indian psychiatric society western zonal branch indian psychiatry · 2012. 6. 15. · dattatrey...

Editorial

5HTT Gene-environment interactions in human behaviour

Chittaranjan Andade 4

Review Article

Night Eating Syndome Ameya Amritwar, Nilesh Shah

5

Developmental Psychopathology an d its relevance to Child Psychiatry – a Clinical Perspective

Avinash deSouza8

Original Articles

16

Traditional Healing practices inPsychiatric Out Patients

Rahul ShidhayeG .K .Vankar

28

Newspaper Portrayal of Psychiatry Laxeshkumar PatelG .K .Vankar

31

E! cacy of Social Skills Training as Intervention for Stuttering for adolescents v /s adults

Sadhana DeshmukhAnuradha Sovani

37

Stress and Coping among Resident Doctors Sohang BhadaniaMinakshi Parikh, G .K .Vankar

44

Who cares for caregivers?: A ReviewPooja DangarParag Shah

50

Case Reports

Familial Hypokalemic Periodic Paralysis : A Case Report

Rajat Oswal,Devendra Chaudhari,Ritambhara Mehta

61

Quiz Bhavesh Lakdawala 64

Archives ofIndian Psychiatry

O! cial Publication ofIndian Psychiatric SocietyWestern Zonal BranchVolume 13, No.2, October 2011

Contents

O! cial Publication of Indian Psychiatric Society, Western Zonal BranchVolume 14, No.1, April 2012

Kaushik GuptePresident

Vivek KirpekarHon. Secretary

Vivek Kirpekar Vice President

Jay ShastriTreasurer

Bansi SuwalkaImm. Past President

Govind BangKishor GujarRepresentatives of

Central Council

Kausar AbbasiNeena SawantKailash JhalaniP.M.ChuguleRajendra HegdeRavindra KamathExecutive Council Mambers


Chairpersons Subcommittees

Dattatrey DhavleAwards Committee

Sudhir BhaveCME

Mukesh JaggiwalaConference

S.M.AminConstitution

Sandip DeshpandeLegal

Deepak RathodMembership

Sandesh Patil Mental Health Awareness

Kamlesh Dave Psychiatric Education

Malay Dave Quiz

Rahul Tadke Accreditation

Abhishek Somani Website


O! cial Publication of Indian Psychiatric Society, Western Zonal Branch

Volume 13, No.2, October 2011

Honorary Editor

G. K. VankarProfessor and HeadDept. of PsychiatryB.J. Medical College andCivil Hospital,Ahmedabad-380016.Cell. : 09904160338

Rahul ShidhayeStatistics ConsultantRajat OswalWebsite Development

Editorial O! ce

Dept. of Psychiatry,OPDBuilding,Wing 1I FloorCivil Hospital,Ahmedabd-380 016.E-mail : [email protected]: http://archivesindianpsychiatry.wordpress.comhttp://www.archindianpsychiatry.org

Phone : 079-65542770Fax : 079-65542770

Type SettingPankit Patel Karnavati Computer

Editorial Board

R. Srinivasa MurthyE. MohhandasVikram PatelNimesh DesaiK. S. JacobNilesh ShahChittaranjan AndradeBharat PanchalShekhar SheshadriAshok Nagpal

Board of Directors Laxman DuttJitendra NanawalaI. R. RajkumarV. G. VatweMukesh JagiwalaRajendra HegdeK. S. AyyarHemangee DhavleGovind BangShubhangi ParkarKaushik Gupte

Corresponding Members

Dinesh BhugraStuart MontgomaryAfzal JavedJoseph JoharPrakash MasandAndre JoubertManoj Shah

Journal Committee

Rashmin CholeraParag ShahRitambhara MehtaKhyati MehtaliaAnuradha SovaniCharles PintoYusuf MatchewalaRjaesh DhumeD.M. DhavleShivarathnammaVivek Kirpekar

Archieves of Indian Psychiatry is the o! cial journal of Indian Psychiatric Society, Western Zonal Branch published twice in a yearSubscitpion :Annual subscription rates are Rs. 700/- for individuals andRs. 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 o! ce.

Copyright : Indian Psychiatric Society Western Zonal Branch

O cial Publication of Indian Psychiatric Society, Western Zonal BranchVolume 13, No.2, October 2011


Bansi SuwalkaPresident

Vivek KirpekarHon. Secretary

Vivek Kirpekar Vice President

Jay ShastriTreasurer

G.K.Vankar Editor

Shrikant DeshmukhImm. Past President

Mukesh JagiwalaKishor GujarRepresentatives of

Central Council

Lalit VayaMangalam RathodLalit J.ShahPramod " akreDeepak RathodRavindra KamathExecutive Council Mambers

Chairpersons Subcommittees

Dattatrey DhavleAwards Committee

Neena SawantCME

Mukesh JagiwalaConference

Govind BangConstitution

Sanjeev SaojiLegal

Jayita DeodharMembership

Rajesh KumarMental Health Awareness

Henal Shah Psychiatric Education

Kousar AbbasiQuiz


O! cial Publication of Indian Psychiatric Society, Western Zonal Branch

Volume 13, No.2, October 2011

Honorary Editor

G. K. VankarProfessor and HeadDept. of PsychiatryB.J. Medical College andCivil Hospital,Ahmedabad-380016.Cell. : 09904160338

Rahul ShidhayeStatistics ConsultantRajat OswalWebsite Development

Editorial O! ce

Dept. of Psychiatry,OPDBuilding,Wing 1I FloorCivil Hospital,Ahmedabd-380 016.E-mail : [email protected]: http://archivesindianpsychiatry.wordpress.comhttp://www.archindianpsychiatry.org

Phone : 079-65542770Fax : 079-65542770

Editorial Board

R. Srinivasa MurthyE. MohhandasVikram PatelNimesh DesaiK. S. JacobNilesh ShahChittaranjan AndradeBharat PanchalShekhar SheshadriAshok Nagpal

Board of Directors Laxman DuttJitendra NanawalaI. R. RajkumarV. G. VatweMukesh JagiwalaRajendra HegdeK. S. AyyarHemangee DhavleGovind BangShubhangi ParkarKaushik Gupte

Corresponding Members

Dinesh BhugraStuart MontgomaryAfzal JavedJoseph JoharPrakash MasandAndre JoubertManoj Shah

Journal Committee

Rashmin CholeraParag ShahRitambhara MehtaKhyati MehtaliaAnuradha SovaniCharles PintoYusuf MatchewalaRjaesh DhumeD.M. DhavleDevavrat KumarVivek Kirpekar

Archieves of Indian Psychiatry is the o! cial journal of Indian Psychiatric Society, Western Zonal Branch published twice in a yearSubscitpion :Annual subscription rates are Rs. 700/- for individuals andRs. 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 o! ce.

Copyright : Indian Psychiatric Society Western Zonal Branch

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.

