifting of illness attributions as well as increasing their problem solving capacity and coping skills. Provision of adequate and effective support and services to caregivers, especially access to emergency services. Strengthening the community based interventions by training mental health community workers. Spreading awareness in general population about mental disorders will help in decreasing caregivers burden by reducing stigma and increasing the level of community support and understanding. We should try to spread message that mental health is everybodys business. Its a public health concern. Providing services that are easily available, accessible, appropriate to the needs, culturally acceptable and affordable to the caregivers. Caregivers consideration of the affordability of services should not only include financial costs, but also costs in terms of time, effort, potential loss of confidentiality, and potential family conflict. Introduction of a social support system like specialized institutes for disabled, which can be backed by government, public trends of charity or organization.
Future Recommendations
At Individual Level Caregivers should be regularly accessed with regards to their capacities, stress levels, ability to cope and available resources for the role they perform. Carers should be taught self care and making them realize its importance as they can effectively help others only when they help themselves. Sensitizing health professionals regarding the needs of carers, so that they have enough time, support and information for them along with that of patients. It is of concern that sometimes caregivers themselves are not receptive to treatment interventions after discharge and it is therefore important to try to engage these families during the time of the patients hospitalization (Heru, 2002). Education for caregivers about mental illness course and prognosis. Caregivers eventual recognition that they cannot control their family members illness allows them to decrease involvement without guilt. Special attention to be given to women caregivers who are more vulnerable to the burden of care giving. Generation and dissipation of supportive resource materials especially designed for caregivers At Community Level While implementing the policy of deinstitutionalization, giving utmost priority to community resources developmental plans including building up alternative social support systems like half way homes, day care and rehabilitation centers. This would not only divide the care among various stakeholders but will also help patients to reintegrate into the society, remain gainfully employed as well as face less negative expressed emotions. Establishment of respite centers to help caregivers cope with their role. Respite care enables caregivers to be temporarily relieved from their care giving responsibilities, providing them opportunity to attend Archives of Indian Psychiatry 10(2) October 2009
At Government Level Mental health care system should not over burden caregivers by assigning them majority of the responsibilities of managing the patient. Civil commitment of patients, who are dangerous to themselves or others or otherwise unmanageable, should be the responsibility of the mental health care system. Mental disabilities should be well recognized and benefited by social security schemes and social insurances by the state. Insurance schemes should recognize mental illness and reimburse expenses not only on physical ailments but also mental ailments. Health policies and legislation should give priority to caregivers of people with mental illness considering the uniqueness of mental health care. Considering caregivers as one of the important component of treating team, they should be included in all policy making and health care service developmental plans (Gautam S. et al, 2009). 23
Pooja Dangar : Who cares for caregivers? Caregivers should unite on a common platform (e.g. caregivers support groups, conferences, associations) and express their issues in front of the government, mental health care authorities and others concerned. Cuijpers, P. & Stam, H. (2000). Burnout among relatives of psychiatric patients attending psychoeducational support groups. Psychiatric Services, 51(3), 375-379. Dixon, L., Luckstead, A., Stewart, B., & Delahanty, J. (2000). Therapists contact with family members of persons with severe mental illness in a community treatment program. Psychiatric Services, 51(11), 1449-1451. Gautam, S., Nijhawan, M. (1984). Burden on families of schizophrenia and chronic lung disease patients. Indian Journal of Psychiatry, 26, 156-159. Gautam, S., Jain, S., Batra, L., Sharma, R., Munshi, D. (2009). Human rights and priveledges of mentally ill persons. IPS Clinical Practice Guidelines, 2009. Gopinath, P.S., Chaturvedi, S.K. (1992). Distressing behaviors of schizophrenia at home. Acta Psychiatrica Scandinavica, 86, 185-188. Heru, A., Ryan, C. (2002). Depressive Symptoms and Family Functioning in the Caregivers of Recently Hospitalized Patients with Chronic/ Recurrent Mood Disorders. International Journal of Psychosocial Rehabilitation, 7, 53-60. Kapor, R.L. (1992) The family and schizophreia: Priority areas for intervention research in India. Indian Journal of Psychiatry, 34, 3-7 Karp, D.A., Tanarugsachock, V. (2000). Mental illness, caregiving, and emotion management, Qualitative Health Research, 10(1), 6-25. McCusker J., Latimer E., Cole M., Ciampi A., Sewitch M. (2007). Major depression among medically ill elders contributes to sustained poor mental health in their informal caregivers. Age Ageing, 36, 400-406. Montgomery, A., Feinberg, L.F. (2003). The Road to Recognition: International Review of Public Policies to Support Family and Informal Caregiving. Issue Brief. San Francisco, CA: Family Caregiver Alliance. Pai, S., Kapur, R.L. (1981). The burden on the family of a psychiatric patient. British Journal of Psychiatry, 138, 332335. Pickett-Schenk, S.A., Cook, J.A., Laris, A. (2000). Journey of Hope program outcomes, Community Mental Health Journal, 36(4), 413-424. Prince, M. J. (2009). The 10/66 dementia research group 10 years on. Indian Journal of Psychiatry, 51(5), 8-15. Archives of Indian Psychiatry 10(2) October 2009
Conclusion Thus society has yet a long way to go before caregivers are fully recognized, their burdens and challenges acknowledged and their needs met. But with continued advocacy and a commitment to raise caregivers voices, those who work on behalf of care giving families - and caregivers themselves - can continue to educate lawmakers about what is needed to support family caregivers and to affect change at the public policy level. . Health professionals and policy makers need to develop greater insight into the care giving experience, interact with caregivers more collaboratively, and implement strategies that facilitate better outcomes for not only patients but also all members of the family. It is important to help them to protect their individuality, provide support, respite care, legal protection, respect and consideration for the role they perform.
References
Abramowitz, I.A., Coursey, R.D. (1989). Impact of an educational support group on family participants who take care of their schizophrenic relatives. Journal of Consulting and Clinical Psychology, 57(2), 232-236. Australian Bureau of Statistics (1998). Mental health and wellbeing: profile of adults, Australia, Canberra. Berry, D. (1997). Living with Schizophrenia, Institute of Psychiatry, London. Brady, A. (1996). A Study on the Effects of Schizophrenia on Carers (Thesis), Department of Psychology, University of Dublin. British Columbia Ministry of Health (1993). Task Force of Families of People with a Mental Illness: Families Sharing the Caring, Mental Health Services Division, B.C. Ministry of Health, Victoria, Canada. Carers NSW (2003). Response to the consultation paper on the National Mental Health Plan 2003-2008. . Chapman, H. (1997). Self-help groups, family carers and mental health. Australian & New Zealand Journal of Mental Health Nursing, 6(4), 148-155. 24
Pooja Dangar : Who cares for caregivers? Reay-Young, R. (2000). Support groups for relatives of people living with a serious mental illness: An overview, International Journal of Psychosocial Rehabilitation, 5, 56-80. Sethi, B.B., Manchanda, R. (1978). Socioeconomic, demographic and cultural correlates of psychiatric disorder with special reference to India. Indian Journal of Psychiatry, 20, 199- 211. Varghese M., Patel V. (2004). The Graying of India. In: Agarwal S, Goel D, Salhan R, Ichhpujani R, Shrivastava S, editors. Mental Health: an Indian Perspective 1946-2000. New Delhi: Elsevier; 240-8. Wintersteen, R.T., Young, L. (1988). Effective professional collaboration with family support groups. Psychosocial Rehabilitation Journal, 12(1), 19-31. Wyman K., Clarke S., McKenzie P., Gilbert M. (2008). The Impact of Participation in a support Group for Carers of a Person with Schizophrenia: A Qualitative Study. International Journal of Psychosocial Rehabilitation, 12 (2), 97-109.
Sources of support : None Dr. Pooja Dangar, MBBS Postgraduate student, Dr. Parag S. Shah, MD, DNB Assistant Professor, Department of Psychiatry Government Medical College & SSG Hospital Baroda, India
Corresponding author: Dr. Parag S. Shah A-404, Jeevandham Tower, Nr. Bimanagar, Satellite Road, Ahmedabad 380015, India Telephone: +91.9426138318 e-mail: drparagsshah@rediffmail.com
25
Original Article
Newspaper Portrayal of Psychiatry

Laxeshkumar Patel G. K. Vankar
Abstract Media reporting have a direct impact on both community attitudes towards mental illness and suicide attempts. This study examined how suicide and mental health are portrayed in the media in Baroda. In this cross sectional study of five daily newspapers, total 350 cuttings were analyzed, about 2/3 had suicide theme and 1/3 had non-suicide theme. In portrayal of suicide theme they dramatized/sensationalized the headline in about half cuttings 109(47.2%), used outdated, negative or inappropriate language in 38(16.5%) cuttings, did not mentioned about the helpline in 230(99.6%) cuttings, detailed discussion of the method used was given in 89(38.5%), oversimplification of reason of suicide done in 104(45%) cuttings and in 217(93.9%) cuttings the bereaved were not interviewed. In portrayal of non-suicide theme, inaccurate headline were in 26(21.8%) cuttings, headline or content was dramatic or sensational in 51(42.9%) cuttings, outdated or negative language used in 18(15.1%) cuttings. 73(61.3%) cuttings have disclosed that a particular individual has a mental illness or identified the person by name. About a quarter reinforced negative stereotype about mental illness. There were 49(41.2%) cuttings that emphasis the illness rather than person. Key words: media portrayal, suicide, mental health
Introduction
The expansion and implementation of different types of media-derived information transmission have driven farreaching changes for both individuals and society, with particular implications for children and adolescents. Most studies suggest that the medias depiction of mental illness and suicide is mostly negative, inaccurate and unhelpful 2-14. This is an important finding as media portrayal may be an important influence on community attitudes towards mental health issues 15. However, not all results have been negative. Two recent studies of nonfiction media found that the vast majority of items were of good quality, the only failing being the absence of information on appropriate services 16, 17. Methodological problems with previous research include the representativeness of the samples, retrospective collection of data, and the use of secondary data, which meant that researchers could not independently evaluate the importance or definition of mental illness to the item14. A related problem is that few studies have used standardized instruments with explicit criteria 16. Finally, although most have been restricted to nonfiction media, some have been restricted to print media, while others have included electronic media as well. These differences make it difficult to compare studies 3,4,16. There is only one study from Canada on reporting of mental illness in the last decade and half, and this was restricted to a single newspaper in Calgary 16. Although there have been studies of the effect of reporting on suicide, there had been little in the way of systematic collection of the extent, type and quality of reporting on the issue 4. The only Canadian 26
study to examine the portrayal of suicide by the media were conducted 20 years ago 4: one was a survey of editors policies on the portrayal of suicide that showed that a story was most likely to printed if it involved a prominent person, occurred in a public place, or was done by an unusual method 18; the other compared the frequency of suicide items in Toronto news papers before and after suicides in epidemic and non-epidemic suicide years. Neither specifically examined the content of actual news items 19. In response, the Prevention Promotion and Advocacy (PPA) network committee and anti Stigma / Discrimination Working Group of the Department of Health in Nova-Scotia undertook a six month survey to monitor all non-fiction media items (newspaper, radio and television) that referred to suicide, mental health and illness. Media professionals are constantly required to make judgment about what to publish and how to tell the story, but when we make decisions that could influence the behavior of others whom we do not know, it is incumbent upon us to ensure that our judgments are as informed as might reasonably be expected. If there is expert advice available we have a responsibility to listen. The power and influence of the media on suicidal behavior has been a key subject of debate over many years. Public attitudes to suicide (decriminalization of suicide and reduction of its taboo status) have become more empathic, and although suicide rates are falling, they remain high. Although psychiatrist should encourage open discussion of suicide among individuals and in a wider media context, there are specific concerns when fictional and real suicides Archives of Indian Psychiatry 10(2) October 2009
Laxeshkumar Patel : Newspaper Portrayal of Psychiatry are represented in the media. Schmidtke & Hafner (1989), in an extensive review with 131 references, examined the influence of the mass media, predominately news media, on suicidology. The evidence for imitation (with regard to explicit details of method and celebrity suicides) proved conclusive, thus retrospectively justifying the American Academy of Medicines first proposal for press constraints in 1911 20. Two subsequent studies have examined the relationships between print media and the choice of suicide method. Etzersdorfer et al 1992 21 showed how attempted and completed suicides on the Viennese underground railway have been reduced to single figures after the media were given guidelines for reporting suicide. The occurrence of imitative suicides following media stories is largely known as the Werther effect derived from the impression that Goethes novel The Sorrows of Young Werther in 1774 triggered an increase in suicides, leading to its ban in many European states. Research on the Werther effect was advanced by the systematic work of Phillips 22-27, whose research consistently found a strong relationship between reports of suicide in newspapers or on television and subsequent increases in the suicide rate. The magnitude of the increase in suicides following a suicide story is proportional to the amount, duration, and prominence of media coverage. A dose-response relationship has recently been reported by Etzersdorfer, Voracek, and Sonneck 28 in an examination of the relationship between the regional distribution of a tabloid newspapers coverage of a celebrity suicide by firearms in Austria and an increase in firearm suicides. Nearly 40% of the variance in changes in suicide by firearm was attributable to the differential distribution of the tabloid. This is consistent with the dose-response effect first reported by Phillips 24. In a quantitative analysis of 293 findings from 42 studies, Stack 29 found that studies assessing the effect of the suicide of an entertainer or political celebrity were 14.3 times more likely to find a copycat effect than studies that did not. Furthermore, studies based on real suicides in contrast to fictional stories were 4.03 times more likely to find an imitation effect. Following newspapers were included: Gujarati( Gujarat Samachar, Sandesh, Divya Bhaskar) and English ( The Times of India andThe Indian Express). Instrument: The newspaper cuttings were analyzed with the checklists. Both checklists were derived from previous research in Australia, Achieving the balance: A resource kit for Australian media professional for the reporting and portrayal of suicide and mental illness 1. These checklists were also influenced by WHO guidelines for reporting suicide and by guidelines on coverage of suicide given by Hong Kong Journalist Association. The checklists include 18 questions to determine reporting of suicide news and 9 questions to determine reporting of non-suicide news. Screening: Each question has three alternative answers: yes, no, not applicable. Response of yes and no indicate poor and good quality of portrayal respectively, except in the dimensions of the helpline, suicide note included and bereaved interviewed, where the direction was reversed. Media professionals were interviewed for the following questions: 1. How do they portray suicide or mental health issues? Is there any qualified person or group to decide regarding the same? 2. Do they have any specific guidelines for printing news regarding suicide or mental health issues? 3. How do they decide to print a photograph of suicide scene while reporting the news of suicide? 4. What is the qualification of the reporter? 5. What are the bases for the statistical records of suicide? Analysis: The statistical analysis of the collected data was done by using EPIINFO 6.0 software
Aims and objectives

To investigate how the non-fiction media in Baroda portray both suicide and mental health. To know the attitude of media people towards psychiatry.
Results and Discussion

1. Frequency of news: Five newspaper articles on themes of mental health were analyzed. We have received 350 newspaper cuttings. Out of which 116(33.1%) were from Gujarat Samachar, 92(26.3%) were from Sandesh, 98(28%) were from Divya Bhaskar, 19(5.4%) were from The Times of India and 25(7.1%) were from The Indian Express. Gujarat Samachar, Sandesh, Divya Bhaskar are the news papers in the regional language (Gujarati) which covers major parts of the cuttings, each comprise more than about 25%. While the rest two newspapers The Times of India and The Indian Express, which are in the English language covers small part of the total cuttings, each comprise less than about 8%.
Material and Methods

Sample: Five newspapers (three Gujarati newspapers and two English newspapers) over a period of 3 months were seen for the stories related to mental health or suicide news and such stories related to the mental health or suicides were collected in form of cuttings.
27
Laxeshkumar Patel : Newspaper Portrayal of Psychiatry
Table 1: Newspaper portrayal of Suicide theme
Finding
Headline inaccurate or inconsistent with the items focus? Headline or content unnecessarily dramatic or sensationalized Use of language that is outdated, negative or inappropriate? Disclosure that a particular individual has a mental illness or identifying the person by name? Medical terminology used inaccurately? (Not in correct context) Reinforcement of negative stereotypes about mental illness? Does the item emphasize the illness rather than the person? Does the item imply that all mental illnesses are the same? Is direct/indirect suggestion of help given? Use of the word suicide in the headline? Inappropriate language? (frequent use of the term committed suicide or that suicide was a desirable outcome) Any reference to the fact that the person who died by suicide was a celebrity? Is a photograph, diagram or footage of the suicide scene, precise location or method used in the item? Is there detailed discussion of the method used? Suicide portrayed as merely a social phenomenon as opposed to being related to mental disorder? Are bereaved interviewed? Over simplification of the reason of suicide? Is the suicide note included?
Yes
10.0 47.2 16.5 93.9 0.9 7.4 5.6 2.6 0.4 80.1 23.4
% No
90.0 52.8 83.5 5.6 14.3 68.5 67.5 55.6 99.6 19.9 76.6
No Answer
0 0 0 0.4 84.8 76.2 26.8 42.2 0 0 0
10.0 17.3 38.5 74.5 6.1 45.0 13.4
90.0 82.7 61.5 7.4 93.9 31.6 86.6
0 0 0 18.2 0 23.4 0
Table 2: Newspaper portrayal of non-suicide theme
2. Frequency of themes: All cuttings were distributed according to its content into the following themes: Suicide, Informative ,Questionanswer, Law and order, Substance and others. 28
Majority of the cuttings had the theme of suicide. Out of the 350 cuttings, 231 had the theme of suicide. This was 66%. It means about 2/3 cuttings had the theme of suicide and 1/3 cuttings had non-suicide theme. Archives of Indian Psychiatry 10(2) October 2009
Laxeshkumar Patel : Newspaper Portrayal of Psychiatry Informative theme was found in 33(9.4%), questionanswer theme was found in 1(0.3%) cutting only. Law and order theme was found in 19(5.4%), substance theme was found in 32(9.1%) and 34(9.7%) cuttings fell into others category. 2. Today morning at 7:00 oclock when Rameshbhai was brushing his teeth outside his house, as soon as she got a chance, his wife poured kerosene over the body of her daughter Daksha and lit it with a matchstick. After that she poured kerosene over her own body also and lit it with a matchstick. A night, a suicide attempt was made by adding a poisonous insecticide powder, used to kill ants and insects into a bottle of the cold drinks- thumps up and then gulping down the drink. On 19th, at night she hung herself by tying a duppatta on the hook of the fan and committed suicide.
