Spectrum of intimate partner violence in patients with psychiatric illness-From victimization to perpetration.

PURPOSE: Persons with psychiatric illness are vulnerable to be the victims of intimate partner violence (IPV) and at risk of perpetrating IPV. OBJECTIVES: To estimate the prevalence and association of IPV in patients with psychiatric disorders, both as victims and as perpetrators. METHODOLOGY: We conducted a questionnaire based, cross-sectional study using systematic random sampling at psychiatric Outpatient Department (OPD) in a tertiary care hospital, in Haryana, India. A total of 500 participants diagnosed with psychiatric disorder were assessed using Operational WHO Criteria for IPV Victimization assessment and IPV Perpetration Assessment scale by Rhodes et al. RESULTS: The prevalence of IPV victimization was 16% during the last year and 26% during lifetime. IPV victimization was found significantly more in females (especially sexual), young and unemployed participants, during the initial 10 years of marriage and 10 years of the illness. Sexual IPV was the most common. The prevalence of IPV perpetration by the participants was 6% during last year and 10.6% in lifetime. Perpetrators were more likely to be males of higher age (40-50 years), unemployed, having lower income, belonging to joint family, and residing in rural areas. Diagnosis of a psychiatric illness, especially psychosis increased chances of perpetration. As the duration of illness increased, prevalence of IPV perpetration increased. CONCLUSION: Intimate partner violence among persons with psychiatric disorders is common and they are more vulnerable to being victims of IPV, rather than perpetrating IPV. Vulnerability and risk factors for IPV should be taken into account and optimized strategies should be devised for prevention.

Informed consent in psychiatry outpatients.

Background & objectives: Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study. Methods: The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended. Results: A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study. Interpretation & conclusions: Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.

Akathisia with Erythromycin: Induced or precipitated?

OBJECTIVE: A 28-year-old male diagnosed with schizophrenia, maintaining well on Olanzapine, developed akathisia soon after addition of Erythromycin for Pityriasis Rosea. This prompted us to evaluate the relationship of Erythromycin and akathisia. METHOD: We report the case and the literature focusing on akathisia as a possible adverse event of Erythromycin. RESULTS: Akathisia resolved after Erythromycin was stopped following 5 days of treatment. Akathisia was possibly induced or precipitated with use of Erythromycin. Possible etiological reasons of this clinically significant association are discussed. CONCLUSION: Erythromycin, by itself, may induce akathisia or precipitate akathisia in individuals by interfering with metabolism of other culprit drugs.

A comparative study of fixed tapering dose regimen versus symptom-triggered regimen of lorazepam for alcohol detoxification.

AIMS: The study aimed at comparing the fixed tapering dose and the symptom-triggered regimens of lorazepam for alcohol detoxification. METHODS: We carried out a prospective, randomized, double blind controlled trial involving 63 consecutive consenting male patients admitted with diagnosis of uncomplicated alcohol withdrawal. The patients were randomized into two groups based on the type of lorazepam dosage: symptom-triggered (n = 33) and fixed tapering dose regimens (n = 30). Alcohol withdrawal symptoms were rated on CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised). The main outcome measures were the total amount and duration of lorazepam treatment and the incidence of adverse events or complications. RESULTS: The mean lorazepam dose administered in the symptom-triggered group was significantly lower than in the fixed tapering dose group (9.5 versus 19.9 mg, P < 0.001) and for a significantly shorter duration of time (47.8 versus 146 h, P < 0.001) with more significant results for higher initial CIWA-Ar scores. There were no significant differences between both the groups in terms of the incidence of complications like seizures or delirium tremens. CONCLUSION: Symptom-triggered lorazepam treatment for alcohol withdrawal resulted in administration of lower total doses of medication for a shorter duration of treatment and was as safe as the fixed tapering dose.

Patterns and predictors of female sexual dysfunction in diabetes mellitus.