! e serotonin transporter protein (5HTT)! e serotonin transporter protein (5HTT) is responsible for the reuptake of serotonin from the synaptic cle" . ! is protein, therefore, in# uences the intensity and duration of 5-HT signalling in the brain. Genetic variations in 5HTT in# uence 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 (! ierry et al, 2004) in patients with seasonal a$ ective disorder. A rare mutation of this gene may result in OCD or obsessive-compulsive personality disorder (Ozaki et al, 2003).

! e s/l 5HTT polymorphism

A functional polymorphism in the promoter region of the 5HTT gene has been described. ! is polymorphism is expressed as a short (s) or long (l) allele. ! e short allele is associated with a decrease in the level and activity of the 5HTT protein.

! e pattern of the s/l alleles in the genotype of an individual has been shown to in# uence the individual's 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 di$ erences 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 in# uence of the environment on 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). ! at 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 modi& ed? ! e 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 e$ ect of the short allele of the gene.

5HTT gene-environment interaction and

substance abuse

In the most recent study on the 5HTT gene-environment interaction, Brody et al (2009) studied 253 African-American children and adolescents in rural Georgia, USA. ! e 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

Archives of Indian Psychiatry 13(2) October 20114

drinking, and 5% had used cannabis. ! is increase in substance use was examined in the context of 5HTT polymorphisms and the quality of parenting.

! ere were two important " ndings:

1. Among children who received low levels of involved-supportive 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 involved-supportive parenting, presence of the short allele did not increase the risk of substance use.

! e study therefore shows that the short allele of the serotonin transporter gene is associated with an increased risk of development of substance use in children and adolescents. Importantly, this risk is neutralized by involved-supportive parenting.

Take-home message

! is series of studies tells us that adverse environmental in# uences are depressogenic or increase the risk of substance abuse in persons with the s allele of the 5-HT transporter gene. However, supportive environmental in# uences bu$ er the risk. ! ese data provide strong support for the importance of social and environmental e$ orts to mitigate genetic risk factors in psychiatry.

Parting note

! e 5HTT gene polymorphism is a good example not only of how a gene may in# uence the experience of certain symptoms but, more dramatically, also of how a gene may in# uence the expression of a speci" c behavior. If the output of a computer is a function of the so& ware which is running, so too is the behavior of a human being a function of the DNA which is expressed. However, the in# uence of the DNA is not invariable, but is modi" ed by constitutional and

environmental factors.

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, Moffi tt TE, Taylor A, Craig IW, Harrington

H et al. Infl uence 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 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 meta-analysis.

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.

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.

Chittaranjan Andrade, M.D.Professor and Head, Department of PsychopharmacologyNational Institute of Mental Health and NeurosciencesBangalore 560 029, Indiae-mail: [email protected]; [email protected]

Archives of Indian Psychiatry 13(2) October 2011 5

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 signifi cant weight gain

and associated metabolic problems. This disorder is thought to exist in signifi cant 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 fi rst 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

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 en-

joying 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 antide-

pressants 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 patient’s ever increasing weight.

Within a span of 5 years patient had gained considerably to 112 kilograms. Her antihypertensive medi-

cation increased in similar proportions. All the investigations such as thyroid profi le, 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 any-

thing 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 fi rst case of NES.


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

fulfi lling 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

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 signifi cant

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].

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 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 fi rst 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

fi rst 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 diffi culty 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 fl uvoxetine was added to

the medications. Most of these patients reported

dysphoric mood though not fulfi lling 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 ½ to 2 years.

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]

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 doesn’t 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 calorifi c value for Indian

food items [42,43,44]. BMI was calculated using

standard formulae [38,39,40,41]

Management

Treatment for this condition is tricky [33].

Researchers have variously used Cognitive

Behavioural Therapy [35,36], dietary modifi cations,

various pharmacotherapy or combination of both

for treatment [35]. Pharmacotherapy includes

melatonin, leptins given therapeutically as

suggested by their defi ciency 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 defi ciency in

synaptic clefts [11]. There have been reports of

other two SSRI’s namely paroxetine and fl uoxetine

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

specifi c and effective treatment for NES have

further strengthened the claims for identifi cation

and inclusion of NES as distinct disorder in DSM [11].

References

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eating syndrome. American Journal of Medi-

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2. Leder Mh, Cardinalli DP, Pand-parumal

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ological approach: Springer; 2006.Birketvedt

GS, fl orholmen JR.28:251.

3. O’Reardon JP, Ringel BL, Dinges DF, Al-

lison KC, Rogers NS, Martino NS, Stunkard

AJ: Circadian eating and sleeping patterns in

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2004; 12:1789–1796

4. Allison KC, Ahima RS, O’Reardon JP, Dinges

DF, Sharma V, Cummings DE, Heo M, Mar-

tino NS, Stunkard AJ. Neuroendocrine profi les

associated with energy intake, sleep and stress

in NES. Journal of clinical endocrinology and

metabolism.nov 2005; 90(11): 6214-17

5. Rand CSW, Macgregor MD, Stunkard AJ: The

night eating syndrome in the general popula-

tion and amongst post-operative obesity sur-

gery patients. Int J Eat Disord 1997; 22:65–69

6. Marshall HM, Allison KC, O’Reardon JP,

Birketvedt G, Stunkard AJ: Night eating syn-

drome among nonobese persons. International

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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 : [email protected]

Tel: 022 24011984


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 psychia-

try. It probes whether a developmental approach is an appropriate one while examining the infl uences 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 multi-modal multi-pronged approach is needed when examining causa-

tive 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 life-span

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, lifeevents, 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 age-related 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[ 1 0 ] . It is well

known that attentionIt 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[ 3 4 ] .

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[ 3 5 ] . This has placed the

neuro-developmental hypothesis for most

psychiatric illness in mainstream thinking.

This has already been accepted for cases

of schizophrenia[ 3 6 ] . 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[ 3 7 - 3 8 ] . 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[ 3 9 - 4 1 ] .

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[ 4 2 ] .

In an influential paper published in 1968,

the author argued that some of the supposed

effects of social ization experiences might

derive from children’s effects on their

rearing en vironments, rather than the other

way round[ 4 3 ] . Thomas and Chess, in

their research on children’s temperamental

styles, made much the same point[ 4 4 ] .

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 selectingenvironments and

in evoking particular responses in other

people[ 4 5 ] .

Emergence Of Resilience As A Factor In

Child Psychiatric DisordersResilience, 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[ 4 6 ] . 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[ 4 7 ] . 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[ 4 8 ] .

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[ 4 9 - 5 0 ] .

Antisocial behav ior may exist in two

forms i.e. life course-persistent antisocial

behavior (which typically begins early and

is associated with neuro-developmental

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[ 5 1 ] . 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[ 5 2 ] .

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 asomewhat 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[ 5 3 ] . 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 Rett’s syndrome have been firmly

established[ 5 4 ] .