3. 3. Media portrayal of suicide theme: About a half of the cuttings 109(47.2%) had headline or content unnecessarily dramatic or sensationalized (Table 1). Examples: 1. Love-birds of Vadodara went to jump from Saradar Bridge at Bharuch but!! 2. Neeta with mehndi on her hands and heart-broken in love Vipul could not live together so They died together!! 3. One female with her seven-year old son had jumped from the 20th floor of a building but perhaps it was the warmth of mothers lap that provided a shield and the child survived the mishap. Thousands of people crowded together at the wall of Kankaria Lake to see the corpses of this loving couple floating in a romantic manner. The way they were together in the water of the lake was telltale sign of their deep love. Truly, this incident brought back memories of song which meant. Oh.!! A pair of swans got separated!! We found 38(16.5%) cuttings had language that was outdated, negative or inappropriate (Table 1). Examples: 1. Terror at the incident of mother wrapped in fire along with daughter!! 2. A dive of death from Ellis Bridge by a retired teacher. 3. Terror prevails as they bid good-bye to this unjust world by jumping into the river. 4. Unsuccessful attempt of suicide. Disclosure that a particular individual has mental illness or identifying the person by name found in 217(93.9%) Direct or indirect suggestion of help was given only in one cutting out of 231 cuttings. It was not given in 230(99.6%) cuttings. Use of the word suicide in the headline were in 185(80.1%) cuttings and 54(23.4%) cuttings had frequently used the term committed suicide or that suicide a desirable outcome. In 23(10%) cuttings they mentioned that the person who died by suicide was a celebrity. Photograph, Diagram or Footage of the suicide scene was given in 40(17.3%) cuttings. 89(38.5%) cuttings had reported the detailed discussion of the method used (Table 1). Examples: 1. Ravji had made noose of the sari twice. One more piece of the sari was found underneath Ravjis dead body. A loop was made at the end of this piece looking at which it seems that Ravji had made noose before committing suicide, but since the sari got torn, he made a noose once again, hung it on the tree and committed suicide. Archives of Indian Psychiatry 10(2) October 2009
4.
Suicide portrayed as merely a social phenomenon as oppose to being related to mental disorder in 172(74.5%) cuttings (Table 1). Examples: 1. 1. Report of suicide committed by a 21 year married woman due to torture at her in laws place. 2. Young female jumped into the river as her lover ditched her 3. Depressed due to the worries of seven daughterfather committed suicide. due to poor financial condition, the daughters could not get married. Hence he has decided to hang himself to death. 4. A woman, who married second time, again became a widow- hence she poisoned herself. Oversimplification of reason of suicide reported in 104(45%) cuttings (Table 1). Examples: 1. due to a quarrel regarding eating puffed rice. 2. because he felt hurt on losing rupees 25. 3. as husband did not allow her to serve him food and took it by him. 4. as father scolded him regarding going for the marriage. 5. On not getting a deserving matched for marriage. 6. As the husband denied her request of visiting her parents. 7. As the mother refused to go outdoor for playing. In 217(93.9%) cuttings the bereaved were not interviewed, even though they are at heightened risk of suicide themselves (Table 1). Reporting was more generally appropriate across the other dimensions. 4. Media portrayal of non-suicide theme: Media items were of poor quality in seven out of nine dimensions measured as compared to the portrayal of suicide theme. The reporting was good in case of non suicide themes in dimensions of disclosure that a particular individual has a mental illness or identifying the person by name and direct or indirect suggestion of help given as compared to the suicide theme portrayal. Inaccurate or inconsistent headline were seen in 26(21.8%) (Table 1). Examples: 1. Beautiful lady caught in a drunken state: chakchar. 2. Black use of the dilutor of white in 29
Laxeshkumar Patel : Newspaper Portrayal of Psychiatry 3. Net chatting: an innocent prank or a little bit of betrayal? Unnecessarily dramatic or sensationalized headline or content was given in 51(42.9%) cuttings (Table2) 6. Comparison of non-suicide theme portrayal in various newspapers: 1. Headline was inaccurate or inconsistent with the item focused in maximum number of the cuttings in The Times of India (29.4%). 2. Outdated, negative and inappropriate language was used the most in Divya Bhaskar (23.8%). 3. Medical terminology was used inaccurately in Divya Bhaskar the most (23.8%). 4. Negative stereotypes of mental illness had reinforced in most of the cuttings of The Indian Express (42.9%) and Divya Bhaskar (38.1%). 5. Emphasis the illness rather than the person were found in most of the cuttings of Gujarat Samachar (54.2%). 6. Divya Bhaskar had depicted maximally that all mental illnesses are the same in 23.8% cuttings. 7. Gujarat Samachar had given direct or indirect suggestion of help in 33.3%(maximum) cuttings while Divya Bhaskar had provided it in only 4.8%(minimum) cuttings. Interview with members of newspaper editor office: Newspaper-1 Newspaper-1 did not have any guideline to report mental health issues or suicide and some of their reporters did not have qualification of journalism. Newspaper-1 even did not feel the need for guideline or qualified reporters for the portrayal of mental health or suicide. Newspaper-1 was reporting news related to mental health or suicide in very professional way and Newspaper-1 was least concerned with impact by their reporting about mental health issues. Though Newspaper-1 told us that Newspaper-1 was planning to start one column regarding mental health awareness but there was no concrete planning as such. Reporting of newspaper-1, about mental health issues and suicide was mainly disappointing. Newspaper-1 had never given helpline and Newspaper-1 never tried to understand the reason for suicide, never interviewed the bereaved person. Newspaper-1 had emphasized on person rather the illness. Newspaper-1 had also used inappropriate language in significant number of cuttings. Newspaper-2 Overall, Newspaper-2 emphasized more on his knowledge and his newspaper but quite disappointingly, Newspaper2 seemed less concerned with the media portrayal of mental health and suicide issues. Newspaper-2 did have any specific guideline for reporting mental health or suicide. Newspaper 2 had reported mental health related issues and suicide with inappropriate language in significant number of cuttings. Newspaper 2 had never given direct or indirect suggestion for the help. Most of the time, Newspaper 2 had not tried to understand the actual reason for suicide, had not interviewed the bereaved and had done over simplification of the reason for suicide. Newspaper 2 had reported headline unnecessarily in dramatic or sensationalized manner. Archives of Indian Psychiatry 10(2) October 2009
Examples: 1. It is unfortunate for the society and a matter of shame that in Gandhijis Guajarat, little kids, innocent as flowers, are made to drink (pockets of) country liquor and being dragged into this business. 2. In the cradle itself, he showed physical and mental signs of being a female and those signs have grown today from a tiny plant to a huge tree and yesterdays guy has become a gal today. 3. This new technique, which can make hearts fall in love even across seven oceans sometimes, proves to be a double edged sword. Net chatting increased by leap and bounds and there after Rima started remaining clung to the computer till late night! And then she goes so intoxicated in love that net chatting became her need just like food, water or alcohol. 18(15.1%) cuttings used inappropriate, negative or outdated language to portray non-suicide themes and 73(61.3%) cuttings disclosed that a particular individual had a mental illness or identified the person by name. In 12(10.1%) cuttings had used medical terminology inaccurately to portray non-suicide themes. About a quarter reinforced negative stereotype about mental illness. There were 49(41.2%) cuttings that emphasis the illness rather than person. 15(12.6%) cuttings implied that all mental illnesses are the same (Table 2).
5. Comparison of suicide theme portrayal in various newspapers: 1. Only 2 reports of suicide have been made by The Times of India and 18 by The Indian Express as compare to 68, 66, 77 reports in Gujarat Samachar, Sandesh, Divya Bhaskar respectively over a period of 3 months. Out of 18 cuttings, The Indian Express had not emphasized the illness in any of the articles and had emphasized the person in 16(88.9) cuttings. Out of all cuttings in all the newspapers, suggestion of help had given in only one cutting in Sandesh. In each newspaper, more than 74% of the cuttings contained the word suicide in the headline. Indian Express had avoided the details of the method used to commit suicide in 83.3% of the cuttings as compare to 57.4%, 65.2%, 6. 57.1% and 50% in Gujarat Samachar, Sandesh, Divya Bhaskar and The Times of India respectively. Out of all 5 five newspapers, over simplification of the reason of suicide had given maximally in Divya Bhaskar (51.9%). Sandesh had included suicide note maximally (10.4%).
2.
3. 4. 5.
7.
8. 30
Laxeshkumar Patel : Newspaper Portrayal of Psychiatry Newspaper-3 Newspaper-3 had reported suicide cases very selectively, without over simplification of reason for suicide, dramatization or inappropriate language. Though Newspaper-3 told us that they dont print photograph of the suicide scene, it was given in half of the cuttings. Newspaper-3 emphasized person more than the illness. Newspaper-3 asserted that the concern for good reporting about the illness or suicide may propagate awareness in the society about mental health. Newspaper 3 also lack of guideline for reporting mental health issues or suicide. Newspaper-3 also had not given direct or indirect suggestion for help. makers in the provincial media in their development 30. There is evidence from both Australia and Canada that local media may be easier to influence than national or international media 16. There should be longer-term strategy to influence the education of journalism students. We should particularly focus on the inclusion of details of how to get help, and on suicide. Journalists would not tell a depressed relative or friend ways of committing suicide in graphic details. Do they not owe the same duty of care to their readers? Strengths: The only study of its kind done in India. Reliability of study maximized by analyzing cuttings by one researcher. Limitations: The comparatively low number of articles on suicide, and thus our sample size for items on mental illness was also much smaller than that of a similar study in Australia 1. However our numbers are comparable of most other studies that have considered media coverage of mental illness 5, 16. Though study conducted on newspapers, having maximum number of reader in the Baroda at the time of study, it did not include other magazines and electronic media in study so it might not represent the media as a whole. Acknowledgement: We acknowledge the support from Dr. P. R. Vesuna for his facilitation, Mrs. Asha Patel for assisting in computer work, Dr. Kunal Bhardwaj and Dr. Nilima Shah for their help in collecting newspaper cuttings. Without whose support our work could not get materialized.
Discussion:
The media are an important source of information on both suicide and mental illness: importantly, reporting can have a direct impact on both community attitudes towards mental illness and suicide attempts, with the strongest evidence for non-fictional media 4, 6. This study was therefore designed to examine how suicide and mental health and illness are portrayed in the media in a standardized way across Baroda. To our knowledge this is the first time such kind of study considered in India. Our results on the portrayal of mental illness are very similar to those from Australia (instead of our 18 dimensions, they used 9 dimensions to check portrayal of suicide) and showed that media reporting on mental illness was predominately positive. There are in contrast to other research where media reporting of mental illness has mainly been negative 3, 5-14. The result for suicide reporting was less encouraging and this is consistent with the existing literature. Inappropriate, dramatic language is a central concern, as particular framing devices and inappropriate language may together contribute t the stigma associated with mental illness. Another area of concern was the absence of information on where to get help in over 99% of suicide items: this is almost identical to the findings from the Australian study, suggesting that this problem is not restricted to Nova Scotia 17. The nature of the reporting of these subjects varies considerably, as does the quality. In general, good items outnumber poorer items, particularly in the case of mental health and illness. However, there are still opportunities for improving the way in which the media report and portray suicide and mental health and illness. Newspaper media have a choice in the way they frame stories about suicide, and mental health and illness. The choice is not an issue of accuracy or objectively, but it does have serious ramifications for the ways in which reader may interpret news and information about suicide, and mental health and illness. If the right choices are made, they can help to de-stigmatize mental illness in our community and improve the lives of many people with mental illnesses. It is important to develop guidelines with the people who will use them; we should try to involve editors and opinion Archives of Indian Psychiatry 10(2) October 2009
References
1. 2. American Heritage Dictionary, 2nd College Edition. New York, Dell, 1983. Department of Health and Aged Care. Achieving the balance: A resource kit for Australian media professionals for the reporting and portrayal of suicide and mental illness. Canberra; Commonwealth Department of Health and Aged Care; 1999. Department of Health and Ageing Reporting suicide and mental illness. Commonwealth Department of Health and Ageing; 2002. Pirkis J. Wawick Blood R. Suicide and the media: a critical review. Canberra; Commonwealth Department of Health and Aged Care; 2001. Francis C, Pirkis J, Dunt D, Wawick Blood R. Mental health and illness in the media: A review of the literature. Canberra; Commonwealth Department of Health and Aged Care; 2001. Day DM, Page S. Portrayal of mental illness in Canadian newspapers. Can J Psychiatry, 1986; 31:813817. Matas M, el-Guebaly N et al. A mental illness and the media: part 2. Content analysis of press coverage of 31
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Laxeshkumar Patel : Newspaper Portrayal of Psychiatry mental health topics. Can J Psychiatry; 1986, 31:431433. Allen R, Nairn RG. Media depiction of mental illness: an analysis of the use of dangerousness. Aust N Z J Psychiatry, 1997, 31: 375-381. Nairn R. Does the use of Psychiatrists as sources of information improved media depictions of mental illness? A pilot study. Aust N Z J Psychiatry 1999, 33:583-589. Wilson C, Nairn R, et al. A. constructing mental illness as dangerous: A pilot study. Aust N Z J Psychiatry 1999, 33: 240-247. Thornton J, Wahl O. Impact of a newspaper article on attitudes toward mental illness. Journal of Community Psychology 1996; 24:17-25. Steadman H, Cocozza J. Selective reporting and the publics misconceptions of the criminally insane. Public Opinion Quarterly 1977, 41:523-533. Angermeyer MC,Matschinger H.The effect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally ill.Soc Sci Med;1996,43:1721-1728.14 Coverdale J,Nairn R,Claasen D. Depictions of mental illness in press media: a prospective national sample.Aust N Z J Psychiatry:2002,36:697-700. Hoggart, R. The Uses of Literacy London: Pelican books 1958. Stuart H. Stigma and the daily news: evaluation of a newspaper intervention. Can J Psychiatry 2003, 48:651-656. Francis C, Pirkis J Wawick Blood R et al. The portrayal of mental health and illness in Australian non-fiction media. Aust N Z J Psychiatry: 2004, 38:541-546. Pell B and Watters D. Newspaper policies on suicide stories. Canadas Mental Health, 1982; 30:8-9. Littmann S K. Suicide epidemics and newspaper reporting. Suicide and Life Threatening Behavior, 1985, 15:43-50. 20. Schmidtke A and Hafner H. Public attitudes towards and effects of the mass media on suicidal and deliberate self harm behavior. In Suicide and its Prevention 1989. 21. Etzersdorfer E, Sonneck G and Nagel-Kuess S. Newspaper reports and suicide. New England Journal of Medicine, 1992; 324,502-503. 22. Bollen K. A. and Phillips D. P. Suicidal motor vehicle fatalities in Detroit: A replication, American Journal of Sociology, 1981; 87,404-412. 23. Bollen K. A. and Phillips D. P. Imitative suicide: A national study of the effect of television news stories. American Sociological Review, 1982, 47,802-809. 24. Phillips D. The influence of suggestion on suicide: Substantive and theoretical implications of the Werther effect. American Sociological Review, 1974, 39,340-354. 25. Phillips D. Suicide, motor vehicle fatalities, and the mass media: Evidence towards a theory of suggestion. American Journal of Sociology, 1979,84, 1150-1174. 26. Phillips D. and Carstensen L.L. Clustering of teenage suicide after television news stories about suicide. New England Journal of Medicine, 1986, 315,685-689. 27. Phillips D. and Carstensen L.L The effect of suicide stories on various demographic groups 1968-1985. In R. Maris (Ed.), understanding and preventing suicide: plenary papers of the first cmbined meeting of the AAS and IASP 1988, (pp. 100-114). New York: Guilford. 28. Etzersdorfer E, Voracek, M, Sonneck G. A dose response relationship of imitational suicides with newspaper distribution, 2001. 29. Stack S. Media impacts on suicide: A quantitative review of 293 finding Social Science Quarterly, 2000, 81, 957-971. 30. Slaven J, Kisely S. The Experience primary prevention of suicide project. Aus N Z J Psychiatry, 2002; 36:61721.