Background Sexual complications of people with diabetes mellitus (DM) are often neglected by the patients as well as clinicians. The neglect is more in women due to the associated stigma and taboo. Indian studies are scanty, varied and inconsistent, regarding the impact of DM on sexual functioning in women. We studied the patterns and predictors of sexual dysfunction in women with DM. Methods We did a cross-sectional questionnaire-based study comprising 50 participants in both the study (women with DM1 and DM2) and control groups (relatives/caregivers of patients and the hospital staff), selected randomly from the medicine outpatient department from May to August 2016. Approval from the institutional ethics committee was obtained. Clinical anxiety and depression were screened using the hospital anxiety and depression scale. Sexual dysfunction was assessed through female sexual function index scale (FSFI), and predictors were assessed by correlating FSFI scores with sociodemographic and clinical parameters. Results We found that 44% of women with DM had sexual dysfunction compared with 20% in the control group (p<0.01). The pattern of sexual dysfunction was seen across the domains of desire, arousal, lubrication and orgasm. High body mass index, higher age, duration of DM, treatment with insulin and complications of DM predicted a greater degree of sexual dysfunction among women. Conclusion Sexual dysfunction is common in women with DM, irrespective of the type of DM and coexisting psychological factors such as depression and anxiety.

Barriers to treatment of alcohol and tobacco use disorders in industrial workers.

Background: Substance use disorders (SUDs) are common among industrial workers and often lead to higher absenteeism and lower productivity. Multiple factors may be responsible for hindering the treatment of SUDs among industrial workers. Objective: The study was planned to assess the barriers to treatment of SUDs among workers employed in organized industries and factories. Materials and Methods: We conducted a cross-sectional study done at a tertiary care hospital associated with medical college in Delhi NCR. A total of 200 participants presenting to medicine outpatient department for the treatment of illnesses other than SUDs were selected by systematic random sampling. Participants consenting for inclusion and fulfilling the Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition criteria for substance dependence were assessed using barriers to treatment inventory and Mini-International Neuropsychiatric Interview 7.0.2. Results: The most commonly reported barriers to seeking treatment were time conflict (99.5%), followed by the absence of problem (80.5%), fear of treatment (68%), and negative social factors (49%). The absence of problem as a major barrier was reported significantly more in younger male participants, whereas fear of treatment was reported more in younger and unmarried females. Privacy concerns showed significant association with older females whereas negative social support was associated with married urban males. Alcohol dependence was observed to be significantly more in barriers such as admission difficulty, poor treatment availability, privacy concern absence of problem, and poor treatment availability and admission difficulty as a barrier was observed to be more in mild severity of illness. Conclusion: Educating employees through company wellness programs, Employee Assistance Program, and Work/Life programs to educate them about the harmful effect of substance use and various treatment availability options. Efforts should be made to reduce stigma in the workplaces, making necessary amendments so as to allow workers to have sufficient time for proper rehabilitative services and to ensure the patient about the privacy and confidentiality of the illness and treatment.

Psychological Impact of COVID-19 Patient Care on Families of Healthcare Workers.

Objective: The Coronavirus­19 (COVID­19) pandemic has perpetrated a significant mental health burden amongst health care workers (HCWs) and their families. Families of HCWs are at significant risk of various mental health problems due to concerns regarding the wellbeing of the HCW, fear of contacting the virus from HCWs, staying isolated during periods of quarantine and being the passive recipient of public stigma directed towards HCWs. The objective of this study was to assess the perceived stress, resilience and coping tendencies of families of HCWs managing the COVID 19 crisis. Method : A cross sectional study was conducted at a tertiary care hospital in India, where close relatives of 150 HCWs managing COVID-19 patients (directly or indirectly involved in patient care) were selected using systematic random sampling. They were evaluated using the Perceived Stress Scale, Brief Resilience Coping Scale, and the Hospital Anxiety and Depression Scale. Pearson's correlation and Independent t-test were used for statistical analysis using the SPSS software. Results: Majority (75%) of the family members associated with frontline HCWs had moderate to high level of perceived stress, while23% and 17% had clinically significant anxiety and depressive symptoms, respectively. More than 50% had low resilience and coping scores. High levels of stress, anxiety and depression were seen in female respondents, those less than 40 years old, having a child or an elderly family member and when the HCW had direct involvement in COVID-19 patient care. Conclusion: Families of HCWs suffer from significant psychological burden due to the COVID-19 crisis. They face significant risk of depression and anxiety associated problems, which are augmented by low resilience and impaired coping. Mental health of HCWs and their family members should be given due attention with a focus on early identification, providing psychological support and improving resilience.