For many years, few psychosocial

researchers showed much interest in the

varied mechanisms by which environments

might have long-term effects[ 5 5 ] . Cross-

foster 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[ 5 6 - 5 7 ] .

Evidence from both human and animal studies

suggests that there are biological programming

effects from environmental infl uences dur-

ing sensitive periods of development. A human

example is provided by the long-term effects of

institutional deprivation, which have been found

to be surprisingly persistent and highly sensitive

to specifi c developmental phases.

There is increasing evidence on the neuro-


endocrine ef fects of acute and chronic

stress experiences[ 5 8 - 5 9 ] . At present, we

lack evidence on the role of the neuro-

endocrine 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 neuro-

endocrinology[ 6 0 ] .

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[ 6 1 ] .

When combined with longitu dinal studies,

brain imaging may also throw light on the

brain changes as sociated with both neural

development[ 6 2 ] and the development of

psychopathology[ 6 3 - 6 4 ] . Serial studies

in the same population across various

ages may help determine neurobiological

factors that determine psychopathology

and its variations across the life span.

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[ 6 5 ] . 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[ 6 6 - 6 7 ] .

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[ 6 8 ] and indicated in studies of

human twins[ 6 9 ] . 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[ 7 0 ] ,

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 whetherthey 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[ 7 1 ] .

However, how applicable these are to

treating neuropsychiatric disorders is

not clear—although valproate has HDAC

inhibitor properties and may, in part, exert

its action through epigenetic effects on the

schizophrenia candidate gene Reelin[ 7 2 ] .

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)[ 7 3 -

7 4 ] , and the general influence of HDAC

and DNA methyltransferase inhibitors

on gene expression. It is hoped that the

ongoing epigenome project[ 7 5 ] 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[ 7 6 ] .

The big questions that demand our attention

involve fi ve 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 gene-

environment 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 ?

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 age-

indexed variations ?

6. 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[ 7 7 ] .

7. 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[ 7 8 ] .

8. We also need to integrate the fi ndings 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 fi elds.

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 fi gures 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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Sources of support : None

Confl ict of Interest : None


Original Article

Prevalence of Traditional Healing practices in Psychiatric Outpatients

Rahul Shidhaye G.K.Vankar

AbstractTraditional 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 irrespective 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 defi nes “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 signifi cant, but growing

rapidly (1). In most African countries primary

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 co-exist

with modern mental health care, and they are

seen as providers of curative, rehabilitative

and restorative benefi ts. 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

identifi ed 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 patients. So

we designed this study in order to address this

research gap.

Aims and objectives

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 and duration of illness

are analyzed using t-test. This analysis is

done in SAS ver. 9.2 using proc t test 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


Table 2 : Pattern of disorder and traditional healing

Variable Patients who visited Tradi-tional Healer

Patients who did not visit Traditional Healer

t-value chi-square value

degree of freedom

p-value

Diagnosis [No. (%)]$ 110(54.7) 91(45.3) -2.69 NA

Schizophrenia 30(83.3) 6(16.7) NA 14.49 1 <0.001*

Major Depression 40(44.0) 51(56.0) NA 7.78 1 0.005*

Bipolar Disorder 5(38.5) 8(61.5) NA 1.48 1 0.22

Epilepsy 7(53.8) 6(46.2) NA 0.004 1 0.22

Mental Retardation 7(70.0) 3(30.0) NA 0.991 1 0.32

Substance Use 2(40.0) 3(60.0) NA 0.449 1 0.50

Possession Disorder 22(100) 0 NA 1 <0.001*

Duration (Mean, SD) 67.4(78) 65.0(96.1) NA NA 199 0.84


Table 1: Comparison between patients who visited Traditional Healer and those who did not visit Tradi-

tional Healer

Variable

Patients

who visited

Traditional

Healer

Patients who

did not visit

Traditional

Healer

t-value chi-square

value

degree

of free-

dom

p-value

No. of patients (%) 110(54.7) 91(45.3) -2.69 NA 0.007*

Socio-demographic characteristics

Age [Mean( SD)] 34.32 (12.2) 37.5(14.3) 1.69 NA 199 0.09

Sex [No. (%)]

Male

Female

70(63.6)

40(36.4)

59(64.9)

32(35.1) NA 0.03 1 0.86

Education[No. (%)]

Less than 10th grade

10th grade

Beyond 10th grade

63(57.0)

34(31.0)

13(12.0)

59(64.8)

30(33.0)

2(2.2)

NA 6.7

2

0.03*

Monthly income (Mean,

SD)

2225(2073) 2166(1619) -0.2 NA 150 0.85

Family Type [No. (%)]

Nuclear

Joint

36(32.7)

74(67.3)

41(45.1)

50(54.9) NA 3.20 1 0.07

Domicile [No. (%)]

Urban

Rural

80(73.6)

30(26.4)

67(72.7)

24(27.3)

NA 0.021 1 0.89

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 fi ve years

of illness were 35.32%, fi ve to ten years were

18.41% and beyond ten years were 14%.

Table 3 :

Patients who visited traditional healer (N=110)%

Number of Visits

One Two-three More than ! ree

233641

Number of traditional

healers consulted

One Two-three More than three

493120

Setup from where services

were o! ered

Temple Dargah Home other

2519479

Physical abuse

Yes (beating, cut ting hear) No

10.889.2

Expenses incurred

upto Rs. 500 Rs.500-Rs.2500 more than Rs.2500

601822

Belief that traditional

healing is e! ective

Yes No

22.777.3

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.

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 fi gures are

very high and similar to the fi gures quoted in

WHO report on traditional medicine (1). This

report 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 signifi cant 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

diffi cult to generalize from this fi nding that

higher education leads to help seeking from

traditional healers. Of all the diagnoses,

possession syndrome, and schizophrenia were

signifi cantly associated with traditional healing

consultation.

All 22 patients who had possession syndrome

were fi rst 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 fi nding of signifi cant 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

cross-sectional data, traditional healers would

seem often to be a last resort for patients with

persistent problems who were presumably

dissatisfi ed 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 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 diffi cult for

rural population to access (1). Corresponding

fi gures 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 diffi cult 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


References

1. WHO Traditional Medicine Strategy 2002–

2005. Available at http://whqlibdoc.who.int/

hq/2002/WHO_EDM_TRM_2002.1.pdf

and accessed on September 29, 2008

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Initiative, Manual on traditional

healers-1999.

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Botswana. The Australian and New Zealand

journal of psychiatry. 1985 Mar;19(1):88-

91.

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Zaramo of Dar-es-Salaam. Dar-es-Salaam:

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non-psychotic mental disorder: a study of

the CISR and care provider assessment in

Harare. Social psychiatry and psychiatric

epidemiology. 1997 Feb;32(2):84-9.

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(CAMH). Health and healing in western

Maharashtra- the role of traditional healing

centers in mental health service delivery.

2006.

