Delirium with Concurrent Use of Lithium and ECT and the Safety Implications: Case Reports and Review of the Literature.

Using electroconvulsive treatment and lithium together to treat acute manic episodes is common, but the effects of combining these therapies vary according to the literature. Some studies have found severe adverse side effects, while others have found the combination of both medications safe and helpful. To investigate potential adverse side effects, this study reports on two cases where bipolar affective disorder patients developed delirium after receiving electroconvulsive therapy and lithium concurrently. The delirium was attributed only to the combined administration of these medicines after ruling out other potential causes. Additionally, alterations in blood-brain barrier permeability, such as those caused by electroconvulsive therapy and age, increased the likelihood of delirium. As a result, caution should be taken when using this combination of medicines, especially in those predisposed to delirium. This study established links between these medications and adverse effects, such as delirium. Further research is necessary to determine the efficacy and risks of combining these medications, establish causality, and develop prevention strategies.

Quality of Life, Sexual Health, and Associated Factors Among the Sexually Active Adults in a Metro City of India: An Inquiry During the COVID-19 Pandemic-Related Lockdown.

Background: Sexual dysfunction (SD) and its effect on our life is an important but less studied topic especially during post-COVID era. This study examines the extent of SD and other mental health predictors and their effect on quality of life. Methods: A cross-sectional survey of sexually active adults was conducted in an Indian metro-city. Along with sociodemographic data, sexual dysfunction, depression, anxiety, stress, and quality of life were assessed by Arizona Sexual Experience Scale (ASEX), Depression Anxiety and Stress Scale (DASS), and WHOQOL-BREF, respectively. Structural equations modeling was used to understand their relationship. Results: Out of the total 1,376 respondents, 80.52% were male, 65.98% were married, and 48.54% were graduates. The mean age of the participants was 34.42 (±9.34) years. Of the participants, 27.18% had sexual dysfunction. Majority of the respondents did not have depression (59.30%), anxiety (52.33%), or stress (44.48%). Mild and moderate levels were the commonest findings among those who had depression, anxiety, or stress. Among the respondents, 27.18% had sexual dysfunction as per the ASEX instrument. Increase in age and female gender were associated with sexual dysfunction overall and also all its components. Presence of depression adversely affected ease of achieving orgasm and satisfaction from orgasm and was associated with sexual dysfunction overall. The respondents had a mean score of 73.57 (±13.50) as per the WHO-QOL. Depression and stress emerged as statistically significant factors for poor quality of life, while sexual dysfunction was not associated statistically. Conclusion: More than one-fourth of the study population reported sexual dysfunction during the first wave of the pandemic in India. The study findings highlight the role of poor mental health issues in this regard. In fact, issues like depression and stress were associated with poor quality of life as well. The current findings unequivocally warrant specific interventions to improve mental health of the respondents.

Stress, Sleep and Psychological Impact in Healthcare Workers During the Early Phase of COVID-19 in India: A Factor Analysis.

Background: Risks to healthcare workers have escalated during the pandemic and they are likely to experience a greater level of stress. This cross-sectional study investigated mental distress among healthcare workers during the early phase of Coronavirus disease-2019 (COVID-19) outbreak in India. Method: 140 healthcare workers of a tertiary care hospital in India were assessed for perceived stress and insomnia. A factor analysis with principal component method reduced these questions to four components which were categorized as insomnia, stress-related anxiety, stress-related irritability, and stress-related hopelessness. Further statistical analyses were done on these factor scores to identify the predictors and investigate the differences between the different categories of healthcare workers. Result: Doctors had the highest level of anxiety among the healthcare workers. Both doctors and nurses perceived a greater level of irritability than the other HCWs. Compared to doctors and nurses, other HCWs were more likely to experience insomnia. Lower age, higher education, female gender, and urban habitat were associated with greater perception of anxiety. Older age, being quarantined, and single marital status were the significant predictors of irritability. Female gender, single marital-status, and higher number of medical ailments contributed to perceived hopelessness. Quarantine significantly predicted insomnia. Conclusion: Different categories of healthcare workers are experiencing varied mental health problems owing to their heterogeneous socio-demographic backgrounds. Tailored and personalized care, as well as policies, might help in alleviating their problems. Further research is warranted to explore the psychological distress and remedies among these frontline workers during and after the ongoing pandemic crisis.

Validation of revised reading the mind in the eyes test in the Indian (Bengali) population: A preliminary study.