From stress to stigma - Mental health considerations of health care workers involved in COVID19 management.

BACKGROUND: Healthcare workers (HCWs) involved in administration and patient management during COVID-19 pandemic are at high risk of developing psychological problems related to fear and stress of contacting COVID infection. This is augmented by the stigma faced at home and society, owing to the nature of their job. AIM: To assess the mental health issues and stigma amongst health care workers involved in COVID care. METHODOLOGY: We conducted a hospital based cross sectional study where 150 health care workers involved in the care of COVID-19 patients, directly and indirectly, were selected using systematic random sampling. They were assessed using Depression, Anxiety and Stress Scale (DASS-21) Hindi Version, The Impact of Event Scale - Revised scale and a Modified Stigma scale. RESULTS: Significant psychological stress, anxiety, depression and high risk for developing post-traumatic stress disorder was found in more than half of the healthcare workers, albeit more in those having direct contact with COVID patients (p < 0.05). Stigma was significantly reported in most HCWs, especially with concerns regarding public attitude and disclosure of their work profile. CONCLUSION: Healthcare Workers are at a higher risk for developing psychological disorders and post-traumatic stress disorder because of the immensely stressful work-related conditions and stigma related to working with COVID patients. This may lead to long lasting psychosocial consequences which may affect more severely than the infection itself. Early identification of psychological issues of HCWs and timely intervention is the key.

Marijuana use experiences and expectancies of urban youth in India.

Objective: To gain information on the marijuana experiences and expectancies of youth in an urban Indian area, which may be used for forming the framework for the development of effective primary prevention strategies in the future. Method: This was a cross-sectional study conducted in various colleges of Mumbai; 260 students from three colleges who were above 18 years were selected by systematic random sampling. The participant had to fill a sociodemographic questionnaire and marijuana effect expectancy questionnaire (MEEQ-B) and it was analyzed by using the SPSS software. Results: A significant association was found between negative marijuana expectancies and type of family, with cannabis users and non-users, who want to try cannabis and those who are aware of the legal issues and harmful effects of cannabis. Conclusion: Preventive drug education should begin in early adolescence and should deter or delay drug use through changes in knowledge, attitude, behavior, and expectation. Adolescent drug education must meet the needs of those naive to drugs as well as those experiencing initial drug exposure. This is the first study which highlights the youth experiences and expectancies about marijuana in India.

Pathway to care and clinical profile of children with attention-deficit hyperactivity disorder in New Delhi, India.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is a common childhood neurobehavioral disorder, which may cause impairment in multiple domains. Understanding the pathway to care helps in planning effective early interventions. The study aims to provide a quantitative description of the factors affecting the help-seeking pathway. MATERIALS AND METHODS: The study was conducted at an outpatients department of a tertiary care multispecialty hospital. Fifty consecutive consenting children aged 5-15 years were screened and diagnosed for ADHD using Conners' Parent Rating Scale-Revised: Short Form, Diagnostic and Statistical Manual of Mental Disorders fourth edition text revision criteria, and Kiddie Schedule for affective disorders and schizophrenia. A semi-structured questionnaire was used to study the pathway of care, using the WHO template. The data were analyzed using appropriate parametric and nonparametric tests in SPSS software. RESULTS: The average delay from the onset of the illness to first consultation with a qualified health professional was 2.32 ± 1.9 years. Children with an urban background, from a nuclear family, with literate mothers, with a family income of more than Rs. 30,000/month, having hyperactive and combined type of ADHD, and who were referred by school teachers presented significantly earlier. The main source of referrals were school teachers and general medical practitioners. The most common parental beliefs for delay were the views that the "child is naughty" and that "hyperactivity is part of normal growth." CONCLUSION: Parents' help-seeking behavior is affected by different sociocultural beliefs. Such factors as the lack of recognition and awareness of ADHD, resulting in the delay in seeking treatment should be addressed through health promotion programs.