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Religious Beliefs and Traditional Healing

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presented at the 50th Annual Conference of

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8. Kulhara A. Psychopathology. 2000;33:62-

9. Sethi BB, Trivedi JK, Shitholey P.

Traditional healing practices in Psychiatry.

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experiences among psychiatric patients

Unpublished MD (Psychiatry) Dissertation,

Gujarat University. 2003.

11. Kakar S. Shamans, Mystics and Doctors.

A Psychological Inquiry into India and its

Healing Traditions. 1982.

12. 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.

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 socio-demographic 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 fi eld.

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 benefi ts of traditional

medicine (1). Communities consistently and

predictably choose traditional healers, often as

fi rst 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 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-à-

vis modern psychiatric practice.


16. 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.

17. 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.

13. 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.

14. 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.

15. SAS Version 9.2. SAS Institute, Cary, NC.

2008.

Dr.Rahul R. Shidhaye M.D.(Psy) M.H.S.(Mental Health)*

Faculty

Public Health Foundation of India

Indian Institute of Public Health,

Opp. Nalanda College,

Vengal Rao Nagar,

Hyderabad. 500038.

e-mail:[email protected]

cell:: +919848520340

Dr.G.K.Vankar MD,DPM

Professor and Head

Dept. of Psychiatry

B.J. Medical College and Civil Hospital,

Ahmedabad 380016

*Correspondence


Original Article

Newspaper Portrayal of Psychiatry

Laxeshkumar Patel

G. K. Vankar

AbstractMedia reporting have a direct impact on both community attitudes towards mental illness and suicide attempts. ! is study examined how suicide and mental health are portrayed in the me-dia in Baroda.In this cross sectional study of " ve 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 cut-tings 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%), oversimpli" cation 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 identi" ed the person by name. About a quarter reinforced negative stereotype about mental illness. ! ere were 49(41.2%) cuttings that emphasis the illness rather than per-son.Key words: media portrayal, suicide, mental health

Introduction

! e expansion and implementation of di# erent types of media-derived information transmission have driven far-reaching changes for both individuals and society, with particular implications for children and adolescents.Most studies suggest that the media’s depiction of mental illness and suicide is mostly negative, inaccurate and unhelpful2-14. ! is is an important " nding as media portrayal may be an important in$ uence on community attitudes towards mental health issues 15. However, not all results have been negative. Two recent studies of non-" ction 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 de" nition 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 non" ction media, some have been restricted to print media, while others have included electronic media as well. ! ese di# erences make it di& cult to compare studies 3,4,16. ! ere 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 e# ect 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. ! e only Canadianstudy to examine


the portrayal of suicide by the media were conducted 20 years ago 4: one was a survey of editor’s 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 a! er suicides in ‘epidemic’ and ‘non-epidemic’ suicide years. Neither speci" cally 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-" ction 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 in# uence 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 ex-pert advice available we have a responsibility to listen. $ e power and in# uence of the media on sui-cidal behavior has been a key subject of debate over many years. Public attitudes to suicide (de-criminalization 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 speci" c concerns when " ctional and real suicidesare represented in the media. Schmidtke & Hafner (1989), in an extensive review with 131 refer-ences, examined the in# uence of the mass me-dia, predominately news media, on suicidol-ogy. $ e evidence for imitation (with regard to explicit details of method and celebrity sui-cides) proved conclusive, thus retrospectively justifying the American Academy of Medicine’s " rst proposal for press constraints in 1911 20.

Two subsequent studies have examined the re-lationships 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 " gures a! er the media were given guidelines for reporting suicide.$ e occurrence of imitative suicides following media stories is largely known as the “Werther e% ect” derived from the impression that Goethe’s novel ‘$ e Sorrows of Young Werther’ in 1774 triggered an increase in suicides, lead-ing to its ban in many European states. Re-search on the “Werther e% ect” was advanced by the systematic work of Phillips 22-27, whose research consistently found a strong relation-ship between reports of suicide in newspapers or on television and subsequent increases in the suicide rate.

$ e magnitude of the increase in suicides fol-lowing a suicide story is proportional to the amount, duration, and prominence of media coverage. A “dose-response” relationship has recently been reported by Etzersdorfer, Vora-cek, and Sonneck 28 in an examination of the relationship between the regional distribution of a tabloid newspaper’s coverage of a celebrity suicide by " rearms in Austria and an increase in " rearm suicides. Nearly 40% of the variance in changes in suicide by " rearm was attribut-able to the di% erential distribution of the tab-loid.

$ is is consistent with the dose-response e% ect " rst reported by Phillips 24. In a quantitative analysis of 293 " ndings from 42 studies, Stack 29 found that studies assessing the e% ect of the suicide of an entertainer or political celebrity were 14.3 times more likely to " nd a “copycat” e% ect than studies that did not. Furthermore, studies based on real suicides in contrast to " ctional stories were 4.03 times more likely to " nd an imitation e% ect.

Aims and objectives

1. To investigate how the non-" ction media in Baroda portray both suicide and mental


health.2. To know the attitude of media people

towards psychiatry.

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.Following newspapers were included: Gujarati( Gujarat Samachar, Sandesh, Divya Bhaskar) and English ( ! e Times of India and! e Indian Express).

Instrument

! e 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.! ese checklists were also in" uenced by ‘WHO guidelines for reporting suicide’ and by ‘guidelines on coverage of suicide’ given by Hong Kong Journalist Association.! e 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 portray-al 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 quali# ed person or group to decide regarding the same?2.Do they have any speci# c 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 quali# cation of the reporter?5.What are the bases for the statistical records of suicide?

Analysis

! e statistical analysis of the collected data was done by using EPIINFO 6.0 so$ ware

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 ! e Times of India and 25(7.1%) were from ! e 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 ! e Times of India and ! e Indian Express, which are in the English language covers small part of the total cuttings, each comprise less than about 8%.

Informative theme was found in 33(9.4%), ‘question-answer’ 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.

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…!!


Table 1: Newspaper portrayal of Suicide

theme(%)

(N=)

Item Yes No No Answer

Headline inaccurate or inconsistent with the items focus? 10.0 90.0 0

Headline or content unnecessarily dramatic or sensationalized 47.2 52.8 0

Use of language that is outdated, negative or inappropriate? 16.5 83.5 0

Disclosure that a particular individual has a mental illness or identifying the person by name?

93.9 5.6 0.4

Medical terminology used inaccurately? (Not in correct con-text)

0.9 14.3 84.8

Reinforcement of negative stereotypes about mental illness? 7.4 68.5 76.2

Does the item emphasize the illness rather than the person? 5.6 67.5 26.8

Does the item imply that all mental illnesses are the same? 2.6 55.6 42.2

Is direct/indirect suggestion of help given? 0.4 99.6 0

Use of the word “suicide” in the headline? 80.1 19.9 0

Inappropriate language? (frequent use of the term committed suicide or that suicide was a desirable outcome)

23.4 76.6 0

Any reference to the fact that the person who died by suicide was a celebrity?