BACKGROUND: Social cognition deficits are common in clinical populations but there is a dearth of standardized social cognition assessment tools in India. Theory of mind (ToM) is an important aspect of social cognition which is often assessed with the revised reading the mind in eyes test (RMET-R). However, we do not have a statistically validated version of the test for the Indian population. AIM: This study aims to assess the acceptability, reliability, and validity of the Bengali version of the RMET-R. MATERIALS AND METHODS: We administered the RMET-R to 23 patients with chronic schizophrenia (SCZ), 22 patients with bipolar disorder, and 104 healthy controls (HCs) to evaluate the reliability and validity of the instrument in the Indian (Bengali) population. RESULTS: We obtained moderate internal consistency (Cronbach's alpha = 0.6) and test-retest reliability (intraclass correlation coefficient = 0.64, P < 0.001). Positive correlations were found between RMET-R and Wechsler picture arrangement (r = 0.60, P < 0.001), picture completion (r = 0.54, P < 0.001), and comprehension subtests (r = 0.48, P < 0.001). Patients with SCZ (M = 49.7, standard deviation [SD] = 16.5) scored significantly lower than HCs (M = 68.9, SD = 13.8) (P = 0.008; Cohen's d = 1.3) on the RMET-R. Thus this tool could discriminate patients who are reported to have Theory of Mind deficits from healthy controls. CONCLUSION: The Bengali version of the RMET-R is a reliable and valid tool for assessing first-order ToM insofar as the original RMET-R measures this construct.

Anticholinergic medications even in therapeutic range can cause recurrence of psychosis.

Anticholinergic drugs are commonly used in psychiatry to attenuate antipsychotic induced extrapyramidal syndrome (EPS). Psychosis as a side effect is generally explained under the rubric of anticholinergic toxicity or induced delirium. Anticholinergic induced worsening of psychosis in patients with normal cognition is extremely rare in literature. Here, we arepresenting a case of young female who was prescribed with multiple anticholinergics to reduce EPS, and each time had worsening of psychosis with intact cognition. We then discussed the possible neurobiological explanation with special reference to muscarinic hypothesis of schizophrenia.

Attitude, practice, behavior, and mental health impact of COVID-19 on doctors.

BACKGROUND: COVID-19, like every other pandemic, has imposed an unprecedented threat to doctors' physical and mental health. Literature in this area is sparse. The present study has been done to explore the knowledge, attitude, and behavior of doctors regarding this pandemic and how it influences their depression, anxiety, and stress level. MATERIALS AND METHODS: This online survey has been done for 10 days. Data were collected on background characteristics, knowledge, attitude, and behavior of the respondents in a semi-structured pro forma, and psychiatric morbidity was measured by the Depression, Anxiety, and Stress Scale-21. A total of 152 complete responses have been received. The data were assessed using SPSS software. RESULTS: Out of 152 study participants, 34.9% were depressed and 39.5% and 32.9% were having anxiety and stress, respectively. Significant predictors for psychiatric morbidities were experience in health sector, duty hours, use of protective measures, and altruistic coping. Multivariable logistic regression showed most of the factors to be significantly associated with depression, anxiety, and stress level. DISCUSSION: Doctors who were working during COVID pandemic have a high prevalence of psychiatric morbidity. Age and having multiple comorbidities are significant predictive factors. Adequate protective measures should be warranted. Altruistic coping and a sense of greater goal are significant among the doctor community, in this pressing time. The doctors are pushing themselves to the best of their capacity and also protecting their patients' best interest. A large-scale, multicentric study will probably give a larger picture and will guide us for better service planning and delivery.

A case of craniopharyngioma presenting as rapidly progressive dementia.

Rapidly progressive dementia (RPD) is generally obvious to family member but often difficult for physicians to pinpoint the underlying pathology. Some common causes, such as prion's disease, Alzheimer's disease, central nervous system vasculitis, or infection, might present with disease-specific signs or symptoms where many etiologies do not produce such warning signs. Here, we are presenting a case who attended the psychiatric clinic for decreased motivation to do work, easy fatigability, infrequent falls, recent memory impairment, increased appetite, polydipsia and polyuria, and provisionally diagnosed with RPD. Magnetic resonance imaging revealed solid cystic lesion in suprasellar location involving hypothalamus, optic chiasma, and optic tracts, compressing the floor of the third ventricle suggestive of craniopharyngioma which is one of the very few reports in literature.

Gulliver's world: Persistent lilliputian hallucinations as manifestation of Charles Bonnet syndrome in a case of cataract and normal pressure hydrocephalus.

Charles Bonnet Syndrome (CBS) typically occurs in elderly people with peripheral vision impairment, or interruptions in the connections from eyes to visual cortex. The heterogeneity of presentations and causal mechanisms warrants clinical caution. In this report, we describe a case of CBS developing in the form of Lilliputian Hallucinations in an elderly gentleman, on the background of cataract and normal pressure hydrocephalus, the complexities arising out of such aetiogenesis, and its management. We emphasize upon the fact that CBS might develop through two concurrent mechanisms in a given individual. Treating one of these would mean persistent symptoms, and failing to recognize these would lead to continued morbidity.

"The Twisted Mind" - Psychogenic Dystonia in An Adolescent, Responding to Antidepressant Therapy.