Hyponatremia with Olanzapine - A Suspected Association.

Hyponatremia is a rare, yet potentially life threatening complication of antipsychotics. Here, we report a case of a 45-year-old female diagnosed with schizophrenia who developed hyponatremia soon after addition of olanzapine to the existing treatment. This prompted us to evaluate the relationship between hyponatremia and olanzapine, as timely management is crucial. Naranjo algorithm established a "probable" causal relation between olanzapine and hyponatremia. Possible etiological reasons of this clinically significant and life threatening adverse event have been discussed. We report the case and the literature focusing on hyponatremia as a possible adverse event of olanzapine. Medical illnesses are often ignored or missed in patients with psychiatric disorders either due to patients' inability to report complaints or non-serious attitude of physicians towards such patients. A high index of suspicion should be kept while dealing with this probable complication.

Comorbid Neurocognitive Impairment in Patients with Epilepsy

Background: Epilepsy is a common chronic non-communicable neurological disorder in which the brain function is impaired. Cognitive function is more frequently impaired in people with epilepsy than in the general population. The neurocognitive outcome of epilepsy in children and adults is vital for social prognosis and quality of life assessment. Cognitive changes in epilepsy have multifactorial etiology, including the epilepsy itself, age at onset, duration of epilepsy, treatment of epilepsy, reaction to epilepsy and any associated brain dysfunction and /or damage. This study was conducted to check association of neurocognitive impairment with the socio-demographic factors and disease associated factors in patients with epilepsy. Methodology: This study was a single centre cross-sectional study in which 96 patients were included. Severity of neurocognitive impairment was measured by Addenbrookes’ Cognitive Examination- R (ACE- R) score. Results: Out of 96 patients, neurocognitive impairment was seen in 23 (23.95%) patients. Conclusions: This study shows that neurocognitive impairment was found to be more when the age at onset of epilepsy was less, when the duration of the illness was more and when frequency of seizure was higher. Conclusion: Neurocognitive impairment is noted in patients with epilepsy and must be treated in the long- term management of epilepsy

Patterns and Predictors of Premenstrual Symptoms among Females Working in a Psychiatry Hospital.

Introduction. Premenstrual syndrome presents with vague psychological, somatic, or biological symptoms. It may be seen more commonly in a specific profile of patients. We try to evaluate the patterns and predictors of premenstrual symptoms among females working in a tertiary care psychiatry hospital. Methodology. We recruited working females at a tertiary care psychiatry hospital in India, through purposive sampling, and assessed them cross-sectionally. Premenstrual Symptom Checklist was used to assess the frequency and distribution of premenstrual symptoms, which were correlated with various sociodemographic variables to evaluate the predictors for premenstrual symptoms. Results. 150 working females were included, belonging to different sociodemographic profile. Somatic symptoms (backache, joint and muscles pain, and fatiguability) were most commonly reported followed by psychological (irritability and losing temper easily) and biological symptoms (increased micturition). Premenstrual symptoms were seen more commonly in women with higher educational status and nursing profession and residing in nuclear families (p < 0.05), while age and marital status did not correlate significantly. Discussion. Premenstrual symptoms are common and distressing, especially for working females. Somatic symptoms such as backache and joint pains predominate over psychobiological symptoms. Women with higher educational status and professions like nursing belonging to nuclear families are more prone to these symptoms. Attention needs to be given to premenstrual symptoms in such population of working females.

Effect of Poly Unsaturated Fatty Acids Administration on Children with Attention Deficit Hyperactivity Disorder: A Randomized Controlled Trial.