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Sources of support : None Dr.Laxeshkumar Patel Resident Doctor Dept. of Psychiatry Medical College and S.S.G. Hospital, Baroda Dr.G.K.Vankar Professor and Head Dept. of Psychiatry B.J. Medical College and Civil Hospital, Ahmedabad 380016
Conflicts of interest: None
Address for Correspondence: Dr. Laxeshkumar Patel F-6, Dream Plaza Flats, Camp Road, Shahibaug, Ahmedabad 380 004. Cell: 98258 47475 E-mail: laxesh_patel@yahoo.com
32
Rahul Shidhaye : Traditional Healing Practices Original Article
Traditional Healing practices in Psychiatric Out Patients

Rahul Shidhaye G.K.Vankar
Abstact: Traditional healing is widely practiced by psychiatric patients.This study explored traditional healing practices in 201 psychiatric patients attending Psychiatry OPD in a tertiary care center in Western India. 54.7% patients in this study irresepective of diagnosis consulted a traditional healer. Sixteen of the 110 patients had to pay an amount greater than Rs 2500. The view that traditional healing is effective for mental health problems was supported by 22.7% of the patients and 20.9% would recommend going to a traditional healer.Implications of these for psychiatric practice are discussed Key words: Traditional healing, psychiatry,India
Introduction Traditional Healing practices are commonly used especially in the developing world. WHO defines Traditional medicine as a comprehensive term used to refer both, to Traditional Medicine systems such as traditional Chinese medicine, Indian ayurveda and Arabic unani medicine, and to various forms of indigenous medicine (1). Aboriginal concepts of health and wellness involve not only the physical but also the mental, spiritual and emotional aspects of health. This holistic approach to health is widely accepted and practiced in aboriginal communities, through traditional medicine and healing practices and rituals conducted by the traditional healers (2). Historically, individuals known as traditional healers were known to be the experts on holistic health practices. They were sought extensively by community members, as they were considered to have different gifts to assist individuals in maintaining a balance in health (2) . The opinion about traditional healers widely varies from being uncritically enthusiastic to being highly skeptic without much information. Despite historical efforts by mainstream society to obliterate various traditional healing practices and replace them with Western medical concepts of health, there is a resurgence in the use of traditional holistic concepts of health and healing practices all over the world (2). In Africa up to 80% of the population uses TM to help meet their health care needs. In Asia and Latin America, populations continue to use TM as a result of historical circumstances and cultural beliefs (1). In many parts of the world expenditure on traditional medicine (TM) / complementary and alternative medicine (CAM) is not only significant, but growing rapidly (1). In most African countries primary Archives of Indian Psychiatry 10(2) October 2009
care is provided by traditional healers as well as by biomedical practitioners, the former often being more accessible (3-5). In India, traditional healing systems coexist with modern mental health care, and they are seen as providers of curative, rehabilitative and restorative benefits. Traditional healing systems and practices play an important but controversial role in mental health service delivery (6). In India, the percentage of patients seeking traditional faith healing in various studies have been like follows: 85.6% (7), 57.5% (8), 33.3% (9) and 74.7% (10). It seems that over a period of years the percentage of patients consulting traditional faith healer is increasing (10). Shamans and mystics play a very important role in mental health disorders (11). Knowledge of traditional healing practice and of the use of these services by people with common mental disorders is limited and impressionistic (12). Westernized studies on traditional healing systems tend to be derogatory, exposing only what are seen as abusive in such methods (6). There is a tendency to disregard such realities, which is characteristic of medical practitioners and other medical care professionals in Western countries (13). In India many people troubled by emotional distress or more serious mental illnesses go to Hindu, Muslim, Christian, and other religious centers (14). The healing power identified with these institutions may reside in the site itself, rather than in the religious leader or any medicines provided at the site. Studies of these healing sites have focused primarily on ethnographic accounts (14). Research has not systematically examined the psychiatric status of the people coming for help at these religious centers or the clinical impact of healing. It has focused primarily on possession and non-psychotic disorders, rather than serious psychotic illnesses (14). Very few studies have been conducted in India which have focused on traditional healing practices in psychiatric 33
Rahul Shidhaye : Traditional Healing Practices
Table 1: Comparison between patients who visited Traditional Healer and those who did not visit Traditional Healer:
Variable
Patients who visited Traditional Healer 110(54.7)
Patients who did not visit Traditional Healer 91(45.3)
t-value
chisquare value
degree of freedom
p-value
No. of patients (%)
-2 .69
NA
0.007*
Socio-demographic characteristics
Age [Mean( SD)] Sex [No. (%)] Male Female Education[No. (%)] Less than 10th grade 10th grade th Beyond 10 grade Monthly (Mean, SD) income
34.32 (12.2) 70(63.6) 40(36.4) 63(57.0) 34(31.0) 13(12.0) 2225(2073)
37.5(14.3) 59(64.9) 32(35.1) 59(64.8) 30(33.0) 2(2.2) 2166(1619)
1.69 NA
NA 0.03
199 1 2
0.09 0.86
NA
6.7
0.03*
-0.2
NA
150
0.85
Family Type [No. (%)] Nuclear Joint Domicile [No. (%)] Urban Rural
36(32.7) 74(67.3) 80(73.6) 30(26.4)
41(45.1) 50(54.9) 67(72.7) 24(27.3)
NA NA
3.20 0.021
1 1
0.07 0.89
Table 2: Disease related Characteristics and Traditional Healing
Variable
Patients who visited Traditional Healer 30(83.3) 40(44.0) 5(38.5) 7(53.8) 7(70.0) 2(40.0) 22(100)
Patients who did not visit Traditional Healer 6(16.7) 51(56.0) 8(61.5) 6(46.2) 3(30.0) 3(60.0) 0
t-value
chisquare value
degree of freedom
p-value
Diagnosis [No. (%)]$ Schizophrenia Major Depression Bipolar Disorder Epilepsy Mental Retardation Substance Use Possession Disorder Duration (Mean, SD)
NA NA NA NA NA NA NA
14.49 7.78 1.48 0.004 0.991 0.449
1 1 1 1 1 1 1
<0.001* 0.005* 0.22 0.22 0.32 0.50 <0.001*
67.4(78)
65.0(96.1)
-0.2
NA
199
0.84
34
Rahul Shidhaye : Traditional Healing Practices Table 3: Traditional healer Consultation (n=110)
% Number of Visits One Two-three More than Three Number of traditional healers consulted One Two-three More than three Setup from where services were offered Temple Dargah Home other Physical abuse Yes (beating, cutting hear) No Expenses incurred upto Rs. 500 Rs.500-Rs.2500 more than Rs.2500 Belief that traditional healing is effective Yes No 23 36 41 49 31 20 25 19 47 9 10.8 89.2 60 18 22 22.7 77.3
and duration of illness are analyzed using t-test. This analysis is done in SAS ver. 9.2 using proc ttest and proc univariate. Categorical variables sex, education, family type, domicile and diagnosis are analyzed using chi-square test. This analysis is done in SAS ver. 9.2 using proc freq.
Results
The study sample consisted of 201 patients. The mean age of the sample was 35.75 years and it ranged from 8 years to 72 years. Males were 64.18% and females were 35.82%. Ninety-two percent of the patients were Hindus and 27 % of the total sample belonged to rural areas. Education up to SSC or beyond it was completed by 39.3% of the patients. Nearly one-third (38 %) of the patients were from nuclear family and 62% from the joint family setup. The information related to income was available only for 152 patients, with the mean income being Rs 2198 per month. There was wide variation in the income ranging from Rs 200 per month to Rs 15000 per month. Major depression was the predominant diagnosis, with 45% of the patients suffering from it. Eighteen percent of the patients had schizophrenia and 6.5% had bipolar disorder and epilepsy. Possession syndrome was present in 10.5% of the cases. The mean duration of illness was 5.5 years. Patients with up to one year of illness were 32.34%, one to five years of illness were 35.32%, five to ten years were 18.41% and beyond ten years were 14%. Hundred and ten out of the total two hundred and one (54.7%) of the patients had consulted traditional healer before coming to the psychiatric hospital. Table 1 gives the comparison between patients who had attended traditional healers and those who had not, as regards socio-demographic and disease-related characteristics. Various characteristics related to traditional healer consultation are described in table 2. Of the patients who had consulted traditional healers, 49% had visited only 1 healer while 31% had gone to 2-3 healers. Thirty-six percent patients visited 2-3 times and 41% went for more than three times. Most of traditional healers offered services from their home (47%) while 25% from a temple set up. Physical abuse in the form of being beaten up or hair being cut was experienced by 10.8% of the patients who had visited traditional healer. A quarter of the patients only paid up to Rs 5 to the healer while half of them paid an amount up to Rs 300. Sixteen of the 110 patients had to pay an amount greater than Rs 2500. The view that traditional healing is effective for mental health problem was supported by 22.7% of the patients and 20.9% would recommend going to a traditional healer.
patients. So we designed this study in order to address this research gap. The aims and objectives were: 1. To study the prevalence of traditional healing consultation in patients coming to the psychiatry OPD. 2. To study the socio-demographic and disease related characteristics associated with traditional healing consultation.
Methods
This is a cross-sectional study which was carried out in psychiatry department of a general hospital. Consecutive 201 OPD patients irrespective of their diagnosis were selected for the study. Either the patient or the relative accompanying the patient were interviewed using the questionnaire. Following information was collected: Socio-demographic characteristics: This included information related to age, sex, education, religion, family type, domicile and monthly income. Disease related characteristics: The DSM-IV diagnosis of the patients was based on clinical interview by a trained psychiatrist. The duration of the illness was noted. Traditional Healer Consultation: Every patient/relative was asked whether they had consulted a traditional healer before coming to the hospital. The response was noted as either yes or no. Information regarding number of visits, expenses incurred intervention by the traditional healer and whether they think that it was effective or not, was also recorded. Data analysis was done using SAS version 9.2 (for windows) (15). Continuous variables age, monthly income Archives of Indian Psychiatry 10(2) October 2009
Discussion
In our study we found that 54.7% of the patients who had some kind of mental illness had consulted traditional healer before coming to the psychiatric hospital. This means that every second patient whom we see in the hospital setting has already consulted someone from the indigenous and culturally acceptable system of practice/cure. These figures are very high and similar to the figures quoted in WHO report on traditional medicine (1). This report 35
Rahul Shidhaye : Traditional Healing Practices mentions that in developing countries 40 to 80% of the population seeks traditional medical systems (1). In this study, traditional healer refers to individuals who offered faith-based services either from Hindu temples, Muslim dargahs or similar kind of intervention from their homes. We did not study the Indian systems of medicine like Ayurveda, Unani or Siddha medicinal systems. Inclusion of these systems might have increased the prevalence of non-psychiatric setting consultation. There was no significant difference between patients who visited traditional healer and those who did not as regards socio-demographic characteristics. Age, sex, family type, domicile, monthly income, were not associated with traditional healer consultation. No gender disparities were associated with traditional healing consultation, even though it has been well documented that males get preference in conventional/alternative mental health services utilization. Higher education was associated with visiting traditional healer. Out of the 15 patients who had studied beyond S.S.C. (10 th grade), 13 had gone to the traditional healer (p=0.05). This result needs to be very carefully interpreted. People with higher education may be more motivated to relieve their stress and hence they may have more consultations even with traditional healers also. It is very difficult to generalize from this finding that higher education leads to help seeking from traditional healers. Of all the diagnoses, possession syndrome, and schizophrenia were significantly associated with traditional healing consultation. All 22 patients who had possession syndrome were first taken to the traditional healer and it is easy to understand this as possession syndrome is a culture-bound disorder and traditional healer is largely viewed as the best resource for such kind of complaints. Schizophrenia and mental retardation are chronic illnesses and our finding of significant association with traditional healing is consistent with the one reported by Ngoma et.al (12). They reported that traditional healers patients had long-standing complaints and the primary care patients had more acute complaints. Although caution is needed when making dynamic inferences from crosssectional data, traditional healers would seem often to be a last resort for patients with persistent problems who were presumably dissatisfied with the outcome of previous consultations with biomedical providers (12). In case of patients suffering from chronic mental health problems, higher referrals to traditional healers may be because of caregiver burnout. In the light of this information it is very important to identify the reasons for such widespread use of traditional healers for mental health problems. In the developed world, common mental disorders are costly and disabling disorders, which present often in primary care but are rarely recognised or treated (16). In developing countries, broad use of traditional medicine is often attributable to its accessibility and affordability. In Uganda, for instance, the ratio of traditional practitioners to population is between 1:200 and 1:400. This contrasts starkly with the availability of allopathic practitioners, for which the ratio is typically 1:20 000 or less (1). In rural Tanzania the ratio of doctors to population is 1:20000 whereas that of the 36 traditional healers is 1:25 (4). Moreover, distribution of such personnel may be uneven, with most being found in cities or other urban areas, and therefore difficult for rural population to access (1). Corresponding figures for India are not available, but it may not vary much. Psychiatric consultations are free in general hospitals, but consultation time is short, with little opportunity to discuss symptoms or receive explanations about health problems. Mental disorders are often perceived as a source of misfortune; ancestors and witches are believed to have a crucial role in bringing them about. Such disorders may be viewed in terms of magical, social, physical and religious causes, but rarely as diseases within the Western biomedical paradigm (17). Traditional healers rituals are linked to these belief systems and patients may think that this can result in over-all well-being.
Limitations: The sample for this study comes from the hospital setting, which has resulted in an important problem related to external validity of the study. It is difficult to generalize the results of this study to the community as the patients coming to the psychiatric hospital may be essentially different than the patients in the community who have not come to the hospital. The prevalence for seeking help from traditional healer may be higher in community setting for the individuals suffering from mental health disorders. The other limitation of this study is the sample size. With 201 patients this study did not have enough power to detect sociodemographic and disease related differences between patients who had visited traditional healers and those who had not.
Implications: Many traditional healers seek continued or increased recognition and support for their field. At the same time many allopathic medicine professionals, even those in countries with a strong history of traditional medicine, express strong reservations and often frank disbelief about the purported benefits of traditional medicine (1). Communities consistently and predictably choose traditional healers, often as first choice of help seeking. The community logic of this choice has to be understood before evaluation of the choice (6). Patients with common mental disorder constitute a large part of the workload of both psychiatric hospitals and traditional healers. There is little time, particularly in hospital setting, to explore the possible psychological basis of the complaints related to common mental disorders, or to investigate the wider family and social context of the disorder (12). Traditional healers may be better placed in this respect; it would certainly be interesting to know more of their approach to these cases in terms of their formulation, their management and the treated outcome. With the support of the formal health system, indigenous practitioners might become important agents in organising efforts to improve the mental health of the community. Traditional healers may have much to Archives of Indian Psychiatry 10(2) October 2009
Rahul Shidhaye : Traditional Healing Practices offer, and could usefully participate in joint training programmes in medical schools (12). Further studies especially with qualitative/ethnographic design should be undertaken to address the questions related to role of traditional healers in providing mental health services and what are the community perceptions regarding traditional healing vis--vis modern psychiatric practice. 8. Kulhara, A., (2000) Magic religious beliefs in schizophrenia; a study from north India. Psychopathology; 33; 62-8 Sethi BB, Trivedi JK, Shitholey P. Traditional healing practices in Psychiatry. Indian Journal of Psychiatry. 1977;13:5-13. Johri N. Religious beliefs, practices experiences among psychiatric patients Unpublished MD (Psychiatry) Dissertation, Gujarat University. 2003. Kakar S. Shamans, Mystics and Doctors. A Psychological Inquiry into India and its Healing Traditions. 1982. Ngoma MC, Prince M, Mann A. Common mental disorders among those attending primary health clinics and traditional healers in urban Tanzania. Br J Psychiatry. 2003 Oct;183:349-55. Salan R, Maretzki T. Mental health services and traditional healing in Indonesia: are the roles compatible? Culture, medicine and psychiatry. 1983 Dec;7(4):377-412. Raguram R, Venkateswaran A, Ramakrishna J, Weiss MG. Traditional community resources for mental health: a report of temple healing from India. BMJ (Clinical research ed. 2002 Jul 6;325(7354):38-40. SAS Version 9.2. SAS Institute, Cary, NC. 2008. Ormel J, VonKorff M, Ustun TB, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures. Results from the WHO Collaborative Study on Psychological Problems in General Health Care. Jama. 1994 Dec 14;272(22):1741-8. Ndetei DM, Muhangi J. The prevalence and clinical presentation of psychiatric illness in a rural setting in Kenya. Br J Psychiatry. 1979 Sep;135:269-72.
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References
1. 2. 3. WHO Traditional Medicine Strategy 20022005. Ontario Aboriginal Health Advocacy Initiative, Manual on traditional healers-1999. Ben-Tovim DI. Therapy managing in Botswana. The Australian and New Zealand journal of psychiatry. 1985 Mar;19(1):88-91. Swantz L. The Medicine Man Among the Zaramo of Dar-es-Salaam. Dar-es-Salaam: University Press. 1990. Patel V, Mann A. Etic and emic criteria for nonpsychotic mental disorder: a study of the CISR and care provider assessment in Harare. Social psychiatry and psychiatric epidemiology. 1997 Feb;32(2):84-9. Centre for Advocacy in Mental Health (CAMH). Health and healing in western Maharashtra- the role of traditional healing centers in mental health service delivery. 2006. Gandhi P, Bhatt S, Tilwani M, Vankar GK. Religious Beliefs and Traditional Healing Practices among Psychiatric Patients Paper presented at the 50th Annual Conference of Indian Psychiatric Society at Jaipur. 1998.
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Dr. Rahul Shidhaye,

Indian Institute of Public Health, Opp. Nalanda College, Vengal Rao Nagar, Hyderabad. 500038.