10.0 90.0 0

Is a photograph, diagram or footage of the suicide scene, pre-cise location or method used in the item?

17.3 82.7 0

Is there detailed discussion of the method used? 38.5 61.5 0

Suicide portrayed as ‘merely a social phenomenon’ as opposed to ‘being related to mental disorder’?

74.5 7.4 18.2

Are bereaved interviewed? 6.1 93.9 0

Over simpli! cation of the reason of suicide? 45.0 31.6 23.4

Is the suicide note included? 13.4 86.6 0

Table 1: Newspaper portrayal of Suicide theme

Item Yes No No Answe

r

Headline or content unnecessarily dramatic or sensational-ized

42.9 57.1 0

Use of language that is outdated, negative or inappropriate? 15.1 84.9 0

Disclosure that a particular individual has a mental illness or identifying the person by name?

61.3 34.5 4.2

Medical terminology used inaccurately? (Not in correct context)

10.1 48.7 41.2

Reinforcement of negative stereotypes about mental illness? 21.0 52.9 26.1

Does the item emphasize the illness rather than the person? 41.2 50.4 8.4

Does the item imply that all mental illnesses are the same? 12.6 74.8 12.6

Is direct/indirect suggestion of help given? 20.2 79.8 0


2.Neeta with mehndi on her hands and heart-broken in love – Vipul could not live together so… ! ey died together…!!3.One female with her seven-year old son had jumped from the 20th # oor of a building but perhaps it was the warmth of mother’s lap that provided a shield and the child survived the mishap.! ousands of people crowded together at the wall of Kankaria Lake to see the corpses of this loving couple # oating in a romantic manner. ! e 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 $ re 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 men-tal illness or identifying the person by name found in 217(93.9%) Direct or indirect sugges-tion 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 head-line were in 185(80.1%) cuttings and 54(23.4%) cuttings had frequently used the term commit-ted 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 under-neath Ravji’s 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 com-mitted suicide.2.Today morning at 7:00 o’clock when Ramesh-bhai was brushing his teeth outside his house, as soon as she got a chance, his wife poured kerosene over the body of her daughter Dak-sha and lit it with a matchstick. A& er that she poured kerosene over her own body also and lit it with a matchstick. 3.A night, a suicide attempt was made by add-ing 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.4.On 19th, at night she hung herself by tying a duppatta on the hook of the fan and committed suicide.

Suicide portrayed as ‘merely a social phenom-enon’ as oppose to ‘being related to mental dis-order’ in 172(74.5%) cuttings (Table – 1).Examples:1. Report of suicide committed by a 21 year married woman due to torture at her in law’s place.2.Young female jumped into the river as her lover ditched her…3.Depressed due to the worries of seven daugh-ter- father committed suicide…. “due to poor $ nancial 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.

Oversimpli$ cation of reason of suicide report-ed in 104(45%) cuttings (Table – 1).Examples:1.…due to a quarrel regarding eating pu* ed 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 height-ened 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. ! e 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 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 (Table–2)

Examples:1.It is unfortunate for the society and a matter of shame that in Gandhiji’s Guajarat, little kids, innocent as " owers, 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 yesterday’s guy has become a gal today.3.! is 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 a# er 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 identi& ed 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.

! ere 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 ‘! e Times of India’ and 18 by ‘! e Indian Express’ as compare to 68, 66, 77 reports in ‘Gujarat Samachar’, ‘Sandesh’, ‘Divya Bhaskar’ respectively over a period of 3 months.2.Out of 18 cuttings, ! e Indian Express had not emphasized the illness in any of the articles and had emphasized the person in 16(88.9) cuttings.3Out of all cuttings in all the newspapers, ‘suggestion of help’ had given in only one cutting in Sandesh.4.In each newspaper, more than 74% of the cuttings contained the word ‘suicide’ in the headline.5.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 ! e Times of India respectively.7.Out of all 5 & ve newspapers, ‘over simpli& cation of the reason of suicide’ had given maximally in Divya Bhaskar (51.9%).8.Sandesh had included suicide note maximally (10.4%).


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 ! e 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 ! e 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 o! ce:

Newspaper-1

Newspaper-1 did not have any guideline to report mental health issues or suicide and some of their reporters did not have quali" cation of journalism. Newspaper-1 even did not feel the need for guideline or quali" ed 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. ! ough 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 signi" cant number of cuttings.

Newspaper-2

Overall, Newspaper-2 emphasized more on his knowledge and his newspaper but quite disappointingly, Newspaper-2 seemed less concerned with the media portrayal of mental health and suicide issues. Newspaper-2 did have any speci" c guideline for reporting mental health or suicide. Newspaper 2 had reported mental health related issues and suicide with inappropriate language in signi" cant 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 simpli" cation of the reason for suicide. Newspaper 2 had reported headline unnecessarily in dramatic or sensationalized manner.

Newspaper-3

Newspaper-3 had reported suicide cases very selectively, without over simpli" cation of reason for suicide, dramatization or inappropriate language. ! ough Newspaper-3 told us that they don’t 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.

Discussion

! e 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-" ctional media 4, 6. ! is 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 ! rst 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. " ere are in contrast to other research where media reporting of mental illness has mainly been negative 3, 5-14." e 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 ! ndings from the Australian study, suggesting that this problem is not restricted to Nova Scotia 17.

" e 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. " e choice is not an issue of accuracy or objectively, but it does have serious rami! cations 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 opinionmakers in the provincial media in their development 30. " ere is evidence from both Australia and Canada that local media may be easier to in# uence than national or international media 16." ere should be longer-term strategy to in# uence 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:

" e only study of its kind done in India.Reliability of study maximized by analyzing cuttings by one researcher.

Limitations:

1. " e 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.

2. " ough 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.

References

1. American Heritage Dictionary, 2nd College Edition. New York, Dell, 1983.

2. 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.

3. Department of Health and Ageing Reporting suicide and mental illness. Commonwealth Department of Health and Ageing; 2002.

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5. 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.

6. Day DM, Page S. Portrayal of mental illness in Canadian newspapers. Can J Psychiatry, 1986; 31:813-817.

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13. Angermeyer MC,Matschinger H.! e e" ect of violent attacks by schizophrenic persons on the attitude of the public towards the mentally ill.Soc Sci Med;1996,43:1721-1728.14

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15. Hoggart, R. ! e Uses of Literacy London: Pelican books 1958.

16. Stuart H. Stigma and the daily news: evaluation of a newspaper intervention. Can J Psychiatry 2003, 48:651-656.

17. Francis C, Pirkis J Wawick Blood R et al. ! e portrayal of mental health and illness in Australian non-# ction media. Aust N Z J Psychiatry: 2004, 38:541-546.