INTRODUCTION: Attention Deficit Hyperactivity Disorder (ADHD) is a common disorder of childhood. Studies have indicated nutritional deficiencies, particularly Poly Unsaturated Fatty Acids (PUFA) deficiency in these children and have suggested supplementation with PUFA for clinical improvement. AIM: The present study aimed at evaluating the effect of PUFA administration in Indian children with ADHD. SETTINGS AND DESIGN: The study was conducted in the paediatrics and psychiatry departments of a tertiary care hospital. We conducted a prospective double blind randomized control trial on children aged 4-11 years, diagnosed with ADHD according to DSM-IV TR criterias and Kiddie-Schedule for Affective Disorders and Schizophrenia - Present and lifetime version. MATERIALS AND METHODS: The study subjects were randomized into study and control groups. The control group was administered Atomoxetine, while the study group received Atomoxetine along with Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA). Both groups were followed up every 2 weeks over the next 4 months using Conner's Parent Rating Scale - Revised (CPRS-R). STATISTICAL ANALYSIS: The data was carefully analysed by SPSS (17th version) software with the help of a statistician. Confidence interval of 95% was used. The complete data was analysed using appropriate parametric and non parametric tests. Correlation was done between various socio-demographic and illness related parameters. For all analyses, probability of 5% or less was assumed to represent statistical significance. RESULTS: Fifty children diagnosed with ADHD were randomized to study group (n=25) and control group (n=25). The study group had greater reduction in ADHD scores as compared to the control group, although not statistically significant (p = 0.08). Improvement was more significant in male study subjects with combined type of ADHD. CONCLUSION: It may be concluded that PUFA supplementation improves the symptoms of ADHD. However, the effect is not clinically significant if supplementation is not given for prolonged duration and in adequate doses.

Perceived caregiver stress in Alzheimer's disease and mild cognitive impairment: A case control study.

OBJECTIVES: Cross sectional studies have reported a tremendous amount of stress in caregivers of patients with Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI). The present study aimed at evaluating the perceived stress in caregivers of patients with AD and MCI compared to controls. MATERIALS AND METHODS: Caregivers of patients diagnosed with Alzheimer's disease/Mild Cognitive Impairment were recruited at the Memory Clinic of Neurology Department of a Tertiary Care Hospital in Northern India. The controls included caregivers of patients with chronic medical and psychiatric disorders. Caregivers were interviewed using Perceived Stress Scale (PSS) and the patients were assessed using The Blessed Activity of Daily Living (ADL), Mini Mental State Examination (MMSE) and Clinical Dementia Rating scale. The perceived stress of caregivers was compared amongst both groups and correlated with the severity of illness and activities of daily living of the patients. RESULTS: Caregivers of a total of 31 patients of AD/MCI (Males = 24, Females = 7), and 30 controls (Males = 18, Females = 12) were interviewed. PSS Score was 23.29 ± 7.17 in cases and 7.5 ± 3.12 in controls. ADL Score was 7.97±5.53 in cases and 0.00 in controls. There was a significant difference between the PSS and ADL scores between those with AD and controls (P < 0.0001). Caregivers of patients with MCI had lower PSS scores compared to AD caregivers but significantly higher scores compared to caregivers of other chronic disorders. Similarly, correlation between Perceived Stress and ADL was significant (P < 0.001). CONCLUSIONS: Present study shows that caregivers of patients with AD/MCI have a high perceived stress compared to caregivers of patients with other chronic illness.

Alcohol-Related Dementia and Neurocognitive Impairment: A Review Study.

CONTEXT: Alcohol consumption has escalated rapidly in many countries over the past decade. Evidence suggests a correlation between alcohol use and cognitive decline. We have systematically reviewed the concept and controversies, epidemiology, nosology, neuropathology and neurobiology, neuropsychology and management updates of alcohol-related dementia (ARD) in this paper. EVIDENCE ACQUISITION: We retrieved papers for this review by searching the PubMed database for terms "alcohol and dementia", "alcohol and cognitive impairment", and "alcohol and wernicke-korsakoff" mentioned in the title of the published papers. A total of 131 studies showed up. Appropriate studies were shortlisted and included (n = 72). Cross-references if relevant were considered from the selected studies. Eligible articles were fully read by the authors and the results were compiled. RESULTS: The prolonged and excessive use of alcohol may lead to structural and functional brain damage, leading to ARD. The cognitive deficits are most frequently observed in domains of visuospatial functions, memory and executive tasks, with a potential of partial recovery if abstinence is maintained. However, there are doubts regarding the etiopathogenesis, nosological status, prevalence and diagnostic criteria for ARD, due to difficulty in assessment and various confounding factors. CONCLUSIONS: With growing cohort of young and middle-aged people, there is a probable risk of upsurge of ARD. Presently, there are dilemmas over the diagnosis of independent ARD. Thus, there is a need to develop evidence-based guidelines for diagnosis and management of ARD through further systematic studies.