Sources of support : None
Rahul R. Shidhaye M.D.(Psy) M.H.S.(Mental Health)* Indian Institute of Public Health, Opp. Nalanda College, Vengal Rao Nagar, Hyderabad. 500038. e-mail:rahulshidhaye@yahoo.com Cell: +919848520340 Dr.G.K.Vankar MD,DPM Professor and Head Dept. of Psychiatry B.J. Medical College and Civil Hospital, Ahmedabad 380016
*Correspondence
Archives of Indian Psychiatry 10(2) October 2009 37
Original Article
Efficacy of Social Skills Training as Intervention for Stuttering for adolescents v/s adults
Sadhana Deshmukh Anuradha Sovani Abstract
The purpose of the study was to examine the efficacy of Social Skills training in the treatment of stuttering. The sample consisted of 15 adolescents and 15 adults. The mean age of the adolescents and adults was 17 years and 26.6 years, respectively. Each of the participants were required to attend ten sessions of one hour each, on a weekly basis. The therapy was conducted in accordance to the treatment module, which had a structured plan. The dependant variables were situational anxiety, communication attitude, assertiveness, self-esteem and fluency. These were assessed using Speech Situational Checklist-(short form), the S-24 Communication Attitude scale, Rathus Assertiveness Schedule, Rosenberg Self-Esteem Scale and the Speech Severity Index, respectively. Analysis of results indicated that adults showed more improvement than adolescents with respect to most of the variables. Hence, it can be concluded that the social skills training approach proved to be more efficacious overall in the treatment of adults who stutter, as compared to adolescents, especially when dealing with situational anxiety. Key words: Stuttering, Social Skills Training, Adults, Adolescents
Introduction
The ability to interact with others in a competent way is of great importance to all humans. Ease in both verbal and non-verbal communication is a vital factor in competent communication. As a direct result of their impairment, persons who stutter have a self-imposed restriction to acquire interpersonal skills necessary for skilled social functioning or the subtleties of relationship exchange. There are resultant avoidances of social exchanges, and inhibitions in social settings, which further reduce learning opportunities. The persons who stutter tend to examine a number of issues through the prism of their speech defect. This fixation on the speech defect not only results in morbid suffering, but further impacts communication - both verbal and nonverbal. As a result of the vicious cycle of tension, fear leading to helplessness in turn leading to anxiety and avoidances, the persons who stutter find themselves depriving and denying themselves the opportunity to observe and practice normal social interaction skills. The term Social Skills was coined by a British social psychologist, Argyle (1) when he explored analogies between human-machine and human-human interaction. L Abate and Milan, (2). Libet and Lewinsohn (3) defined social skills as the complex ability both to emit behaviours which are positively or negatively reinforced and not to emit behaviours that are punished or extinguished by others. Bellack and Hersen (4) refer to social skills as an individuals ability to express both positive and negative feelings in the interpersonal context without suffering consequent loss of social reinforcement. In a large variety 38
of interpersonal context (involving) .the coordinated delivery of appropriate verbal and non-verbal response. Birdwhistell (5) , one of the earliest authorities in the field of non-verbal processes in communication, estimated that in atypical dyadic encounter verbal components carry about one-third of the social meaning of the situation, while the non-verbal channel conveys approximately twothirds. Non-verbal signals are more important than verbal in expressing feelings and attitudes. Argyle et al, (6) elaborate that the non-verbal channels indicate how a message should be interpreted. The term non-verbal includes all form of human communication that is not controlled by the spoken word. An overlap exists in the paralinguistic aspects of speech i.e. voice, rate and volume and other non-verbal information like body movement, facial expressions and appearance. According to Dickson et al (7) there are six main functions of non-verbal communication: 1) to replace speech 2) to complement the verbal message 3) to regulate and control the flow of communication 4) to provide feedback 5) to define relationships between people 6) to convey emotional states. It is widely acknowledged that many persons who stutter demonstrate deficits in social skills. These do not appear at the onset, but become increasingly evident as the normal process of social communication is disrupted by the breakdown in fluency. Awkwardness experienced by such individuals in social situations only adds to the social disadvantages that already exist as a result of their communication disorder. There is evidence that interaction between stuttering children and their families plays an important role in the development and maintenance of the problem. Therefore Archives of Indian Psychiatry 10(2) October 2009
Sadhana Deshmukh : Efficacy of Social Skills Training according to Rustin et al (8) simply teaching parents of children who stutter, to reevaluate and make small changes in their social interaction skills has proved to be a powerful tool in early remediation of stuttering. There are many factors that have been shown to be influential and these include observation and listening skills, rate of speech and reducing the complexities of interactions. Sheehan (9) emphasized that stuttering occurs in communicative situations where others are present, it takes two to stutter. He described stuttering to be a disorder of interpersonal self-presentation, occurring via social context. For the persons who stutter, the establishment of social relationships within the family and later outside is central to healthy, adaptive functioning, according to Rustin and Kuhr (10) . Prins (11) and Wingate(12) concur that over the broad range of measures (self-report, behavioural and observational) children and adolescents who stutter do show more difficulties with social adjustments than children who are fluent. These include poor interpersonal skills, avoidance of social contact, withdrawal from social interaction and low rates of initiating social contacts. According to Bloodstein (13), there are many factors that are influential in the remediation of stuttering and these include observation and listening skills, rate of speech, etc. Especially for older children, where the stuttering has become more firmly established, it begins to affect their ability to deal with a wide range of social situations. Repeated experience of communication breakdown results in persons who stutter having increasing difficulties with social adjustment. Rustin and Kuhr (10) proposed a hierarchy of seven distinct skills: observation, listening, turn-taking, negotiation, relaxation, praise and reinforcement and problem solving. The researchers found them to be important parameters of communication and what enabled them to become more objective about their own skills, particularly if used in conjunction with video recordings. Interpersonal functioning or deficits in social skill repertoire of persons who stutter has been shown to influence the ability to maintain fluency following therapy (Rustin (14) , Rustin and Kuhr (10). A theoretical and methodical aspect of group psychotherapy for treatment of stuttering was developed after researching 200 patients by Shklovskiy, Krol & Mikhailova (15). According to them clients below 20 years of age experience significant problems of status among peers and lack communicative skills of older patients. The topics frequently featuring in the group were: social opinion, professional growth, relationship with superiors and subordinates. They felt that persons who stutter usually examined a number of topics through the prism of their speech defect. Therefore low level of awareness of their problems is determined mainly by a fixation on their speech defect. The psychological effect of fixation on the speech defect is that it results not only in morbid suffering and subjective exaggeration of its manifestation, but also Archives of Indian Psychiatry 10(2) October 2009 a tendency to selectively and inadequately perceive, interpret and construct any situation related to spoken communication. Along with this, there is also an overestimation of the verbal aspects of communication. They observed that in the process of group interaction those people who stutter do not make much use of nonverbal behaviour and are not inclined to give any significance to non-verbal behaviour of others. In a stutterer, the non-verbal signals of paralinguistic as well as extra linguistic type are eclipsed. This gives the speaker, under the effects of those techniques, a robot like effect. (It could be either decoding weakness traced back to reduced eye contact or it could be encoding weaknessin that the person who stutters does not produce the signals, which indicate to his partner that it is now his turn). Due to the peculiarities in the way in which the communicational personality of the person who stutters is formed it is observed that there is not only an absence of elementary communicative skills, (non-verbal communication) but also a deficit of information necessary for interaction. Therefore, it is important to deal with the learning of new role behaviour in its finer non-verbal aspects. Clients must practice maintaining eye contact, practice to keep calm in a group as well as to resist any form of time related pressure. According to Kraaimaat et al (16) the discomfort level in social situations, which leads to high levels of social and speech anxiety in persons who stutter, calls for anxiety reduction as well as social skills training. According to them social skills training is highly recommended because it includes exposure to social situations and performing social responses. Closely related to this is a novel concept by Shklovskiy et al (15) of communication portrait, which prepares and achieves qualitative change in the client, a sort of psychological correction. This change involves the extremely important task of changing the patients image of himself as the subject of communication and of communication in general. Towards this it is important to build a detailed communicative portrait of every patient in the context of group interaction. Creating communicating portrait of every patient introduces many new features into the ideas the group participants have about their own peculiarities, these ideas being corrected and expanded. In organizing this process it is important to give attention to micro components of speech that is; details of behaviour at the level of a single communicative act. An important place here is occupied by various characteristics of non-verbal communication. (Facial expression, gestures, voice parameter, and eye contact). The person who stutters, as he does not link it with his major problem, does not take non-verbal communication into consideration. Communicative portrait is in principle (i.e. allowing for alterations, additions, detailing) a comprehensive 39
Sadhana Deshmukh : Efficacy of Social Skills Training description by the group of individual features in a participants communicative behaviour. In other words, the communication portraits reflect and consider an essential quality of communication, namely its wholesome and systematic character .; Krol, (17). If so much of the information we are transmitting and receiving is being conveyed via the non-verbal channel then it becomes essential to incorporate training of these skills. Improvement in the non-verbal interaction skills of the persons who stutter, despite the deficits in their verbal skills should increase the effectiveness of their communication and in turn maximize the social reinforcement they receive from others. The consequent rise in the self-esteem and confidence levels should also encourage an increase in their ability to initiate and maintain conversation, skills which are vital to successful communication. Looking at the problem of persons who stutter from this point of view, social skills training might be a way of breaking this vicious cycle as the repertoire of skills one has and uses appropriately goes a long way in contributing to a satisfying social interaction. Procedure Each of the clients was subjected to a detailed intake interview. This standard format gathered information on, presenting complaints medical, family, social, academic and psychological history and any other earlier intervention. Subsequently, they responded to the five assessment tools as a part of the pre-test procedure. The tools used were Speech Situational Checklist, S-24 Communication Attitude Scale, Rathus Assertiveness Scale, Rosenberg Self-Esteem Scale, and Speech Severity Index. Speech Severity equivalence was ensured at the time of allocation of clients to the two age groups. Instructions before starting therapy were: You will be part of a group treatment with other clients who have the same problem as yours i.e.: stuttering. By giving your consent to participate in this you will be part of a study, which will help to understand more about interventions in the treatment of stuttering. A written consent was taken by having the clients sign on a consent form. In case of children, the consent of the parent or guardian was taken. Very careful records were maintained through the study, the client details recorded along with the treatment module they were subjected to. The pre and post intervention test scores of all the subjects were also meticulously noted.
Materials and Method

Sample: Thirty clients who were self-referred or referred from institutes, hospital and private clinics and schools. Individuals, who had been diagnosed as having stuttering, of any severity, (mild, moderate, severe, profound) with onset in childhood. They were more or less equally distributed in the two groups in terms of severity. The ages ranged from 13 to 40 years, both males and females. Exclusion criteria were presence of intellectual challenge or having psychiatric illness, as well as any organic or neurological disorder. Tools and definitions of variables 1) Southern Illinois Speech Situational Checklist (SFS.S.C) by Hanson, Gronhovd and Rice (18) shortened form. Situational anxiety is a feeling of worry or uneasiness in certain situations. S-24 Communication Attitude Scale (S-24) by Andrews and Cutler (19). Communication attitude is the clients self-perception as a communicator. Rathus Assertiveness Scale (R.A.S) by Rathus (20). Assertiveness is an active, direct and an honest approach, working for win-win outcome. Rosenberg Self-Esteem Scale (R.S.E) by Rosenberg (21). Self Esteem is the value or worth that one assigns to self. Stuttering Severity Index (S.S.I) by Riley (22). Fluency is the smooth flow of speech without repetitions, prolongations or blocks. Stuttering severity measures disruption of this fluency.
The treatment condition was structured in accordance to a predetermined plan, session by session, down to the details of activities in each session. Each module had 10 sessions of a given treatment condition of 60 minutes each on a once a week basis. The first session began with selfintroductions by the researcher and the group members. Thereafter the rules to follow, as a result of group membership were made known.
The Skills Training module focused on inputs for communication skills, which are essential for interpersonal interaction. Handouts consisting of skills steps were given to all the clients in this module. The importance of verbal and non-verbal communication was emphasized. These inputs for skill development were given over ten sessions of one hour each. The skills covered were (Table 1): body language, voice indices, listening, observation, conversation, expressing and responding to feelings, compliments and complaints, requests and refusal, and asking for information. In the sessions there was at first information giving by researcher, this was followed by viewing of a model video recording of the skill in question, followed subsequently by a discussion amongst members. Appropriate exercises were done to practice the skill in the safe environment of the group, after which the feedback from the researcher and the participants was given. The session ended with homework assignments for the week.
2)
3)
4)
5)
40
Sadhana Deshmukh : Efficacy of Social Skills Training
Skill Communication Body Language Voice Indices Listening Observation Conversation Expressing Feelings Responding to Feelings Compliments Complaints Requests Refusals Asking for Information Group Interaction
Description Importance of both verbal and no- verbal aspects of communication. The four non-verbal skills: eye contact, facial expressions, posture / gesture, and physical distance. The paralinguistic features of voice: rate of speech, loudness / volume, intonation, and tone voice. Importance of active listening, barriers in active listening and skill steps of listening Importance of self and other observation in interaction, and the skill steps involved. Skill steps required in initiation, entering / maintaining, and ending conversation included. Importance of expressing feelings, and the skill steps involved. Importance of responding to feelings, and the skill steps involved. Importance of giving and receiving compliments, and the skill steps involved. Importance of making and receiving a complaint, and the skill steps involved. Importance of making and responding to requests, and the skill steps involved. Importance of making and accepting refusals, and the skill steps involved. Importance of asking for information, and the skill steps involved. Importance of group participation, and the skill steps involved.
Table 2: Comparisons between D-scores of adolescents and adults for the five dependent variables post Skills Training intervention.
Adolescents Dependent Variables Mean Speech Situation Checklist Communication Attitude Scale Rathus Assertiveness Schedule Rosenberg Self-Esteem Scale Speech Severity Index 6.53 3.33 7.60 1.60 3.53 S.D 16.25 2.99 8.65 2.59 4.41 Mean 18.20 5.87 11.73 2.80 3.87 S.D 13.79 5.00 15.13 3.91 4.45 2.56 1.54 0.29 1.01 0.38 p < .05 NS NS NS NS Adults t Signif.
Table 2, shows that for SSC the mean scores are higher for adults (18.20) as compared to adolescents (6.53) and the difference between the two groups is significant (p< 0.05). The same trend is seen over the remaining four measures as well, viz the S-24, RAS, RSE, and SSI, wherein the mean scores of adults tend to be greater than those of adolescents, but not significantly so. What is striking in the findings with respect to the variable of situational anxiety is that the adults benefited significantly more than the adolescents. The adolescent who stutters has been seen as a client who is difficult and challenging to treat. Van Riper (23) commented that adolescents are difficult cases to treat and Daly, Simon and Burnett-Stolnack (24) agreed that this age group was particularly challenging. Some researchers reported similar experiences. One such was a survey of 287 school-based Archives of Indian Psychiatry 10(2) October 2009
clinicians by Brisk, Healey and Hux (25), who reported they found that they had fewer successes with adolescents who stutter than any other student age group. This would explain the significant improvement seen in the adults as compared to the adolescents in the In order to critically evaluate this study, it is necessary to consider the limitations. The sample consisted of a small group, hence the generalizations of the results to the wider population of adults and adolescents who stutter may be limited. Also, the sample under investigation involved persons who stutter who had been referred for intervention may differ from a group who were willing to receive support in a clinic, on own accord. To conclude then the findings that have resulted from this study highlight the importance of behaviours 41
Sadhana Deshmukh : Efficacy of Social Skills Training secondary to stuttering, which are often aberrant and attention getting nature and the fact that they interfere with communication all point to the need of incorporating these along with the conventional forms of intervention of such clients, so as to get global benefits. 11. Prins, D. (1972). Personality, stuttering severity, and age. Journal of Speech and Hearing Research, 15, 148-154. In F. H. Silverman, Stuttering and Other Fluency Disorders (p.78). Englewood Cliffs, NJ: Prentice-Hall. 12. Wingate, M. E. (1962). Personality needs of stutterers. Logos, 5, 35-37. In O. Bloodstein, A Handbook of Stuttering (p.217). Singular Publishing. 13. Bloodstein, O. (1995). A Handbook on Stuttering (5th. ed.). San Diego, CA: Singular Publishing. 14. Rustin, L. (1984). Intensive treatment models for adolescent stuttering: A comparison of social skills training and speech fluency techniques. Unpublished M. Phil Thesis: Leicester. In L. Rustin and A. Kuhr, Social Skills and the Speech Impaired. Whurr Publishers, London. 15. Shklovskiy, V. M., Krol, L. M., & Mikhailova, E. L. (1988). The psychotherapy of stuttering: On the model of stuttering patients psychotherapy group. Soviet Journal of Psychiatry and Psychology Today, 1, 130141. 16. Kraaimaat, F., Vanryckeghem, M., & Van-DamBaggen, R. (2002). Stuttering and social anxiety. Journal of Fluency Disorders, 27, 319-331. 17. Krol, L. M. (1979). Logo neurosis as a model for studying the semiosis of oral speech. Tartu, 164-184. In V. M. Shklovskiy, L. M. Krol, E. L. Mikhailova, The psychotherapy of stuttering: On the model of stuttering patients psychotherapy group. Soviet Journal of Psychiatry and Psychology Today, 1, 130141. 18. Hanson, B. R., Gronhovd, K. D., & Rice, P. L. (1981). A shortened version of the Southern Illinois University Speech Situation Checklist for the identification of speech- related anxiety. Journal of Fluency Disorders, 6, 351-360. 19. Andrews, G., & Cutler, J. (1974). Stuttering therapy: The relation between changes in symptom level and attitudes. Journal of Speech and Hearing Disorders, 39, 312-318. 20. Rathus, S. A. (1973). A 30-item schedule for assessing assertive behaviour. Behaviour Therapy, 4, 398-406. 21. Rosenberg, M. (1962). Self - esteem scale. In Primary reference M. Rosenberg, (1979). Conceiving the Self. New York: Basic Books. 22. Riley, G. D. (1972). A stuttering severity instrument for children and adults. Journal of Speech and Hearing Disorders, 37, 314-321.
References
1. Argyle, M. (1969). Social Interaction. New York: Aldine-Atherton. In L. Rustin & A. Kuhr, Social Skills and the Speech Impaired (2nd. ed.). (p.5). Whurr Publishers, London. LAbate, L., & Milan, M.A. (Eds.). (1985). Handbook of Social Skills Training and Research. New York: Wiley. Libet, J. M., and Lewinsohn, P. M. (1973). Concept of social skills with special reference to the behaviour of depressed persons. Journal of Consulting and Clinical Psychology, 40, 304-312. In L. Rustin and A. Kuhr, Social Skills and the Speech Impaired (2nd. ed.). (p.6). Whurr Publishers, London. Bellack, A. S., and Hersen, M. (Eds.). (1979). Research and Practice in Social Skills Training. New York: Plenum. In L. LAbate, & M. A. Milan (Eds.), Handbook of Social Skills Training and Research (p.4). New York: Wiley. Birdwhistell, R. (1970). Kinetics and Context. Philadelphia: University of Pennsylvania Press. In L. Rustin, & A. Kuhr, Social Skills and the Speech Impaired (2nd. ed.). (p.18). Whurr Publishers, Ltd. London. Argyle, M., Furnham, A., & Graham, J. (1981). Social Situations. Cambridge: Cambridge University Press. In L. Rustin & A. Kuhr, Social Skills and the Speech Impaired (2nd. ed.). (p. 18). Whurr Publishers, London. Dickson, D. A., Hargie, O., & Morrow, N. (1993). Communication Skills Training for Health Professionals: An Instruction Handbook. London: Chapman & Hall. In L. Rustin and A. Kuhr, Social Skills and the Speech Impaired (2nd. ed.). (p.18). Whurr Publishers, London. Rustin, L., Cook, F., & Spence, R. (1995). The Management of Stuttering in Adolescence: Communication Skills Approach. Whurr Publishers. Sheehan, J. G. (1970). Stuttering: Research and Therapy. New York: Harper & Row. In C. Van Riper, The Nature of Stuttering (pp. 279-322). Englewood Cliffs, NJ: Prentice-Hall.