18. Pell B and Watters D. Newspaper policies on suicide stories. Canada’s Mental Health, 1982; 30:8-9.

19. Littmann S K. Suicide epidemics and newspaper reporting. Suicide and Life ! reatening Behavior, 1985, 15:43-50.

20. Schmidtke A and Hafner H. Public attitudes towards and e" ects 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 e" ect of television news stories. American Sociological Review, 1982, 47,802-809.

24. Phillips D. ! e in$ uence of suggestion on suicide: Substantive and theoretical implications of the Werther e" ect. 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 a% er television news stories about suicide. New England Journal of Medicine, 1986, 315,685-689.

27. Phillips D. and Carstensen L.L ! e e" ect


of suicide stories on various demographic groups 1968-1985. In R. Maris (Ed.), understanding and preventing suicide: plenary papers of the ! rst 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 ! nding Social Science Quarterly, 2000, 81, 957-971.

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Sources of support : None Con! icts of interest: None

Dr.Laxeshkumar Patel

Resident DoctorDept. of PsychiatryMedical College and S.S.G. Hospital,Baroda

Dr.G.K.Vankar

Professor and HeadDept. of PsychiatryB.J. Medical College and Civil Hospital,Ahmedabad 380016

Correspondence:

Dr. Laxeshkumar PatelF-6, Dream Plaza Flats,Camp Road, Shahibaug,Ahmedabad 380 004.Cell: 98258 47475E-mail: [email protected]


Original Article

Effi cacy 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 effi cacy 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 fl uency. 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 effi cacious 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 fi xation 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 fi nd 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) defi ned

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 individual’s ability to express both positive

and negative feelings in the interpersonal

context without suffering consequent loss of

social reinforcement…. In a large varietyof

interpersonal context… (involving) ….the

coordinated delivery of appropriate verbal

and non-verbal response.”


Birdwhistell (5) , one of the earliest authorities

in the fi eld 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 two-thirds. 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 fl ow of

communication

4. to provide feedback

5. to defi ne relationships between people

6. to convey emotional states.

It is widely acknowledged that many persons

who stutter demonstrate defi cits 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 fl uency. 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.

Thereforeaccording 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 infl uential 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 diffi culties with social adjustments

than children who are fl uent. 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 infl uential 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 fi rmly 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 diffi culties 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

defi cits in social skill repertoire of persons who

stutter has been shown to infl uence the ability

to maintain fl uency 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 signifi cant 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 fi xation on their speech

defect. The psychological effect of fi xation on

the speech defect is that it results not only in

morbid suffering and subjective exaggeration

of its manifestation, but alsoa 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 non-verbal

behaviour and are not inclined to give any

signifi cance 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 weakness–in 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 defi cit of

information necessary for interaction.

Therefore, it is important to deal with the

learning of new role behaviour in its fi ner

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 comprehensivedescription by the group

of individual features in a participant’s

communicative behaviour. In other words, the

communication portraits refl ect 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

defi cits 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 confi dence 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 ap-

propriately goes a long way in contributing to

a satisfying social interaction.

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 defi nitions of variables

Southern Illinois Speech Situational

Checklist (SF-S.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 client’s 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 fl ow of speech

without repetitions, prolongations or blocks.

Stuttering severity measures disruption of this

fl uency.

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 fi ve 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.


TTable 1 Communication Skills

Skill Description

Communication Importance of both verbal and no- verbal aspects of communi-

cation.

Body Language The four non-verbal skills: eye contact, facial expressions, pos-

ture / gesture, and physical distance.

Voice Indices The paralinguistic features of voice: rate of speech, loudness /

volume, intonation, and tone voice.

Listening Importance of active listening, barriers in active listening and

skill steps of listening

Observation Importance of self and other observation in interaction, and the

skill steps involved.

Conversation Skill steps required in initiation, entering / maintaining, and

ending conversation included.

Expressing Feelings Importance of expressing feelings, and the skill steps involved.

Responding to Feelings Importance of responding to feelings, and the skill steps in-

volved.

Compliments Importance of giving and receiving compliments, and the skill

steps involved.

Complaints Importance of making and receiving a complaint, and the skill

steps involved.

Requests Importance of making and responding to requests, and the skill

steps involved.

Refusals Importance of making and accepting refusals, and the skill steps

involved.

Asking for Information Importance of asking for information, and the skill steps in-

volved.

Group Interaction Importance of group participation, and the skill steps

involved.

Table 2: t-test comparisons between D-scores of adolescents and adults

Dependent Variables

Adolescents Adults t Sign.

Mean S.D Mean S.D

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

16.25

2.99

8.65

2.59

4.41

18.20

5.87

11.73

2.80

3.87

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


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 fi rst session

began with self-introductions 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 fi rst 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

home-work assignments for the week.

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 signifi cant (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

signifi cantly so.

What is striking in the fi ndings with respect

to the variable of situational anxiety is that

the adults benefi ted signifi cantly more than

the adolescents. The adolescent who stutters

has been seen as a client who is diffi cult

and challenging to treat. Van Riper (23)

commented that adolescents are diffi cult 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 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 signifi cant

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 fi ndings that have resulted

from this study highlight the importance of

behaviours 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 benefi ts.

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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: [email protected]

*Correspondence


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 signifi cant 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 meas-

ured by General Health Questionnaire-30(GHQ-30), methods of coping by Brief COPE-28 and demo-

graphics, 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 fi ve 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 intimi-

dation 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 signifi cant 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 signifi cant 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 profi cient 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 person’s relationship to his or her work,

whereas depression globally affects a person’s life. [6]

Coping is often defi ned 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 one’s 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 effi ciency 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 patient’s safety as

well as in the training, quality of life and education

of the residents. [29, 30]

Aim

We investigated the psychiatric morbidity, stress-

ors and coping in resident doctors.

Material and Methods

Participants

Subjects were chosen who were working as

residents at tertiary care medical college affi liated

general hospital. It was cross sectional, voluntary

and anonymous study. Residents were interviewed

personally at their convenience and also asked to

fi ll selected questionnaires during the interview.

All the data were collected over a fi ve 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 Gold-

berg 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

(“I’ve not done this at all”) to 4 (“I’ve been doing

this a lot”). These include, for example, ‘Active

Coping’ (I’ve been taking action to try to make

the situation better), ‘Religion’ (I’ve been praying

or meditating), ‘Venting’ (I’ve been expressing

my negative feelings) and ‘Substance Use’ (I’ve

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

individual’s 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 fi ve sections: de-

mographics, stress, intimidation and harassment,

well-being and resources. Survey questions in-

cluded 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 nega-

tively 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 defi ne

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 in-Archives of Indian Psychiatry 13(2) October 2011

46

stances group data was collapsed to increase num-

bers within response categories. As a part of the

study we have also included mental illness screen-

ing 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 cur-

rent 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

signifi cant 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 fi rst 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. between the genders as regards experience

of stress. No specifi c 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%).Whenasked 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 profi le and gender. Among 14 different

coping styles negative styles were associated with

stress

Discussion

The number of participants were (40%) of all


Table: 1 Stress in residency and Characteristics of Residents

GHQ

positive

N=53

n(%)