Psychogenic dystonia is one of the most common problems encountered in movement disorder patients and accounted mostly for misdiagnosis, management confusion and treatment resistance. Psychiatric morbidities often are the culprit, hence proper psychiatric history taking is of utmost importance. Here we report one case where dystonia was the main presenting complaint of an underlying depressive episode and discuss how managing the cause alleviated the symptoms.

"Mind, body, and water!" - Postherpetic polydipsia masquerading as obsessive-compulsive disorder.

Polydipsia has always been an intriguing entity in clinical psychiatry, since long. Other than being commonly associated with patients of chronic schizophrenia, as described in past, it can also mimic and present in other psychiatric disorders; and thus may be elusive for diagnosis and treatment. Here we describe a patient having polydipsia with prominent obsessive compulsive symptoms, which, after detailed investigations, was found to be secondary to herpes encephalitis. The organic nature of the illness was ascertained by distinct signal changes in right uncus, hippocampus and cingulate cortex; whereas conventional workup for polydipsia ruled out both central and nephrogenic diabetes insipidus. Treatment with fluoxetine, proper behavioural management and psychoeducation resulted in slow but sustained improvement in this patient. We then deconstruct the clinical manifestations and discuss the neurobiological explanation.

Dissociative Experience in Unipolar and Bipolar Depression: Exploring the Great Divide.

OBJECTIVE: Unipolar and bipolar depression (UD and BD) differ strikingly in respect to neurobiology, course and management, but their apparent clinical similarity often leads to misdiagnosis resulting in chronicity of course and treatment failure. In this study we have tried to assess whether UD and BD can be differentiated on the basis of their dissociative symptoms. METHODS: Thrty-six UD patients and 35 BD patients in active episodes, without any psychiatric comorbidity were selected from outpatient department and compared for depressive and dissociative symptoms using Hamilton Depression Rating Scale and Dissociative Experience Scale-II (DES-II). RESULTS: We found that thought the two groups didn't differ in terms of the socio-demographic or clinical variables, BD group had significantly higher dissociative experience (U=343, p=0.001) than UD and the difference remained significant even after adjusting for the confounding factors. CONCLUSION: Our study shows that dissociative symptoms are significantly more prevalent in the depressive episodes of bipolar affective disorder as compared to the UD and can be an important tool in differentiating between the two disorders with very similar clinical profile. The difference can be measured using a simple self-report questionnaire like DES-II.

Serum uric acid levels in first episode mania, effect on clinical presentation and treatment response: Data from a case control study.

Bipolar disorder (BD) patients have increased serum Uric Acid (UA) levels as compared to their healthy counterparts. They also demonstrate higher impulsivity - while symptomatic, as well as when in remission. Impulsivity adds a risk of self-harming behavior to BD, and studies show that it increases with UA levels. Given this complex relationship, the current project aimed at comparing UA levels in first-episode mania patients with matched controls, and analyzes its relationship with impulsivity, symptom severity and disease prognosis. Thirty-one first-episode mania patients were assessed on BIS-11 and YMRS, serum uric acid levels were measured, and compared to matched controls. A follow up YMRS was rated after one month to evaluate the effects of treatment. We found significantly higher levels of UA in patients, which showed positive correlation with impulsivity and a negative correlation with symptom improvement at 1 month. The results of the study support a purinergic system dysfunction hypothesis in first-episode mania, and suggest its influence on impulsivity in this patient group. Further, the mentioned dysfunction appears to have a negative impact on treatment outcomes in such cases.

Mania in Wolfram's Disease: From Bedside to Bench.

Wolfram syndrome is a relatively unexplored entity in clinical psychiatry. Historically, the discovery of a specific WFS1 gene had generated huge fanfare regarding specific genetic causations of psychiatric disorders. While the initial enthusiasm has faded now, association of Wolfram syndrome with psychiatric illnesses like schizophrenia, psychosis and suicidal behavior still remain important for understanding biological underpinnings of such disorders. We report a case of Wolfram syndrome presenting with multiple manic episodes, discuss possible genetic underpinnings for the affective symptoms and then discuss certain issues regarding management.

Psychiatry and Cinema: What Can We Learn from the Magical Screen?

Cinema, a vehicle of social transformation sheds light on different aspects of mental illness. Due to its dramatic and stigmatising depictions, it often spreads a negative aspect of psychiatric disorders and the patients who are suffering from them. Though it brings out a few positive and inspiring stories, they are sparse in comparison to its negative views. Here, we are going to describe the dual impact of cinema on psychiatry.

Dermatitis Artefacta Mimicking Borderline Personality Disorder: Sometimes, Skin Could Be Misleading.

Dermatitis artefacta lies in a gray zone, between the specialities of psychiatry and dermatology. The condition could mimic a number of other lesions and therefore is a source of much confusion in clinical practice. Here, we describe a case of dermatitis artefacta in an 11-years old girl, which resembled self-harming behavior in Borderline personality disorder. We then discuss how the two could be differentiated and why this becomes imperative while dealing with such cases.