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Sadhana Deshmukh : Efficacy of Social Skills Training 23. Van Riper, C. (1971). The Treatment of Stuttering. Englewood Cliff NJ: Prentice-Hall. 24. Daly, D., Simon, C., & Burnett-Stolnack, M. (1995). Helping adolescents who stutter focus on fluency. Language, Speech, and Hearing Services in Schools, 26, 162-168. 25. Brisk, D. J., Healey, E. C., & Hux, K. A. (1997). Clinicians training and confidence associated with treating school-age children who stutter: A national survey. Language, Speech, and Hearing Services in Schools, 26, 162-168. 26. Cooper, E. B., & Cooper, C. S. (1985b). Cooper Personalized Fluency Control Therapy-Revised. Allen: DLM. In E. B. Cooper, Treatment of dysfluency: Future trends. Journal of Fluency Disorders, 11, 317-327. 27. Shames, G., & Florence, C. (1980). Stutter Free Speech: A Goal for Fluency. Merrill, Columbus. In H. H. Gregory, Stuttering: A Contemporary Perspective. Folia Phoniatrica, 38, 89-120. 28. Craig, A., Franklin, J. A., & Andrews, G. (1984). A scale to measure locus of control behaviour. British Journal of Medical Psychology, 57, 173-180. In L. F. De Nil, & R. M. Kroll, The relationship between locus of control and long-term stuttering treatment outcome in adult stutterers. Journal of Fluency Disorders, 20, 345-364. 29. Krause, R. (1976). [Problems in psychological research on stutterers and their treatment]. Zeitschrift fur klinische Psychologie and Psychotheropie, 24(2): 128: 143. 30. Rustin, L., Purser, H. (1984). Intensive Treatment Models for Adolescent Stuttering: Social Skills versus Speech Techniques. Proceeding of the XIX Congress of the ILP. London: The College of Speech Therapists. In L.Rustin, F. Cook, & R.Spence, The Management of Stuttering in Adolescence: Communication Skills Approach. Whurr Publishers. 31. Rustin, L. (1987). Assessment and therapy programme for dysfluent children. Windsor: NFER-Nelson. In L. Rustin, F. Cook, & R. Spence, The Management of Stuttering in Adolescence: A Communication Skills Approach. Whurr Publishers. 32. Rustin, L., Botterill, G., & Kelman, E. (1996). Assessment and Therapy for Young Dysfluent Children: Family Interaction. London: Whurr. In P. Butcher, A. Elias & R. Raven, Psychogenic Voice Disorders and Cognitive Behaviour Therapy (p.38). Whurr Publishers, London.
Dr. Sadhana Deshmukh Clinical psychologist Ali Yavar Jung National Institute for the Hearing Handicapped (AYJNIHH), Mumbai. Dr. Anuradha Sovani* Clinical psychologist Reader, Department of Applied Psychology, University of Mumbai. Consultant and Trustee, Institute for Psychological Health, Thane, Maharashtra. e-mail: anuradhasovani@gmail.com *Correspondence This paper is drawn from Doctoral work completed by the first author,
43
Original Paper
Stress and Coping among Resident Doctors

Sohang Bhadania Minakshi Parikh G.K.Vankar Abstract
Background: Studies have shown medical school training to be a source of significant stress. Despite the critical importance of stress and well-being during residency training, only a few Indian studies have examined stress in residency. Aim: We investigated the psychiatric morbidity, stressors and coping in residents. Methods: We conducted a cross-sectional descriptive teaching hospital based study involving 145(40%) residents voluntarily at a tertiary care medical college hospital.. Level of stress was measured by General Health Questionnaire30(GHQ-30), methods of coping by Brief COPE-28 and demographics, stressors, resources and intimidation by Resident Physician Questionnaire. Simultaneously we interviewed them one by one and it was kept anonymous. Results: Thirty seven percentages of residents were under stress. Fifty five percentages of those who were in stress worked more than 80 hours per week. Being 1st year resident was associated with more stress. No gender differences were seen in experience of stress. Fifty nine percent PGs reported intimidation more than once. Residents mostly sought help from colleagues, chief residents and psychiatrists when in stress. Those who were in stress more often used substance and self blame as coping skills. Conclusion: Many residents experience significant stressors and psychiatric morbidity. This study can serve as a basis for future resource application, research and advocacy for overall improvements to well-being during residency training. Key words: stress, residents, coping
Introduction:
Studies [5] have shown medical school training to be a source of significant stress. Stress is throughout the medical training (i.e. under graduate [16, 17, 18] , internship [7], residency [4, 12, 13]). Given the goals of residency training, some stress seems inevitable[8] even favorable [9] yet scattered studies suggest that residents experience high rates of burnout, a severe stress reaction, and that burnout may be associated with adverse mental health and work performance. [4] The expectations and responsibilities only increase during residency training. [1] Also residents live in their respective training hospitals and they are expected to be proficient clinicians, educators, researchers and administrators by the time they have completed their training. Many residents report psychological symptoms during residency, feelings of becoming less humanistic and more cynical and burning out. [3, 4] Stress and Burn out differs from depression in that they only involve a persons relationship to his or her work, whereas depression globally affects a persons life. [6]
Coping is often defined as cognitive and behavioral efforts made in response to a threat. A common model of coping set forth by Lazarus and Folkman (1984) stresses that coping choices are dependent on both the appraisal of the threat (primary appraisal) and the appraisal of ones resources to address the threat (secondary appraisal). [20,
24]
The Resident Service Committee of the Association of Program Directors in Internal Medicine, Philadelphia, has grouped these stresses into situational, personal and professional stressors. [28] Our hypothesis was to see if there is any association between long working hours, stress and the greater use of maladaptive coping strategies. Also we have studied stress and its relation with demographics, branch of post graduation and gender difference of coping style. Firstly, it might be important to decrease the workload to enhance the efficiency of the residents. On the other hand, it may be important to identify and discourage the use of negative coping mechanisms, which might further contribute to the stress of these individuals, rather than helping them in relieving it. These measures would help improve patients safety as well as in the training, quality of life and education of the residents. [29, 30]
44
Sohang Bhadania : Stress and Coping Among Resident Doctors
Aim
We investigated the psychiatric morbidity, stressors and coping in resident doctors.
Material and Methods:

Participants Subjects were chosen who were working as residents at tertiary care medical college affiliated general hospital. It was cross sectional, voluntary and anonymous study. Residents were interviewed personally at their convenience and also asked to fill selected questionnaires during the interview. All the data were collected over a five months period (September through January 2008). We have applied 3 different standardized tools. Demographics, stressors, intimidation and resources were assessed by Resident Physician Questionnaire adopted from a Canadian study, level of stress assessed by use of General Health Questionnaire (GHQ-30), use of maladaptive coping mechanisms through Brief Cope. General Health Questionnaire (David Goldberg 1978) The level of stress was measured through the General Health Questionnaire (GHQ-30), which is a measure of current mental health [14, 32]. The questionnaire was originally developed as a 60-item instrument but at present a range of other shortened versions of the questionnaire including the GHQ-28, GHQ-20 and GHQ-12 are available. The scale asks whether the respondent has experienced a particular symptom or behavior recently. Each item is rated on a four-point scale (less than usual, no more than usual, rather more than usual, or much more than usual). A score of 0-0-1-1 for the 4 responses from left to right was given. The cut off score would be between 3 and 4, as described by Goldberg. All those who had scored 4 and above were considered to be suffering from psychological morbidity due to stress, and were labeled as Stressed and those with the score of 3 and below were labeled as Not stressed. Brief COPE (Carver CS 1997) The frequency of different coping strategies employed by the residents in the past 2 weeks was determined with the Brief COPE 28. [25] It has 28 items measuring 14 different coping styles (2 questions for each coping method). The responses to these questions are measured on a 4-point Likert-type scale with responses ranging from 1 (Ive not done this at all) to 4 (Ive been doing this a lot). These include, for example, Active Coping (Ive been taking action to try to make the situation better), Religion (Ive been praying or meditating), Venting (Ive been expressing my negative feelings) and Substance Use (Ive been using alcohol or other drugs to make myself feel better). As evident, some of these coping mechanisms will have a positive effect on the individuals life and can be termed positive. On the other hand, others that can worsen the situation can be termed as maladaptive. [26, 27]
Resident Physician Questionnaire (Happy doc Jordan CS 2005) Because the goals of the study were broad-based and descriptive, a decision was made to cover a large number of variables using single items and small modules, rather than including a restricted set of detailed gold standard measures. The questionnaire was divided into five sections: demographics, stress, intimidation and harassment, well-being and resources. Survey questions included qualitative rating scales, multiple responses and yes / no questions. To minimize a bias in rating scales responses (response acquiescence bias); the survey included a mixture of positively and negatively stated items. [31] The purpose of this study was to measure perceived stress which might vary both quantitatively and qualitatively among individuals. For similar reasons we did not define the term intimidation and harassment as this is also perceived differently among individuals. We also decided to keep the two terms (intimidation and harassment) linked to avoid any confusion among resident when completing the survey. In certain instances group data was collapsed to increase numbers within response categories. As a part of the study we have also included mental illness screening questions. To avoid any stigmatization and thus decreased response rate, we did not further screen these individuals for psychiatric diagnoses. Resources questions focused on knowledge of current resources (list provided of all resources and residents were asked which resource they were aware of prior to the survey) and perceived need for future resources. Statistical analysis The data was imported in Microsoft Excel and Statistical Package for Social Sciences 10 (SPSS 10) for further analysis. All percentages reported in this paper were rounded to the nearest whole number. In addition, decimal points were rounded to 1. p-values less then 0.05 were interpreted as indicating statistical difference
Results:
Demographic characteristics The response rate for the survey was 40% (145/365). Of those residents who completed the survey, 68% (n = 98) were male and 32% (n = 47) were female. The marital status among residents revealed that 23% were married, 55% were never married, and 22% were engaged. There is significant difference found between genders as regard to marital status (p=0.006). More males (25%) were found as engaged while females (41%) were mostly married. The levels of residency were as under: 34.5% were from first year of post-graduate training, 35% were in second year, 30.5% were in third year. The average number of hours worked per week among residents was 78 15 hours. Stress Thirty seven percentages of residents were under stress (53/145) as per GHQ>3. There was no significant difference
45
Sohang Bhadania : Stress and Coping Among Resident Doctors Table: 1 Stress in residency:Demographic Characteristics
GHQ positive N=53 n(%) 28 25 26 23 4 34 6 13 21 32 38 15 33 20 GHQ negative N=92 n(%) Significance
Hours of work
80 or less hrs work >80 hrs work 1st year 2nd year 3rd year Single Engaged Married Surgical Non surgical Clinical Para clinical
71 21 24 28 40 46 26 21 27 65 62 30 65 27
p=0.002
Level of training Marital status
p=4.3E-05(<0.05)
p=0.01
Faculty
p=0.2
p=0.6
Gender
Male Female
p=0.3
Table 2 : Top resident ranked contributors to stress Contributors Female N=47 % 9 8.3 6.2 4.1 1.4 1.4 Male N=98 % 24.1 17.9 8.3 4.8 1.4 1.4
Not enough time Own work situation Emotional problem Residency program Personal relationship Physical problem
Table 3: Resident experience of Intimidation and harassment Forms N=145 n, (%) 83 (57.2) 39 (26.9) 31(21.4) 16 (11.0) 8 (05.5) 1 (0.7) 1 (0.7)
Inappropriate verbal command Work as punishment Privileges/opportunity taken away Recrimination (i.e. accusation, counter-attack) Others (e.g. criticism, partiality etc.) Inappropriate or unwanted physical contact Sexual harassment
46
Sohang Bhadania : Stress and Coping Among Resident Doctors Table: 4 Ways of coping and gender Coping Mechanism Female N=47 Mean(SD) 6.13(1.3) 6.0(1.24) 3.0(1.1) 2.1(0.52) 6.0(1.33) 5.6(1.3) 3.6(1.2) 5.4(1.6) 5.9(1.2) 5.6(1.1) 3.7(1.4) 5.9(1.0) 5.1(1.9) 3.7(1.4) Male N=98 Mean(SD) 6.16(1.4) 6.2(1.4) 2.5(0.9) 2.24(0.8) 5.6(1.41) 5.9(1.2) 3.1(1.4) 4.8(1.5) 5.9(1.4) 6.2(1.3) 4.1(1.5) 5.7(1.3) 5.0(1.5) 3.4(1.6) Significance
Self Distraction Active Coping Denial Substance Use Emotional Support Instrumental Support Behavioral Disengagement Venting Positive Reframing Planning Humor Acceptance Religion Self Blame
p=0.5 P=0.4 p=0.006 p=0.08 p=0.006 p=0.09 p=0.2 p=0.02 p=0.5 p=0.002 p=0.058 p=0.2 p=0.5 p=0.1
between the genders as regards experience of stress. No specific specialty was associated with higher stress. First year of residents were in more stress than second year and third year students (p=0.01). Overall engaged were found to be in least stress compared to the single or married residents (p=0.01). We found that those who worked for more than 80 hours in a week were in stress (p=0.002). When asked to rank the most important thing contributing to feelings of stress, both males and females ranked time pressure as their number one choice. Intimidation and harassment Ninety three (64%) residents reported experiencing intimidation and harassment. Of those who responded 59 per cent have reported it occurring more than once. Residents reported intimidation and harassment from many members of the healthcare team. Intimidation and harraassment was reported from nursing staff(38%), from staff physician(27%), from residents of same specialty(26%), % from residents of other specialties(38%), patients and their relatives(22%) Only 43% of residents who reported intimidation and harassment were aware of the process to address this issue and 32% of residents felt this process was not adequate, fair and independent. Also they have reported different forms of intimidation and harassment (see Table-3). Residents were questioned on what was the basis for the reported intimidation and harassment. Here also multiple responses were permissible. The primary reported basis for intimidation and harassment was language (n = 22/93). Resources Residents have reported very few available resources to use when in stress. They explained need mainly of resident support group (72%), career counselor (70%), spiritual counselor (63%) and family support program (47%).When Archives of Indian Psychiatry 10(2) October 2009
asked to rank the top three well-being resources a resident in a situation where they were experiencing an emotional or mental health problem, resident colleagues were ranked as the number one choice, followed by external psychiatrists and psychologists and senior residents.
Coping with the stress There is difference in styles of coping as per stress profile and gender. Among 14 different coping styles negative styles were associated with stress
Discussion
The number of participants were (40%) of all resident doctors working at the institute which is comparable to other studies of this type. [5, 27, 12] In our study 37% of 145 residents were found to be under stress (GHQ>3). Jordan et al. [12] reported 34% and Pashtoon et al [27] reported 55% of residents in stress in other similar studies. As regards the socio demographic characteristics, the results are similar to results found by Jenny et al. [33] we found no difference in stress level between genders. This finding is contrary to findings of Toews et al. and Jordan at el. [11, 12] This might be possibly explained by the fact that other studies have used only self reporting questionnaire sent impersonally by mail whereas our questionnaire filling was preceded by a personal psychiatric interview which probably made the male counterpart equally psychological minded and expressive as female students. Also we found that there is significant difference between genders with respect to marital status. Here we identified significant number of males being engaged while significant number of females was married. We found that engaged were having least stress as compared to married and singles. Studies have shown that 47
Sohang Bhadania : Stress and Coping Among Resident Doctors favorable life events help to reduce stress. [19] So it might have facilitated to lower gender difference in stress. As engagement period has significant occupancy in life of residents, we have included it in our study. No study of such kind has demonstrated stress in residents those who were engaged. The probable explanation for such difference might be that those who were engaged might be getting dual benefits of less family responsibility and a supportive affectionate near one, facilitates to reduce stress. [7] Similar results were found by Kerby et al, [12] Catherine et al [22] and C van Ineveld et al. [23] Shanafelt et al [2] and Lemakau et al [15] found no relationship as regard to marital status. No other significant differences were found as regard to socio demographic factors. Regarding stress and work, more number of junior residents reported stress than senior residents. Residents that are more senior in training have other stresses that may be equally concerning (e.g. final examinations, higher expectations) [12] but we have not found them significant. Similar findings were reported by DB Reuben [10] and Garg G. [36] The possible stressors reported for such difference might be less experience so required constant learning, high skill work, work load [34,36] hours of work [35,4] , reduced sleep [37, 47] and intimidation by senior residents and nursing staff. [12, 39, 40] These stressors lead to fatigue and poor care delivery. [5, 37, 41, 42] We found that those who worked for more than 80 hours in a week were in more stress. Some studies found higher incidence of emotional exhaustion, depersonalization and ultimately reduced level of satisfaction with more hours of work per week. [43] In our study we are able to provide estimates of working hours of residents. We, however, from the above results cannot suggest the limit for the working hours but taking the 80 hours limit as suggested by the American College of Graduate Medical Education [27]; a lot of individuals were overworked. Along with evidences from other studies [42] we can say that work hours per week were one of the major causes of stress in residents. Also more working hours means less amount of continuous refreshing sleep. Residents from some specialty (i.e, gynecology, surgery, orthopedics) found to work on scheduled call duty extending from 24 to 48 hours in single stretch. This may be the reason why working for long hours having relationship with stress. For over 10 years, the United Kingdom and other Western countries have been substantially reducing the work hours of junior doctors. [44] A good review of the complex provisions in various countries was prepared by the Australian Medical Association. [45] In the United Kingdom, the current weekly limit for actual work is 56 hours (with an overall limit of 72 hours, including other inhospital activities). [42] Even more stringent restrictions are mandated by the European Working Time Directive, some had been implemented by 2004, and others to be by 2009. [46] Although such changes are not easy to implement but certainly it would be taken as a guide for making future strategies. Some suggestions from residents were recruitment of more postgraduates as per the load of patients, nursing staff should work responsibly, and equal 48 distribution of work as per skill and clerical and paper work should be done by staff other than post graduates. Studies have shown that work hours, work load and sleep are dependent on each other. [4, 21] So addressing one issue effectively would automatically bring changes to others.