GHQ negative

N=92

n(%)

Signifi cance

Hours of

work

80 or less hrs work

>80 hrs work

28

25

71

21 p=0.002

Level of training

1st year

2nd year

3rd year

26

23

04

24

28

40p=4.3E-05(<0.05)

Marital status

Single

Engaged

Married

34

06

13

46

26

20p=0.01

Faculty

Surgical

Non surgical

21

32

27

65 p=0.2

Clinical

Para clinical

38

15

62

30 p=0.6

Gender Male

Female

33

20

65

27p=0.3

Table: 2 Top resident ranked contributors to

feelings of stress

Contributors Female

N=47

%

Male

N=98

%

Not enough time 9 24.1

Own work situation 8.3 17.9

Emotional problem 6.2 8.3

Residency program 4.1 4.8

Personal relationship 1.4 1.4

Physical problem 1.4 1.4

Financial problem 00 4.8

Discrimination 00 1.4

Table: 3 Forms of intimidation and harass-

ment reported by residents.

Forms

N=145

n, (%)

Inappropriate verbal command83 (57.2)

Work as punishment39 (26.9)

Privileges/opportunity taken

away

31(21.4)

Recrimination (i.e. accusation,

counter-attack)

16 (11.0)

Others (e.g. criticism, partiality

etc.)

8 (05.5)

Inappropriate or unwanted phy-

sical contact

1 (0.7)

Sexual harassment1 (0.7)


Table: 4 Ways of coping and stress

Coping

Mechanism

GHQ Positive

N=53

Mean(SD)

GHQ Negative

N=92

Mean(SD) Signifi cance

Self Distraction 5.85(1.61) 6.33(1.18) p=0.03

Active Coping 5.91(1.47) 6.28(1.23) p=0.07

Denial 2.81(1.14) 2.60(0.90) p=0.1

Substance Use 2.38(1.02) 2.10(0.39) p=0.03

Emotional Support 5.75(1.54) 5.67(1.32) p=0.4

Instrumental Support 5.68(1.22) 5.91(1.20) p=0.1

Religion 5.08(1.83) 5.05(1.58) p=0.5

Behavioral Disengagement 3.43(1.37) 3.20(1.38) p=0.2

Venting 5.11(1.54) 4.92(1.57) p=0.4

Positive Reframing 5.74(1.57) 5.97(1.21) p=0.2

Planning 5.85(1.36) 6.11(1.18) p=0.1

Humor 3.62(1.46) 4.13(1.45) p=0.02

Acceptance 5.81(1.35) 5.72(1.14) p=0.3

Self Blame 3.81(1.89) 3.30(1.22) p=0.04

Table: 5 Ways of coping and gender

Coping

Mechanism

Female

N=47

Mean(SD)

Male

N=98

Mean(SD) Signifi cance

Self Distraction 6.13(1.3) 6.16(1.4) p=0.5

Active Coping 6.0(1.24) 6.2(1.4) P=0.4

Denial 3.0(1.1) 2.5(0.9) p=0.006

Substance Use 2.1(0.52) 2.24(0.8) p=0.08

Emotional Support 6.0(1.33) 5.6(1.41) p=0.006

Instrumental Support 5.6(1.3) 5.9(1.2) p=0.09

Behavioral Disengagement 3.6(1.2) 3.1(1.4) p=0.2

Venting 5.4(1.6) 4.8(1.5) p=0.02

Positive Reframing 5.9(1.2) 5.9(1.4) p=0.5

Planning 5.6(1.1) 6.2(1.3) p=0.002

Humor 3.7(1.4) 4.1(1.5) p=0.058

Acceptance 5.9(1.0) 5.7(1.3) p=0.2

Religion 5.1(1.9) 5.0(1.5) p=0.5

Self Blame 3.7(1.4) 3.4(1.6) p=0.1


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 fi nding is contrary to

fi ndings 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 fi lling 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 signifi cant difference between genders

with respect to marital status. Here we identifi ed

signifi cant number of males being engaged while

signifi cant number of females was married. We

found that engaged were having least stress as

compared to married and singles. Studies have

shown thatfavorable life events help to reduce

stress. [19] So it might have facilitated to lower

gender difference in stress. As engagement period

has signifi cant 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 benefi ts 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 signifi cant 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. fi nal examinations, higher expectations) [12]

but we have not found them signifi cant. Similar

fi ndings 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

in-hospital 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 equaldistribution 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 signifi cant difference

between specialties for the level of stress. Contrary

fi ndings 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 fi ndings

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

signifi cance. 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 well-being. 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

confi dence 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

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 signifi cant 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

1. Residents from only a single center were

studied and the study was cross sectional.

2. All residents from studied specialties were not

willing to participate.

Conclusion

It is clear that there are signifi cant stressors incurred

during residency. Intimidation and harassment

occurs among many residents. It is also important

to recognize that a signifi cant 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 resident’s 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.



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Sources of funding: None Confl ict of interet :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

Ahmedabad 380016

*Correspondence

e-mail:[email protected]

cell:+919904160338


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 fam-

ily. The burden, stress, and socio-economic effects on the people caring for them are not suffi ciently

appreciated. The societal neglect is evident from the absence of any established framework that pro-

tects their rights.

Health professionals and policy makers need to develop greater insight into the care giving experi-

ence, 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.

Keywords: 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” [1] and

the “paraprofessionals who play a signifi cant role

in the service delivery system” [2].

Who are the carers?Caregivers are the person most closely engaged

in a patients experience with illness and also in-

volved in maintaining a person’s ability to live in-

dependently 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 illness…they pro-

vide housing, fi nancial aid, companionship and

emotional support”. [3]

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 world’s mentally

ill); families are the main caregivers for patients

suffering from psychiatric illness.

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 pri-

orities and redirection of resources. The average

amount of time that caregivers spend on care giv-

ing is about 20 hours per week. Even more time is

required when the care receiver has multiple dis-

abilities. 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 fi nances.

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 care-giving demands.[4,5].

Increased survival of patients: With latest advances

in medical science, survival of patients with illness

/ disabilities has risen. In Australia, one person in

fi ve will at some stage in their life experience the

burden of a major mental disorder [6]. 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 [7]. World

Health Report 2001 stated that 40% of the countries

in the world don’t have mental health policy and

over 30% have no special programs related to

mental and behavioral disorders. Moreover, health

plans most often don’t cover mental and behavioral

disorders unlike other illness.

Literature mentions about both objective and

subjective burden placed on the caregivers.

Objective burden [8] 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 [1,2,9,10,11].

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 patient’s behavior

which can be extremely diffi cult to cope with or

disruptive. [1,2,9,10].

Subjective burden [8] can be:

Subjective burden experienced by caregivers

is directly linked to the experience of objective

problems [12]. 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 [11]. 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 [13]. Also, fi nancial costs were found to

be the most commonly experienced ‘felt burden’ [14].