Internet Gaming Addiction: A Technological Hazard.

INTRODUCTION: The Internet is considered a beneficial tool in research, communication, and information. Still, its excessive and prolonged use has the potential of causing addiction. The presentation of this technological hazard may range from a mild socio-personal distress to a gross disorganization in behavior and self-care. No reported study on Internet gaming addiction is available from India. CASE PRESENTATION: We reported a case of two brothers, diagnosed with Internet gaming addiction, who showed grossly disorganized behavior and severely compromised self-care. The condition was managed by pharmacological and non-pharmacological therapies, with sustained improvement after 6 months follow up. CONCLUSIONS: Internet gaming addiction may cause severe personal, social, and occupational problems. Despite the range of severity and various presentations of this disorder, DSM-5 lacks the severity classifier. Early identification and management may result in complete recovery.

Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond.

Alcohol dependence is an increasing and pervasive problem. Alcohol withdrawal symptoms are a part of alcohol dependence syndrome and are commonly encountered in general hospital settings, in most of the departments. Alcohol withdrawal syndrome ranges from mild to severe. The severe complicated alcohol withdrawal may present with hallucinations, seizures or delirium tremens. Benzodiazepines have the largest and the best evidence base in the treatment of alcohol withdrawal, and are considered the gold standard. Others, such as anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists have been tried and have evidence. Supportive care and use of vitamins is essential in the management. Symptom triggered regime is favoured over fixed tapering dose regime, although monitoring through scales is cumbersome. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on 'Alcohol withdrawal syndrome' in humans during the last 10 years. A total of 1182 articles came up. Articles not relevant to clinical utility and management were excluded based on the titles and abstract available. Full text articles, meta-analyses, systematic reviews and randomized controlled trials were obtained from this list and were considered for review.

Non Pharmacological Cognitive Enhancers - Current Perspectives.

Cognition refers to the mental processes involved in thinking, knowing, remembering, judging, and problem solving. Cognitive dysfunctions are an integral part of neuropsychiatric disorders as well as in healthy ageing. Cognitive Enhancers are molecules that help improve aspects of cognition like memory, intelligence, motivation, attention and concentration. Recently, Non Pharmacological Cognitive Enhancers have gained popularity as effective and safe alternative to various established drugs. Many of these Non Pharmacological Cognitive Enhancers seem to be more efficacious compared to currently available Pharmacological Cognitive Enhancers. This review describes and summarizes evidence on various Non Pharmacological Cognitive Enhancers such as physical exercise, sleep, meditation and yoga, spirituality, nutrients, computer training, brain stimulation, and music. We also discuss their role in ageing and different neuro-psychiatric disorders, and current status of Cochrane database recommendations. We searched the Pubmed database for the articles and reviews having the terms 'non pharmacological and cognitive' in the title, published from 2000 till 2014. A total of 11 results displayed, out of which 10 were relevant to the review. These were selected and reviewed. Appropriate cross-references within the articles along with Cochrane reviews were also considered and studied.

Case report of comorbid schizophrenia and obsessive compulsive disorder in a patient who was tube-fed for four years by family members because of his refusal to eat.

Refusal to eat is a common presentation in many psychiatric disorders including obsessive compulsive disorder and schizophrenia. In the acute situation it may be a medical emergency; when it becomes chronic it can become an ingrained behavior that is difficult to change. The diagnosis of individuals who refuse to eat may be difficult, particularly in persons with comorbid medical problems, impaired intelligence, or lack of insight into their condition. Tube-feeding is an effective short-term intervention that can be discontinued when the patient re-starts oral intake. However, in some situations patients may become dependent on the use of tube-feeding. We present a case report of a patient with schizophrenia, obsessive compulsive disorder, borderline intelligence, and seizure disorder who was tube-fed by his family members for more than three years because he refused to eat orally.