[21]
In this study 93% (n=135/145) postgraduates reported learning new things as stressor while 75% (n=109/145) reports requirement of high level of skill as stressful. Geoffrey JR [21] also reported so. We have not found any significant difference between specialties for the level of stress. Contrary findings were reported by Thomas NK. [4] The probable reasons may be stressors unique to branches and tend to differ with it and as we have measured perceived stress, there is more reliance on subjectivity and resultant different sensitivity to stressors. Perception of intimidation at educational environment is known to all. [38] In our study inappropriate verbal comments from seniors reported by 57% of residents in form of nagging in presence of patient and their relatives, verbally abusive and shouting at students. These findings are consistence with earlier studies. [12] Apart from these work as punishment and privilege taken away remain major causes. The primary basis reported for the intimidation and harassment was language n=22/ 145(15.2%) a difference that could not attain statistical significance. Surprisingly, contrary to other studies [12, 40] we found gender was less reported as bases of intimidation in our studies. The reason may be lying in cultural values and customs as comparable studies are western. As residents were also allowed to express other forms of intimidations, they mostly reported jealousy, arrogance, ego, seniority and incomplete work in preset time frame as annoying. Most reported senior residents and nursing staff as a source of harassment. Intimidation and harassment occurred often multiple times (more than once in 59% of those responding to the study) in both genders. Twenty one per cent of the residents felt that the process to deal with it was not adequate, fair and independent. This speaks to the need for further educating all individuals in the healthcare system on resident wellbeing. For bullying to be tackled, trainees need a safe means of complaining. They also need to be made aware of the impact that their own behavior may have on colleagues. If some of the behaviors that erode trainees professional confidence or self esteem attempted by trainers to improve their performance then educational rather than a punitive approach should be needed to help trainers to develop effective ways of encouraging better performance without becoming a source of distress to junior colleagues. [48] In time of stress most students prefer to contact their own colleague or senior ones. Apart from this they aware of family members and nearby psychiatrist. They explain mainly need of resident support group and career counselor .So more education should be applied to this area as also suggested by others. [12, 39, 40] Here we have found those using positive coping skills were in less stress than those Archives of Indian Psychiatry 10(2) October 2009
Sohang Bhadania : Stress and Coping Among Resident Doctors who were using maladaptive ones. Studies have shown using positive coping skills help to reduce stress. [49, 50] So help seeking should be encouraged. There is also significant difference found in ways of coping used by males and females. [24] We have found females using more emotional support and venting while males mostly use planning and humor. Limitation of study Residents from only a single center were studied and the study was cross sectional. All residents from studied specialties were not willing to participate. Conclusion It is clear that there are significant stressors incurred during residency. Intimidation and harassment occurs among many residents. It is also important to recognize that a significant amount of residents are vulnerable to emotional and mental health concerns. Residents need to be better informed about well-being resources. Ensuring the education of other healthcare professionals in the area of well-being is needed, so that residents who ask for help will be directed the correct sources. Substantial reform is possible within the current system of medical care. Focus should be made towards identifying preventable factors of stress. 9. Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med.2001; 76:142-150. DB Reuben. Depressive symptoms in medical house officers. Effects of level of training and work rotation. Arch Intern Med.1985; 145(2). Toews JA, Lockyer JM, Dobson DJ, Simpson E, Brownell AK, Brenneis F. Analysis of stress levels among medical students, residents, and graduate students at four Canadian schools of medicine. Acad Med.1997; 72:9971002. Jordan SC and Scott P. Well-being in residency training: a survey examining resident physician satisfaction both within and outside of residency training and mental health in Alberta.BMC Med Educ.2005; 5: 21. Kirby H, Victor M. Prevalence of Depression and Distress in a Large Sample of Canadian Residents, Interns and Fellows. Am J Psychiatry.1987; 144:156166. TG Sriram, CR Chandrashekar, MK Isaac, V. Shanmugham. The General Health Questionnaire (GHQ). Comparison of the English version and a translated Indian version. Social psychiatry and psychiatric epidemiology.2005; 24:317-20. Lemkau JP, Purdy RR, Rafferty JP, Rudisill JR. Correlates of burnout among family practice residents. J Med Educ.1988; 63:682-691. Chandrashekhar TS, Pathiyil RS, VS Binu, Chiranjoy M, Biswabina R, Ritesh GM. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Medical Education 2007; 7:26 Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: a five-year prospective longitudinal study. J R Soc Med 1998; 91:237-243. Supe AN. A study of stress in medical students at Seth G.S. Medical College. J Postgrad Med 1998; 44:16. Holmes T. Life situations, emotions and diseases. Psychosom Med.1978; 9:78. John D, Catherine MacArthur, Shelley Taylor .Coping Strategies. Summary prepared in collaboration with the Psychosocial Working Group. Last revised July, 1998. Geoffrey J Riley. Understanding the stresses and strains of being a doctor.MJA.2004; 181:350353. Catherine M., Wayne S, Mary O, Harry R, Robert L. Stress and Coping Among Orthopedic Surgery Residents and Faculty. The American Journal of Bone and Joint Surgery.2004 86:1579-1586. C. van Ineveld. Stress in residency training: Symptom management or active treatment? Can Med Assoc J.1994; 150 (10). Lisa KT. Sex Differences in Coping Behavior: A MetaAnalytic Review and an Examination of Relative Coping. Personality and Social Psychology Review 2002; 6(1):2-30. 49
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Sohang Bhadania : Stress and Coping Among Resident Doctors 25. Carver CS. You want to measure coping but your protocols too long: consider the Brief COPE. Int J Behav Med 1997; 4(1): 92-100. 26. Vosvick M, Koopman C, Gore-Felton C, Thoresen C, Krumboltz J, Spiegel D. Relationship of functional quality of life to strategies for coping with the stress of living with HIV/AIDS. Psychosomatics 2003; 44(1):51-8. 27. Pashtoon MK, Talha K, Farooq HK, Jawad GK, Umber ZK, Hadi MK, Urooj BK, Musa R. Studying the association between postgraduate trainees work hours, stress and the use of maladaptive coping strategies. J Ayub Med Coll Abbottabad 2007; 19(3):37-41. 28. Resident Services Committee, Association of Program Directors in Internal Medicine. Stress and Impairment during Residency Training: Strategies for Reduction, Identification and Management. Ann Int Med.1988; 109:154-61. 29. Steinbrook R. The Debate over Residents Work Hours. N Engl J Med.2002; 347(16):1296-1302. 30. Gaba DM, Howard SK. Patient safety: Fatigue among clinicians and the safety of patients. N Engl J Med 2002; 347(16):1249-55. 31. Guyatt GH, Cook DJ, King D, Norman GR, Kane SC, van Ineveld C. Effect of the framing of questionnaire items regarding satisfaction with training on resident responses. Acad Med.1999; 74:192194. 32. FA Huppert, DE Walters, NE Day, BJ Elliott. The factor structure of the General Health Questionnaire (GHQ30). A reliability study on 6317 community residents. The British Journal of Psychiatry.1989; 155:178-185. 33. Jenny FC, Leslie AM. Sources of stress and ways of coping in junior house officers. Stress Medicine.1988; 5(2):121-126. 34. Ndom RJ, Makanjuola AB. Perceived stress factors among resident doctors in a Nigerian teaching hospital. West Afr J Med.2004; 23(3):232-5. 35. Ravi Gopal, Jeffrey JG, Tom JM, Allan VP. Burnout and Internal Medicine Resident Work-Hour Restrictions. Arch Intern Med.2005; 165:2595-2600. 36. Garg G. Postgraduate lifestyle: Stress and satisfaction. Indian J Pediatr 2005; 72:991-991. Sources of support : None Sohang Bhadania,MD Resident Minakshi Parikh,MD Professor G.K.Vankar,MD* Professor and Head Dept.of Psychiatry B.J.Medical College and Civil Hospital Ward E1 Ahmedabad 380016 e-mail:drgkvankar@yahoo.com Cell:+919904160338 *Correspondence 50 Archives of Indian Psychiatry 10(2) October 2009 37. Sigrid V, Raymond R, Barbara B, Ilene R, Judith O. Sleep Loss and Fatigue in Residency Training: A Reappraisal. JAMA.2002; 288:1116-1124. 38. Tibbo P, de Gara CJ, Blake TM, Steinberg C, Stonehocker B. Perceptions of intimidation in the psychiatric educational environment in Edmonton, Alberta. Can J Psychiatry. 2002 Aug; 47(6):562-7. 39. Elisabeth P, Maryanne A, Anita H, Jenny FC. Bullying among doctors in training: cross sectional questionnaire survey. BMJ 2004; 329; 658-659. 40. Lyn Quine. Workplace bullying in junior doctors: questionnaire survey. BMJ 2002; 324:8789. 41. Chen-CL, Lawrence SW. Residents who stay late at hospital and how they perform the following day. Medical Education 2008; 42: 7481. 42. David MG, Steven KH. Fatigue among clinicians and the safety of patients. N Engl J Med.2002; 347(16):1249-55. 43. Ravi Gopal, Jeffrey JG, Tom JM, Allan VP. Burnout and Internal Medicine Resident Work-Hour Restrictions. Arch Intern Med. 2005; 165:2595-2600. 44. Pickersgill T. The European working time directive for doctors in training. BMJ 2001; 323:1266. 45. Overseas experience in regulating hours of work of doctors in training. Australian Medical Association,1998. (Accessed September 24, 2002, at http://www.domino.ama.com.au/dir0103/IRRemun.nsf 46. Pickersgill T. The European working time directive for doctors in training. BMJ. 2001; 323:1266. 47. A Bibliography of Articles on the Effect of Sleep Loss on Performance. Compiled by Ingrid Philibert. Updated March 2005. 48. Paice E, Firth-Cozens J. Whos a bully then? BMJ 2003; 326(supple):S127. http://careerfocus. bmjjournals.com/cgi/content/full/326/7393/S127 49. Pino Morales Socorro M, Lpez-Ibor Alio JJ.Stress during post-graduate medical training. Actas Luso Esp Neurol Psiquiatr Cienc Afines.1996 Mar-Apr; 24(2):75-80 [Article in Spanish]. 50. Ratanawongsa N, Wright SM, Carrese JA. Well-being in residency: a time for temporary imbalance? Med Educ.2007; 41(3):273-80. Conflicts of interest: None
Case Report
Familial Hypokalemic Periodic Paralysis : A Case Report
Rajat Oswal Devendra Chaudhari Ritambhara Mehta
Abstract Patients with motor weakness or paralysis are frequently sent for psychiatric evaluation especially young female patients, without pain or paraesthesias, those who are fully alert, conscious and oriented. Those who have episodic motor weakness with full recovery and have sensations over involved parts with marked psychosocial stressor are readily diagnosed as suffering from Conversion Disorder. Some neurological conditions may follow a similar symptom profile and are often difficult to diagnose due to its reversible nature and almost no signs and symptoms when the patient is well. Psychiatrists must have thorough knowledge of such conditions to make a correct diagnosis of Conversion Disorder. Here we discuss a case of Familial Hypokalemic Periodic Paralysis in a 45 years old male patient referred to us with history of recurrent muscle weakness. Key words: Familial Hypokalaemic Periodic Paralysis
Case Report
A case of 45 years old male married Hindu patient who was referred from Department of Medicine with history of episodes of weakness (paralysis) in his limbs lasting from few hours to up to 3 days for last 25 years. These episodes of paralysis started at the age of 20 years. He would go to bed at night with no weakness and wake at morning with inability to move his upper or lower extremities. The episodes would last for few hours to 3 days followed by full recovery. During the episodes patient would be fully conscious & oriented, alert and sensations were also intact. These episodes vary in terms of degree of inability to move limbs and time duration of the episodes. He had no respiratory or swallowing difficulty and was able to move his neck and facial muscles during most episodes. But during severe episodes he had difficulty even in moving his eyelids, neck & facial muscles. He denies of any pain or paraesthesia during the episodes. These episodes have been occurring 15-20 times every year, more during winter, after physical exertion and after eating sweets or sour foods. Movement of fingers or other muscles helped him recover from paralysis faster and it would take longer time to recover if he were to sleep. Drinking coconut water would also help him recover faster. There were no major psychosocial stressors associated with or preceding the episodes. Patient felt distressed by the fact that during the episodes he would be functionally impaired. There was no history of any substance abuse. Family History: Patient has four brothers and one sister. Patients father and fathers younger brother were suffering from similar complains. Both died before 1 year and patients uncle Archives of Indian Psychiatry 10(2) October 2009
died during severe episode of paralysis. Patients two brothers are also suffering from similar complains. His youngest brother is having more severe symptoms compared to other brothers. He has more than 25 episodes every year and his episodes usually last for 2-3 days. A week after the initial consultation by the patient, his younger brother had an episode of paralysis after waking up from sleep. He was visited at his home and examined. The weakness was bilateral and involved both the proximal muscles of the shoulders and hips as well as the distal extremities. Patient was conscious and oriented to time, place & person. Neurological examination of the patients brother revealed flaccid type paralysis of all extremities which involved the proximal and distal muscles and included the hips and shoulders but sensation was intact. Cranial nerve function was grossly intact. Routine blood investigation, liver enzymes and complete blood count were normal except for a potassium level of 2mEq/lt (3.8-5.4mEq/lt). Thyroid stimulating hormone (TSH), triiodothyronine (T3) and thyroxine (T4) levels were also normal. Inter episodic potassium levels were normal. General examination & systemic examination did not reveal any other abnormality. The patient was diagnosed with Hypokalemic Periodic Paralysis. Patients family started giving him coconut water and it took him 2 days to recover fully from the episode without any residual weakness.
Discussion Conversion disorder is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is 51
Rajat Oswal : Familial Hypokalemic Periodic Paralysis preceded by conflicts or other stressors. (Sadock & Sadock, 2007) The immediate cause of conversion disorder is a stressful event or situation that leads the patient to develop bodily symptoms as symbolic expressions of a long-standing psychological conflict or problem. Associated features are evidence of secondary gain, The following disorders must be considered in the differential diagnosis: multiple sclerosis (blindness resulting from optic neuritis) myasthenia gravis (muscle weakness) myopathies (muscle weakness) polymyositis (muscle weakness) Guillain-Barr syndrome (motor and sensory symptoms) The usual pattern of inheritance is autosomal dominant with reduced penetrance in women (male-to-female ratio of 3 or 4 to 1). The typical attack comes on during the second half of the night or the early morning hours, after a day of unusually strenuous exercise; a meal rich in carbohydrates favours its development. Excessive hunger or thirst, dry mouth, palpitation, sweating, diarrhoea, nervousness, and a sense of weariness or fatigue are mentioned as prodromal symptoms but do not necessarily precede an attack. Usually the patient awakens to discover a mild or severe weakness of the limbs. However, diurnal attacks also occur, especially after a nap that follows a large meal. The attack evolves over minutes to several hours; at its peak, it may render the patient so helpless as to be unable to call for assistance. Once established, the weakness lasts a few hours if mild or several days if severe. The distribution of the paralysis varies. Limbs are affected earlier and often more severely than trunk muscles, and proximal muscles are possibly more susceptible than distal ones. The legs are often weakened before the arms, but exceptionally the order is reversed. The muscles most likely to escape are those of the eyes, face, tongue, pharynx, larynx, diaphragm, and sphincters, but on occasion even these may be involved. When the attack is at its peak, tendon reflexes are reduced or abolished and cutaneous reflexes may also disappear. Sensation is preserved. As the attack subsides, strength generally returns first to the muscles that were last to be affected. Headache, exhaustion, diuresis, and occasionally diarrhoea may follow the attack. Myotonia is not seen; indeed, clinical or EMG evidence of myotonia essentially excludes the diagnosis of hypokalemic periodic paralysis. Attacks of paralysis tend to occur every few weeks and tend to lessen in frequency with advancing age. Rarely, death may occur from respiratory paralysis or derangements of the conducting system of the heart. Mainly, such fatal cases were reported in the era before modern intensive care. Laboratory Findings The attacks are accompanied by reduction in serum potassium levels, as low as 1.8mEq/L, but usually at levels 52 that would not be associated with muscle weakness in normal subjects. The fall in serum potassium is associated with little or no increase in urinary potassium excretion. Presumably, large quantities of potassium enter the muscle fibres during an attack, but this explanation may not be complete. Some episodes occur with near-normal levels of potassium, and weakness persists for a time after the serum level has been restored.. Rudel and associates attribute the latter change to an increased Na conductance. The ECG changes also begin at levels of potassium that are slightly below normal (about 3meq/L); they consist of prolonged PR, QRS, and QT intervals and flattening of T waves. Diagnosis at a time when the patient is normal may be facilitated by provocative tests. With the patient carefully monitored, including the use of an ECG, the oral administration of 50 to 100 g of glucose or loading with 2 g of NaCl every hour for seven doses, followed by vigorous exercise, brings on an attack, which then can be terminated by 2 to 4 g of oral KCl (the opposite of what pertains in hyperkalemic periodic paralysis).