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 pre-sickness 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 [15]. Studies have found that the relatives

with chronic schizophrenia experienced severe

burden than those of patients with chronic lung

disease [16]. As a result, thousands of mentally sick

persons, some of them affl icted 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.

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 [1,2,9,10,].

Lowered self-esteem and increased isolation and

withdrawal due to stigma and lack of resources [9,17].

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” [11].

For disorders like dementia, as the disease

progresses—the person may experience the

loss of self-esteem, dependency, and there can

be behavioural diffi culties 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 [18].

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 [18]. A large majority

of persons with mental illness either remain

unemployed or underemployed, which further

adds to the fi nancial 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 [19].

Carers often become more vulnerable, with little

or no formal training in mental illness, lack of

information about the disorder and its medication,

lack of resources and treatment facilities and, at

times, a lack of responsive professional [2].

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, and stigma.

Higher levels of both objective stress (care

receivers’ behavior problems) and subjective

stressors (caregivers feeling of overload) infl uence

the various dimensions of caregiver health, namely:

poorer self-reported 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 [20].

The potential compromise of caregiver’s health

brought on by demands of role is poignantly

exemplifi ed in well publicized Canadian story

known as “Latimer Case” where father had taken

extreme action of killing his child with disability.

The father’s explanation for committing this act

emphasized feelings of stress he experienced

relating to take care of his child, child’s 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% identifi ed

detrimental changes in their level of emotional

health [21]. 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

co-residents of controls [18].

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”.

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:

1. What if I get sick? Who will care whom?

2. Will I outlive the patient?

3. 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?

4. What if I get physically, mentally or fi nancially

exhausted?

5. Is there an end to this (care)?

6. How long will this (care) continue?

7. When will I be able to live my life?

8. Do I have a right to live a healthy life?

The health care system needs to fi nd 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 caregiver’s Bill of Rights has been

suggested by Wendy Lustbader, which asserts that

all individuals have needs that have to be fulfi lled.

It includes:

1. Protecting ones individuality, taking care of

self so that with more capability better care can

be given.

2. Seeking help from others & recognizing one’s

limits.

3. Getting angry, depressed, or expressing

themselves.

4. Receiving consideration, affection,

forgiveness, and acceptance in return to care

giving.

5. Deciding when to help and when not to help.

6. Finding the balance between family, work and

care giving.

7. Setting attainable goals.

8. Treating one self well, same as the person for

whom caring.

9. Accepting that their best is good enough.

Current Caregivers’ Policy Across

Globe [22]

In United States the National Family Caregiver

Support Program (NFCSP) provides direct

services (e.g., counseling, respite care), fi nancial

compensation to family caregivers, tax incentives,

etc. Caregivers are provided fi nancial 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 benefi ts

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.

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

benefi ts.

In India government provides tax benefi t and free

bus and railway pass at a concession rate that

help to ease burden on patient’s family [18]. Under

Mental Health Act it is proposed that the costs of

maintenance of mentally ill persons detained as

in-patient in any Government Psychiatric hospital

or nursing home shall be borne by the State

Government concerned. This helps caregivers in

reducing fi nancial burden of care giving.

It is well evident that only few countries have

formulated special policies for carers of mentally

ill and that too insuffi cient.

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 patient’s hospitalization [23].

Education for caregivers about mental illness’

course and prognosis. Caregivers’ eventual

recognition that they cannot control their family

member’s 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 de-

institutionalization, 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 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 infl uence legislation, redirecting

community services and infl uencing attitudes of

people who lack intimate contact with mentally

ill [24]. They also help in decreasing objective

burden by increasing knowledge about illness and

health services, demystifi cation 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 everybody’s business”. It’s 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 fi nancial costs,

but also costs in terms of time, effort, potential loss

of confi dentiality, and potential family confl ict.

Introduction of a social support system like

specialized institutes for disabled, which can be

backed by government, public trends of charity or

organization.

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

benefi ted 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 [29].

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.


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.

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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 profi le and are often diffi cult 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 diffi culty and was able to move

his neck and facial muscles during most episodes.

But during severe episodes he had diffi culty 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 fi ngers 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 as-

sociated 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. Patient’s

father and father’s younger brother were suffering

from similar complains. Both died before 1 year

and patient’s uncledied 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

patient’s brother revealed fl accid 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.

Patient’s 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 defi cits 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 ispreceded by confl icts

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 confl ict 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-Barré 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 refl exes are reduced or abolished and

cutaneous refl exes may also disappear. Sensation

is preserved. As the attack subsides, strength

generally returns fi rst 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 levelsthat 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 fi bres

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 fl attening 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 indefi nitely. 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 insuffi cient, and

if there is no improvement in 1 or 2 h, KCl may

have to be given intravenously—0.05to 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 fi t

is desirable. (Ropper & Brown, 2005)

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 signifi cant 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

1. Encyclopedia of Mental Disorders. (n.d.). Retrieved from

http://www.minddisorders.com/Br-Del/Conversion-disorder.

html

2. Mastalgia, F. L., & Jones, D. H. (July 2007). Myopathies and

Muscle Diseases, Handbook of Clinical Neurology. Elsevier.

3. Ropper, A. H., & Brown, R. H. (2005). Adamsa and Victor’s

Principle of Neurology (8th ed.). McGraw-Hill.

4. Sadock, B. J., & Sadock, V. A. (2007). Synopsis of Psychiatry.

Philadelphia: Lippincott Williams & Wilkins.

Sources of support : None Confl ict of Interest : None

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


Quiz

1. Who gave “Biopsychosocial model” of disease?2. Who described temperamental di� erences among infants?3. What is “Anamnesis” in psychiatric history?4. Who escribed the term “Paranoid Pseudocommunity”- a perceived community of plotters,

for development of delusional disorders?5. For pedophilia to diagnose what should be the age of the victim according to DSM-IV-TR?6. Who � rst described the term Trichtillomania?7. Cytochrome P-450(CYP) enzymes act primarily on which cells of the body to a� ect drug

metabolism?8. Phase –III trials should be conducted in atleast how many patients to validate the � ndings

of the phase-II studies for new drug development?9. For neuroleptic induced Tardive Dyskinesia to diagnose according to DSM-IV-TR, what

should be the minimum exposure to neuroleptic medication?10. For a seizure to be e� ective in the course of ECT, it should be of how much duration?

Contributed byDr.Bhavesh Lakdawala MD

Asst.Prof of PsychiatryB.J.Medical CollegeAhmedabad


Answers:

1. George Engel2. Stella Chess & Alexander ! omas3.Personal History4.Norman Cameron5.13 Years or younger6. Richard Asher7.Endoplasmic reticulum of hepatocytes8. 1000 to 3000 patients.9. 3 months (1 month if age 60 yrs or older)10. At least 25 seconds

indian psychiatric society western zonal branch indian psychiatry · 2012. 6. 15. · dattatrey...

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