Treatment: A low-sodium diet (160 mEq/day), avoidance of large meals and exposure to cold, and Acetazolamide 250 mg three times daily may be helpful in preventing attacks. That Acetazolamide reduces attacks is somewhat surprising since it is kaluretic, but it may work through the production of acidosis; a few patients have worsened with the drug. Patients who are unresponsive to Acetazolamide may be treated with the more potent carbonic anhydrase inhibitor, Dichlorphenamide, 50 to 150 mg per day or with the potassium-sparing diuretics Spironolactone or Triamterine (both in doses of 25to 100 mg/day) but caution must then be exercised with the simultaneous administration of oral potassium supplements. The daily administration of 5to 10 g of KCl orally in an unsweetened aqueous solution prevents attacks in many patients, and apparently this program can be maintained indefinitely. If this approach fails, a low-carbohydrate, low-salt, high-potassium diet combined with a slow-release potassium preparation may be effective. For an acute attack, 0.25meq KCl/kg should be given orally or, if this is not tolerated, some other potassium salt may be tried. This dose may be insufficient, and if there is no improvement in 1 or 2 h, KCl may have to be given intravenously0.05to 0.1 mEq/kg intravenously initially in a bolus at a safe rate, followed by 20 to 40 mEq KCl in 5% Mannitol, avoiding glucose or NaCl as the carrier solution. For the late progressive polymyopathy that follows many severe attacks of periodic paralysis, Dalakas and Engel report successful restoration of strength by the long-term administration of the carbonic anhydrase inhibitor Dichlorphenamide. Regular exercise (not too strenuous) to keep the patient fit is desirable. (Ropper & Brown, 2005) Archives of Indian Psychiatry 10(2) October 2009
Rajat Oswal : Familial Hypokalemic Periodic Paralysis Conclusion: Periodic Paralysis is important to consider when seeing a patient with sudden onset weakness or paralysis, especially those with family history of similar condition and no history or evidence of other diseases and no significant risk factors for stroke. Failure to properly diagnose and treat Periodic Paralysis can be fatal, but rapid correction of potassium abnormalities can resolve the symptoms quickly and completely. Bibliography Encyclopedia of Mental Disorders. (n.d.). Retrieved from http://www.minddisorders.com/Br-Del/Conversiondisorder.html Mastalgia, F. L., & Jones, D. H. (July 2007). Myopathies and Muscle Diseases, Handbook of Clinical Neurology. Elsevier. Ropper, A. H., & Brown, R. H. (2005). Adamsa and Victors Principle of Neurology (8th ed.). McGraw-Hill. Sadock, B. J., & Sadock, V. A. (2007). Synopsis of Psychiatry. Philadelphia: Lippincott Williams & Wilkins.
Dr. Rajat M. Oswal, Assistant Professor, Dr. Devendra Chaudhari, M. D. Psychiatry Dr. Ritambhara Y. Mehta, Professor & Head Department of Psychiatry, Govt. Medical College, Surat
53
Case Report
Olanzapine Induced Tardive Dystonia

Vipul Prajapati Bhavesh Lakdawala G.K.Vankar
Abstract Today second generation atypical antipsychotics are mostly used for management of schizophrenia.They have low propensity to cause extrapyramidal side effects including tardive dyskinesia and tardive dystonia. Olanzapine is a thienobenzodiazepine derivative serotonin dopamine antagonist (SDA) drug. Very few reports of olanzapine induced tardive dystonia (TDt) are available in the literature. Here we wish to report a case of TDt, in a 22 years old female patient with schizophrenia and borderline intellectual functioning, which developed after 15 months of treatment with Olanzapine. (Key Words: Olanzapine, Tardive Dystonia (TDt), Atypical Antipsychotics) Introduction Extra-pyramidal symptoms (EPS) and tardive syndromesare commonly associated with the use of typical antipsychoticdrugs. Tardive dystonia (TDt), a very rare side effect induced byantipsychotics, is characterized by twisting and sustained muscle spasms that cause repetitive movements or abnormal postures. TDt can affect any areaof body. The muscles of the head and the neck are usually affected producing retro-, latero-, antero- or torti-collis [1-3].Tardive dystonia isusually disabling and persistent, and treatment seldom results in satisfactory relief or remission of symptoms. The remission rate is considered to be only 10%. As comparedto tardive dyskinesia, TDt develops at a younger age and after shorter exposure to antipsychotic drugs [1-3]. The estimated prevalence of TD with typical antipsychotics is 3% in a clinical population. Olanzapine, a thienobenzodiazepine derivative, is a second generation (atypical) antipsychotic agent, with a low propensityto cause tardive dystonia Compared with typical antipsychotic drugs, it has a greater affinity for serotonin5HT2A than dopamine D2 receptors [4]. Olanzapine is thought to have more action at mesolimbic than nigrostriatal dopaminergic pathways and is, therefore, associated with a very low incidence of EPS than observed with typical antipsychotic drugs. Furthermore, there are case reports of patients with various psychiatric disorders, suggested thatolanzapine also improves preexisting symptoms of tardive movements [15-18]. Till date, only few reports of Olanzapine relatedTDt are available in the current literature [6-9]. Here we are reporting a case of TDt, which developed after 15 months of treatment with Olanzapine. side(torticollis), elevation of the right shoulder,difficulty in walking and keeping right hand to support her waist while walking and difficulty speaking fluently because of her head bending for last 3 months. Patient was on psychotropic medications for her psychotic illness for last 2-3 years. Her illness started with paranoid features like someone is against her and might kill her, verbally and physically abusive towards family members and neighbors, auditory hallucinations, laughing without reason and sleep disturbance. After trying many faith healing practices, relatives consulted to Psychiatrist. She was diagnosed as Paranoid Schizophrenia. For initial 10 months, patient was treated with typical antipsychotic Trifluoperazine 10 mg, anticholinergic Trihexyphenidyl 4 mg and benzodiazepine Lorazepam 2mg daily with only 10-20% improvement in her symptoms. Because of little improvement other Psychiatrist was consulted; where patient was prescribed atypical antipsychotic Olanzapine up to 20 mg, Trihexyphenidyl 4 mg and Lorazepam 2mg daily for 15 months with 60-70% improvement in her symptoms. No typical antipsychotic was given during this period. Then patient started complaining to and fro movement of head, gradually worsening and eventually leading to bending of head towards right side(torticollis), elevation of the right shoulder, difficulty in walking and keeping right hand to support her waist while walking and difficulty speaking fluently. After onset of these symptoms Olanzapine was stopped and patient was put on Trihexyphenidyl 6 mg, Clonazepam 1.5 mg, Baclofen 20 mgand Clozapine 25 mg; but because of no further improvement relatives brought patient to Dept. of Psychiatry, Civil Hospital, Ahmedabad. We admitted the patient and investigated her thoroughly. Relatives reported no improvement in dystonic symptoms, decreased interaction with others, remaining more sad than before and laughing without reason occasionally after stopping Olanzapine. In family history, patients uncle had psychotic illness, who died many years back.
Case Report This is a case of 22 years old Hindu, Guajarati speaking, unmarried female patient presented with difficulty holding her head straight and head bending towards right 54
According to mother patients milestones were delayed than her siblings and she was poor at study so left study after 7th Standard. On Mental status Examination, her mood was depressed without any suicidal ideation, was not having any delusion or hallucination and had borderline intellectual functioning on psychological testing. Patients BPRS, HAM-D and AIMS scores were 45, 19 and 18 respectively. Her investigations CBC, RBS, LFT, RFT, Serum electrolytes, Serum Calcium, Serum Copper, serum Ceruloplasmin,ECG, Chest X-ray, Ophthalmoscopy, EEG and CT-Brain were all within normal limit. X-ray whole spine had loss of cervical lordosis possibly due to her difficulty maintaining head in erect position because of dystonia.Neuromedical and Orthopedic consultations did not reveal any abnormal findings. We kept patient on same medication except stopping Clozapine because of few case reports of even Clozapine induced tardive dystonia [1314]. Patients diagnosis of Tardive Dystonia was put according to Burke et al. criteria. No major improvement in her symptoms noted even one month of continuous treatment. Discussion Criteria forTardive Dystonia (TDt)defined byBurke et al. [5] are: 1. Presence of chronic dystonia 2. History of antipsychotic drug treatment 3. Exclusion of known causes of secondary dystonia 4. Negative family history for dystonia In our observation, the medication period of 15 months with Olanzapine and the relatively long time between development of TDt andwithdrawal of the Trifluoperazine, led decision that the TDt was secondary to Olanzapine.Regarding the pathophysiology of TDt, Olanzapine has D2 receptor occupancy higher than that of Clozapine or Quetiapineand similar to that of Risperidone, which may have accountedfor the development of tardive dystonia [4], though the exactpathophysiological mechanisms are still not clear. Also, there might be individual susceptibility for developing antipsychotic induced side effects including TDt. This is further supported by the observations that this patient did not develop tardive dystonia with Trifluoperazine, which is a more potent D2 receptor antagonist than olanzapine.Available literature supports the use of Clozapine inthe management of TDt, [11, 12] although TDt has been reported tooccur with Clozapine also [13, 14]. The treatment of TDt is very difficult. Several pharmacological or other somatic interventions have been tried with poor results. Pharmacotherapy interventions are of some benefit in only 50% of patients. Besides, only few patients have been considered to make a full recovery of TDt in a long-term follow-up examination. In this patient also no major improvement in her symptoms noted even after one month of continuous treatment.There are reports that the atypical antipsychotic Clozapine has special therapeutic effect on TDt. The efficacy of Clozapine on TDt may be due to its anti-D1 action rather to its built-in anticholinergic action. Clozapine has higher affinity for Archives of Indian Psychiatry 10(2) October 2009
D1 and lower affinity for D2 dopamine receptors. Trugman et al [12] proposed that repetitive stimulation of the D1 receptor by endogenous dopamine, resulting in sensitization of the D1-mediated striatal output in the presence of D2 receptor blockade, is a fundamental mechanism mediating tardive dystonia. But because there are case reports of evenClozapine induced tardive movements so we stopped Clozapine in this patient. Moreover, the combination therapy with Clozapine and the antispasmodic agent Clonazepam proved to be effective in some patients [11]. It should be noted that, there are no case reports showing improvement of TDt with other atypical antipsychotics, except three cases successfully treated with olanzapine [16-18].Several reports of the use of BTX for the treatment of TDt have been published [19-23]. Treatment with BTX injections is considered as the foremost treatment option for TDt .BTX injected into the affected muscles causes a permanent blockage of neurotransmission at the motor endplates by inhibiting acetylcholine release from nerve endings. Most of the patients show marked to moderate benefit but their improvement is transient usually, lasting a few months [19-23]. But because of poor affordability of this patient we didnt try this therapeutic option. Tetrabenazine, dopamine depleting agent inone study was effective in 80.5% of patients with tardive dystonia [24].The starting dose is 25 mg daily, which can be increased by 25 mg weekly or biweekly. In conclusion, our report illustrates the possibility of developing tardive dystonia with Olanzapine. Therefore, until further data are available, careful assessments are required for movement disorders in patients receiving atypical antipsychotics. Also, more data is required to know the typical characteristics and risk factors associated with Olanzapine induced TDt. References 1. Kiriakakis V, Bhatia KP, Quinn NP, Marsden CD. The natural history of tardivedystonia: A long term followup study of 107 cases. Brain 1998; 121:2053-66. 2. Adityanjee, Adezibijde YA, Jampala C, Mathews T: The current status of tardive dystonia. Biol. Psychiatry 1999, 45:715-730. Van Harten PN, Kahn RS. Tardive dystonia. Schizophr Bull 1999; 25:741-8. Kapur S, Zipursky RB, Remington G, Jones C, DaSilva J, Wilson AA, et al. 5-HT2 and D2 receptor occupancy of olanzapine in schizophrenia: A PET investigation. Am. J Psychiatry 1998; 155:921-8. Burke RE, Fahn S, Jankovic J, Marsden CD, Lang AE, Gollomp S, et al. Tardive dystonia: Late onset and persistent dystonia caused by antipsychotic drugs. Neurology 1982; 32: 1335-46. Dunayevich E, Strakowski SM. Olanzapine induced tardive dystonia. Am JPsychiatry 1999; 156:1662. 55
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Aggarwal and Jiloha RC : Olanzapine induced tardive dystonia. Indian J of Pharmacology 2008; 40:237-238 Gunal DI, Onultan O, Afsar N, Aktan S. Tardive dystonia associated witholanzapine therapy. Neurol Sci 2001;22:331-2. Charp F, Cohen D, Houeto J, Soubrie C, Mazet P. Tardive dystonia inducedby atypical neuroleptics: A case report with olanzapine. J Child Adolesc Psychopharmacol 2004;14:149-52.
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16. Lucetti C, Bellini G, Nuti A, Bernardini S, DellAgnello G, Piccinni A, et al.Treatment of patients with tardive dystonia with olanzapine.Clin Neuropharmacol2002; 25:71-4. 17. Littrell KH, Johnson CG, Littrell S, Peabody CD: Marked reduction of tardive dyskinesia with olanzapine. Arch Gen Psychiatry 1998, 55:279-280. 18. Fukui H, Murai T: Marked improvement of Meiges Syndrome with olanzapine in a schizophrenic patient. J Neuropsychiatry Clin Neurosci2002, 14:355-356 19. Tsui JKC, Eisen A, Stoessl AJ, Calne S, Calne DB: Duble-blind study of botulinum toxin in spasmodic torticollis .Lancet 1986, 2:245-246. 20. Tsuong D, Hermanowicz N, Rontal M: Botulinum toxin in treatment of tardive dyskinetic syndrome. J Clin Psychopharmacol1990, 6:438-439. 21. Kaufman DM: Use of botulinum injections for spasmodic torticollis of tardive dystonia. J Neurochem Clin Neurosciences 1994, 6:50-53. 22. Chatterjee A, Forrest GM, Giladi N, Trosh R: Botulinum toxin in the treatment of tardive dystonia. J Clin Psychopharmacol1997, 17:497-498. 23. Tarsy D, Kaufman D, Sehti KD, Rivner ME: An openlabel study of botulinum toxin A for treatment of tardive dystonia. Clin Neuropharmacol1997, 20:90-93. 24. William CK, Catherine C:Tardive Dystonia Following Antipsychotic Treatment. Medscape Neurology & Neurosurgery. 2004,6 :( 2).
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10. Gourzis P, Polychronopoulos P, Papapetropoulos S, Assimakopoulos K, ArgyriouAA, Beratis S. Quetiapine in the treatment of focal tardive dystonia inducedby other atypical antipsychotics a report of 2 cases. Clin Neuropharmacol2005; 28:195-6. 11. Shapleske J, Mickay AP, Mckenna PJ. Successful treatment of tardive dystoniawith clozapine and clonazepam. Br J Psychiatry 1996; 168:516-8. 12. Trugman JM, Leadbetter R, Zalis ME, Burgdorf RO, Wooten GF. Treatment ofsevere axial tardive dystonia with clozapine: Case report and hypothesis. Mov Disord 1994; 9:441-6. 13. Molho ES, Factor SA. Possible tardive dystonia resulting from clozapine therapy.Mov Disord 1999;14:873-4. 14. Duggal HS, Mendhekar DN. Clozapine-induced tardive dystonia (blepharospasm).J Neuropsychiatry Clin Neurosci 2007; 19:86-7. 15. Jaffe ME, Simpson GM. Reduction of tardive dystonia with olanzapine.Am J Psychiatry 1999; 156:2016.
Sources of support: None
Vipul Prajapati, Resident Bhavesh M Lakdawala, M.D., Assistant Professor G.K.Vankar, M.D., Professor & Head Dept. of Psychiatry, B.J. Medical College & Civil Hospital, Ahmedabad. Correspondence: Dr. Bhavesh M Lakdawala, M.D. Assistant Professor Dept. of psychiatry B.J.Medical College E-1 ward, Civil Hospital, Ahmedabad-380016 e-mail: dr_bmlakdawala@yahoo.co.in Cell:+919687284967
56
Case Report
Rumination Disorder in an Adult: A Case Report

Ela vatsala Sharma Deepak Tiwari Bharat Panchal
Abstract: Rumination disorder has been reported to be relatively rare disorders of eating during infancy. There has been rejuvenated interest in adult rumination in recent years. Some authors have begun to link it with eating disorders, mental sub normality and depressive symptoms. This paper presents 22 years old, college girl of normal intelligence. More identification and study of adult rumination is required to clarify its course and medical significance. Key word: Rumination Disorder, Adult, Normal Intelligence.
Rumination disorder or merycism [1] is an uncommon disorder. According to the Diagnostic and Statistical Manual of Mental Disorder IV-TR[6] , the essential feature of this disorder is the repeated regurgitation and re chewing of the food that develops in an infant or a child after a period of normal functioning and duration of at least one month. International Classification of diseases 10th Revision (ICD-10)[8], WHO describe it under the heading of feeding disorder of infancy and childhood, but do not accord it a separate category. Rumination Disorder has been reported in infants and mentally retarded[]. We report here, an adult female patient of normal intelligence with Rumination Disorder. Case Report A 22 year old, unmarried college girl presented in Psychiatry outpatient department with chief complaints of repeated regurgitation of digested food which started at age of 12 years. She either spat regurgitated food when alone or re chewed and re swallowed the regurgitated food when among people. Initially, she avoided social functions and gatherings because she felt ashamed of chewing or spitting in public. Later, she did not feel any discomfort even in class and social gatherings and continued chewing or spitting regurgitated food. She developed dental caries[] because of acidic regurgitated food, which required dental treatment. In this patient, regurgitation did not increase in lying down position after meals. She did not have features suggestive of Bulimia or Anorexia Nervosa. Investigations like X- ray chest, abdomen, and barium swallow and meal, gastroscopy and USG abdomen were reported normal. She was treated in last one year by Physician and gastroenterologist with H2 blockers, proton pump inhibitors, anti emetics without any improvement. Eldest daughter of nursing professionals, Ms. A lived in a nuclear family consisting of her parents, a brother and a sister. As both parents were working, she was brought up by her grandmother till 6 years of age when she was separated from her grandmother to live with parents. She reacted with difficulty and protest. At 12 years of age her problems of regurgitation started after death of her grandmother. Archives of Indian Psychiatry 10(2) October 2009
The patient was treated with Cap. Fluoxetine 20 mg once a day, psycho education about the disorder and progressive muscle relaxation training. She was instructed to take deep breaths as soon as she felt impending regurgitation. She was told to squirt [4] with lime and brush teeth after regurgitation. After three weeks treatment, consistent improvement was reported without any symptoms of regurgitation, re chewing or spitting. A 3 months treatment was continued where after she dropped out. Discussion Rumination disorder is generally considered a rare [6] disorder but in presence of eating disorder like Bulimia, it is not a rarity in adults. Our patient did not have any symptoms suggestive of Bulimia or any other eating disorder. Although, Rumination was described mostly in males at all periods before 20th century, DSM IV-TR [6] suggests that rumination is equally common in males and females. ICD-10 [8] does not comment on sex distribution in Rumination disorder (WHO). Rumination disorder is classified specifically as feeding disorder of infancy and childhood both in DSM- IV-TR [6] and ICD-10[8]. Our patient had onset at the age of 12 years. Cautley (1910)[] reported onset of rumination in early childhood or between 10 and 20 years. In adults, the diagnosis of rumination syndromes is usually based on eliciting classical symptoms in the absence of structural disease. Unfortunately, our experience at a tertiary care center suggests that pediatric and adolescent patients with rumination syndrome often undergo extensive [2][3] , costly, and invasive testing, and are frequently misdiagnosed as having gastro esophageal reflux disease or gastro paresis. Our patient also under vent such investigations for one year. We believe that insufficient awareness of the clinical features of rumination syndrome in pediatric and adolescent patients contributes to the difficulty in diagnosing this important medical condition. Formal diagnostic criteria for rumination syndrome occurring in children and adolescents with onset beyond infancy have not been defined in the consensus criteria. 57
Ela Vatsala Sharma : Rumination Disorder in an Adult Causation of this disorder has been a subject of controversy. Phylogenetic, anatomical, physiological and psychogenic theories have been forwarded. Earliest concept of bovine inheritance (Rumination is a natural process in herbivores) is only of historical interest. Stomach with insufficient gastric secretions was held as a hereditary condition on basis of several generations of ruminators in one family. Sinkler (1898)[] suggested that rumination was a gastric neurosis and patients had neurotic, hysterical and hypochondriac traits. Association between rumination and anorexia and bulimia nervosa is under consideration. No psychopathology in ruminators and their families was found by Lavigne et al[10]. There may be two behavioral causes of rumination [5]: 1) reward learning through increased attention for regurgitation, and 2) social deprivation. Treatment of rumination disorder has consisted of food, adequate chewing, diversion or distraction (e.g. ringing a bell or providing a toy to infant ruminator , behavioral[3] techniques based on pleasant and unpleasant contingencies and psychotherapeutic approaches focusing on improving family dynamics, providing a warm nurturing environment (Chatoor et al, 1989)[and group therapy (lorocca, 1988; Williamson et al, 1989). Various other strategies like weight reduction, relaxation therapy and also while eating, diaphragmatic breathing, taking sips of water in between meals etc can be implemented. [4]Aversion techniques such as electrical shock, scolding, and the application of unpleasant tastes to the tongue had also been recommended and have, understandably, been met with resistance because of ethical considerations. More recently the treatment of choice has been psychotherapy. An excellent review of psychosocial treatments of rumination disorder is available (Tierney and Jackson (1984) [10] . With behaviorally oriented treatment [3] and SSRI for 5 months our patient improved. Reason for her dropout from treatment was not known. Outcome of this disorder varies from short term benign course to life long and sometimes fatalities depending of degree of nutritional impairment. Infant mortality from malnutrition associated from rumination disorder is reported in 25% of patients (DSM III R). Blinder (1986) reported social impairment, dental complications, pneumonia, anemia, esophageal abnormality, eating disorders affective disorders as concomitant to rumination disorder. Our patient also suffered social anxiety due to rumination, required filling of dental caries and depressive symptoms. She responded favorably to treatment both in frequency of regurgitation and depressive symptoms in 3 months. Her long term outcome is not known. ERecent review literature (Parry Jones, 1994) has pointed out that Current classification systems DSM IV-TR [6] and ICD-10 describe rumination as an exclusive disorder of infants and young children while historical evidence and current research suggest broadening of the definition in existing psychiatric classification. Our patient, a college student of normal intelligence who had onset of rumination at age 12 supports this.
References:
1. Fleisher David R. Regurgitation, Rumination and the Rumination Syndromes. ON https://mospace.umsystem.edu/xmlui/bitstream/ handle/10355/5150RegurgitationRumination Syndromes.pdf?sequence assessed on 25 June,2010 Chial, Heather J, Camilleri Michael, Williams, Donald E., Litzinger, Kristi , Perrault Jean Rumination Syndrome in Children and Adolescents: Diagnosis, Treatment, and Prognosis Pediatrics Vol. 111 No. 1 2003, pp. 158-162 Ellis, Cynthia R , Schnoes, Connie J :Eating Disorder, Rumination: Treatment & Medication http://emedicine.medscape.com/article/916297treatment Effective Treatment of Rumination with Nissen Fundoplication. Brant K. Oelschlager, M.D., Maren M. Chan, M.D., Thomas R. Eubanks, D.O., Charles E. Pope II, M.D., Carlos A. Pellegrini, M.D. Jackson HJ,Tierney DW. Rumination Disorder of Infancy: Some Diagnostic Issues in Need of ClarificationJournal of Intellectual and Developmental Disability1984, Vol. 10, No. 4 , Pages 243-245 Chatoor I: Feeding and Eating disorders of infancy and early childhood, in Comprehensive Textbook of Psychiatry Eds. Sadock Benjamin J. , Sadock Virginia A. , Lippincott Williams & Wilkins Publishers; 7th edition (January 15, 2000) I Woolston J.L.,Hasbani S.M. Eating and Growth Disorders in Infants and Children in Lewiss Child and Adolescent Psychiatry: A Comprehensive Textbook 4th Edition2007 Lippincott Williams & Wilkins assessed online on on 25 June,2010 http://www.msdlatinamerica.com/ebooks/LewisChild AdolescentPsychiatry/sid657745.html WHO: The ICD-10 Classificationof Mental and Behavioural Disorders, Geneva
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Ela vatsala Sharma, Resident Deepak Tiwari, Associate Professor Bharat Panchal, Professor and Head Department of Psychiatry Medical College and Sir T.Hospital Bhavnagar Cell: e-mail: 58 Archives of Indian Psychiatry 10(2) October 2009
Case report
Treatment of Ego-Dystonic Homosexuality with Behaviour Therapy Using Principle of Classical Conditioning: a Case Report Suhas Gajbhiye Kranti Kadam Nilesh Shah
Abstract People with Homosexual orientation are increasingly accepted as normal sexual minority.Vast literature documents change in sexual orientation from homosexual to heterosexual, mainly behavioral techniques using conditioning procedures. We report here a case of young man with ego dystonic homosexuality treated sucessfully using classical conditioning based procedure. Although tAmerican Psychological Association cautions using behavior therapy to change sexual orientation, the case supports use of this treatment especially in patients distressed due to their sexual orientation. (Key words: ego-dystonic , homosexuality, classical conditioning) The term homosexuality describes a person overt behavior, sexual orientation, and sense of personal and social identity. Various other terms have been used like lesbians, gay men to describe them. There have been many psychiatric theories about its origins, its social and personal meaning, its diagnostic implication, and what constitutes correct clinical approach toward it. In 1973, the American Psychiatric Association (APA) officially accepted a normal variant model and removed homosexuality per se from its Diagnostic and Statistical Manual of Mental Health Disorders (DSM). In 1992, the World Health Organization (WHO) followed the American example and made a similar change in International Classification of Diseases (ICD). (1) Psychiatric and medicines nosological changes reflect a dramatically increased social acceptance of openly gay, lesbian, and bisexual individuals in Western societies. This acceptance is rapidly evolving social phenomenon. The day to day lives of lesbians and gay men may often be similar to those of heterosexual people, the former also face unique developmental task throughout the life cycle. For example, during childhood and adolescence, young people who become aware of significant attraction to someone of same sex need to understand what make them different from the majority of people around them. Some choose to disclose their homosexuality to others through the process of coming out. During adulthood, these men and women confront unique challenges as they try to establish close relationship and to create families. They may do so even without traditional, formal ritual that celebrates their relationship or laws to protect their families. Homosexual persons need to face the adversity of having stigmatized sexual identity, as well as potentially life affirming factors associated with finding out true self, finding ones true partner, and being part of a community in which one can be oneself. The term antihomosexual attitude use to refer to a wide range of critical and disapproving beliefs and filling about homosexuality. Term homophobia refers to fear or hatred of homosexuality (external homophobia) or self hatred of that gay people feel about themselves (internal homophobia). A developing gay or lesbian person psychologically incorporate disapproving societal view of homosexuality and then experiences these feeling and beliefs in the form of a critical self evaluation. For many instances it may produce variety of psychiatric and behavioral symptoms, including depression, anxiety, denial, and sometimes even suicide. Internalized homophobia may produce a unique interaction in each gay and lesbian person, but its comman root lies in anxiety about being criticized and shamed. (1) Because of various problems faced by these people in personal and social life where they have to maintain the cultural norms, social values; many of these homosexuals may try to change their sexual orientation. Recently organizations such as the American Psychological Association have issued warnings against the use of therapies aimed at changing sexual orientation, however a vast amount of reports about change in sexual orientation from homosexual to heterosexual are documented in the literature. The outcomes of interventions, using a variety of techniques, aimed at changing sexual orientation, are vast and varied.
59
Suhas Gajbhiye : Treatment of Ego-Dystonic Homosexuality The techniques of classical conditioning using sexually he tried to rub genitals. But as many of his friends came to arousing materials have been reported. For instance, know his behavior, they started avoiding him. He tried McCrady (1973) reported the successful therapy of a 27- male to male sex for the first time, during which he was year-old gay man who had occasional same-sex able to get pleasure after rubbing genitals on abdomen. experiences from age 16. McCrady showed the client a Then he continued male to male sexual contacts for two nude female and then faded the image into a nude male. years, as he was getting more pleasure with sex than During the course of therapy, the client reported the onset rubbing his genitals on others abdomen. He frequently of heterosexual fantasies. (2) Barlow and Agras (1973) engaged himself in homosexual activities with gay friends. reported similar techniques although in their procedure, the nude male pictures were faded into the nude female Six months prior to coming to psychiatry out patient pictures. These researchers reported physiological department at municipal hospital, his father asked him measures of changed arousal which improved in a about marriage. As he never disclosed his sexual heterosexual direction at follow up for all three subjects in orientation and behaviors to parents; he was afraid of their study. (3) This case report provides use of classical parental response if he disclosed. He remained constantly worried and thinking about same.Afriend at that juncture conditioning, in changing sexual orientation. advised him to take psychiatric reference. He consulted a private psychiatrist who started him on tab. Sertraline Case Report 200 mg per day and oral preparations of testosterone to A 22 years old man was referred from department of increase libido and sexual performance with females. He dermatology for psychiatric evaluation as he was not continued medication regularly for six months; he had comfortable with his sexual orientation toward males. some improvement in worries and continuing thoughts According to him in childhood he was getting sexual but was not getting arousal and erection on seeing female pleasure with boys after rubbing his genitals to their pictures.As he was not getting rid of his homosexual abdomen. Therefore in schooldays he was purposefully orientation, he consulted dermatology OPD for engaged in fighting with boys so that he can sit on their evaluation,from where he was referred to psychiatry out abdomen and would rub his genitals to get sexual pleasure. patient department for detailed evaluation. In keeping He continued this habit throughout his schooldays. During with psychiatric history and treatment, tab. Sertraline 200 college period he was unable to maintain similar behavior mg per day was advised, testosterone preparation was hence he started helping friends in massage during which discontinued.
CLASSICAL CONDITIONING IN TREATMENT OF HOMOSEUAL BEHAVIOR In classical conditioning where repeated pairing of neutral [conditioned stimulus (CS)] with one that evokes a response [unconditioned stimulus (UCS)], is done, such that neutral stimulus eventually comes to evoke the response, e.g. before conditioning; food (UCS) causes salivation [unconditioned response(UCR)] and when bell (CS) paired with food (UCS) causes salivation , after repeated conditioning bell (CS) causes salivation (CR). Before conditioning Food (UCS) Salivation (UCR) Pairing Bell (CS) paired with food (UCS) Salivation (UCR)
After conditioning Bell (CS) Salivation (CR) (4) Similarly pairing of neutral stimulus of female photograph (CS) with male photographs (UCS) during masturbation was used repeatedly, so that he can get erection, masturbation and orgasm even after seeing female photographs alone. Before conditioning Male photographs (UCS) erection, masturbation and orgasm (UCR) Pairing Female photograph (CS) paired with male photographs (UCS) erection, masturbation and orgasm (UCR) After conditioning Female photograph (CS) erection, masturbation and orgasm (UCR)
60
Suhas Gajbhiye : Treatment of Ego-Dystonic Homosexuality Homework was assigned as a part of classical conditioning training, 1) Initially he was advised to see female photographs before masturbation and then to masturbate after seeing male photographs; Then was advised to keep females photographs along side of male photographs while he was masturbating on subsequent days ; Gradually trained to overlap female photographs over male photographs & was told to try masturbation with female photographs. At last was told to masturbate while watching female photographs only . He continued this practice 2-3 times a week for more than a month. Johnsons 1979) had been described by many authors with varying results.(5) In our clinical set up, we apply behavior therapy using classical conditioning principles but follow ups are poor or patient participation is not adequate. This is one example of clinical improvement after behavior therapy to change homosexual behavior.
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References
1. Jack Drescher, Terry SS, William MB. Homosexuality, Gay and Lesbian Identities, and Homosexual Behaviour. In: Kaplan & Sadocks comprehensive text book of psychiatry, 8th ed., Sadock BJ, Sadock VA, editors. Lippincott William And Wilkins: Philadelphia; p 1936-51. McCrady, R. (1973). A forward-fading technique for increasing heterosexual responsiveness in male homosexuals. Journal of Behavioral Therapy & Experimental Psychiatry, 4, 257-261. Barlow, D. & Agras, W.S. (1973). Fading to increase heterosexual responsiveness in homosexuals. Journal of Applied Behavior Analysis, 6, 355-366. Agras WS, Wilson GT. Learning theory. In: Kaplan & Sadocks comprehensive text book of psychiatry, 8th ed., Sadock BJ, Sadock VA, editors. Lippincott William And Wilkins: Philadelphia; p 541-44. Warren Throckmorton. (1998) Attempts to Modify Sexual Orientation: A Review of Outcome Literature and Ethical Issues (volume 20, pages 283-304) of the Journal of Mental Health Counseling.
He was advised to follow up in psychiatry out patient department weekly for fifteen days and then every fortnight for one month, at end of one month he claimed that, he can get erection during masturbation while seeing female photographs. He married after two months to a woman, now enjoys his married life and has fallow up every month for psychiatric medications.
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Discussion
Reports about change in sexual orientation from homosexual to heterosexual began to appear in literature as early as the nineteenth century. Charcot, in 1882, published a paper entitled, Inversion of the Genital Sense. Albert von Schrenck-Notzing (1892) also recounted a case of treatment success using suggestion and hypnosis therapies. Prince (1898) reported treatment of sexual paraphilias, including homosexuality, and stated that 70% were essentially improved or cured (Fine, 1987). Though various modalities of treatment such as behavior therapy, psychoanalysis, group therapy, hypnosis, ExGay or Religiously Mediated Therapies, Spontaneous Change (Wolpes 1969), sex therapy (Masters and
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Dr.Gajbhiye Suhas*, 3rd year resident, Dr.Kranti Kadam, Lecturer, Dr. Nilesh Shah, Professor Dept. of Psychiatry OPD 21, College Building Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai 022 Correspondence* e-mail: suhas3010@rediffmail.com
61
Poetry
Constipation
Urban teacher recently transferred to rural school Had complaint of inability to pass stool. His wife thought, Husband might be telling lie Let me take him to Freud,Citys sexiest guy. Freud said, I can cure illness in fifty sittings But since it is emergency I will call psychaitrists meeting. He decided to call psychiatrist all And they gathered in big conference hall. Freud started, Pt is perfectionist and punctual So it is fixation at state anal- psychosexual. Karl Jung angrily shouted at Sigmund Freud You always bring sexuality, Are you Freud or fraud? Then he mocked at Freud, Do you have brain or bladder You cannot diagnose even simple matter. Sigmund Freud confessed, You know I am sexually perverted But you also know that personality cannot be reverted. Then he added shyly, Phallus comes to my mind uppermost When I see pen, pendulum, pillar or post. Then Jung added, It is simple case of fight Between conscious complex and unconscious archetype. Anna Freud said to Jung, You are speaking in jest Otherwise go east or west, my father is best. Alfed Adler said, I can see very clearly, It is a case of organ inferiority. Maslow interrupted, Pt has problem in climbing pyramid So please give him some push form behind. It is birth trauma someone spoke from back When all look back it was Otto Rank. Adolf Meyer said, There is no need to guess It is case of reaction to life stress. Basic Anxiety Karen Horney spoke anxiously But no one took her seriously. Briquet said, It is conversion disorder and secondary gain There is no pain without gain Erickson said- flashing his mobile EricssonIt is problem of stage transition. Heinz Kohut said, Pt is not getting job satisfaction Because he is not getting narcissistic gratification. It is adjustment disorder, spoke Sheth Hitesh Everyone looked at him with interest. Pt said, You all fool, please keep cool Im not passing stool, because there is no latrine in school.
Dr Hitesh Sheth,MD Superintendent and Psychiatrist 202,Aashrayadeep Apartment Gautamnagar Society. Alwa Naka, Manjalpur,Vadodara, Gujarat,India. e-mail: hiteshcsheth@rediffmail.com Cell : 98241682430
62
Quiz
1. What is the full form of P.W. D. Act? 2. Games People Play is a popular introduction to Transactional Analysis.Who is the author? 3. Learned Helplessness theory of depression was proposed by which Psychologist? 4. What is Mellanby effect? 5. What is ANOVA? 6. What is Cotard syndrome? 7. EEG Neurofeedback training utilizes which brain waves? 8. What is Haptic hallucination? 9. Name the syndrome in which the husband/partner of an expectant mother experiences some of the same symptoms and behavior as the mother. 10. What is PANDAS? 11. The feeling that what one is thinking has been thought about sometime in the past, is called 12. IQ = Mental Age X 100. What is highest divisor , as Chronological Age?
Contributed by Dr.Parag Shah MD
Asst.Prof of Psychiatry Medical College Vadodara e-mail:drparagsshah@rediffmail.com
Chronological Age .
cell:09426138318
Answers :
1. The Persons with Disability Act 2. Eric Berne 3. Martin Seligman 4. The intoxicating effects of alcohol are more pronounced when the Blood Alcohol Level is rising than when it is falling 5. Analysis of Variance a statistical method 6. A nihilistic delusion consisting of an intense sensation of death and disintegration 7. Mu waves 8. Hallucination associated with the sensation of touch 9. Couvade Syndrome 10. Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection 11. deja pense 12. 15
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Archives of Indian Psychiatry 10(2) October 2009